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--- intern:pgy2-pgy3_off-service [2019/08/12 16:23] – [UCH Burn] melissa
+++ intern:pgy2-pgy3_off-service [2020/06/11 18:39] (current) – old revision restored (2019/09/22 15:14) jonathan
@@ Line 356: / Line 356: @@
 Surgery Clinic Charge RN – Meghan Amiot (x27582)\\
+We look forward to working with you in the STICU.
+I want to make you aware of the website that contains all of the protocols and guidelines used in the UCH STICU.\\
+http://www.ucdenver.edu/academics/colleges/medicalschool/departments/surgery/divisions/Trauma/Trauma-at-UCH/Pages/Welcome.aspx
+On the left hand you will find links to the STICU protocols as well as the TACS Service protocols and the STICU curriculum. The only link that is protected is the curriculum. The user name is criticalcare and the password is cusurgery.com.\\
+I want to make a special note to the Department Guidelines at the bottom of the page of STICU protocols. There you will find surgeon specific guidelines. As example, there is a protocol for the liver transplant patient care during the first 48 hours after transplant.\\
+While on service, you will participate in the resident critical care curriculum, managed by Drs. Martin Krause and Lauren Steward, including:\\
+)      Critical Care Didactic Lecture Series – 3pm on Monday, Tuesday, Wednesday, Friday\\
+)      Critical Care Grand Rounds – 12pm on 1st/3rd Thursday\\
+)      Ultrasound M&M Conference – 12pm on 2nd Thursday *free pizza\\
+)      Critical Care Journal Club – 12pm on 4th Thursday (residents will be assigned manuscripts for presentation) *free pizza\\
+While on service, please refrain from eating food in patient care areas and nurses’ stations. Also, all liquids must be kept in a closed container with a lid.\\
+If you have questions please feel free to contact me or Jason Brainard.\\
+Further if you have any suggestions about the protocols, interest in developing a new one, interest in a QI project, or other observations about the STICU education please let us know.\\
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 ==== UCH Burn ====
-Cover the ICU on Wednesdays when the ED resident is off and a weekend day
+Burn Service Information:\\
+General Information on how service runs:\\
+  * Usually Monday is your 24 hr call and Tuesday you are post-call day but check the schedule. Sometimes if they cannot find enough moonlighters they will change it up.
+  * Typically first Monday of rotation they will want you to round on all patient so that you know service.
+  * When you work overnight you can leave at 6am, you don’t have to stay for rounds!
+  * When the EM resident isn’t there then it is your responsibility to pick up the pager from the night intern and then go get sign-out from the ICU resident. On these days I would usually show up around 5:30 - 5:45, so I could try my best to get the night person from the ICU out by 6.
+  * You typically work one weekend day each week rather than blacks/golds because the EM residents complained because they apparently have to have one day off for every 7.
+  * On the days there is an EM resident (usually every day except Wednesday and the weekend day) I often would get to work between 6-6:30am.
+  * When both you and an EM resident are there, you go to the OR and are not responsible for the ICU. You do have to see any patient who is going to the OR  that day and write their note prior to the OR.
+  * During the day, between cases you need to be consenting people and putting in their pre-op orders for the next day. The EM resident and APPs will not do this so it falls on you to order blood, hold heparin drips and make sure people are NPO. Consent patient’s for everywhere they could possibly be operated on. Usually type and cross between 2-4 units of blood per case.
+  * Anyone who has a protected airway (ET tube or trach) can keep their tube feeds running prior to and during the OR.
+  * When you are in the ICU (when the ED resident is off) you often carry 6-12 patients. You always carry the ICU/stepdown patients but also any other patients the APPs tell you to. They usually divide the list evenly (even though you carry icu patients which are a lot more work than their floor patients but it is what it is). When there are two APPs, it usually ends up being 6ish patients and when there is only one it ends up being more. There is always only one APP on the weekends so it’s usually more patients then.
+  * On the weekends, once you and the APP have finished all the work on the floor patients you can go sign out to the crosscover intern and then you only have to cover the icu/stepdown people until 6 when the night moonlighted comes in.
+  * Overnight, you should go to the burn alerts/activations but if a burn alert is stable the intern should admit/work it up. The activations will almost always come to you but Jess and/or the attending will always come in for those so you won’t be alone.
+  * When an alert/activation come, go down to the ED and take initial photos and send to attendings. You will then have to fill out a Lund and Browder.\\
+ In the OR:\\
+  * Wear shoe covers and eye protection always the cases are messy
+  * Takedown whatever dressings you are dealing with then all attendings prep with a chlorhexidine soap on lap pads that the scrub will have in a bucket for you. Prep limbs circumferentially and torso to bed (if involved in the excision). Dr. Wiktor likes you to prep the donor area with a chloraprep stick. Dr. Duffy does not use hand table (Wiktor and Wagner both do).
+  * Drape using blue towels and a million half sheets. The scrubs are pretty helpful with this.
+  * They put tumescence in everything with Pitkin’s solution. Bleeding is typically stopped with Thrombin spray then epinephrine soaked telfas. Dr. Wagner and Dr. Duffy are ok with VERY judicious use of the bovie (spray saline/GU solution on area of bleeding and then stop bleeding. Dr. Wiktor does NOT like the bovie and puts Vicryl stitches in anything bleeding.
+  * Grafts are put into place using Artiss spray and occasionally staples. The dressing for grafts are:
+  * Limb:  Mepitel 1, bacitracin (+/- Medihoney), kerlix and Ace if on a limb
+  * Front or Back: Mepitel 1, bacitracin (+/- Medihoney), burn pad, therabond
+  * Dressing from Graft donor site typically is Mepitel transfer Ag, kerlix, ace
+  * Cover the ICU on Wednesdays when the ED resident is off and a weekend day
 hour in-house call on Mondays
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 ==== UCH Vascular ====
 Great experience with getting to sew vessels. Be in the OR as much as you can with any of the surgeons especially the open procedures (AVF, bypass)
+**UCH VASCULAR TEAM DELEGATIONS**
+__
+WEEKLY SCHEDULE__
+  * Monday
+:30 – Core curriculum (Conference center)\\
+:00 – Grand rounds (Conference center)\\
+:00 – Aortic conference (Conference center)\\
+  * Tuesday
+Jacobs – clinic all day\\
+:00 – Vascular conference (AO1 5th floor conference room)\\
+  * Wednesday
+Wohlauer – OR\\
+Nehler – clinic all day\\
+  * Thursday
+Jacobs – OR\\
+Wohlauer – clinic all day\\
+  * Friday
+:00 – Multidisciplinary vascular conference (IR conference room)\\
+Jacobs – every other Friday OR/clinic (half day)\\
+Nehler – OR\\
+**BASIC DUTIES of the R1**
+  * Work up and medical management of all admitted floor patients – shared duty with NP
+  * Write all daily orders of floor patients – shared duty with NP
+  * Write all daily progress notes of floor patients – shared duty with NP
+  * Vascular consults – shared duty with R2/NP
+  * Attend all vascular conferences/lectures/rounds
+  * Communicate daily events and follow up plans with team for floor patients
+  * Disposition planning for all vascular patients – shared duty with NP
+  * Hold vascular pager – shared duty with R2/NP
+  * Attend clinic as directed by fellow (GOAL: 2-3 days/week)
+  * Scrub on surgical cases (3rd tier and double scrubbed) (GOAL: 1-2 days/week)
+  * Preoperative orders and consents on patients when assigned cases
+  * Postoperative orders on all cases when scrubbed
+  * Weekend rounding – shared duty with R2
+**BASIC DUTIES of the R2**
+  * Work up and medical management of all admitted ICU patients (including floor status patients)
+  * Communicate all plans with the respective ICU teams by 7:00 am daily
+  * Preoperative orders and consents on all patients
+  * Vascular consults – shared duty with R1/NP
+  * Attend all vascular conferences/lectures/rounds
+  * Communicate daily events and follow up plans with team for ICU patients
+  * Hold vascular pager – shared duty with R1/NP
+  * Attend clinic as directed by fellow (GOAL: 1-2 days/week)
+  * Scrub on surgical cases (3rd tier and double scrubbed) (GOAL: 2-3 days/week)
+  * Postoperative orders on all cases when scrubbed
+  * Case presentations and didactics as assigned by fellow for Monday meeting
+  * Weekend rounding – shared duty with R1
+**BASIC DUTIES of the R4**
+  * The R4 is expected to act as if they are running the service with or without the fellow; role of the fellow is   to be more of a junior attending than service chief
+  * Direct AM vascular rounds with team – shared duty with fellow
+  * Discuss all medical/ surgical plans with attendings – shared duty with fellow
+  * Available to communicate with ICU teams as needed for issues – shared duty with fellow
+  * Postoperative orders on ICU cases – shared duty with ICU team
+  * Sign out in person to ICU practitioner for any ICU status postoperative patient
+  * See and staff vascular consults with attending – shared duty with fellow
+  * Attend clinic as directed by fellow (GOAL: 0.5-1 day/week)
+  * Scrub on surgical cases (1st/2nd tier and double scrubbed) (GOAL: 4-5 days/week)
+  * Take senior call – shared duty with fellow
+  * Attend all vascular conferences/lectures/rounds
+  * Present appropriate cases at M&M
+  * Case presentations and didactics as assigned by fellow for Monday meeting
+**BASIC DUTIES of the VASCULAR FELLOW**
+  * Direct AM vascular rounds with team – shared duty with R4
+  * Discuss all medical/ surgical plans with attendings – shared duty with R4
+  * Available to communicate with ICU teams as needed for issues – shared duty with R4
+  * Postoperative orders on ICU cases – shared duty with ICU team
+  * Sign out in person to ICU practitioner for any ICU status postoperative patient
+  * See and staff vascular consults with attending – shared duty with R4
+  * Assign and scrub on surgical cases, direct junior residents as appropriate through 2nd/3rd tier cases
+  * Take senior call – shared duty with R4
+  * Coordinate presentations for M&M (biweekly)
+  * Attend all vascular conferences/lectures/rounds
+  * Assign and present weekly cases/didactics for Monday conference
+  * Preoperative chart review for operative schedule
+  * Compile and distribute weekly schedule for vascular service with duty assignments
+  * Call schedule for R4 and fellows
+**BASIC DUTIES of the NURSE PRACTITIONERS**
+  * Work up and medical management of all admitted floor patients – shared duty with R1
+  * Write all daily orders of floor patients – shared duty with R1
+  * Write all daily progress notes of floor patients – shared duty with R1
+  * Communicate with Vascular social worker and case manager, daily 8:30 am
+  * Interface plans with bedside nurse daily
+  * Responsible for discharge coordination of care including FMLA and other patient documentation
+  * Prepare for all weekend discharges
+  * Primary responsibility for discharge summaries during week
+  * Arrange appropriate follow up appointments and vascular testing
+  * Available for rounds with attendings mid-day and PRN
+  * Hold vascular pager – shared duty with R1/R2
+  * Vascular consults – shared with R1/R2
+  * Attend clinic as needed (GOAL: 1-2 days/week)
+  * Tuesday PM – operative schedule review with patient communication as appropriate
+  * Attend all vascular conferences/lectures/rounds
+**GENERAL RULES OF ENGAGEMENT**
+  * All cases should be double scrubbed if team members available
+  * All plans must be communicated to attendings by R4/fellow and referred back to the team by 7:30 am, prior to first scrubbed cases
+  * All ICU plans should be communicated by R2 (or in their absence R4/fellow) to ICU team member by 7:30 am, prior to first scrubbed cases
+  * ANY EMERGENT OR URGENT QUESTIONS SHOULD BE COMMUNICATED IN PERSON (either via phone call or come to the OR if R4/fellow scrubbed)
+  * If unable to obtain a response from R4/fellow please communicate directly with attending to ensure timely response to consults
+  * Leave appropriate pager number for communications in all consult notes, H&Ps, and progress notes
+  * Primary contact for all floor questions is the vascular pager/R1
+  * Primary contact for all ICU questions is the R2 pager
+  * Primary contact for all dispo questions is the vascular pager/R1
+  * Pre-surgery order set should be completed the day before all operations
+  * Preoperative antibiosis
+  * NO heparin and NO SCDs usually; ask fellow or attending for exceptions
+  * Labs within 30 days for major cases
+  * Postoperative orders
+  * Utilize vascular order sets for patient orders
+  * Vascular Surgery Floor Postoperative Order Set
+  * Vascular Surgery ICU Postoperative Order Set
+  * Extended Stay PACU Carotid Endarterectomy Order Set
+  * Extended Stay PACU EVAR Order Set
+  * Clarify anticoagulation plan prior to leaving OR
+  * Clarify bedrest, pulse checks, etc. prior to leaving OR
+  * Clarify need for postoperative imaging prior to leaving OR
+  * Clarify all imaging/studies on patients prior to ordering
+  * “Vasc Dx” orders for any vascular lab studies
+  * All CTAs with 1 mm cuts – specified within order comments
+  * Generally NO PO CONTRAST unless specifically requested by R4/fellow or attending
+  * Consults should be staffed with a senior (R4/fellow) within 1 hour of receiving the call with communication back to consulting team
+  * All consults requested by our team should be followed up on within that day
+  * Every day, R1/R2/NP should communicate with social work and case management to identify disposition needs
+  * Clarify anticoagulation, clinic visit, and follow up imaging plans prior to D/C and include this information in patient’s D/C summary
+  * Discharge summaries should be completed within 24 hours of discharge, including the weekends
+  * Strive to make communication efficient in any group messaging thread in order to minimize “lost” or “missed” messages
+  * Communications that do not need to be shared with the entire team should be done separately
+  * Limit to important updates, not general “FYIs” throughout the day
+  * Questions that need urgent response are best posed in a directed fashion to the appropriate person
+  * All ICU cases must be signed out in person to the ICU team within 15 minutes of leaving the OR
+  * Daily PM rounds should be performed by the R1/R2/NP prior to leaving for the day
+  * If available, the R4 or fellow should attend
+  * If scrubbed, please report to the OR to discuss with the R4 or fellow
+  * Weekday notes should be assigned to surgical attending, while weekend notes should be assigned to on-call attending
+  * List should be constantly updated and include ACCURATE pulse/signal exam
+  * Days off/schedule changes should be requested 4 weeks in advance and be in accordance with CU surgical residency policies with appropriate approvals
+  * Signout should be given to the call team by Friday afternoon
+  * Method of signout (verbal, in-person, written email) is determined by preference of person on call receiving signout
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 Friday is breast conference. There are cases presented and pimped on. Know the studies sent out at the beginning of the rotation. Additionally you may be asked to present an article.
+**Basics:**
+Conferences:\\
+Monday-grand rounds\\
+Tuesday-MM\\
+Friday-GI conf at 645 and breast conference 730-9 (same room)\\
+For breast conference several attendings will be present. They may present cases and ask questions about management/next steps or have you present a paper. Knowing the papers sent out is helpful for this.\\
+Attending preferences:\\
+Ahrendt: Your role in cases will primary be to retract. In exchange, you also don't have much expectation in clinic. You'll go see patients and present to Ahrendt. She will almost always have the note prewritten. She prefers that you do not write a note if she already has. Know the studies that she sends out for her weeks and for her clinic have a plan for each of the patients based on literature.\\
+Kounalakis: The opposite. She lets you do most of the case and in exchange she wants you to do as much as possible in clinic. Specifically, she wants you to fill out the EPIC staging questions in the problem list. In your note, she wants you to include the stage and who referred the patient. For melanomas, she wants you to include the depth, ulceration, LVI, mitotic rate.\\
+Murphy: I only worked with her a couple times. She works almost exclusively at Lone Tree unless she is doing a combined case with plastics. Watch out for that as you make the schedule. She expects you to write notes in clinic. Lets you do progressively more in the OR\\
+Tevis: So far she has only had clinic. She wants you to write the notes. Bring a stethoscope as she expects a full exam.\\
+Serenity: On days when there is nothing else going on (Fridays) expect to go to her clinic. She does some benign breast and initial breast mass work-up.\\
+Other things:\\
+It's helpful for the 3 to write and send out a schedule, the attendings will read it.\\
+There is a post-op admit breast mastectomy order set. Just add valium.\\
+It's a pretty great and chill month. For the combo plastics cases, the breast DIEP flaps go to the plastics service. The tissue expanders go to the breast service. For their discharge, just touch base with plastics on whether they want antibiotics or not. They usually go home with valium for muscle relaxation as well.\\
 ==== UCH SICU ====
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 Must alert the intensivist as well as the pulm transplant attending and the thoracic fellow for all
 major issues including worsening shock, hypoxia, need for reintubation, bleeding, etc as above
+====  UCH STICU  ====
+Here is a very brief and candid rundown of the STICU. You show up every morning at 0600 and get sign out from the night person. Essentially you just claim whomever - the APPs will be there to tell you who you should take on the first day and then you can try to pick up the same patients on the days thereafter. The night person will present and write notes on all the new patients but you will "claim" them and take over their care once the night person has left. You get ~2 hours to prep your patients - which is usually more than enough time. The note template is ""Create in NoteWriter" and type "Progress" and then choose "ICU Progress (Systems) UCH IP".\\
+You will begin rounds at 0800 and usually the night person goes through all their patients first and then will break off to go write their notes and then the day team finishes rounding. In an average day the team will consistent of 1-2 residents, 2-3 APPs, and 1 fellow. There is a Gyn Onc fellow there right now as well and she essentially acts similar to the residents or APPs. Some mornings she isn't there because of other Gyn Onc obligations. In addition, you have your attending, pharmacy (usually Bonnie), and nutrition (Caitlyn).\\
+Presentations are you give a brief summary of the patient and state overnight events. Then nursing goes through their portion. Then you run the patient head to toe. Some attendings (i.e. Ferrigno) like you to list the pertinent vitals or labs. Some attendings want to know I&Os whereas others just want to know relevant outs (i.e. drains, tubes, urine). Usually the attendings will tell you ahead of time what they like, otherwise it's just learning by trial and error.\\
+You will get random admissions throughout the day. Usually they have a general idea of which patients will be coming to the unit and then of course there are any TACS patients that pop up that might need to come in. The APPs DO NOT admit after 0300. After rounds, you get work done - procedures, notes, consults, etc.\\
+At 0300 there is lecture most days. They are actually pretty useful and are usually given by the fellows or APPs. They last about 30 minutes and there is no pre-reading. Once a month there is grand rounds on a Thursday that is at noon. You do not have lecture that day.\\
+For night shift, you have to show up at 0300 and then usually go to lecture and then get sign out. If there is no lecture you still have to show up at 0300 and get sign out then. At night you'll occasionally be on with a fellow but not always. Most attendings want to be called or texted about admissions, starting someone on pressors, massive transfusion, or unstable patients in general. Otherwise you have some free reign to manage patients if you feel comfortable. The one exception is transplant patients.. as you know they are very particular so I would usually just default to calling them.\\
+TACS Tuesdays are always super fun :/. The TACS second year presents the patients to a giant team of lots of people of whom I know only half. It sucks for the second year on TACS because they usually aren't super privy to what's happening in the unit. But nice for you because you just write the note and don't have to present.\\