Attendings: Dr. Clay Burlew Dr. Alex Morton Dr. Fred Pieracci Dr. Campion Dr. Moore

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)

copy_of_cu_esophagectomy_pathway-2.xlsx

Copper Surgery Information and Bariatric Pathways

Team Chief: Peter [914-523-6713]

R3s: Julia Coleman [614-406-8829], Ryan Gupta [504-931-8419]

Intern: Nick Schmoke [231-690-1360]

Important Contacts

1. Copper 0440
2. Gen Surg Clinic 303-724-2728
3. Bariatric Clinic 720-848-2070
4. Fluoro Read 85969/85263
5. Fluoro Sched 81085
6. Bariatric Clinic 82070
7. Pharmacy: Main 8139, Atrium 84083, ED 88400, PAS 83150
8. Bariatric Dietician (Lisa) p6166
9. Radiology 85343/93438/83434
10. SW/CM/PRL 83779/34527/83784
11. OR Bridge 84351
12. PACU 86203
13. OR Charge 83597
14. OR Room: 307XX
15. Montero p0065
16. Schoen p0872
17. Rothchild p2517
18. 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

1. Make sure follow up appointments are made

• Bari patients: 1 week and 3 week
• Unordered List ItemGen surg: 2 week

1. 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)
2. 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

Cover the ICU on Wednesdays when the ED resident is off and a weekend day

24 hour in-house call on Mondays

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)

-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.

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