Plastics

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):

• EEM – phone call after 7am
  
• CCB – is in her office at 7am or phone call
  
• EC – phone call after 7am
  
• FMP- phone call after 7 am
  

- 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:

• All patients, even post-ops, should be discussed with the attending staffing clinic.
• Interns should get their work done prior to coming to clinic.
• Please remember professional attire: white coats over scrubs. You do not need to dress up for Monday Gray clinic.
• Perhaps obvious, but please use your stethoscope for the daily physical exam of your patients. Your exam, particularly for patients who have not undergone surgery, should contain 8-10 exam findings.

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:

• BCVI: remains asymptomatic, continue ASA
• R scalp hematoma: stable, no acute issues, wound care prn
• B pulmonary contusions: supportive measures, still with intermittent oxygen requirements, pulm toilet
• B small PTX: not evident on CXR, cont to monitor
• B rib fx: working on pain control - improved with epidural and now weaning, encourage IS, pulm toilet, mobilize pt
• acute resp insufficiency: due to rib fx; still remains primary issue, working on pulm toilet as noted above and will wean oxygen as tolerates. Now able to IS over 1000 during the day - will continue to work on this to optimize.
• HTN: better controlled now, will continue home beta-blocker and added lisinopril
• Small volume anterior mediastinal hematoma: no acute issues
• Nutrition support: tolerating diet, will continue
• acute blood loss anemia: stable Hb on last check, no signs of acute bleeding
• hypokalemia: resolved
• R tib/fib fx: s/p ORIF
• R femur fx: s/p IMN
• R acetabular fx / posterior hip dislocation: s/p ORIF
• L anterior hip dislocation: reduced
• Acute resp insuff – due to rib fx, overall improving, will encourage pulm toilet and wean oxygen

- 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.

• It can contain the problem list of all diagnoses for your patients throughout their hospital course (at admit the TACS team will generate the beginning of the list) – by updating it in the navigator, this will autopopulate into the handoff as well as the d/c summary.
• This should be used preferentially over the “problem list” provided in EPIC as it seems that list is not always accurate or reliable for a particular diagnosis.

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

• if this tab is not present, select the “MORE” tab at the bottom left. Select “Quick Navigators” there is the “Prep for case” tab. Select the yellow star to the right of this tab to move it to your toolbar.

-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

• 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)

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

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

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