Plastics

This page is read only. You can view the source, but not change it. Ask your administrator if you think this is wrong.
===== Denver Health =====

==== DH Gray Surgery ====

Attendings:\\
Dr. Clay Burlew - 303 332 8194\\
Dr. Alex Morton - 406 212 6501\\
Dr. Fred Pieracci - 303 968 0218\\
Dr. Eric Campion - ?\\
Dr. Gene Moore - ?\\

PAs:\\
Jake Krause - 305 915 0226\\
Juliana Hoppman (Bariatric) - 303 507 5653\\
Nepur ? - 347 685 6444\\
Stephanie ? - 970 402 1687\\

Team:\\
PGY5, PGY3, Intern shared between RGB services, Family Medicine Interns at times\\

Clinics:
Monday - Gray clinic all day (Mandatory)
Tuesday - Dr. Morton clinic with afternoon lumps and bumps removal (Optional) 
Thursday - PM Pieracci Thoracic Clinic (1 resident must cover)


A few tips/expectations of the Gray Team Attendings (From Dr. Burlew):\\
- The chief resident is expected to know all the patients, and round on them daily.
- The 4 attendings would like to hear about their patients each morning (i.e. please don’t wait until the afternoon, particularly if there are significant decisions/changes):\\
  * EEM – phone call after 7am\\
  * CCB – is in her office at 7am or phone call\\
  * EC – phone call after 7am\\
  * FMP- phone call after 7 am\\
- The admitting resident is expected to discuss all patients with the attending. \\
- Elective surgery patients should be seen in pre-op prior to 7am; the consent form should be co-signed by the operating resident indicating they have discussed the case including R/B/A with the patient.  This holds true on Wednesday mornings when the resident is expected to attend Muffins & Meditation conference with Dr. Platnick – the H&P should be updated and the consent on the chart before you leave for conference.  You may elect to stay and do the case if it is a chief level case rather than go to conference.\\
- The attendings expect the operating resident for each case to discuss the patient, indication for operation, potential pitfalls and your operative plan for the case at least 48 hours prior to the case.  This is also an opportunity to review pertinent imaging.   The weekly email from chief resident with the Gray schedule is not a substitute for that conversation.
- The Gray team APPs are willing to take the pager if interns want to go to an OR case, and also for all morning educational conferences.\\
- For Gray clinic on Mondays:\\
  * All patients, even post-ops, should be discussed with the attending staffing clinic.
  * Interns should get their work done prior to coming to clinic.
  * Please remember professional attire: white coats over scrubs.  You do not need to dress up for Monday Gray clinic.
  * Perhaps obvious, but please use your stethoscope for the daily physical exam of your patients.  Your exam, particularly for patients who have not undergone surgery, should contain 8-10 exam findings.

For progress notes, please list the diagnosis and then follow it with the assessment and plan.  Important for everyone to get used to this method – both for good documentation as well as billing. This should include all medical problems as well (COPD, HTN, CAD, diabetes, etc). For example:\\
Issues under current management:\\
  * BCVI:  remains asymptomatic, continue ASA
  * R scalp hematoma:  stable, no acute issues, wound care prn
  * B pulmonary contusions:  supportive measures, still with intermittent oxygen requirements, pulm toilet
  * B small PTX:  not evident on CXR, cont to monitor 
  * B rib fx:  working on pain control - improved with epidural and now weaning, encourage IS, pulm toilet, mobilize pt
  * acute resp insufficiency:  due to rib fx; still remains primary issue, working on pulm toilet as noted above and will wean oxygen as tolerates.  Now able to IS over 1000 during the day - will continue to work on this to optimize.
  * HTN: better controlled now, will continue home beta-blocker and added lisinopril
  * Small volume anterior mediastinal hematoma:  no acute issues
  * Nutrition support:  tolerating diet, will continue
  * acute blood loss anemia:  stable Hb on last check, no signs of acute bleeding
  * hypokalemia:  resolved
  * R tib/fib fx:  s/p ORIF
  * R femur fx:  s/p IMN
  * R acetabular fx / posterior hip dislocation:  s/p ORIF
  * L anterior hip dislocation: reduced
  * Acute resp insuff – due to rib fx, overall improving, will encourage pulm toilet and wean oxygen

- The list of diagnoses should be kept current in the handoff in the medical history section – this can then be cut and paste into the d/c summary to ensure complete documentation.

**Bariatric surgery**
- All current bariatric information is on the bariatric surgery subsite of the Pulse. All current bariatric guidelines (i.e. admission, post-op, radiology, anesthesiology) are in PolicyStat.
- Dr. Pieracci is currently the only surgeon doing elective bariatric surgery at DH and is always the surgeon on call for bariatric consults during working hours (as long as he is in town/reachable/etc). The TACS attendings provide coverage after hours and weekends for emergent bariatric issues, though Dr. Pieracci can always be called for guidance even if he is not on call.  
- Elective bariatric cases are Tuesdays and Wednesdays.
- Bariatric clinic is Thursdays (new patients) and Friday (post op) mornings and staffed by Juliana, the RDs and the bariatric corrdinator. You are welcome but not required to attend
- All bariatric patients get routine UGI POD#1
- The usual post op course for bariatric patients is NPO the day of surgery, bariatric clears POD#1 (assuming the UGI is normal) and bariatric puree POD#2. The patients are typically discharged the afternoon of POD#2. Juliana usually takes care of all of this but she does actually go on vacation sometimes. 
- Have a low threshold to workup sustained tachycardia > 100 bpm after bariatric surgery. The test is CT with PO and IV contrast. There is a contrast protocol (on the pulse and in PolicyStat) that specifies the reduced volume of oral contrast and wait time for post bariatric patients. 
- The Gray team is the default admission service for a patients with a bariatric surgical problem. There is a bariatric admission protocol on PolicyStat that outlines when we are to be consulted on post bariatric patients, as well as their admission destination as a function of time from their index surgery.
- The Gray chief is expected to evaluate patients in the ED with bariatric surgical problems (regardless of who did their surgery and where it happened). The TACS midlevel or APP will direct these consults to the Gray chief. If the Gray chief is acutely busy (e.g., scrubbed in), then he/she should direct the TACS midlevel to the TACS chief to see the consult in a timely fashion. But, in all other cases, the Gray chief should evaluate the patient and staff it with Pieracci or, if Pieracci is out, the TACS attending on call. 

**Thoracic surgery**
- Thoracic surgery clinic is Thursday 1-3 and staffed by Dr. Pieracci. At least one resident from the Gray team, and preferably the chief, is expected to attend this clinic.
- Multidisciplinary chest conference is immediately prior to thoracic clinic from 12:30 – 1 PM on Thursday in the clinic. At least one Gray resident is expected to attend this conference. 
- Dr. Pieracci is currently the only surgeon doing EBUS so all EBUS consults are to be staffed by the Gray team and then presented to Dr. Pieracci. 
- All other thoracic consults (e.g., VATS decort, esophagus perforation, lobectomy ,etc) are to be seen by the TACS team and staffed by the TACS attending. If the TACS attending does not feel comfortable managing the case, Dr. Pieracci may assume care of the patient, in which case the patient will be transferred to Gray. 

- Don’t be surprised when Dr. Burlew edits the handoff for the Gray team – feel free to add but please don’t delete her additions.  
- The Hospital Course functionality is now available in the Discharge Navigator. 
  * It can contain the problem list of all diagnoses for your patients throughout their hospital course (at admit the TACS team will generate the beginning of the list) – by updating it in the navigator, this will autopopulate into the handoff as well as the d/c summary.
  * This should be used preferentially over the “problem list” provided in EPIC as it seems that list is not always accurate or reliable for a particular diagnosis.

==== DH Red Surgery ====

Hello, 
Welcome to Blue Surgery! Below is some important information and tips for this rotation. 
 
Contact information: 
Attendings:\\ 
Dr. Mitch Cohen, General Surgery, Director of Surgery\\
Dr. Barry Platnick, General Surgery, Director of Trauma Services\\
Dr. Charles Fox, Chief of Vascular Surgery\\
Dr. Kshama Jaiswal, Breast Surgery\\
APPs:\\
Nupur Sehdev, General Surgery PA (supporting Dr. Cohen and Dr. Platnick). Cell:  347-685-6444, Office: 2-1801\\ 
Steffanie Durkin, Vascular Surgery PA (supporting Dr. Fox). Cell: 970-402-1687, Office: 2-1862\\
Pam Crawford, Breast Surgery NP (supporting Dr. Jaiswal). Cell: 303-917-8712 Office: 2-1267\\

Nurses: 
Katie Stoekle, Vascular Surgery RN, ext: 2-7632\\
Brenda Colburn, General Surgery RN, ext: 2-5791\\
Kipenda Ritcherson, Vein clinic and Breast RN ext: 2-7592\\
 
OR scheduler:
Rachel Fryc, ext: 2-7588\\
Contact Rachel for OR scheduling for Dr. Cohen and Dr. Platnick. Contact Steffanie for OR scheduling for Dr. Fox.  That is for elective cases, for urgent cases that are to be done within the next 24 hours, call the OR bridge at 2-1061\\
 
Clinic Tips: 
-For clinic days, residents should dress professionally (No scrubs).\\
-Vascular clinic and Blue Surgery clinic are both on Tuesday, at the same time and in the same bullpen. All residents are to come to clinic on Tuesday, starting at 8:20am.\\ 
-There is an Epic Tipsheet that is also attached, please print this and bring to clinic to help you navigate how to write a note, complete an encounter, complete a pre-op, etc.\\ 
-Pre-op’s: See the Epic Tipsheet and/or ask Nupur/Steffanie to show you how to properly pre-op a patient. In addition, when you pre-op an open inguinal hernia repair for Dr. Platnick (only for Dr. Platnick), the patient will also need a pain catheter. When you are putting in the orders for pre-op, make sure to order “on-q-pump”\\
 
Inpatient Tips:
-At the end of each day, send an email with the day’s discharged patients who need follow up appts. Send this email to both of the nurses (Katie and Brenda) as well as cc Nupur and Steffanie. Please indicate their diagnosis and which clinic the patient is to be seen in. All of Dr. Fox’s patients are to be scheduled in “Vascular Clinic” (regardless of diagnosis). All of Dr. Platnick’s and Dr. Cohen’s patients are to be scheduled in “Blue Clinic”.\\ 
-Any inpatient who is admitted with rib fractures and/or pneumothorax will need to be discharged with a 2 week follow up appt in clinic (Blue or Vascular depending on the attending) and will also need a CXR on day of clinic appt. You must put in the order for’ Ambulatory CXR’ and instruct the patient to arrive 30 minutes early to their clinic appt in order to stop by Radiology for the CXR prior to their clinic appt. Make sure to write this on their discharge summary prior to patient leaving.\\
- CCMF patients (incarcerated patients): All CCMF patients need a doc to doc report with the provider at the inmate’s facility. Ask the CCMF nurse which jail they belong to and phone number and call to give signout to the jail provider. Make sure to indicate in their discharge summary when the patient needs to return for follow up in CCMF clinic.\\ 
- All wound vac and home health care orders need a signature by an attending. The social worker will usually ask the resident to sign and then they will track down the attending for a signature.\\
- Prescriptions or any other paperwork can be completed by and signed by the PA (Steffanie or Nupur depending on the attending)\\
-FMLA paperwork cannot be completed by residents at DH. Provide this to Steffanie or Nupur and they will take care of it.\\  
 
Weekly schedule: Below is a brief overview of what to expect each day of the week.
Everyday:\\
-Sign-out is at 6am everyday (including weekends) unless your team was on call the night before (ie; if a blue attending was on call). Whichever team was on call the night before must arrive for sign-out by 5:45am.\\ 
-Interns are expected to attend social work rounds on Mondays and Wednesdays from 8:45-9:15am\\

Monday:
Nupur is off on Mondays\\
Grand Rounds/Teaching Conference 7:00-8:00am. If you plan to attend this, Steffanie and/or Pam are available to hold the pager from 7:00-8:00am\\
Clinic: Monday morning is Vein clinic with Steffanie, 8:20am-11:40am. The intern is expected to report to clinic after morning rounds and social work rounds are done.\\ 
OR cases:  Dr. Jaiswal (Breast) has OR block time on Mondays. Dr. Platnick does not have block time on Mondays, but typically adds cases when time is available. You can expect OR cases with Dr. Platnick on most Mondays. The midlevel resident and chief resident are expected to cover these cases.\\  

Tuesday:
Clinic, 8:20am-4:00pm. This includes both Blue Surgery and Vascular Surgery. All residents are expected to come to clinic for the entire day. Attached is a tipsheet for clinic. Please review this and print it to bring to clinic with you.\\ 
(Interns do not need to prepare clinic notes for the team. Nupur and Steffanie will prepare a list of who is coming to clinic and why. This will be available in clinic on Tuesday and/or emailed out ahead of time.)\\ 
OR cases: None.\\
 
Wednesday: 
Steffanie is off on Wednesdays\\
Breakfast with Barry, 7:00-8:00am. Nupur will take the pager in order for residents to attend this conference. 
Interns must attend social work rounds from 8:45-9:15am.\\
Clinic: CCMF clinic (jail clinic). This is a rotating responsibility between all surgery teams, Nupur or the chief resident will let you know if you need to be present for CCMF.\\ 
Breast clinic, 8:00-5:00pm. The intern or midlevel resident is expected to attend breast clinic. Do not bring the floor pager to breast clinic, give this pager to a fellow Blue resident for the time you are in breast clinic. 
OR cases:  There is no official block time for Blue on Wednesdays, but occasionally cases will be added if time is available\\
 
Thursday:
M&M conference, 7:00-8:00am\\
Clinic: None\\
OR cases: Dr. Fox has OR block time in Pav A on Thursdays. You can expect a full OR day\\
 
Friday:
Pam is off on Fridays\\
Burlew Chapter Club, 7:30-8:30am (You can pick up the assigned reading near the surgery administrative offices on 3A. It is usually available for pick-up by Monday or Tuesday each week). Nupur is available to hold the pager during this conference\\
ICU attending/teaching rounds, 11:00am\\
Clinic: None\\
OR cases: Dr. Fox has OR block time in Pav M. You can expect a full OR day, this is usually vein cases. Steffanie will be there to assist the cases\\
 
Other Important numbers: 
303-602-7600  -Surgery clinic front desk number, this is the number to provide to patients\\
303-602-7609 -Surgery clinic front desk (back line), for you to call to schedule appts for patient follow up (do NOT give this number to patients)\\
303-436-4949 -Denver Health Appointment Center, for any scheduling needs. Please provide this number to patients who need to schedule other appts or get a new PCP.\\ 
 

I have also attached a sheet of helpful phone numbers and an Epic Tipsheet for clinic\\

**EPIC TIPSHEET – BLUE AND VASCULAR SURGERY CLINIC**

1. Seeing the patient:\\
-Patients are marked with a GREEN dot once they are roomed and ready to be seen by a provider. Their chart (stickers) will be placed in the clear rack by the door\\
-Turn the dot YELLOW when you grab the chart and go to see the patient\\
-RED if the patient is a pre-op in need of RN teaching\\
-BLUE if you need labs\\
-GREY if you are done with the patient and they have left.\\ 
-WHITE if you need the RN to schedule f/u appts, imaging, etc\\
-Review/update the “ROOMING” tab (visit info, hx, meds, allergies, etc)\\
-Review/update the “PLAN” tab (visit diagnosis, problem list, etc)\\

2. Create a Note\\
-For a regular progress note:\\
-Type “DH GEN VASC” in the small box that states “insert smart text” and this will pull up the vascular template options. You are welcome to use any other template options you are familiar with and would like to use\\
-For a Pre-op H&P:\\ 
-Type “DH SUR H&P” in the small box that states “insert smart text” to write a formal H&P. this should be done if the surgery is within 30 days\\ 

3. How to Pre-op a patient, Pre-op H&P, and enter the Case Request\\
-Obtain an OR date from Steffanie or Dr. Fox for vascular surgery patients and obtain an OR date from Rachel Fryc (OR scheduler) for Dr. Platnick or Dr. Cohen for general surgery patients.\\ 
-Obtain a consent for surgery (If the surgery date is within 30 days)\\
-In the “WRAP UP” section of the note, add the following information: OR date, Pavilion, Surgery to be done, Dispo and Pre-anesthesia needs\\
-Flag the patient with a RED dot and go find the RN to inform them of the pre-op\\
-Select the “PREP FOR CASE” tab on the left\\
    *if this tab is not present, select the “MORE” tab at the bottom left. Select “Quick Navigators” there is the “Prep for case” tab. Select the yellow star to the right of this tab to move it to your toolbar. 
-In the “Order Sets and Pathways” section, type “Sur Vascular” to bring up the vascular order set
**Make sure you check the yellow case request “Second Sign” box and add the attending who will sign the order*** This must be done for the case to properly be added to the OR schedule\\

4. Referrals\\
-To place a referral to any other service, select the “PLAN” tab on the left and in the “orders” section, type “Amb Referral to…” and indicate which specialty and reason for referral.\\ 
-if this is a referral to outside of Denver Health, open the referral order and change the “Class” from “internal referral” to “outgoing referral”\\

5. Write a Work Note\\
-Select the “COMMUNICATIONS” tab on the left\\
-Click “New Communication” and select your note type “work/school, release, etc”\\

6. To close/sign all encounters\\
-if no f/u is needed and the patient is ready to leave, print out the AVS and give to patient and tell them they may leave. Turn their dot GREY\\
-If f/u is needed, fill out the “Patient Instructions” under the “WRAP UP” tab, inform the nurse of the f/u needed and turn their dot WHITE\\

-To close the encounter:\\
-Under the “WRAP UP” tab, select “Need LOS” as their LOS charge\\
-In the far left bottom corner, hit the “sign encounter/visit” tab and assign the appropriate attending as the cosigner\\

==== DH TACS ====
Welcome to TACS! We are a busy trauma and emergency general surgery consult and inpatient service. Here are some tips to help guide assignments, documentation, orders, discharges, and follow ups. If you have any questions please do not hesitate to ask any of the APPs. 

Assignments and Sign Out\\
  * Day shift starts at 0600. At that time communicate with other team members to determine who is covering what. The basic TACS structure is –\\ 
- Trauma: one chief, one intern, one APP – intern and APP are to divide patients equally\\
- EGS : one chief, one intern, one PGY2/3 – intern and PGY2/3 are to divide patients equally\\
- EM intern available on Mon/Tues/Thurs - helps whichever team has more PCU/floor patients. Whichever team they help, all patients are divided equally.\\
- If there are two PGY2/3s – one each on trauma/EGS and all patients are divided equally. They are not to only see PCU patients.\\
- One APP on consults, EM intern takes consult pager at noon\\
- Weekend staffing – TACS typically functions as one large team. PGY2/3, surgery intern, EM intern (Sat AM), and one APP split all PCU/floor patients equally while taking continuity of care into consideration. EM intern signs patients out to surgery intern on Sat AM after rounding and writing notes. One APP holds consult pager.\\
-  TACS clinic on Friday is covered by GenSurg APPs but the team should help out between rounds.\\ 

  * Adjustments may need to be made daily to meet the needs of the team. Communication with your team members is key!\\ 
  * Between 0600-0700, round on patients, start progress notes, etc.\\ 
  * Morning sign out w/ Attendings 0700-0730 (except Mondays 0800). Tuesday – Friday sign out takes place in Nightingale/Osler in basement of Pav C. Saturday – Monday sign out is in Surgery conference room, 3rd floor Pav A\\
  *  Trauma service interdisciplinary floor rounds with Attending begin at 0900 on 4B. Please have COWS ready at first room on 4B.\\

Consults\\

  * All consults, including trauma consults, need a consult order placed by the requesting team. Consult orders must be linked to all consult notes.\\
  * Trauma Alerts and Activations do not need a consult order.\\
  * Medicine consults from the floor - if a medicine resident is requesting the consult, confirm with them that their attending has seen the patient that day and okayed the surgery consult. Obtain medicine attending name and contact number.\\ 

Documenting\\

  * Trauma Alerts and Activations should be documented as note type – H&P. Use “SUR TRAUMA H&P/CONSULT – DH IP” note\\
  * All other consults, including trauma consults, are documented as note type - CONSULT with a consult order linked to the note. Use “SUR CONSULT – DH IP” for these notes except for trauma consult, use the Trauma note as above.\\
  * Ensure the service you are documenting under is “Surgery”\\ 
  * Every note should include –\\
  - A complete HPI, including four modifiers of the patient’s pain.
  - A full PMH, PSH, Fam Hx, Social Hx. 
  - ROS needs 10 systems reviewed (DO NOT DOCUMENT “SEE HPI”)
  - If you are unable to obtain the above information due to patient condition, please note this as encephalopathy, patient intubated, etc. “Not on file” or “Not reviewed” should not be populated in the patient note. 
  - Physical Exam needs 8 systems
  - Problems/Injuries should be listed with an Assessment and Plan for each (example below). This should include all medical comorbidities/antecedent medical problems and the inpatient management. 
Left 4-9 rib fx – IS is currently 1000mL, SpO2 95% on 4L. Will admit SICU for aggressive pain control, consider epidural vs pain cath, pulmonary toilet\\
Grade 2 Splenic laceration – FAST+, Hgb 14, normotensive, nontachy, to IR for embolization, monitor q4 Hgb\\
CAD – will hold home ASA until repeat imaging for TBI demonstrates stable bleed\\
HTN – need to restart home Bblocker in the SICU\\
  - Incidental Findings are often found on imaging. Please document these findings in the A/P and note them in the “To Do” section of patient handoff w/ plan for follow up.
  - Be sure to review the attending/final Radiologist read for all CT scans.

Lists and Epic Handoffs\\

  * If a patient is being admitted to TACS or TACS will be following, the patient needs to be put on the appropriate TACS EGS or TACS Trauma list and handoff completed.\\ 
If the patient has a history with another team (i.e., post op complication of elective ventral hernia repair, or AV fistula complication), they go back to the appropriate team – Gray, Blue, Red. Bariatric patients are admitted to Gray.\\
  * Complete and update handoff daily on all patients admitted to, or being followed by, TACS.\\
  * In the MEDICAL HISTORY (top box) of the Handoff, every diagnosis the patient has carried since admission should be listed (i.e., grade 2 splenic lac, acute hypoxic respiratory failure, hypokalemia, encephalopathy), including resolved ones and chronic medical conditions.\\ 
  * For patient transferred from SICU, copy and past handoff from Surgical ICU to Surgery handoff\\


Orders\\
  * SICU admit – use “SICU admission”, “ICU Pain, Agitation & Delirium (PAD)” and “MINDS Alcohol Withdrawal” as appropriate\\
  * Floor admit – use “General Surgery Admission” and “SEWS EtOH Protocol” as appropriate. Only order low dose SEWS protocol (ativan) for TACS patients. DO NOT order high dose (phenobarbital). If a TACS patient is requiring higher dose they may need to be in the SICU\\
  * ED to OR – if patient is going directly to OR from ED, one of the operating residents will place orders post-op\\
  * Residents - If placing an OR Case Request, uncheck 2nd sign box\\

SICU Hand off –\\
  * The Chief or Midlevel resident should hand off patients that are being admitted to the SICU to the SICU resident/APP/fellow. Always confirm who is doing the handoff so patients do not show up in the SICU without hand off.\\
  * For patients that go from the ED to the OR to the ICU, there is a specific hand off process that should be done at the bedside in the ICU. The operating resident must accompany the patient to the SICU for this handoff between trauma team/anesthesia and the SICU resident/APP and nurses.\\ 

Transferring Patient to a Different Service –\\ 
  * If a patient is transferring to a different service, ie Neurosurgery or Ortho, TACS starts the discharge summary by listing all diagnoses under “Discharge Diagnoses” and a summary of patient’s hospital stay up until day of transfer. This ensures all diagnoses are captured at time of discharge.\\ 
  * When signing out to the team taking, please inform them of the existing Discharge Summary you have started and shared.\\

Discharges and Clinic Follow Up-\\ 
  * When completing the Discharge Summary, all diagnoses the patient carried during their inpatient stay must be listed under “Discharge Diagnoses”, including resolved ones and chronic medical problems. If the list in the Handoff has been updated, you should just be able to copy and paste.\\
For Incidental findings - \\
  - Email the admitting attending and appropriate general surgery APP
  - Ensure patient has PCP follow up (SW can help set up PCP if patient does not have one)
  - Tell the patient and family about their incidental finding and need to follow up with PCP
  - Provide a copy of the CT scan report with the finding to the patient with the finding highlighted
  - Document #3 and #4 in your daily progress note or in the discharge summary
  * Prior to discharge, determine if the patient will follow up in TACS clinic versus a general surgery clinic. In general, TACS clinic is a “one and done” clinic. If patient will require multiple follow up visits, they should be scheduled directly into a general surgery clinic. If a patient has undergone rib plating, they should follow up in Thoracic Clinic with a CXR ordered to be done prior to visit that day. Our goal is for patients and family to know their clinic follow up date and time prior to discharge. The steps below show you how to view available clinic dates and times.\\ 

Viewing TACS clinic schedule-\\
 
  - Click on Clinic Schedule icon

  - Select TACS Clinic and desired date

  - Click on Open Slots. This will show all open and booked appointments. 
  * A green box with a no. 1 is an open slot/appointment\\
  * A red box with a no. 0 is a booked slot/appointment\\

  - After picking a clinic appointment-\\
  * Once you have determined with the patient a date and time that works for follow up, send a staff message via Epic to “c tacs”  - include patient name, MRN, date/time of follow up, and why they are coming to clinic (i.e., s/p lap chole, needs sutures removed, wound check). Clinic staff will enter the appt and reply that the request has been completed.\\ 
Clinic staff will NOT be calling the patient to confirm appointment. Patient will receive a reminder call one day prior to appointment and can view appointment in MyChart if signed up.
  * CCMF patients - send to **Ccmf Op Front Desk**\\
  * Enter follow up date and time in the Discharge Orders and Summary. Ideally, request the appointment as soon as you know the patient will be discharging and need for follow up is identified. Once the appointment is scheduled, it will auto populate in the patient’s discharge paperwork.
  * If you are unable to confirm a date and time with the patient before they discharge (or you are unsure of what is available because it is the weekend), send the same information as above but request that the patient be called and an approximate time frame for them to follow up, i.e. 1-2 weeks. If two patients get scheduled at the same time, the clerks will attempt to reschedule the patients and call them. 
  * Please DO NOT place a Surgery Referral for follow up
  * If patients are following up in another general surgery clinic, message the appropriate APP and RN for that service (listed below) and they will schedule the appointment. This should be determined on attending rounds.
If the patient needs imaging or lab work prior to clinic, order those tests for the date you would like them done. 
  - Xrays and labs do not need an appointment as they are walk-ins 
  - CTs do need an appointment and clinic staff can help schedule those. Please note that in your Epic staff message regarding the request for appointment AND place an outpatient ambulatory order for CT (clinic staff cannot place the order)
  * If you have questions, please ask one of the APPs or clinic staff. Brenda Colborn is the TACS RN and Meghan Amiot is the surgery clinic charge RN (contact info below). 
  * Please remember, not every patient that is admitted to TACS needs to follow up in TACS clinic – some may only need Orthopedic or Neurosurgery clinic appointments. If you are not sure, please ask before requesting an appointment.\\
  
Conferences (Immediately after Morning Sign Out with Attendings, 0730)
Monday – Grand Rounds starts at 0700, sign out starts at 0800\\
Wednesday – Breakfast with Barry (a.k.a. Muffins and Meditation)\\
Thursday – M&M\\
Friday – Burlew Chapter Club. Chapters can be found in the Dept of Surgery, 3rd floor\\

General Surgery and TACS Information\\
-When requesting appts in General Surgery clinics (not TACS), please email both APP and Clinic Nurse

Teams and Attendings\\
Blue – Cohen, Platnick, Lawless, Coleman\\
Gray - Burlew, Moore, Campion, Pieracci, Morton\\
Red – Fox and Hoehn (Vascular), Jaiswal (Breast), Bensard/Kulungowski/Somme (Pediatric Surgery)\\

Clinic Contacts for Outpatient Follow-Up Appointments\\
TACS – Clinic on Fridays\\
EPIC message – C TACS Clinic w/ appt date and time (refer to TACS Tip Sheet for more information)\\
Brenda Colburn RN (x25791)\\

Gray –  Clinic on Mondays\\
Susan Jackson NP - Burlew, Moore\\
Jacob Krause PA - Campion, Morton\\
Juliana Hopman NP - Pieracci & Bariatric\\
Brenda Colborn RN (x25791)\\

Blue –  Clinic on Thursdays\\
Paula Gust PA - Lawless, Coleman\\
Nupur Sedhev PA - Cohen, Platnick\\
Brenda Colborn RN (x25791)\\

Thoracic - Clinic on Thursday afternoons\\
Julianna Hopman NP & Katie Stoeckle RN (x27632)\\

Vascular (Fox and Hoehn) – Steffanie Durkin PA, Katie Stoeckle RN (x27632)\\

Breast – Pam Crawford NP, Kipenda Ritcherson RN (x27592)\\

Pediatric Surgery – Susan Jackson NP, Jake Krause PA, Ann Turner, RN, Perla Butanda, clerk\\

CCMF – Epic message under Pools **CCMF OP Front Desk**\\

OR Scheduler – Jonathan Lebois (x27588)\\

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:\\

1)      Critical Care Didactic Lecture Series – 3pm on Monday, Tuesday, Wednesday, Friday\\

2)      Critical Care Grand Rounds – 12pm on 1st/3rd Thursday\\

3)      Ultrasound M&M Conference – 12pm on 2nd Thursday *free pizza\\

4)      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.\\




==== DH EGS ====

==== DH SICU ====

===== UCH =====

==== UCH Copper ====
{{ :intern:copy_of_cu_esophagectomy_pathway-2.xlsx |Copper Surgery Information and Bariatric Pathways}}

Attendings:\\
Paul Montero - 720 273 9481\\
Akshay Chauhan - 901 319 8649\\
Kevin Rothchild - 216 702 4245\\
Jonathan Schoen - ?\\

PAs:\\
Linda Fernekes - 706 726 6756\\

Important Contacts 
  - Copper 0440	
  - Gen Surg Clinic 303-724-2728
  - Bariatric Clinic 720-848-2070	
  - Fluoro Read 85969/85263
  - Fluoro Sched 81085
  - Bariatric Clinic 82070	 
  - Pharmacy: Main 8139, Atrium 84083, ED 88400, PAS 83150
  - Bariatric Dietician (Lisa) p6166	
  - Radiology 85343/93438/83434
  - SW/CM/PRL  83779/34527/83784	
  - OR Bridge 84351
  - PACU 86203
  - OR Charge 83597
  - OR Room: 307XX 
  - Montero  p0065
  - Schoen p0872
  - Rothchild p2517
  - Chauhan 901-319-8649, p1996

Pathways

General Rules
Diet: NPO → GBCLD → GBFLD\\
  * Diet: ‘GI Surgical’ in Epic → choose GBCLD/GBFLD\\
Meds
  * No NSAIDS\\
  * Some home meds can be restarted- do not typically restart anti-HTN, statins, antiglycemics, etc\\
  * NPO: order IV meds\\ 
  * Unordered List ItemGBCLD/GBFLD\\
  * Chauhan: pills okay\\
  * Occasionally meds need to be liquid if patient is having po intolerance, etc (case by case)\\
  * Rothchild/Schoen: liquid meds or crushed only\\
  * Sometimes pill is okay if it is small (smaller than peanut) and only formulary (effexor or other psychotropics, for example)\\
Precautions:\\
  * Patient tachy (>110), pain, fever, restless, anxious (call attending)\\

Roux-en-Y Gastric Bypass Pathway:

POD0: D5LR @150 if not diabetic, if diabetic LR @ 150, SQH TID 8hrs post op, protonix IV (pepcid IV BID or lansoprazole-dissolving tablet decent alternatives if PPI reserved for GI bleed), resistant ISS for DM pts, no CPAP/BiPAP x48h (Chauhan ok w/ CPAP/BiPAP in particular circumstances) 

POD#1 AM: Consider DC NGT, dc foley, decrease IVF decreased to 125, UGI?
If Patient is NPO with NGT post-op with scheduled UGI POD#1 am: NPO until UGI, if UGI negative → advance to sips/chips/GBCLD by afternoon
If patient is on GBCLD post op without POD#1 UGI: Continue GBCLD in am
  * Occasionally patients will be on GBCLD immediately post op but will still have UGI in am

POD#1 PM: advance to GBCLD or GBFLD, IVF @125, dc PCA (and/or dilaudid IV if no PCA) and start liquid Roxicodone and APAP (pills okay for Chauhan patients)

POD#2: bcivf, advance diet to GBFLD, oral analgesics, dc home if tol 200cc/shift 

Sleeve Gastrectomy Pathway:

Same as LRYGB except on POD#1: dc NGT then do UGI for both Schoen and Rothchild (calling fluoro helps get patients in faster in am)
  * if no leak → advance to CLD→ FLD + bciv, oral analgesics (apap/oxy- liquid for S/R, pills for AC)
  * d/c on FLD when tolerating 20cc/shift

Discharge
  - Make sure follow up appointments are made
  * Bari patients: 1 week and 3 week
  * Unordered List ItemGen surg: 2 week
  - AVS (depending on what patient has/needs at d/c): attach JP drain document (and make sure patient has drain teaching), Bariatric Full liquid diet document, Lovenox teaching doc (and make sure patient has teaching) 
  - Discharge Info
  * Meds: Apap/oxy, zofran, PPI (20 mg daily, 9 weeks)
  * Chauhan: pills okay
  * Schoen/Rothchild: liquid or crushed meds only (or cut to smaller than peanut if particular drug cannot be crushed and is not available as solution)
  * Meds: DVT prophylaxis
  * Schoen/Rothchild: BMI>50 and RYGB/Sleeve: Lovenox 2 weeks; BMI >50 with hx of PE/DVT: Lovenox 4 weeks
  * Chauhan: BMI >50 RYGB: Lovenox 3 weeks, BMI >45 Sleeve: Lovenox 3 weeks
  * Home meds:
  * Antihypertensives: do NOT restart unless inpatient SBPs >160,
  * Unordered List ItemAntiglycemics (metformin, insulin, etc): do not restart metformin, only restart insulin/other antiglycemics if glucose uncontrolled inpatient
  * Statins
  * Schoen: does not restart statin
  * Rothchild: restarts statin
•	Diet: Bariatric fulls, multivitamin

I have great smartphrase for basic d/c instructions: Madeline Thomas, starts with mtbari


==== UCH Burn ====
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

24 hour in-house call on Mondays

{{ :intern:burn_rotation_resident_orientation_ppt.pdf |}}

[[https://podcasts.apple.com/us/podcast/traumaburn/id1434771181?mt=2]]





 


==== 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         
6:30 – Core curriculum (Conference center)\\
7:00 – Grand rounds (Conference center)\\
8:00 – Aortic conference (Conference center)\\
  * Tuesday
Jacobs – clinic all day\\
4:00 – Vascular conference (AO1 5th floor conference room)\\
  * Wednesday
Wohlauer – OR\\ 
Nehler – clinic all day\\
  * Thursday
Jacobs – OR\\
Wohlauer – clinic all day\\
  * Friday
7:00 – 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




====  UCH TACS  ====
-As the two you handle all of the consults. A and B alternate taking call, A takes call on odd days, B on even

-Get pager and signout from overnight resident at 6am in the SICU

-Typically around noon a PA will come in for the swing shift. They will often take the pager and help finish up any remaining details. After this is a good time to attempt to make it to the OR

-If you are not on call you will cover clinic on Monday and wednesdays. Monday pm (6th floor surgery area) are uncomplicated post-op patients (appy, gallbladder) that you will not staff. Wednesday am are more complicated follow-ups or pre-ops that are staffed with an attending. 

-Tuesday am you will present all of your SICU inpatients on 'big boy' multi-disciplinary rounds in the ICU starting at 0830. If you are on call you NEED to give the pager to a PA as there is no escape from these rounds. 


==== UCH Breast====
 
Dr. Ahrendt you will retract and close skin. Expect her to pimp you on all aspects of the procedure and literature

Dr. Tevis

Dr. Kounalakis- unfortunately leaving. Does a mix of breast and melanoma excision. Will let you do as much as you are capable of in the OR

In past years the 3 and the two have alternated: two weeks with Ahrendt/Murphy and two weeks with Dr. Kounalakis. Unclear how this will change with the addition of the two to the white service and Kounalakis leaving. 

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 ====
Q4 call, afternoon teaching.
Will get one "platinum" weekend your third weekend in which you will be post call friday, off sat/sun and pre-call monday

Splitting into two teams so unclear how this will affect things. 
Less acute than DGICU but more time for didactic education

==== UCH CTICU ====

CT ICU Rotation Survival Guide & Expectations\\
CT ICU APPs: Caitlin Blaine (lead), Alexis Keyworth, Beth Devine,, Erin McIntyre, Lisa Bauers\\

__Monday-Friday__

Night resident responsibilities for list (to be done prior to 06:00)- write in 24 hour drain outputs,
gtts and gtt doses, ECMO/VAD numbers, am SVO2 off VBG and other appropriate labs that do
not print off. On conference days, please write in the most recent PA cath numbers and vital
signs as well. *Ranges of HRs, BP, spo2, temps NOT necessary to copy down on
non-conference days. This takes too long and results in the list not being ready by 0600*

06:00 - list is updated and printed. Receive brief systems signout on non-cardiac patients from
night resident and split patients among providers. On Tuesdays and Wednesdays, fellow rounds
start at 6am SHARP (see below), be prepared with list and numbers!

06:30 - Fellow rounds (except for on Tuesdays/Wednesdays as below). Overnight resident
presents CARDIAC patients only to fellow. 3 dayshift providers need to each have computer so
that one can put in orders, one pulls up CXRs, and one pulls up the adult comprehensive lab to
review BP and PA cath numbers. This starts at 6:30 sharp.

● Tuesday is cardiac conference and Wednesday is thoracic conference. Each start at
06:30 in specified locations and usually end at 7am. On conference days, fellow rounds start at
6am SHARP!

**Anesthesia residents DO NOT need to attending conference.
**Surgical residents MUST attend conference.

07:00-07:30- Providers caring for lung transplants will pre-round on lung transplant patients prior
to presenting at 07:30

07:30- Providers who are caring for lung transplants will present on rounds with the intensivist,
pulm transplant attending + pulm transplant team (fellow, pharmacist, social work), and the
thoracic surgeon.

07:00-08:30am- pre-round on all other patients, finish getting handoff from night resident, get
transfer orders in on those transfering off unit.

08:30/9am - ICU rounds. The overnight resident is expected to stay and present any active
patients or new admits from overnight. Providers not presenting need to have a computer for
CXRs and orders.

11:00am (ish)- finish rounds, pull drains/wires as soon as rounds are completed (do not wait
until the afternoon), finish putting in transfer orders, complete procedures , update list, write
notes.

15:00-15:30- Resident ICU Lecture in the STICU Conference Room (does not occur on
Thursdays)

16:00- have list updated with day’s events and major events added to the hospital course. Be
ready to sign out to the night resident and make afternoon rounds

17:00-18:00- complete notes. If you have already finished your notes and tasks for the day, you
may leave only after ALL patients are signed out to the night resident.

__Weekend & Holidays__

Similar responsibilities for night resident in terms of list updating, but have to be ready by 0700
instead of 0600.

07:00 – Overnight resident presents all patient to fellow and ICU attending. Typically ICU
attending will be present for 07:00 rounds but sometimes attending comes in later and will have
to round again. WIll need 2 computers similar to fellow rounds- one on CXRs/orders, one on
Adult Comprehensive tab

08:00- Lung transplant rounds

__Admissions__

An APP comes in at 12:00 M-F for admissions. We call this the A2 shift. However, if
admissions arrive before 12:00 or there is no admitting APP due to staffing issues or if multiple
admission in short time span, then all providers are expected to help take admissions.
Delegation starts with zoning (i.e., if patient admitted to room 222 and XYZ provider taking care
of rooms 218, 219, 221, 223, then XYZ provider will admit/care for patient. If there is a provider
with very low acuity patients or multiple move outs, then consideration for them to take patient).

*When admitting patients, please avoid side conversations prior to formal sign-out. Nursing
staff will alert the admitting provider (resident or APP) that the patient is rolling or here. Sign-out
will occur when the admitting nurse is ready and the patient has safely been transferred onto the
bed and vitals are on the monitor. Once the nurse is ready, the surgical fellow will go first to
give report, followed by anesthesia. Always make sure to the get the patients LV and RV
function and reasoning for any gtts and if these gtts can be weaned or not.

**New Update for resident criteria regarding admissions** : In the first 2 weeks you are on
service, you will have 2 shifts where you will admit with the A2 APP. You will still come in at
6am for your typical day and leave after 4pm signout, and will be given patients to present on
rounds. Please let the A1 APP know that you would like to admit that day, so you will be able to
take the less acute or fewer patients to allow for some of your energy to be focused on admitting
with the A2 APP. The reason for this change is that some residents have expressed regret not
getting more experience with admissions, as these patients are more dynamic and there is
typically more autonomy in decision making. This will also help when it comes to night shifts and
weekends when you are alone and need to admit.

● Cardiac Surgery Admissions\\
o Place orderset depending on admission type (post op vs MCS vs OSH admit, etc)\\
o Write H&P or progress note\\
o Add to list\\

● Thoracic Surgery Admissions\\
o Post op orders are written by fellow. If transfer from OSH or floor, talk to fellow\\
regarding placing orders\\
o Add to list\\
o Write progress note or H&P\\

● Vascular Surgery Admissions\\
o Post op orders and admission orders are written by VSurg Fellow\\
o Add to list\\
o Write progress note\\

**Transferring Patient Out of ICU

On all transferring patients, please add/modify the following orders:

-dc all central lines/aline that are no longer indicated\\
-dc foley if no longer indicated\\
-dc IV pain meds if no longer indicated\\
-dc q 1 hour vitals/PA cath monitoring\\
-Please add vital signs (q4 for floor, q2 for stepdown), continuous pulse ox, telemetry\\
-For cardiac patients please add a “notify physician” order with the following written in:
“please page cardiac floor resident at 4316 when patient arrives to floor”\\
-**If cardiac surgery patient, please add patient to the cardiac surgery floor list (epic
and signout) immediately after transfer orders are placed**\\

● Cardiac Surgery Patients
o Transfer to MS PCU (floor or stepdown), CPCU Stepdown for LVAD/OHT patients\\
o **Report MUST be called to the Cardiac Surgery Floor resident (266-4316) at the
time patient physically moves out of ICU**\\
▪ Please do not call report prior to patient receiving bed assignment\\
o Place patient on Cardiac Surgery Floor signout list & EPIC list\\
o ICU providers continue to write notes and care for cardiac surgery patient while still in
ICU awaiting stepdown or floor assignments\\

● LVAD and OHT patients
o Cardiac surgery is primary when in the CTICU immediately postop\\
o When patients transfer to the stepdown unit (always CPCU), Heart Failure becomes\\
the primary service (attending and service need to be updated on the “transfer patient”
order. This transfer of service does not occur until the patient physically leaves the unit.\\
o Calling patient out to the Heart Failure team is appreciated and considered a courtesy\\
o **Calling out and giving report to the CT surgery team however is still\\
MANDATORY. Please also add these patients to the cardiac surgery floor epic and
signout list when transfer orders are placed.\\
*For all Cardiac Surgery patients who transfer out of the unit to the floor or
step-down, we must always call the CT surg resident (pager 4316) to give report
EVEN IF THE PATIENT IS TRANSFERRING SERVICES (ie Heart failure or TACS
becomes primary)\\
**
● Thoracic Surgery Patients
o Transfer to Pulm Floor (9)\\
o No need to call report to Thoracic Surgery Floor resident or place on Thoracic
Surgery list\\
o ICU providers continue to write notes and care for thoracic surgery patients while still
in ICU awaiting floor bed assignment\\

● Vascular Surgery Patients
o Transfer to MS PCU (floor or stepdown). VSurg team will designate location\\
o Clarify with Vasc Surg R2 regarding who will place transfer orders\\
o Once patient has been downgraded, ICU team no longer writes notes or cares for
patient. Direct all RN questions to Vasc Surg R2.\\

● Pulm Transplant Patients
o Transfer to Transplant Floor (6th floor, no step down status)\\
o ICU providers continue to write notes and care for lung transplant patients while in ICU
awaiting floor bed assignment\\

**Who to call when things go down at night:**

**Cardiac patients:**
As a rule of thumb if you are dealing with any of the following issues:
-adding new vasoactive infusions (pressors or inotropes)
-uptitrating vasoactive infusions significantly
-significant drain output (ie >200ml/hour for more than 2 hours)
-worsening acidosis
Make sure you call the cardiac fellow on call AS WELL AS the CTICU attending. If there is a
critical care fellow rotating and on call that night, a courtesy page to them is appreciated, but
does not substitute calling the cardiac surgery fellow.

If dealing with primarily critical care issues (ie sepsis, afib with RVR, hypoxia), most CT fellows
will state that this is something the CTICU attending should get a call for in the middle of the
night, and that they can personally just be updated on in the morning. But anything remotely
surgical or dealing with the heart function, warrants a page to the CT fellow AND CTICU
attending.

Thoracic patients:
For any decompensating thoracic surg patient, please alert the thoracic surgery fellow and
CTICU attending.

Vascular patients:
As above, anyone decompensating warrants a page to the vascular fellow or in some cases the
attending (ie Kuwayama likes personal pages or calls if his patients aren’t doing well), as well as
the CTICU attending.

Pulm transplant patients:
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.\\