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--- medical_student:university_intern_guide [2021/01/05 19:58] – elliot
+++ medical_student:university_intern_guide [2023/06/13 19:22] (current) – taylor
@@ Line 1: / Line 1: @@
-====How to Rock Plastic Surgery - Intern Guide====
+=====How to Rock Plastic Surgery - Intern Guide=====
-General Daily Flow\\
+====INTERN PEARLS====
+{{ :medical_student:intern_pearls_1_.docx |}}
+====General Daily Flow====
   * Prepare patient lists with pertinent vital signs, lab values, I's & O's, and imaging/culture results.
   * 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
@@ Line 12: / Line 15: @@
-Detailed Daily Flow\\
+====Detailed Daily Flow====
-Before rounds\\
+===Before rounds===
   * Print patient list: Go to plastics patient list,
   * Include Room, Name, Age, Attending, Handoff To do, Blank column for columns\\
   * Get vitals: temp, HR, BP, RR, sats, oxygen requirement\\
   * 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
-  * Any recent labs - BMP, CBC, Lytes, Culture Data\\
+  * Record ecent labs - BMP, CBC, Lytes, Culture Data\\
-  * Any new imaging\\
+  * Record new imaging findings\\
-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\\
+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\\
-***Rounds\\
+===Rounds===
   * Chief/senior resident will text team night before regarding start time and will text team morning of regarding where to meet
   * Rounds are usually casual, very brief SOAP presentation with updates, overnight events, pertinent results, plans/to-do's for the day
   * 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. REMEMBER to take pictures of the wound in Haiku and on your phone. Send photos to senior resident
+  * 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
-Before rounds start give them any patient updates that might be important to know before we start.\\
-At each patient room give a brief synopsis of the patient SOAP\\
-After seeing each patient, clarify anything you don’t understand with the resident and fellow\\
-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\\
-  - After rounds\\
+===After rounds===
--Case management:  Cris Cloney 34075\\
+  * Place orders and call consults first. Then replenish electrolytes as needed.
--Social worker: Rob Albrecht 86639\\
+  * Call Case Management at x34075 for phone rounds. Case manager usually answers their phone after 8:30AM.
-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.\\
+  * Write daily progress notes for all patients that were rounded on
-Go to preop for your assigned case with the resident assigned to your case\\
+  * 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
-update h&p, mark pt (initial and date), make sure has consent \\
+  * 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
- If no consent available, you should consent them for their procedure\\
+  * 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
-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:\\
-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 OR===
-After the case do post-op orders\\
+  * 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.
-Put in a brief op note - look in PACU discharge tab\\
+  * Pro-tip - complete discharge orders for outpatient surgeries prior to starting case
-Ask the attending what they would like as far as patient orders for home or on admission\\
+  * Send outpatient prescriptions to AOP Pharmacy
-Pain meds, abx, DVT ppx, dressings, special restrictions, IP consults\\
+  * Complete a brief op note - look in PACU discharge or Post-Op admit tabs
-Follow-up needs\\
+  * 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
-Place orders\\
+  * If in doubt regarding any orders, please check with the senior resident/attending to clarify
-Post op admissions:\\
+  * 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.
-Med reconciliation (where you continue orders that were previously held or home medications).\\
+  * Complete unfinished floor work in between cases. This service can be busy so figure out the workflow that works best for you
-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:\\
-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
-Take pictures of consults and show the pics to the fellow even if they are scrubbed in
-Cases can be in either AOP or AIP, so look to see where the pt is and go preop them\\
-Discharges:\\
-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.\\
-You can “T-up” discharges (Get them ready because you know they will be leaving soon)\\
-Use discharge tab, and go through reconciliation. Restart home meds as appropriate, and d/c inpatient meds.
-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)\\
-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)\\
-Flaps should go with a 30 day script for baby aspirin, 2 weeks lovenox, oxy, valium, abdominal binder
-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:\\
+===Consults===
-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)”\\
+  * 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
-Pts usually follow up in 7-10 days from discharge. \\
+  * 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
+  * 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
-Clinic 720-848-0800, Nurse line 720-848-0007. Hand clinic 720-848-0485\\
+===Discharges===
-Can start discharge summary at any point, and share it. Make sure to have one signed within 24 hours of discharge.\\
+  * 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.
+  * 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.)
+  * 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
+  * Add appropriate discharge instructions to the patient's After Visit Summary
+  * 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
+  * Clinic number is 720-848-0800. Hand Clinic is 720-848-0485. Nurse Line is 720-848-0007
+  * Create a discharge summary for each discharge - this needs to be completed and signed within 24 hours of discharge
+===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\\
-End of day:\\
-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\\
-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\\
-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\\
-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\\
 Numbers – (or 84845# universal code)\\
 Sixth floor nutrition room: 6060#\\
@@ Line 130: / Line 96: @@
 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).\\
-Hand Call \\
-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.\\
-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.\\
-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.\\