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--- medical_student:denver_health [2021/07/25 09:21] – jonathan
+++ medical_student:denver_health [2025/05/06 15:00] (current) – haley.d
@@ Line 4: / Line 4: @@
 [[resident:corrine_wong|Dr. Corrine Wong]]\\
 [[resident:stephanie_malliaris|Dr. Stephanie Malliaris]]\\
+[[resident: haley_desjardins | Dr. Haley Desjardins ]]\\
 ==== Contact Information ====
-Residents:\\
+PRS NP: Rosa DiPrima. 256-558-3028\\
-Senior Resident: Aline \\
+PRS Clinic RN: Aimee Harmon. 719-661-1555 (MESSAGE FOR FU)\\
-Junior Resident: Haley\\
-Intern: Mike Kirsch \\
-PA - Kendra Keene 316 250 5999\\
-RN - Nichole Fitzgerald 720 683 1770\\
 Attendings:\\
 Stephanie Malliaris: 617 970 7590\\
 Corrine Wong: 972 322 2078\\
+Haley Desjardins: 207 838 1957\\
+Surgery Schedulers:\\
+Ortho: Jacob Geesling\\
+Plastics: Christine Archuleta
+==== Haiku Setup ====
+{{ :medical_student:dh_haiku.pdf |}}\\
+{{:medical_student:initial_patient_activity.png?400|}}
+\\
 ==== Replant/Fellow Hand call ====
-There is a google calendar that is shared that has the schedule of fellow call. It is shared amongst the two ortho hand fellows and the senior plastic surgery resident. Add yourself to 4 weekdays and 1 full weekend for the month you are on. Can be any dates of your choosing (ie multiple weekdays in a week) but first come first serve as far as dates. You will only be called for operative interventions. For the weekdays this mostly means replants as other cases get pushed to the next day. For the weekends means replants, nerve repairs but can also mean mean pus/washouts. \\
+There is a google calendar that is shared that has the schedule of fellow call. It is shared amongst the two ortho hand fellows and the senior plastic surgery resident. Add yourself to 4 weekdays and 1 full weekend for the month you are on. Can be any dates of your choosing (ie multiple weekdays in a week) but first come first serve as far as dates. You will only be called for operative interventions. For the weekdays, this mostly means replants as other cases get pushed to the next day. For the weekends, means replants, nerve repairs,pus/washouts. All attendings take 1 week at a time starting at 5pm Friday\\
+\\
+All hand patients admitted while Malliaris or a PRS attending are on call get admitted to PRS team but are managed in ED by ortho hand team.\\
-Ipak typically takes Mondays/Wed \\
-Malliaris typically takes Tuesdays. \\
-Lauder takes Thursdays\\
-Iorio takes an intermittent weekend. If he is on and has a replant discuss with Malliaris and Ortho team about who will take them following the weekend\\
 \\
-{{url>>https://calendar.google.com/calendar/embed?src=dcj4rv5tr4ng8vdhk8ssrv7o7o%40group.calendar.google.com&ctz=America%2FDenver}}
+{{url>https://calendar.google.com/calendar/embed?src=dcj4rv5tr4ng8vdhk8ssrv7o7o%40group.calendar.google.com&ctz=America%2FDenver,800,600,noborder}}
@@ Line 39: / Line 46: @@
 This is a relatively relaxed rotation. We want the interns to be engaged and see each type of surgery we perform including hand surgery. This is a center of excellence for transgender surgery and female to male and male to female top surgery is common. Please be respectful and use appropriate pronouns (he/his, she/her, they, etc.). There will be multiple opportunities to practice suturing each week.\\
+\\
+There is a new outpatient urgent care that we have limited ability to go see the patient in person. Any time a plastic surgery patient is involved (ie. breast reconstruction where both gen surg and plastics are involved) the plastic surgery senior on call should be called.\\
+\\
+There is a crosscover intern at night. Sign-out is 6pm and then 6am the next day. Please ensure that the overnight intern has the on call Plastic Surgery Resident's phone number that can be found on this wiki. The night intern is also welcome to the wiki. If they do not have access, please have day PRS resident add night intern. It is the day intern's responsibility to make sure that the night intern has read the [[resident:nightfloat|nightfloat responsibilities]]. The ON CALL resident rotates and is the name on the calendar on the [[:start|start page]].\\
-There is a crosscover intern at night. Sign-out is 6pm and then 6am the next day. Please ensure that the overnight intern has the on call Plastic Surgery Resident's phone number. The night intern is welcome to the wiki. If they do not have access, please email Jonathan.Freedman@CUAnschutz.edu. It is the day intern's responsibility to make sure that the night intern has read the [[resident:nightfloat|nightfloat responsibilities]]. The ON CALL resident rotates and is the name on the calendar on the [[:start|start page]].\\
+Every day at 6am, you must log into the plastic surgery service team and plastic surgery consult team on Epic. If patient's get admitted during the day, you must unassign yourself, and re-assign yourself to the team for nurses to know who to contact. All consults come through Epic. If nurses message you with concerns, please try to address or discuss with a senior prior to adding senior resident or attending to Epic chat.\\
-The weekend is split between Urology and Plastics, so as the intern you will cover both of these services. Please let the weekend intern know who is on call and give them the appropriate phone numbers. Additionally, the plastics intern now covers the RGB patients after they have rounded. \\
 You are encouraged to update this wiki as needed. Please update your name and phone number above. Especially at the end of the rotation as you are signing out to the next intern, please take a few minutes and update the wiki and make sure the next intern has access. You will be asked for feedback on the wiki one week before the end of the rotation -- this will improve your fellow intern's experience.\\
 Intern tips\\
-- Almost daily needed wound dressings: xeroform, bacitracin/vaseline, kerlex, ABD pads, ACE wraps, scissors, tape. Get more than you need.\\
 - Take MACRO pictures. Include the whole leg and the foot. Square your pictures with the chest and include both shoulders, breasts, etc... If you are taking pictures in the operating room, make sure to ask what structures are exposed (ie tendons, vessels, bone).\\
 - For I&Ds: 500ml bottles of NS, I&D kit, TUMI syringe, suction, ABD pad, sterile gloves, 1% lidocaine w/ or w/o epi, acute pain meds for patient (50mcg fentanyl)\\
@@ Line 53: / Line 61: @@
 -- for all patients (primary and consults), should include vitals (ranges with and pertinent Tmax, desats, etc), I/Os with special attention to WV and drain output (note the last 24 hr output), and any relevant labs (CBC, BMP, cx, path, etc).\\
 -- for PRIMARY patients: as above with system-based plan/to-do.\\
-- Get notes done early so you can go to the OR. After preoping patient (mark and consent) establish yourself in the OR (work on notes, make calls, etc) and throw your gloves to the scrub tech.\\
+- Get notes done early, so you can go to the OR. After preoping patient (update H&P, mark and consent), establish yourself in the OR (work on notes, make calls, etc) and throw your gloves to the scrub tech.\\
 - Wound vac: do NOT put the black sponge over healthy skin - this can lead to maceration, and in some sick people, further damage to skin edges. Black sponge is hydrophobic; indicated for wound without tunnels, undermining, and/or exposed bone. White sponge is hydrophilic; indicated for wounds that tunnel, undermine, and/or are over exposed bone/tendon/muscle. \\
-- Scheduling follow-up clinic visits: for Plastics (and not hand) patients: send EPIC basket message to Nichole Fitzgerald, RN to schedule patients. Include patient name, MRN, and brief reason for appt.\\
+- Scheduling follow-up clinic visits: for Plastics (not hand) patients: send EPIC basket message to PRS Clinic RN named above to schedule patients. Include patient name, MRN, and brief reason for appt.\\
 Clinic tips:\\
@@ Line 79: / Line 87: @@
 ==== Rounds ====
-- The fellow on service at DG will round with the team (Kendra and intern and sometimes R2) on the plastic surgery service. The fellow will communicate with the primary attending regarding patient care.  On Mondays when the fellows are in conference, Kendra will run the team rounding responsibility\\
+- The residents on service at DG will round on the plastic surgery service. The senior resident will communicate with the primary attending regarding patient care. \\
+- Almost daily needed wound dressings: xeroform, bacitracin/vaseline, kerlex, ABD pads, ACE wraps, scissors, tape. Get more than you need. You can also ask the day before what kind of dressings to have ready on rounds\\
+-If there are rotating sub-I students, you can have them collect necessary supplies and prep consents for the day. Often the attendings will have the exact procedure and associated risks noted in their attestations on the clinic note. You also should feel free to confirm the consent with the senior.\\
 - Please ensure that the first case of the day has a new or interval H&P pended in the chart in order to expedite preop process.\\
-On the weekend if there is a primary plastics patient, this person will be rounded on by the intern covering plastics, who will then communicate with the fellow on call, who will round in reasonably time (usually after CHC and The U)\\
+-The weekend is split between Urology and Plastics, so as the intern you will cover both of these services. Additionally, the plastics intern now covers the RGB patients after they have rounded. Please let the weekend intern know who is rounding and pass along the rounding resident's number. Please also signout any patients on the list to the XCV intern\\
+-The rounding resident will signout patients to on call PRS resident.\\
 ==== Cases / Clinic ====
-Monday: Dr. Wong Pav A, Dr. Malliaris Pav M
+Monday: Dr. Wong Pav A, Dr. Malliaris Clinic
 Tuesday: Dr. Wong Clinic, Dr. Malliaris Pav A
-Wednesday: Dr. Wong Pav M, Dr. Malliaris Hand Clinic
+Wednesday: Dr. Wong Pav L
-Thursday: Dr. Wong Clinic, Dr. Malliaris Pav M
+Thursday: Dr. Wong Clinic, Dr. Malliaris Pav L
-Friday: Dr. Malliaris Clinic, Add on cases
+Friday: Dr. Malliaris Clinic
-Dr. Wong has clinic on Tuesday AM and Thursday AM. Dr. Malliaris has Ortho Hand clinic on Wednesday all-day and general plastics on Thursday afternoon.\\
+Dr. Wong has clinic on Tuesday AM and Thursday AM. Dr. Malliaris has Ortho Hand clinic on Monday all-day and general plastics on Friday morning.\\
 When on plastics, check the board for attending cases.  For Hand cases with Malliaris, please communicate with the Hand Fellow and Ortho hand resident to make sure that Malliaris is covered appropriately.  \\
-If the fellow is assigned to OMFS or Ortho, that clinic and those cases are the priority.  If there is  no other cases for OMFS or Ortho, please check with the plastics team to see if they need help with the cases/clinic.  For the ORTHO month, Livermore is the boss, and you should focus on Hand, ie go to hand clinic and do hand cases with Livermore, Malliaris, and Ipatchki and Benegas if needed.  Again when doing hand, please be equitable with our Hand fellows and Ortho residents!,\\
+Discharge instructions can be found in most senior resident's smart phrase list, or under Kendra Keene where they all start ".DCXYC". Please place the appropriate discharge instruction and PACU discharge order set for outpatient cases.
-Discharge instructions can be found in Kendra Keene's smart phrase list. They all start ".DCXYC". Please place the appropriate discharge instruction and PACU discharge order set for outpatient cases.
 To make follow-up appointments: send a staff message in Epic to the scheduler and ask for a follow-up appointment in the time frame you'd like and include what surgery the patient had. Send to the following:
 -Hand patients: "DH PAV B ORTHO FRONT DESK" under pool (click the "to" button and then you will have the option to search a pool)
--Plastics patients: Nichole Fitzgerald, RN
+-Plastics patients: Aimee Harmon, RN
 Note for consents.\\
@@ Line 112: / Line 123: @@
 Risks include, but are not limited to, infection, scarring, pain, damage to surrounding structures, incomplete resolution of symptoms, need for further procedures, malunion, nonunion and hardware failure. \\
-For Dr. Wong's breast cases, please print out a frontal view of the patient pre-operative photo. Black and white is fine.\\
+For Dr. Wong's breast cases, please print out a frontal view of the patient pre-operative photo and patient's "wish photo". Black and white is fine.\\
 ==== CONSULTS ====
-- The plastics intern takes first call during the day for any plastics consults and occasional face call, but will notify the fellow ASAP.
+- The plastics intern takes first call during the day for any plastics consults. We do not see hand or face consults. \\
-- When called for a consult (ER or inpatient), the intern is responsible for 1) seeing the consult as soon as possible, and 2) presenting the patient to the fellow/attending on-call who may ultimately assume care of that patient.  \\
+- When called for a consult (ER or inpatient), the intern is responsible for 1) seeing the consult as soon as possible, and 2) presenting the patient to the midlevel resident on-call who may ultimately assume care of that patient. The resident will generally staff directly with the attending  \\
+- Dr. Wong covers all PRS consults unless Dr. Malliaris is on call for hand that week. When Dr. Malliaris is on hand call, she also covers PRS call.\\
- Please keep in close contact with attendings and Kendra, as cases will get added on.\\
 === Pressure Ulcers ===
-Pressure ulcers come in waves at DH. PMR wants to see patient before surgery at a pre-operative appointment. Physical therapy, occupational therapy and PMR should be consulted on day 1 regardless of activity restrictions.
-For any wound consult make sure you know nutritional status, if the wound is infected, reason for admission, overall prognosis of the patient, and an assessment of resources for wound care after surgery.
+MOST PRESSURE SORES ARE NON-OPERATIVE.\\
+Pressure ulcers come in waves at DH. PMR wants to see patient before surgery at a pre-operative appointment. Physical therapy, occupational therapy and PMR should be consulted on day 1 regardless of activity restrictions.\\
+For any wound consult, make sure you know nutritional status, if the wound is infected, reason for admission, overall prognosis of the patient, and an assessment of resources for wound care after surgery. Below can be copied into the PRS consult note for all pressure sores and contains all required criteria to be optimized prior to surgical intervention. \\
+Surgical closure of pressure sores has a high rate of failure. To maximizing the patient's chance for success, the following criteria must be met prior to consideration of soft tissue closure or reconstruction for chronic pressure ulcers: \\
+- Wound:\\
+The patient must have source control. Staged reconstruction can be considered for a clean wound after adequate debridement and antibiotic therapy optimization.\\
+Debridements should be performed by the patient's primary surgical service or by the general surgery service. \\
+If evaluation for osteomyelitis or bone biopsy is desired, the orthopedic service should be consulted. Often an MRI is necessary.\\
+The infectious disease service should be involved for antibiotic recommendations. \\
+The clean wound should be managed with a wound vac whenever possible until ready for soft tissue closure. There should be evidence of the ability to form healthy granulation tissue in the wound. If wound care recommendations are needed in the interim, please consult the wound care team.\\
+- Nutrition:\\
+Albumin > 3.0 gm/dl\\
+Prealbumin >16 mg/dl. \\
+In general, patients with osteomyelitis and inflammatory processes do not have a normal prealbumin (negative acute phase reactant). However, if they can show consistent elevation in prealbumin over 3 weeks, they can be considered candidates for reconstruction. A nutrition consult should be ordered if these goals are not being met.\\
+- Medical comorbidities: \\
+Medical comorbidities, such as diabetes, must be well controlled.\\
+Control of any spasms or release of fixed contractures that may impair flap mobilization should be obtained prior to soft tissue closure.\\
+A bowel regimen must be well established and urinary control must be obtained. If necessary, stool diversion must be arranged prior to soft tissue closure. \\
+- Postoperative disposition: \\
+Pressure relieving surfaces should be used during hospitalization and should be obtained for outpatient use prior to closure (e.g. mattress, wheelchair). \\
+Outpatient wound care, if needed, should be arranged.\\
+Medical management follow up and rehabilitation plan should be set up. \\
+Physical therapy, occupation therapy, and social work should be involved with the disposition process.\\
+Once these parameters have been met, the patient can follow up with Dr. *** in outpatient plastic surgery clinic for evaluation. \\
 ==== Replant Protocol ====
@@ Line 156: / Line 197: @@
   *If following pathway, typically discharge POD 4 or 5
+\\
+\\
+==== Discharge Summary ====
+Discharge summaries need to include a complete list of every diagnosis or medical issue that impacted your patient’s care during their hospitalization in the discharge summary. The discharge summary is the first documentation that coders review. If the diagnosis is not present in the DC summary, even though it was treated during the hospital course, payers use this discrepancy to deny payment.
+Ways to phrase things: Apparently there is  widespread use of the words “in the setting of” to possibly link conditions together.  For coders to link conditions together, the physicians and APPs need to use linking verbiage like “due to”, “secondary to”, or “with”.  Do not use “iso” or “in the setting of”.