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)

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 –
  

1. A complete HPI, including four modifiers of the patient’s pain.
2. A full PMH, PSH, Fam Hx, Social Hx.
3. ROS needs 10 systems reviewed (DO NOT DOCUMENT “SEE HPI”)
4. 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.
5. Physical Exam needs 8 systems
6. 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

1. 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.
2. 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 -

1. Email the admitting attending and appropriate general surgery APP
2. Ensure patient has PCP follow up (SW can help set up PCP if patient does not have one)
3. Tell the patient and family about their incidental finding and need to follow up with PCP
4. Provide a copy of the CT scan report with the finding to the patient with the finding highlighted
5. 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-

1. Click on Clinic Schedule icon

1. Select TACS Clinic and desired date

1. 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
  

1. 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.

1. Xrays and labs do not need an appointment as they are walk-ins
2. 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)

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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