Plastics

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=====Children's Hospital =====
Connect to TCH family network for link to work. 
Haiku Setup Link:\\
https://haikusetup.childrenscolorado.org

==== Children's Faculty ====
[[resident:brooke_french|Dr. Brooke French]]\\
[[resident:david_khechoyan|Dr. David Khechoyan]]\\
[[resident:jason_yu|Dr. Jason Yu]]\\
[[resident:Phuong_Nguyen|Dr. Phuong Nguyen]]\\
[[resident:Timothy_Irwin|Dr. Timothy Irwin]]\\
\\
[[https://docs.google.com/spreadsheets/d/15l3skvSUPxqvK8jMCr3UDJxt15PaH9_B0FAXyPeE0Zc/edit?usp=sharing|Attending-Specific OR and Post-op Preferences]]


===== Children's PAs ====
Amber Matzol: 612-229-6907\\
Maggie Webster: 303-681-8224\\
Lindsay Dyer-Kindy: 720-937-7964\\
Mel Mabee: +1 (817) 917-1704\\

==== Schedulers =====
Dr. Irwin: Melinda Bond\\
Dr. French: Joanne Agenar\\
Dr. Khechoyan: Daniela Ramirez\\
Dr. Yu: Daniela Ramirez\\
Amber: Joane Agenar\\
Mel Mabee: Melinda Bond\\
Lindsay: Daniela Ramirez\\
Maggie: Marquise Sanford\\
Brooke (RN): Marquise Sanford\\
ER f/u: message "Plastics Scheduler" pool for APP follow up\\
F/u visits > 1month: message "SIC Schedulers" then select "pool" 
==== Welcome to Children's ====

This page contains a wealth of information about University of Colorado Children's Hospital. The rotation includes high volume pediatric plastic surgery and craniofacial surgery. Please see this[[Mason_Welcome| Welcome Packet]] that includes introductory information, weekday and weekend workflow, resident responsibilities, Day Call, The List and Transition of Care and Children's Specific Conferences including Oral Boards. You are encouraged to read this prior to starting your rotation.

This page contains other informal tips and tricks from prior residents.

**Important phone numbers**:\\
Maureen Andrews: 303-929-7929\\
OR charge: 64890\\
OR Desk: 76492\\
ED: 76888\\
OneCall: 73999\\
Yellow Team: 79247\\
IT: 74357\\
Phone stems: 720-777-XXXX. 720-752-XXXX. Numbers that start with 6 are all internal (usually nurse PCD). The only way to call back from outside is to call OneCall and ask them to connect you.\\
Main OR numbers:\\
OR 1 - 73416\\
OR 2 - 73420\\
OR 3 - 73421\\
OR 4 - 73424\\
OR 5 - 74324\\
OR 6 - 74325\\
OR 7 - 74326\\
OR 8 - 74327\\
OR 9 - 74328\\
OR 10 - 74329\\
OR 11 - 73762\\
OR 12 - 73780\\
OR 14 - 73774\\
OR 15 - 64836\\

**On call**: either call OneCall or go to the Children's home page, click on Quick Links, then Amcom (must be at the hospital or remotely using the CHC Desktop). 

**Lounge space** (ONLY Independents have access): There's a surgeons lounge on the 2nd floor with food and drinks.

**OR Lockers**: There is a designated PRS locker in the Men's and Women's locker rooms.\\
^ ^ Locker # ^ Code ^
| Men's | 68 | 00000 |
| Woman's | 94 & 160 | |

**Expectations**:
OR takes precedence over clinic. However, if you are not in cases, you are expected to attend clinic. If simultaneous cases, cover cases in order of seniority (Dr. French's cases covered first, then Khechoyan). Of course, if one of the more junior attendings is doing a really cool case, talk to French about covering those instead. Please look ahead and coordinate coverage as needed. Some cases require extra hands (ABG, breast reduction, etc).

**Rounding**: You will see all the necessary patients yourself and update the attendings. Maureen will also see the Cleft/Craniofacial patients, but this should not replace your rounding. 

**Supplies**: 
  * The code for the supply rooms on the floor is 13579#. These are not super well stocked and may not have what you're looking for.
  * Most dressings can be found in the burn procedure room in 6 South (the middle unit on 6, rms 625-649). Door code: 13579#. Cabinet code: 3167. 
  * The code for the clinic cart that lives in Hallway B is 1225. Plastics-specific supplies are in the cabinets above the desks in the work room. There is a big supply room with lots of different dressing stuff in the blue side of the MDC.
  * Wound vac sponges are in OR pod 2 ~between OR 14 and 10. The cast/splint cart lives in the far hallway outside of OR 14/15. The burn cart lives across from the dictation room. 

====Consenting====
Children's is all electronic consents. In order to make a consent, you click on the Pre-op Consult tab in Epic and then click Consents. To make a consent - you click on New Surgical Informed Consent (or Panel 2 or Panel 3 if it's a combo case) and fill in the correct information in the boxes on the right. .MOMSNAME or .DADSNAME in the first box and then whatever parent (or patient) is signing for the kid. This MUST be accurate and only have one parent's name spelled correctly. They will hold the case if this is done incorrectly. You can add extra procedures and whatnot in Additional Procedure Information. Fill in your name as Provider Performing Consent. Often the procedure etc will already pre-populate. If you're consulted for a spine closure, etc, you'll have to type in all the stuff yourself. \\
-After the form is filled out, the parent can sign on the computer's signature pad or on the patient's iPad. To log into the iPad you put in the patient's DOB (MMDDYY). The consent must be closed (close the patient's chart) to access the consent on the iPad. 
Click submit after you and the patient have signed the consent. The attending can sign the consent when they're back in the OR. \\
__Caveats__: \\
-If the patient is over 18 and otherwise legally able to consent for themselves, THEY must sign the consent and not a parent. Parent should sign if they are the legal guardian of an otherwise >18 year old patient (delayed, etc).\\
-Transfusion consents are separate than the surgical sent. There is another box to click for the transfusion consent (fill out as above).


====Craniofacial patients====
  * Maureen is an awesome resource. She will seeing everyone herself too, and will write her own note. She'll also check in with people postop. Text her and the attending after any craniofacial or cleft case so she knows how it went. She provides teaching to all the families while in house, and is their main point of contact after they get discharged. If she's ever not there, you can get the teaching handouts for patients on discharge on the Children's home page - Resources - Patient Handouts. 
  * If you put in cranial distractors, Dr. French usually likes to teach the parents pretty quickly on how to turn the distractors themselves. However, for the first day or two, you and Maureen are responsible for distractions. Coordinate with her on who will do the AM versus PM turns.
  * All of the craniofacial patients are neurosurgery primaries post-op. They are responsible for drains and everything. The only thing we are responsible managing are distractions. 
  * Consents - these cases are always booked under the neurosurgery attendings. The fellows are usually slammed in the mornings, so you are responsible for the consents. All the kids need a regular procedural consent as well as a transfusion consent. The plastics attendings are typically not on the consents-- Include under Additional Procedure Information: "Co-surgeon: Dr. Brooke French, MD" as appropriate. 
  * Postop wound care: Do not apply Vaseline or any other ointment after the 48 hours of antibiotic ointment. Start hair washing/incision site washing. If at the incision site check, there is a lot of crusting, we may have parents apply ointment 30-60 minutes before washing the site but that will be case by case.

  

 

====Cleft cases====
  * Maureen helps to manage these patients pre- and post-operatively as well. \\
  * There are multiple applicable ordersets (Plastics IP Alveolar Bone Graft Admission; Plastics IP Cleft Lip Repair Admission; Plastics Cleft Palate Admission)\\
  * These cases are admitted to the hospitalist service Pink Team post-operatively. Since they are non-surgical and rotate every week, they need a lot of hand-holding. Call them after the OR to sign out the patient to them (number above). Be VERY explicit about all instructions, nursing care, diet, pain meds, antibiotics, etc. \\
  * For Dr. Khechoyan - all primary palate repairs go to PICU postop for airway monitoring (French's patients typically go to the floor). Khechoyan will also do a tongue stitch and sometimes a nasal trumpet sutured in that you have to remove the next morning. Sometimes Mo is able to remove these when she does her rounds. Coordinate with her as needed.\\
  * Cleft Marking videos: \\


Cleft and Craniofacial patients:
Once done in the OR, text Mo any updates
Mo rounds and manages these patients along with you, so please keep her in the loop on all things pertaining to these patients. For craniofacial kids, Plastics is "primary" (ie manages the drain, dressings, etc - Pink is still the real primary team) and Neurosurg is secondary. 
====Orthognathic cases====
Khechoyan has a big postop pathway, see separate document.

====Clinic====
  * The clinics are on the second floor of the outpatient side of the hospital. PRS patients are usually in Hallway B. The work room is all the way in the back near hallway G. 
  *   * There are several Multidisciplinary clinics that we attend: Craniofacial, cleft, brachial plexus, vascular malformations. You are mostly observing and writing notes (for some MDC clinics, Dr. Khechoyan will do his own notes). 
  * Plastic Surgery clinic: You are expected to see the patients yourself and then staff as usual. Notes are your responsibility. 
  * Brooke Jacobson is the go-to person for outpatient Plastics stuff. She'll also help you with wound care stuff on the floor if you ask her.
  * Sometimes you will be called by Brooke to help with the odd clinic patient (usually for tissue expander fills, steroid injections, vac changes, etc.).

====Consults====
  * You are first call for all consults (Face on even days, gen plastics, wound). 
  * NEW cleft lip/palate consults: Sometimes if the baby has a prenatal diagnosis, they have seen Mo to get information and to be plugged into the MDC system. I would let Mo know the baby has been born. The consult should go to the attending on call (or whoever is next) between French, Khechoyan, and Nguyen. The primary team should consult OT for feeding. Mo can coordinate NAM/lip taping/follow-up with Dr. Lowe as needed.
  * If Khechoyan is on call, staff EVERYTHING with him in real time, even if it is very simple or in the middle of the night. 

**ED Laceration Repairs**
  * Ask the ED to obtain supplies/local/baci ointment for you. Baci is not freely available in supply rooms and has to be ordered. The ED has a poor selection of sutures. Go to OR Pod 1 (between ORs 4 and 8) to select sutures as well as instruments. There are a few sets specifically set aside for ED lac repairs (they will be labeled as such. This is also where you can find individual peel packed instruments if you don't want the whole set.  
  * For ED facial lacerations, be mindful of absorbable versus non-absorbable sutures based on patient age and location of laceration. Discuss with attending if you are unsure. 

**Coordination of Follow-up visits:**
  * Most ED follow-ups are seen by the PAs. To schedule, send an EPIC Staff Message to Marquise and Joanne (and CC the APPs). Include any relevant scheduling needs (ie, ‘s/p xxx procedure w/xxx MD, needs clinic follow up in 7-10 days’). If Dr. Khechoyan is on call, please clarify when staffing with him whether he wants them scheduled with a PA or with him. 
  * If a patient will require sedation in the Procedure Center for suture removal, this can be scheduled without needing to come to clinic first. Nowadays, the the APPs prefer to schedule this themselves. Communicate this scheduling need to the APPs in your EPIC Staff Message (see above). If a patient does not require sedation for suture removal, can schedule as a regular clinic visit. 
  * Please include the appropriate [[children_s#Schedulers]] if you need to arrange follow-up with a specific attending. 

=====Admitting Patients=====
  * Most plastics "primary" patients, including combo craniosynostosis cases with NSGY, are admitted to the Pink team. For elective cases, you can check if Pink is aware of them by going to Status Board > Team: Pink Med/Surg. To reach out to the Pink provider/attending, go to On-Call Finder > Medical Pink. 
  * Isolated facial traumas that need to be admitted (ie facial fracture we'll operate on tomorrow, etc) are admitted to Pediatric Surgery. 
  * If the patient needs to be admitted to the PICU and you don't know which team is taking them, reach out to PICU White (see On-Call Finder). 
  * PICU patients will downgrade to either Pink (most patients) or Pediatric Surgery (trauma patients). 
  * If there's a complex medical patient coming in or if you want to have a patient stay overnight from the ED (ie lip hematomas etc that we may or may not operate on), they will be admitted to Pink or Pediatric Surgery depending on the context. 

=====Prescriptions=====
   * __Liquid oxycodone is the one med that impacts our kids as it is hard to find outside of CHCO.  Attaching the work around in case you think this is work sharing with the rest of the team.  If not—feel free to discard and no reply back to me is needed.  Happy Friday!  M
 

*From CHCO Pharmacy team:

*15310 E Colfax Ave (M-F 9a.m. - 9p.m., Sat. 9a.m. - 6p.m., Sun. 10a.m. - 6p.m.)
*Yes – 380 mL oxycodone liquid in stock (don’t typically use that much and could get quickly if ordered for the weekend)
*10501 E Colfax Ave (M-F 9a.m. - 9p.m., Sat. 9a.m. - 6p.m., Sun. 10a.m. - 6p.m.)
*No – NO oxycodone liquid in stock
*10601 E Alameda Ave (M-Sat. 9a.m. - 6p.m.)
*Yes – 257 mL oxycodone liquid (wouldn’t be able to get any in stock until Tuesday)
*12051 E Mississippi Ave (M-F 9a.m. - 9p.m., Sat. 9a.m. - 6p.m., Sun. 10a.m. - 6p.m.)
*Yes – 63 mL oxycodone liquid in stock
 

*The last alternative is to use the Afterhours dispense of critical medications policy.  In this policy, critical medications can be dispensed for discharge by the inpatient pharmacy.  However, some rules apply:
*Only use if absolutely necessary on critical meds that can’t be obtained at another pharmacy
*All meds have to have a specific dispense quantity as noted below
*For non-narcotics like decadron, can dispense up to 72 hour supply
*For Schedule IV drugs like Valium, can only be up to 24 hours
*Schedule II drugs like oxycodone CANNOT be dispensed this way at all
 

*For 24 hour options:

*19028 Lincoln Ave Parker, 80134
*4001 E. 120th Ave Thornton, 80233

=====Patient Handouts=====
The language in these is geared toward parents, but includes lots of good information about care. These are helpful to refer to when parents call in about what they're supposed to do.\\
  * Cleft Lip Surgery: {{ :resident:cleft_cleftlipsurgery_eng.pdf |}}\\
  * Lip taping before unilateral cleft lip repair: {{ :resident:cleft_liptapingbeforeunilateraloronesidedcleftliprepair_eng.pdf |}}\\
  * Lip taping before bilateral cleft lip repair: {{ :resident:cleft_bilateralcleftlipandpalateliptaping_eng.pdf |}}\\
  * Feeding a baby with cleft lip/palate: {{ :resident:cleft_feeding_your_baby_with_a_cleft_lip_or_palate_eng.pdf |}}\\
  * Cleft palate handout: {{ :resident:cleft_palate_handout.pdf |}}\\
  * Cleft lip and nose revision: {{ :resident:cleft_cleftlipnoserevoldchild_eng.pdf |}}\\
  * Mouth care instructions for ABG: {{ :resident:cleft_mouthcareinstructionsforalveolarbonegraftsurgery_eng.pdf |}}

=====International Vietnam Rotation=====
**-Prior resident tips**:\\
   *Don't bring scrubs unless you're very large\\
   *IF you want good gloves in OR, latex free, or double glove, or are above size 7, bring from USA\\
   *Bring few disposable gowns if you're large for county hospital as they run very small in Vietnam\\
   *Bring lots of suture (prolene, monocryl, nylon, vicryl on small needles for clefts)\\
   *Bring Adson's, unavailable here\\
   *Bring head lamp with chargers - Ronan may donate?\\
   *Ho Chi Minh hospital less equiped than Hanoi, so bring everything (only have vicryl and nylon)\\
   *Shoes optional - would only bring if you have big feet\\
   *Other supplies to consider: surgical pens (sterile don't exist), eye protection (not a thing here), Bacitracin, clipifiers, mccabe, avagard, scrub brushes, wex spears, greenies, photo of a micro set up, skin staplers, non-sterile latex free gloves, doppler)
   *Hair conditioner was not available in either hotel
\\
-**Application**: Do early October/November \\
-Initial GME application: \\
- https://studyabroad.ucdenver.edu/index.cfm?FuseAction=Programs.ViewProgram&Program_ID=36142\\
- Will need Nguyen CV\\
- Need valid passport that doesn't expire within 6 months of trip\\
- Appeal: Considered high medical risk, so may require appeal process
https://studyabroad.ucdenver.edu/_portal/tds-program-brochure?programid=75200 \\
- SOS App: information/assistance for emergencies while in Vietnam. Download this during application period. //
https://www.internationalsos.com/subscriber/assistance-app \\
CU Membership Number: 11BCAS000006 \\
\\
**- Host institution**: \\
 Vietnam National Children's Hospital Plastic & Reconstructive Surgery\\
18 lane 879 La Thanh Street Lang Thuong, Dong Da Hanoi, Vietnam\\
\\
**Host organization or third-party provider**: Nouy Reconstructive National: an NPO, https://www.nuoy.org/\\ 
**Name of primary contact with host organization and/or third-party provider:** Phuong Nguyen, MD \\
**-Rotation goals & Academic Objectives**: copy & paste this into application\\
The chief resident is expected to be able to perform straight forward cleft lip and palate surgery with minimal assistance from the attendings and to instruct more junior residents in pediatric plastic surgery cases. Case logs will be reviewed to ensure that sufficient experience is obtained in all categories by the conclusion of the rotation.\\

Medical Knowledge Congenital, Aesthetic and Functional Problems of the Skin Goal: The resident will demonstrate knowledge of the common congenital disorders and disease processes of the skin, as well as the pathophysiology of aging. Objectives: • Explain the basic physiology of the aging process of the skin. • Describe the basic physiologic processes of sun exposure and its effect on the skin. • Discern the role of lasers in the management of various skin conditions. • Describe common inflammatory disorders of the skin such as cellulitis, lymphangitis, hidradenitis suppurativa, necrotizing fasciitis, and its medical and surgical treatment. • Discuss common generalized dermatologic diseases such as: scleroderma, dermatomyositis, lupus erythematosis. • Discuss the common congenital disorders of the skin, such as: xeroderma pigmentosa, Ehlers Danlos syndrome, basal cell nevus syndrome, etc. • Recite the basic principles of medical management and surgical treatment of common congenital disorders of the skin. • Explain the surgical aspects of treatment of patients with skin disorders such as scleroderma and lupus erythematosis.\\

Medicolegal and Psychiatric Aspects of Plastic Surgery Goal: The resident will demonstrate a clear understanding of medicolegal and psychiatric aspects of plastic surgery practice, regularly obtain informed consent from patients, and perform a basic psychological evaluation when appropriate. Objectives: • Discuss the medical and legal perspectives of the contractual agreement between a physician and his/her patient. • Discern the concepts of informed consent and implied guarantee. • Discuss the role of the medical record as a legal document. • Discern the impact physical deformity can have on patients and their families. • Discuss techniques to explore the motivations of patients seeking cosmetic surgery, and how to distinguish acceptable, unacceptable, and pathological motivations. • Recite the legal and ethical ways to sever the physician/patient relationship. • Discuss the various types of malpractice insurance. • Discuss the basic principles of risk management. • List the psychiatric and psychological treatment optionsfor patients with physical deformities and their families. • Discuss the strategies to effectively treat the dissatisfied patient/family.\\

Patient Care Goal: The resident will provide patient care that is compassionate, appropriate, and effective for the treatment of pediatric plastic surgery patients. Objectives: • Obtain cephalometric measurements and analyze cephalometric data in the presurgical planning. • Perform a comprehensive head and neck exam followed by facial form analysis. • Utilize radiographic and special diagnostic studies to evaluate head and neck anomalies. • Formulate a definitive short- and long-term treatment plan for common congenital disorders, choosing the most appropriate surgical or nonsurgical modality. • Draw the reconstruction of a cleft lip and palate. • Diagnose and develop a treatment plan for velopharyngeal incompetence. • Coordinate nonsurgical treatment of congenital head and neck disorders. • Participate in the Cleft-Craniofacial Team’s multidisciplinary evaluation and treatment planning for congenital disorders of the head and neck. • Provide perioperative care and participate in surgical treatment of patients with craniofacial anomalies. • Perform systemic therapy and local injection of steroids for treatment of facial hemangiomas. • Perform laser treatment for vascular malformations. • Participate in the reconstruction of congenital deformities of the lower extremity • Participate in surgery on patients with congenital skin disorders.\\

Practice Based Learning and Improvement Goal: The resident will investigate and evaluate his or her own patient care practices, appraise and assimilate scientific evidence, and improved patient care practices. Objectives: • Use information technology to prepare forsurgical cases, bringing to theOR the knowledge of current modalities of care for patients and the scientific evidence for that care. • Routinely analyzes the effectiveness of own practices in caring for patients. • Improve own practices in the care of patients by integrating appropriately gathered data and feedback. • Educate medical students and other healthcare professional in the practices of surgical patients. • Function independently with graduated advancement and appropriate faculty supervision in the evaluation and treatment of patients. Interpersonal and Communication Skills Goal: The resident will demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and professional associates. Objectives: • Educate patients and families in pre- and post-operative care of pediatric and cleft patients. • Demonstrate compassion for patients and families with congenital and acquired anomalies. • Provide adequate counseling and informed consent to patients. • Listen to patients and their families. • Assimilate data and information provided by the craniofacial team and other members of the health care team, in the care of patients with congenital head and neck anomalies. • Foster the doctor-patient relationship with pediatric patients. • Effectively obtain truly informed consent from patients.\\

System Based Practice Goal: The resident will demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Objectives: • Function within the organization of specialty clinics (Cleft Palate Center, Craniofacial Clinic) including the coordination of all special services in the evaluation of children with these anomalies. • Be able to coordinate the nonsurgical treatment of patients with congenital anomalies among contributing specialties (prosthetics, orthodontics, speech therapy). • Advocate for congenital craniofacial patients within the health care and insurance system. • Understand the benefits and functionality of multidisciplinary craniofacial teams. • Refer craniofacial patients to the appropriate practitioners and agencies. • Appreciate the functioning of the multispecialty fetal diagnosis and treatment committees and the potential role prenatal diagnosis plays in the family unit. • Facilitate the timely discharge of patients. • Partner with pediatricians in the combined care of infants undergoing systemic steroid therapy for head and neck hemangiomas. • Demonstrate knowledge of cost-effective surgical care. • Advocate for patients within the health care and insurance system.\\

Professionalism Goal: The resident will demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Objectives: • Develop a sensitivity of the unique stress placed on families under care for surgery. • Exhibit an unselfish regard for the welfare of patients. • Demonstrate firm adherence to a code of moral and ethical values. • Be respectful to patients and their families especially in times of trauma and stress to the family unit. • Respect and appropriately integrate other members of the healthcare team. • Provide appropriately prompt consultations when requested. • Demonstrate sensitivity to the individual patient’s profession, life goals, and cultural background as they apply to their surgical diagnosis. • Be reliable, punctual, and accountable for own actions in the OR and clinic. • Understand the physician/patient relationship. • Understand the benefits and functionality of multidisciplinary health care teams. • Refer patients to the appropriate practitioners and agencies. • Facilitate the timely discharge of patients.\\
\\
**-Pre-travel request via concur**: come up with budget for flights/hotels\\
Hanoi Hotel: Hong Ngoc Hotel - it’s owned by our partners so we get a pretty hefty discount.  https://hongngochotels.com/cochinchine\\
Ho Chi Minh: \\
-Make sure you include budget for roundtrip USA to Vietnam trips as well as flights between cities if rotating at both
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=====Oral Boards=====
As part of your rotation at children's, occasionally attendings will hostoral boards. Dr. Khechoyan tries to make these as straight forwarded as he can. The cases come from the book [[http://libgen.li/search.php?req=9781604068207&lg_topic=libgen&open=0&view=simple&res=25&phrase=1&column=def|Plastic Surgery Case Review: Oral Board Study Guide]]. He gives you 5 cases: Unilateral cleft lip (French), bilateral cleft lip (Mason), cleft palate (Khechoyan), facial paralysis (Domeshek), and syndacytly (Domeshek).\\
\\
Unilateral Cleft Lip (French):
  * Make sure you understand the 3 phases of non-invasive intervention before surgery: Lip taping, Naso-alveolar Molding and palatal lift.
  * Explain what Nordoff's point is (thinning of the white roll)
  * You will want to have frequent appointments to make sure the baby is feeding well. So see the baby 1 week after leaving the hospital. Don't just schedule surgery at 3 months and trust other services.
  * You will be asked about special bottles and how they work. They all use a gravity fed reservoir that squirts the milk into the mouth as the baby bites.

Cleft Palate (Khechoyan):
  * Asks for two syndromes associated with cleft palate: Van der Woude (Lip pits), Stickler Syndrome (Retinal detachment)
  * Then asks for a sequence - Pierre Robin Sequence. This patient will need a sleep study and maneuvers for breathing: prone positioning, nasal trumpet, lip tongue adhesion stitch vs distraction
  * Asks to explain the aberrant anatomy