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):
- 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:
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:
- 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.
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
-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
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
- 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.
Consults
Documenting
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
Lists and Epic Handoffs
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.
Orders
SICU Hand off –
Transferring Patient to a Different Service –
Discharges and Clinic Follow Up-
For Incidental findings -
Viewing TACS clinic schedule-
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.
If the patient needs imaging or lab work prior to clinic, order those tests for the date you would like them done.
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.
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.
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
Pathways
General Rules
Diet: NPO → GBCLD → GBFLD
Meds
Precautions:
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
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)
Discharge
• Diet: Bariatric fulls, multivitamin
I have great smartphrase for basic d/c instructions: Madeline Thomas, starts with mtbari
Burn Service Information:
General Information on how service runs:
In the OR:
24 hour in-house call on Mondays
burn_rotation_resident_orientation_ppt.pdf
https://podcasts.apple.com/us/podcast/traumaburn/id1434771181?mt=2
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
6:30 – Core curriculum (Conference center)
7:00 – Grand rounds (Conference center)
8:00 – Aortic conference (Conference center)
Jacobs – clinic all day
4:00 – Vascular conference (AO1 5th floor conference room)
Wohlauer – OR
Nehler – clinic all day
Jacobs – OR
Wohlauer – clinic all day
7:00 – Multidisciplinary vascular conference (IR conference room)
Jacobs – every other Friday OR/clinic (half day)
Nehler – OR
BASIC DUTIES of the R1
BASIC DUTIES of the R2
BASIC DUTIES of the R4
BASIC DUTIES of the VASCULAR FELLOW
BASIC DUTIES of the NURSE PRACTITIONERS
GENERAL RULES OF ENGAGEMENT
-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.
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.
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
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
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.