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--- medical_student:university_intern_guide [2019/11/07 19:05] – [Detailed Daily Flow] melissa
+++ medical_student:university_intern_guide [2023/06/13 19:22] (current) – taylor
@@ Line 1: / Line 1: @@
 =====How to Rock Plastic Surgery - Intern Guide=====
+====INTERN PEARLS====
+{{ :medical_student:intern_pearls_1_.docx |}}
 ====General Daily Flow====
-  * Get sign-out from night intern on the 6th floor in middle computer flow area there is a room where they hang out; get morning list together prior to rounds
+  * Prepare patient lists with pertinent vital signs, lab values, I's & O's, and imaging/culture results.
-  * Typically after rounds you’ll take care of floor stuff which includes vacuum changes, updating teams on any changes to the plan, writing notes, etc. If there is an R2 on service they will be the consult resident and you’ll update them on any consults, but you still may need to see them. I typically went to the OR when I was done with all of my work unless you are assigned
+  * Sign-out starts anytime before 6AM and occurs on the 6th floor of AIP2 tower in the surgical resident workroom between the second and third nursing station. You are responsible for grabbing the plastic surgery floor pager. There may be instances where the hand team will ask that you grab the hand pager for them and place it in the plastic surgery call room. The hand team will inform you if that is the case
-  * If you are assigned to OR you need to be on time and they will expect you to have pre-op stuff complete for the patient
+  * Complete orders, consults, and notes after rounding. Update the senior resident with any pertinent news, updates, results throughout the day.
-  * There are Plastic PAs that are individual to the attending. They help with clinic but are also in the OR. The hand PA (Katherine) will help take hand consults if you tell her about them. As you get a consult just send a message to the hand resident with the extension that consulted you/give the consulting person the pager number of the resident on hand service.
+  * Usually you will be assigned to one or more surgical cases. If you have a first-start case (i.e. 7:30 start), ordering all pre-operative orders and consenting the patient is the priority before floor work
+  * If you are not assigned to any cases and have finished your floor work, you are encouraged to join ongoing cases
+  * Plastic surgery consults will go through the plastic surgery pager. See the patient and staff the patient with the mid-level resident. If the mid-level resident is unavailable, staff the consult with the senior/chief resident
+  * After all cases are completed, ensure a post op check is performed on patients being admitted to the hospital - this can be signed out to the night intern if the case finishes later in the afternoon
+  * Sign-out the pager to the night intern at 6PM on AIP2 6th floor
-====Schedule====
-Monday: HAND CALL\\
-AM Grand Rounds in big auditorium on 1st floor AIP\\
-:00PM Plastics conference (630am in summer) in 6th floor conf AIP\\
-Wednesday: HAND CALL\\
-Once per month Mathes conference at 6:30am (not required for interns)\\
-Friday: HAND CALL every other week (check schedule)\\
-:30 Hand conference\\
-Weekends: HAND CALL every other weekend\\
-Usually round/cross-cover on Saturday unless you change schedule. Let the fellow who is on that weekend know and ask when they want to round. Same deal for getting the list ready in the AM. If just rounding, once floor work is done you can sign out to the cross-cover intern. If cross-cover, good luck and you will be contacted by other services to get sign out from them throughout the morning/day.\\
 ====Detailed Daily Flow====
-  * Before rounds
-Print cover sheet: Go to plastics patient list, 1. print handoff and 2.  print current list\\
-Include Room, Name, Age, Attending, Handoff To do, Blank column for columns\\
-Get vitals:\\
-temp, HR, BP, RR, sats, on how much oxygen\\
-I/Os: total in (24hrs),\\
-In: PO/G tube in, \\
-Out: UOP, NG tubes, drains, ostomy\\
-Foley? Date placed\\
-Any recent labs\\
-Any new imaging\\
-Any culture results or pending\\
-Add abnormal/pertinent vitals, drain/WV/NGT outputs, and any new culture or imaging results to list cover page\\
-Copy list and handoff: Copy to 2 sided and make enough copies for everyone on the team\\
-Get sign out either right when you come in, or after you get numbers. Must get this before 6 am because this is when the night person leaves\\
-====Rounds====
+===Before rounds===
-Usually either meet at fresh flap room or do gravity rounds, fellow will usually send a message out in the morning or the night before  to let you know where to meet\\
+  * Print patient list: Go to plastics patient list,
-Before rounds start give them any patient updates that might be important to know before we start.\\
+  * Include Room, Name, Age, Attending, Handoff To do, Blank column for columns\\
-At each patient room give a brief synopsis of the patient SOAP\\
+  * Get vitals: temp, HR, BP, RR, sats, oxygen requirement\\
-After seeing each patient, clarify anything you don’t understand with the resident and fellow\\
+  * I/Os: total in (24hrs) - In: PO/G tube in, Out: UOP, NG tubes, drains, wound vac, ostomy - for drains have current and previous day outputs
-At the end of rounds we run the list. This means go through every patient on the list including the ones we did not see and clarify the plan\\
+  * Record ecent labs - BMP, CBC, Lytes, Culture Data\\
+  * Record new imaging findings\\
-====After rounds====
--Case management:  Cris Cloney 34075\\
--Social worker: Rob Albrecht 86639\\
-Case Management for plastics may page you to run the list and ask about patients that we are primary on as far as what are their dispo plans etc.\\
-Go to preop for your assigned case with the resident assigned to your case\\
-update h&p, mark pt (initial and date), make sure has consent \\
- If no consent available, you should consent them for their procedure\\
-look at the chart the night before, understand the procedure they are getting and be prepared to consent them in the morning. If you are unsure what procedure they are getting, look at the last office visit note in which the attending/PA usually lists the OR plan. You can also look at what surgery the patient was scheduled for by checking out the surgical encounter under the encounters tab.\\
-====Consent====
+Get sign out either right when you come in, or after you get numbers. You must get this before 6 am because this is when the night person leaves\\
-Procedure: xyz + possible xyz... + all other indicated procedures\\
-Benefits: improved condition of xyz or reduction of xyz\\
-Risks: pain, bleeding, infection, need for future surgeries, flap failure (if it’s a flap), damage to nearby structures, scarring\\
-Alternatives/Not undergoing procedure: Continued condition of xyz, worsening of condition of xyz\\
-If you time after preop and before case starts, the following are options:\\
-Team breakfast\\
-Drop orders\\
-Write notes - Hint: Try and get Dr. Kaoutzanis’ notes done first.\\
-Page primary teams for some patients\\
-Go to assigned OR\\
-Leave pager with circulator in the OR so she/he can answer your pages as they come in - ask them politely to return pages as they come in, especially if it’s the consult pager.\\
-====After OR====
-After the case do post-op orders\\
-Put in a brief op note - look in PACU discharge tab\\
-Ask the attending what they would like as far as patient orders for home or on admission\\
-Pain meds, abx, DVT ppx, dressings, special restrictions, IP consults\\
-Follow-up needs\\
-Place orders\\
-Post op admissions:\\
-Med reconciliation (where you continue orders that were previously held or home medications).\\
-Don’t put the patients on antihypertensives immediately post op, check with resident when in doubt\\
-DIEP orderset\\
-UCH IV PCA orderset\\
-UCH Gen surg post-op orderset\\
-Discharge\\
-PACU discharge orderset\\
-Discharge instructions\\
-Steal smartphrases to use in discharge instructions\\
-Peggy Walsh has a lot of Chong's\\
-Sara Douglass has a lot of Mathes'\\
-Sometimes you can mix and match if one attending doesn't have a specific one, but make sure to change the name in the instructions\\
-Send meds to Atrium\\
-Sign for narcotics in the PACU by selecting print on the order and picking up the paper script at the PACU Rx printer and put in chart or send to atrium pharmacy (tube to 514)\\
-Pre-op your next case, check-in with resident and fellow\\
-Do any unfinished floor work  including finishing notes\\
-====Consults====
+===Rounds===
-If you get a consult you should let the consult resident know immediately and go and see the consult as soon as you can. The senior resident will either meet you at the consult or ask you to take pictures and send it to him
+  * Chief/senior resident will text team night before regarding start time and will text team morning of regarding where to meet
-Take pictures of consults and show the pics to the fellow even if they are scrubbed in
+  * Rounds are usually casual, very brief SOAP presentation with updates, overnight events, pertinent results, plans/to-do's for the day
-Cases can be in either AOP or AIP, so look to see where the pt is and go preop them\\
+  * Bring appropriate wound care supplies on rounds - RECOMMEND gathering basic supplies in your bag (kerlix, 4x4 boats, xeroform, bacitracin packets, shears, ACE wrap, tape, wound vac dressing)
+  * Dressing changes will be done in the mornings unless otherwise stated. RECOMMEND taking pictures of the wound in Haiku and on your phone. Send photos to senior resident
+  * Run the list after rounds
-====Discharges====
+===After rounds===
-For complicated patients, call to schedule an appointment (Nicole for plastics 82211, or Kaylie for hand 83372). Otherwise, make sure to put the phone numbers in their discharge instructions and type out that they need to call to schedule a follow up for in 7-10 days.\\
+  * Place orders and call consults first. Then replenish electrolytes as needed.
-You can “T-up” discharges (Get them ready because you know they will be leaving soon)\\
+  * Call Case Management at x34075 for phone rounds. Case manager usually answers their phone after 8:30AM.
-Use discharge tab, and go through reconciliation. Restart home meds as appropriate, and d/c inpatient meds.
+  * Write daily progress notes for all patients that were rounded on
-Prescribe any pain meds or abx that may be needed (Make sure you go to the Rx printer closest to the patient to sign narcotic scripts then either put in chart or send to atrium pharmacy (tube station 514)\\
+  * REMEMBER to see patients with free flaps at least twice per day and perform a flap check when they are within the 48 hour window post-op - write a flap check note after each flap check
-Surgeries involving muscles (eg flaps, tissue expanders) should go home with oxy and valium; TEs also go with antibiotics and surgical bra (Nurse may have to call central supply to get a second bra for the patient if this is needed)\\
+  * REMEMBER if you are assigned to a first-start case, prioritize preparing for the case: place pre-operative orders, consent and mark the patient, place discharge or post-operative orders, electronically sign prescriptions or have attending/PA sign prescriptions
-Flaps should go with a 30 day script for baby aspirin, 2 weeks lovenox, oxy, valium, abdominal binder
+  * Most attendings at the University have a dedicated PA who will often assist with pre-op orders, consents and scripts. Double check these are complete before starting floor work
-Click on the discharge order set and fill in, return precautions, clinic number, follow-up information (use dot phrases for some of this)\\
-It will automatically pull up a "discharge pt" order that you can remove under summary\\
-Sign these orders, make sure narcotics and/or all the scripts are "print" when you put them in. You can change this within the order. Some pts like to take their scripts to other pharmacies and you can only send them to the Atrium pharmacy. Have fellow sign scripts in the morning. When clicking "sign" it will prompt you with a screen that shows the attending's name under medication prescription, you can change this to the fellow's name, and that way they can sign it with their DEA number. **Scripts print to where the pt is (eg if on the 7th floor, will print to main 7th floor nursing station script printer, if they are in PACU it will go to PACU)\\
-On actual day of discharge, you will only need to put in a "discharge pt" order and a "discontinue IV" order\\
-====Follow-up====
+===After OR===
-In basket message to “P Plastic Surg Nurse/MA” include patient name and MRN in patient line. Write “Please schedule patient for follow-up in xyz weeks (or for a specific date if known)”\\
+  * After the case do post-op orders - pain meds, antibiotics, bowel regimen, nausea prophylaxis, DVT prophylaxis, wound care orders, weight bearing status, morning labs, inpatient consults.
-Pts usually follow up in 7-10 days from discharge. \\
+  * Pro-tip - complete discharge orders for outpatient surgeries prior to starting case
+  * Send outpatient prescriptions to AOP Pharmacy
+  * Complete a brief op note - look in PACU discharge or Post-Op admit tabs
+  * If the patient is a breast reconstruction with DIEP flap, refer to the DIEP protocol on the Wiki Page. This has day to day orders and milestones for patients
+  * If in doubt regarding any orders, please check with the senior resident/attending to clarify
+  * Add appropriate discharge instructions if outpatient surgery. Each attending has specific smart phrases for various common surgeries they perform. Steal their smart phrases accordingly. Can also ask senior residents for their smart phrases.
+  * Complete unfinished floor work in between cases. This service can be busy so figure out the workflow that works best for you
-Clinic 720-848-0800, Nurse line 720-848-0007. Hand clinic 720-848-0485\\
-Can start discharge summary at any point, and share it. Make sure to have one signed within 24 hours of discharge.\\
-====End of day====
+===Consults===
-Update the handoff based on new information or changes throughout the day. Include plans for the following day/week if applicable ie. change wound vac tomorrow\\
+  * If you get a consult you should let the consult resident know immediately and go and see the consult as soon as you can. The senior resident will either meet you at the consult or ask you to take pictures and send it to them
-Find your fellow (they may be in the OR) and either run the list (can do this while they are scrubbed in)/round on patients, ask what else is going on, update them on what you have done and what is going on on the floor\\
+  * Take pictures of consults and show the pics to the fellow even if they are scrubbed in. Residents are always willing to help with consults even if they are scrubbed in
-Sign out is at 6 PM, there may be a line so it may take some time; try to be the first one there to sign out, otherwise you will have to wait until other teams (with longer list) are done signing out\\
+  * Occasionally, other services will consult you for intraoperative evaluation of wounds. If possible, leave your pager number in the OR that the consult will take place in. Be ready to take pictures of the wound and send the pictures to the senior resident
-Tell night person a brief one liner and what you guys are doing for them. Assume they do not know the person because they carry 6-9 pagers on any given night.\\
-Make sure to let them know if they need to do a postop check (eg pt just got out of the OR/still in the OR/in PACU)\\
-Make sure to let them know if there is anything to follow up and if they should talk to someone about results: eg labs, urine output, a void if a foley was pulled...\\
-Let them know which resident and  fellow is on call for that night. Put their names, pager and cell phone numbers at the top of the list.\\
-Miscellaneous things:\\
-Chong and Mathes flaps get advanced to NO caffeine diets.\\
-All flaps should be on a baby aspirin.\\
-Gordon has his own hand discharge instructions under the discharge tab. If you search for instructions (not smartphrases), just look for Gordon and his postop instructions will come up.\\
-Steal all the smartphrases! They are your best friend\\
-ALWAYS put in specific wound care orders if needed, either in a nursing communication or in a wound care order. Be very specific, otherwise you will get paged a bunch and it won't be done right. Specific to the point where you tell them "use a 4 inch ACE wrap", etc.\\
-If you are confused, or not certain about a pt and their discharge, ask your resident, fellow or the APPs on the service. They are the ones mostly see the pts in follow ups at clinic, so they can tell you what they are looking for or what the pt needs to be sent home with specifically.\\
-White surgery/Breast is primary on mastectomy/tissue expander combo cases\\
-On the list, write who is the primary team\\
+===Discharges===
-Numbers – (or 84845# universal code)\\
+  * Ensure patient has appropriate prescriptions and wound care orders prior to discharge. This includes home health if required for wound vac changes or dressing changes.
-             * Sixth floor nutrition room: 6060#
+  * For specific orders, check with the Wiki page first for various types of cases. If you have additional questions, ask your senior resident about discharge orders (i.e. antibiotics, pain medications, muscle relaxants, DVT prophylaxis, aspirin etc.)
-             * Ninth floor supply room: 9191#
+  * Pro Tip: you are able to electronically sign for narcotics prescribed to the university by changing the provider for medications to yourself. Ask a senior resident or another intern to show you how to do this
-             * Tenth floor supply room: 0180
+  * Add appropriate discharge instructions to the patient's After Visit Summary
-Teaching Topics for Students -- Flap checks, wound vac principles and how to change them, deep dermal and running subQ sutures (these are what you will do mostly in the OR).\\
+  * Verify the patient has a follow-up appointment with their surgeon. If they do not have an appointment in their future encounters, message the plastic surgery clinic scheduler - send message to "P SP AMC Plastic Surg" and "P Plastic Surg Nurse/MA." Include patient's MRN, the surgeon/PA's name, and the approximate date of follow up
+  * As a default, most patients will have follow up in plastic surgery clinic within 7 days of discharge
-====Hand Call====
+  * Clinic number is 720-848-0800. Hand Clinic is 720-848-0485. Nurse Line is 720-848-0007
-History: For all pt's list their name, handedness and what they do (i.e. is fine dexterity extremely important to them, concert pianist vs receptionist). Note if the fracture is open or closed and make sure to do a neurovascular exam.\\
+  * Create a discharge summary for each discharge - this needs to be completed and signed within 24 hours of discharge
-Distal radius fractures: Inject 10cc lidocaine into the fracture (area of swelling and pain) site and hang pt's arm with finger traps. This will reduce the tension on the muscles and allow the fracture to be reset.\\
+===End of day===
+  * Update the handoff throughout the day based on new information or changes throughout the day. Include plans for the following day/week if applicable (e.g. change wound vac tomorrow)\\
+  * Run the list with the senior resident at least once prior to the end of the day. You are encouraged to run the list even while they are scrubbed in a case
+  * Tell night person a brief one liner and what you guys are doing for them. Assume they do not know the person because they carry 6-9 pagers on any given night.\\
+  * If a patient is being operated on during sign out, make sure to sign-out to the night intern to perform a postop check after the patient leaves PACU\\
+  * Let them know which resident is on call for that night and if they will be on hand call. Put their names, pager and cell phone numbers at the top of the list. The resident on call is listed on the wiki front page in the calendar\\
+===Weekend===
+  * You will often round on the day you are cross-covering other general surgery services. You are responsible for rounding on plastic surgery patients, writing notes, updating orders and plans, and performing routine floor work. In addition you will get signout about other services' patients and carry the pager until 6PM
+  * On weekends you are not assigned to cross-cover, coordinate with your senior resident regarding which weekend day you will round. After completing all floor work, you can sign out the pager to the cross cover resident
+===Tips and Tricks===
+  * Refer to the wiki for [[medical_student:diep_post-op_protocol|DIEP flap protocols]]. There is a specific sequence of orders and milestones for each post operative day that is to be followed
+  * Do not hesitate to ask the senior residents for help. This is especially so when you have a question about a flap during a flap check. If you notice any changes to the flap it is better to report it to the senior resident and ask if it needs to be addressed. Flaps are tenuous reconstructions that require attention and interventions are sometimes necessary
+  * Steal all the smartphrases! They are your best friend\\
+  * ALWAYS put in specific wound care orders if needed, either in a nursing communication or in a wound care order. Be very specific it won't be done right.
+  * Refer to the wiki first for any questions. It has many resources including operative reports for different attendings' preferences for different surgeries\\
+Numbers – (or 84845# universal code)\\
+Sixth floor nutrition room: 6060#\\
+Ninth floor supply room: 9191#\\
+Tenth floor supply room: 0180 (of note, the master code doesn't work on this door)\\
+Teaching Topics for Students -- Flap checks, wound vac principles and how to change them, deep dermal and running subQ sutures (these are what you will do mostly in the OR).\\