Plastic Surgery Intern Information Sheet

Welcome to the Plastic & Reconstructive Surgery service! We are glad to have you. Below is a description of your responsibilities as the Plastics Intern. Please feel free to contact anyone listed below if you have any questions.

Independent Residents

• R7: Salih Colakoglu – pager 5445, cell 929-216-1907
• R7: Andrew Peredo – pager 5446, cell 917-828-5523
• R6: Aline Rau – pager 4646, cell 720-724-1887
• R6: Jhade Woodall – pager 5837, cell 561-818-8988

PAs

• Plastics (Mathes): Sara Douglass – pager 4537, cell 303-903-3272
• Plastics (Chong): Joslyn Brown – cell 248-890-9638
• Plastics (Aycock): Marian Brinkman – cell 720-951-4894
• Hand: Kathryn Miller – cell 405-921-4704

ROUNDS

• The senior resident on service at UCH will let you know when and where to meet for rounds each morning.
• During the week the UCH team will round on plastics patients and consults and the Hand team will round on Hand patients and consults. On weekends the rounding team rounds on both plastics and hand patients and consults.
• For pre-rounding and rounds you should print out the “Plastic Surgery” team sign out list found under the “Sign Out Rpt(UCH)” tab along the top of your Patient Lists page.
• Consult requests and orders for things that need to happen that day should be placed on or immediately after rounds, so that patient’s can receive care in a timely fashion.
• All patients that are rounded on, both on service and consults, need a daily progress note.

LISTS

• The Epic list for the service is called “Plastics” and can be found under the Shared Patient Lists on the left hand side of your Patient Lists page. If you don't see it there, ask one of the residents to grant you access.
• The Epic list for hand patients is called “Plastics Hand” and can also be found under the Shared Patient Lists on the left hand side of your Patient Lists page. If you don't see it there, ask one of the residents to grant you access.
• All patients that need to be rounded on, both Plastics patients and Hand patients, need to be added manually to the team sign out list. This list is not updated automatically. Please keep this list up to date, as it is the main resource on patient information for both cross-cover interns and off service rounding residents.
• For rounds you should print out the “Plastic Surgery” team sign out list found under the “Sign Out Rpt(UCH)” tab along the top of your Patient Lists page.

FLOOR WORK

• The amount of floor work varies widely on this service. During times when the service list is long floor work can be a significant time commitment, so organize yourself well and plan your day ahead of time to avoid long hours.
• Try to coordinate dressing changes in between cases so the senior resident can also take a look at the wound. If this is not possible, however, go ahead and do the dressing change and take good pictures of the wound. It is preferable to get things done than to have a pile of work left at the end of the day.
• If you think you are in danger of going over hours, talk to your senior resident so that help can be given and problems can be avoided.

- Care protocols and other useful information can be found in Evernote: https://www.evernote.com/Login.action username: HSC-Surgery-Plastics@ucdenver.edu password: Plastics2015

CASES / CLINIC

• The plastics intern will be assigned to cases and clinic on the Sunday before any given week. The schedule is sent out via email as an Excel file.
• If you are assigned to clinic you are expected to wear “clinic clothes”, see patients, present them to the attending, and write a note. Ask the attending how they prefer you do this.

PRE-OP
It is your responsibility to “pre-op” all inpatients and any outpatients for the cases to which you are assigned. This includes:
• Pre-op orders in EPIC (For inpatients these should be placed the day before surgery. For outpatients these are usually placed in clinic, but not always, so check.)
• H&P, H&P interval update, or daily progress note
• Consent (Please ask what should be written on the consent.)
• Site marking. For most cases, e.g. flaps, breast cases, body contouring) the attendings will mark the patient themselves. Be present when attendings are marking. Markings are integral to the case in Plastic Surgery. For most hand cases, take backs, or other cases where incision placement or symmetry does not matter, you can mark the body part yourself.

POST-OP
It is also your responsibility to post-op all cases you are assigned to. This includes:
• Brief post-op note
• For patients being discharged after surgery: Discharge orders and prescriptions. Please keep in mind that Medicare and Medicaid patients will require an attending to sign your prescription.
• For patients being admitted to the Plastics service: Admission orders and addition to list.
• For patients being admitted to another service: Communication of Plastics-specific orders to primary team.
• For patients returning to the floor (on Plastics or another service): Updated transfer orders and communication of plan to the primary service if applicable.
If for some reason you are running late to a case or clinic to which you are assigned (because you are seeing a consult, dealing with a floor issue, etc.), please let the attending know.

CONSULTS

• The plastics intern takes first call during the day for any plastics consults at the University. This includes seeing the consult, adding them to the appropriate list, staffing with the appropriate person, and writing a consult note.
• Consults should be seen immediately for emergent and urgent consults (this includes any ED consult) and as soon as possible for non-time sensitive consults. This may mean stepping out of clinic, scrubbing out of a case, or making a quick run in between cases. Consults should not be accumulated and left for the end of the day.
• Plastics consults should be staffed with the U senior resident or UCH/VA resident. Weekday hand consults can be triaged directly to the hand PA during business hours when she is not in clinic. During other hours or if she is not available you should see them and staff them with the hand resident. On nights and weekends all consults should be staffed with the on call senior resident.

DISCHARGES

• D/C instructions are standardized for many of the procedures. You can look at the residents’ or PAs’ Epic smart phrase manager to find attending specific and surgery specific d/c instructions.
• For hand cases you can use the .handpostopinstructions SmartPhrase and adjust it as needed.
• Please make sure patients have follow-up appointments at discharge. Send appt request to Plastic Surg Nurse/MA Pool on Epic.
• If the patient is for Hand there is separate scheduler “hand pool” you should message. It is recommended to make 2 separate message templates so that setting up follow ups is rapid and efficient.

SIGN-OUT

• The plastics intern will sign-out the plastics list to the cross-cover night-float intern each evening at the designated sign out time. Sign out will include the name and contact info of the on-call Plastics senior resident for that night. Please also send the contact info of the night float intern to the on call Plastics senior resident.
• On weekends the plastics intern will sign-out the plastics list to the cross-cover intern after rounds and floor work have been completed.

WEEKENDS

• The plastics intern will round one day per weekend and have the other day off. The rounding day is usually Saturday, but may vary depending on when you are on cross-cover.
• Contact the rounding senior resident for that weekend to arrange weekend rounds.

The in-house University intern covering the Plastic Surgery Service is first call for Hand consults ON WEEKENDS whenever there is a Plastic Surgery attending on call for Hand (approx. 15 days/month). The amion system has been updated to state the intern pager should NOT be paged for hand consults on week days.  The schedule identifying the days that Hand consults are covered by Plastics can found on AMION under the Plastics and Hand call schedules. If you are not scrubbed into a case, floor work is completed, and the ED manages to page you anyway about a hand consult on a week day, then it is appreciated if you help with the consult.  Weekday daytime consults can be triaged directly to Kathryn Miller, PA-C.  Evenings and weekends, or if Kathryn is not available, the intern should see the consult immediately, get the history, perform an exam, and then promptly contact the appropriate person for further instruction.  On weekdays consults should be staffed with the Hand Fellow. On evenings and weekends consults should be staffed with the on call Fellow.  If for some reason the intern has not been able to reach anyone, the intern should contact the on call attending directly, rather than sit on an unstaffed consult.  It’s always better for the Fellow to be notified of a consult sooner rather than later.  Consult patients should be added to the “Plastics Hand” shared Epic list upon receipt of the consult. (If you do not have access to this list, ask one of the residents to add you.) If the patient will need a follow up appointment in the Hand Clinic, please make sure the ED puts in an order for “ambulatory referral to Hand Surgery” and specifies the attending who is on call that day (Dr. Gordon or Dr. Iorio). This is the same attending to whom your note should be routed.  Pearls for Common Calls o Always get a sensory/motor exam prior to local anesthesia o Discuss oral and IV pain control with ED o Know how to perform a digital block and a hematoma block o Infections  Obtain a detailed history (including rapidity of onset and progression)  Examine for fluctuance  Give a dose of antibiotics (Get culture first if possible and if necrotizing soft tissue infection is not suspected)  Supplies needed for I&D  1% lidocaine with epi  ED I&D kit  Culture swabs  ¼ inch Penrose drain  1L of NS irrigation with 60cc syringe and luer lock irrigation shield attachment  Bucket  Arm Elevation Pillow from OR (blue foam pillow; need to send OR a patient sticker and go pick it up from the OR desk)

o Lacerations  Ask about the mechanism  Make sure tetanus is up to date  Give a dose of antibiotics  Is there a tendon injury?  Determine this by asking the patient to open and close their hand – do the fingers all move normally?  Is there a digital nerve injury?  Determine this by performing a sensory exam on the radial and ulnar border of EACH finger to test the radial and ulnar digital nerves to each finger.

 Is there an arterial/nerve injury at the wrist?  Perform a complete sensory and motor exam for the ulnar/radial/median nerves.  Does the hand appear ischemic? Was there mention of arterial bleeding in the history?  Supplies needed for repair  1% lidocaine with epinephrine

 Betadine  Gauze  1L of NS irrigation with 60cc syringe and luer lock irrigation shield attachment  Bucket  5-0 nylon sutures  3-0 Supramid from OR if extensor tendon is involved  Suture tray: Hemastat, Needle Driver, Forceps, Scissors (Plastics Minor Set from OR is ideal)  Xeroform, 2 inch Kling wrap, Kerlix, Coban

o Hand/Wrist Fractures/Dislocations  For distal radius fractures: Determine if there is an acute carpal tunnel syndrome, meaning, is there numbness in the distribution of the median nerve (thumb, index, long, and radial border of the ring finger)?  Discuss with ED their ability/availability to perform conscious sedation if needed  Supplies needed for fracture/dislocation reductions:  1% lidocaine with epi  10cc syringe  18G needle  22G needle  Alcohol swabs and Gauze  Finger traps and IV pole from ED  4 liters of IVF in bags and surgical netting (for traction weight)  Mini C-arm (have the ED call the radiology tech to bring it)  2 sets of Lead, including thyroid shield, for the provider and the patient (tell ED to remind radiology tech to bring these, they often forget)  Cast cart for cast padding, 4 inch plaster, and 4 inch ACE or Bias  Scissors  1L of NS irrigation with 60cc syringe, luer lock irrigation shield attachment, & bucket if open fracture  Arm Elevation Pillow from OR (blue foam pillow; need to send OR a patient sticker and go pick it up from the OR desk)

o Amputations  Determine the time and mechanism of the injury  Make sure tetanus is up to date  Give a dose of antibiotics  Determine the level relative to the next more proximal joint (DIP, PIP, MCP – i.e., “the amputation is just distal to the PIP joint”)  Make sure the part (if available) is wrapped in sterile gauze, placed in a bag, THEN placed in an ice bath  Do not delay contacting Plastics Fellow

You will be the “eyes and the ears” on the floor. That means we are relying on you to manage the patients on the floor and triage all the consults. It will be busy, but what I suggest is to try and finish all your work and notes and then come scrub the second case of the day. Getting to the OR makes all the floor work worth it.

You’ll have a number of tasks you need to do every day: Get the number in the morning. See below for an example of how I wrote the numbers. Get tasks done. Prioritize Pulling Chest Tubes>Pulling Drains>Dressing changes You will have to “run the list” with a number of the coordination services including: The Charge RN on 6th floor if at UCH, Social work/Case management, Acute pain service if patients have epidurals, Ostomy RN, Wound care if following patient for wound vacs Write the floor notes and update the list and then try and come to the OR and scrub if you can

Jon’s AM Number Format – this is just a suggestion, not mandatory.

Temp range / HR range / BP range / RR single value / Desaturation events and times + Oxygen/Vent settings

Ins and Outs
PO | UOP
IV | Other

N: # A: #

PO - Includes oral intake and any enteric feeds
IV - Anything intravenous
UOP - Urine output. Please also include dialysis
Other - Everything else. Emesis, stools, etc…
*** Make sure you are opening up all the tabs in Ins&Outs (BTW you can save it open with that little green plus)

N = Net 24 hour volume status
A = Net admission volume status

The List:
Pt info:

Path:

PMH:
PSH:
Home Meds:
——–
N:
CV:
P:
GI:
GU:
Heme:
Endo:
ID:
FEN:
————–
Operation:

Foley: - nice to write when d/c’d and if patient voiding

Drains:
———–
XC – Primary team if a consult, No labs

Team – include the plan for the upcoming days here

Discharge – things for discharge like PT recs or ppx for discharge

The Things I Carried:
4 Color Pen: BIC 4-Color Grip Ball Pen
Flashlight: Streamlight 66118 Stylus Pro LED Pen Light with Holster, Black
Trauma Shears: Prestige Medical Fluoride Scissor, Black, 7 1/2 Inch (Amazon)
Stethoscope: Some attendings want this: Schulick, Vogel
Headlight: Useful on ENT
Reflex Hammer: Useful on NSGY

EPIC Suggestions:
I try to save useful orders per service. You can take a look and copy them in the Preference List Composer
Steal .dot phrases from people using the Smartphrase manager

Fred Gonzales:
I have found the Wiki to be extremely helpful, and I referenced it many times throughout this rotation. I did, however, not have access to the attending pages, which would have been very helpful in preparing for cases.