Plastics

Residents:
Senior Resident: Aline
Junior Resident: Haley
Intern: Mike Kirsch

PA - Kendra Keene 316 250 5999
RN - Nichole Fitzgerald 720 683 1770

Attendings:
Stephanie Malliaris: 617 970 7590
Corrine Wong: 972 322 2078

There is a google calendar that is shared that has the schedule of fellow call. It is shared amongst the two ortho hand fellows and the senior plastic surgery resident. Add yourself to 4 weekdays and 1 full weekend for the month you are on. Can be any dates of your choosing (ie multiple weekdays in a week) but first come first serve as far as dates. You will only be called for operative interventions. For the weekdays this mostly means replants as other cases get pushed to the next day. For the weekends means replants, nerve repairs but can also mean mean pus/washouts.

Ipak typically takes Mondays/Wed
Malliaris typically takes Tuesdays.
Lauder takes Thursdays

Iorio takes an intermittent weekend. If he is on and has a replant discuss with Malliaris and Ortho team about who will take them following the weekend

https://calendar.google.com/calendar/embed?src=dcj4rv5tr4ng8vdhk8ssrv7o7o%40group.calendar.google.com&ctz=America%2FDenver

This is a relatively relaxed rotation. We want the interns to be engaged and see each type of surgery we perform including hand surgery. This is a center of excellence for transgender surgery and female to male and male to female top surgery is common. Please be respectful and use appropriate pronouns (he/his, she/her, they, etc.). There will be multiple opportunities to practice suturing each week.

There is a crosscover intern at night. Sign-out is 6pm and then 6am the next day. Please ensure that the overnight intern has the on call Plastic Surgery Resident's phone number. The night intern is welcome to the wiki. If they do not have access, please email Jonathan.Freedman@CUAnschutz.edu. It is the day intern's responsibility to make sure that the night intern has read the nightfloat responsibilities. The ON CALL resident rotates and is the name on the calendar on the start page.

The weekend is split between Urology and Plastics, so as the intern you will cover both of these services. Please let the weekend intern know who is on call and give them the appropriate phone numbers. Additionally, the plastics intern now covers the RGB patients after they have rounded.

You are encouraged to update this wiki as needed. Please update your name and phone number above. Especially at the end of the rotation as you are signing out to the next intern, please take a few minutes and update the wiki and make sure the next intern has access. You will be asked for feedback on the wiki one week before the end of the rotation – this will improve your fellow intern's experience.

Intern tips
- Almost daily needed wound dressings: xeroform, bacitracin/vaseline, kerlex, ABD pads, ACE wraps, scissors, tape. Get more than you need.
- Take MACRO pictures. Include the whole leg and the foot. Square your pictures with the chest and include both shoulders, breasts, etc… If you are taking pictures in the operating room, make sure to ask what structures are exposed (ie tendons, vessels, bone).
- For I&Ds: 500ml bottles of NS, I&D kit, TUMI syringe, suction, ABD pad, sterile gloves, 1% lidocaine w/ or w/o epi, acute pain meds for patient (50mcg fentanyl)
- The list:
– for all patients (primary and consults), should include vitals (ranges with and pertinent Tmax, desats, etc), I/Os with special attention to WV and drain output (note the last 24 hr output), and any relevant labs (CBC, BMP, cx, path, etc).
– for PRIMARY patients: as above with system-based plan/to-do.
- Get notes done early so you can go to the OR. After preoping patient (mark and consent) establish yourself in the OR (work on notes, make calls, etc) and throw your gloves to the scrub tech.
- Wound vac: do NOT put the black sponge over healthy skin - this can lead to maceration, and in some sick people, further damage to skin edges. Black sponge is hydrophobic; indicated for wound without tunnels, undermining, and/or exposed bone. White sponge is hydrophilic; indicated for wounds that tunnel, undermine, and/or are over exposed bone/tendon/muscle.
- Scheduling follow-up clinic visits: for Plastics (and not hand) patients: send EPIC basket message to Nichole Fitzgerald, RN to schedule patients. Include patient name, MRN, and brief reason for appt.

Clinic tips:
- Seeing transgender patients:
– 1. Ensure you know the preferred pronouns before entering the room (very easy to make mistakes but keep trying!)
– 2. Dr. Wong (and Malliaris) likes to know a a few specific bits of info in the H&P besides the usual things: do they wear a bra, if so what size, do they bind their chest, goals for top surgery (masculinization, nipple importance, etc), smoker, diabetic, what do they do for work (no heavy lifting for 6 wk post op), fam hx of breast cancer (patients still need to undergo routine mammograms).
– 3. Obtain frontal, lateral, and oblique images of chest for preop evaluation (check media tab for images)
– 4. Get a tape measure. Measurements to be obtained during preop visit: sternal notch to nipple (SN-N), base width (BW), and inframammary fold to nipple (IMF-N). These measurement will go in the note.

Common pimp questions:
- stages of skin graft taking
- full thickness vs split thickness skin grafts; pros/cons, uses
- anatomy

Common cases:
- female to male chest reconstruction
– several different surgical approaches but most common is double incisions with free nipple grafting
- muscle flaps, myo/fasciocutaneous flaps for complex wound coverage
- hand surgery
– carpal tunnel release
– trauma ie tendon lacerations, fractures, nerve injury
- skin grafts

- The fellow on service at DG will round with the team (Kendra and intern and sometimes R2) on the plastic surgery service. The fellow will communicate with the primary attending regarding patient care. On Mondays when the fellows are in conference, Kendra will run the team rounding responsibility

- Please ensure that the first case of the day has a new or interval H&P pended in the chart in order to expedite preop process.

On the weekend if there is a primary plastics patient, this person will be rounded on by the intern covering plastics, who will then communicate with the fellow on call, who will round in reasonably time (usually after CHC and The U)

Monday: Dr. Wong Pav A, Dr. Malliaris Pav M Tuesday: Dr. Wong Clinic, Dr. Malliaris Pav A Wednesday: Dr. Wong Pav M, Dr. Malliaris Hand Clinic Thursday: Dr. Wong Clinic, Dr. Malliaris Pav M Friday: Dr. Malliaris Clinic, Add on cases

Dr. Wong has clinic on Tuesday AM and Thursday AM. Dr. Malliaris has Ortho Hand clinic on Wednesday all-day and general plastics on Thursday afternoon.

When on plastics, check the board for attending cases. For Hand cases with Malliaris, please communicate with the Hand Fellow and Ortho hand resident to make sure that Malliaris is covered appropriately.

If the fellow is assigned to OMFS or Ortho, that clinic and those cases are the priority. If there is no other cases for OMFS or Ortho, please check with the plastics team to see if they need help with the cases/clinic. For the ORTHO month, Livermore is the boss, and you should focus on Hand, ie go to hand clinic and do hand cases with Livermore, Malliaris, and Ipatchki and Benegas if needed. Again when doing hand, please be equitable with our Hand fellows and Ortho residents!,

Discharge instructions can be found in Kendra Keene's smart phrase list. They all start “.DCXYC”. Please place the appropriate discharge instruction and PACU discharge order set for outpatient cases.

To make follow-up appointments: send a staff message in Epic to the scheduler and ask for a follow-up appointment in the time frame you'd like and include what surgery the patient had. Send to the following: -Hand patients: “DH PAV B ORTHO FRONT DESK” under pool (click the “to” button and then you will have the option to search a pool) -Plastics patients: Nichole Fitzgerald, RN

Note for consents.

There are many bony fixation tissue cases. Consents for these should always include “non-union, malunion and hardware failure” as well as the normal soft tissue scar, infection, pain, bleeding, damage to nearby nerves, arteries, veins and tendons, and need for additional procedures.

Risks include, but are not limited to, infection, scarring, pain, damage to surrounding structures, incomplete resolution of symptoms, need for further procedures, malunion, nonunion and hardware failure.

For Dr. Wong's breast cases, please print out a frontal view of the patient pre-operative photo. Black and white is fine.

- The plastics intern takes first call during the day for any plastics consults and occasional face call, but will notify the fellow ASAP. - When called for a consult (ER or inpatient), the intern is responsible for 1) seeing the consult as soon as possible, and 2) presenting the patient to the fellow/attending on-call who may ultimately assume care of that patient.

Please keep in close contact with attendings and Kendra, as cases will get added on.

Pressure ulcers come in waves at DH. PMR wants to see patient before surgery at a pre-operative appointment. Physical therapy, occupational therapy and PMR should be consulted on day 1 regardless of activity restrictions.

For any wound consult make sure you know nutritional status, if the wound is infected, reason for admission, overall prognosis of the patient, and an assessment of resources for wound care after surgery.

Operating Room to Inpatient Unit Transfer: After a successful replantation or revascularization, the patient will be transferred to a tropical room in the recovery area or directly transferred to the SICU or PICU as deemed appropriate by the care team. If a tropical room is not available, the operated limb can be placed underneath a “bear hugger” thermal heating blanket per surgical attending preference.

Temperature Measurements: For patients admitted to the ICU, temperature and clinical checks of the replanted part are initiated hourly at admission for the first 24 hours, continued every 2 hours for the second post-operative day, every 4 hours for the third post-operative day, and every 8 hours after the fourth post-operative day. Based on the severity of the injury and perceived chances for a salvage procedure, the attending microsurgeon can recommend to change the monitoring interval. During the first 72 hours vascular checks can help recognize any decrease in temperature of the replanted part. The decreasing temperature can indicate a vascular failure either at the level of the arteries or veins.

• Assess the temperature of the non-affected neighboring digit for a baseline normal temperature reading, then assess the temperature of the replanted (affected) digit according to the schedule listed above.
• The temperature of a successful replantation is usually 31-36 degrees C. Any decrease in temperature below 30 degrees C or a drop of 2 degrees C or more in the replanted digit must be immediately reported to the hand surgery team.
• Temperature measurements are to be taken with an infrared thermometer at the affected finger, as well as any uninjured neighboring finger. In case of a hand replantation, the base line comparative temperature measurements are taken from the contralateral hand.

Anticoagulation: During the patient's hospitalization, anti-thrombosis prophylaxis will be administered per the Hand/Microvascular attending order in adults. In pediatrics, replantation orders will be placed only by pediatricians or the hand surgeon. Pediatric aspirin dosing is weight based.

• Patients weighing less than 16 kg will be discharged home with 40.5 mg aspirin once a day for one month.
• Patients weighing between 16 and 50 kg will be discharged home with 81 mg aspirin once a day for one month.
• Patients weighing greater than 50kg will be discharged home with 325 mg aspirin once a day for one month.

Leech Therapy: Patients with congestion of the revascularized / replanted part or microvascular free flap can benefit from leech therapy. The 2 beneficial effects are A: Removal of congesting blood by the leech and B: Improvement of microcirculation via instillation of a biologic anticoagulant (hirudin) by the leech. While on leech therapy, patients must be placed on prophylactic antibiotic coverage for Aeromonas hydrophilia. This gram negative rod is found in leech gut flora and is associated with wound infections. 1 leech is placed at a time until it detaches after engorgement. The duration of leech therapy as well as the decision on continuous vs intermittent leech treatment is decided upon by the surgical team.

General Protocol:

• Diet: NPO for 12 hours then regular diet. No caffeine, chocolate, nicotine.
• Activity: Bedrest for 12 hours then ambulate.
• Extremity: elevate on at least 2 pillows, bair hugger
• Vitals: q4h. CMS checks q1h through pod 1, q2h pod 2, q4h pod3 through d/c. (Check color, temp, cap refill). Check temp of body part and compare it to the opposite side.
• IO: qShift
• No heat or ice packs
• Tropical room : set to 80 degrees or warmer
• No stressors (limit visitors, no stressful TV or games, etc)
• Pain: block by anesthesia. If NPO: IV morphine. If PO: tylenol, oxy, lorazepam
• Heme: daily CBC and transfuse if hb < 8. ASA per above, lovenox
• ABX: ancef x 24 hours. Bactrim if leeching.
• Bowel regimen.
• If following pathway, typically discharge POD 4 or 5

303 602 ####
OR 303 602 10##
Bridge 21061
PACU 21020

Chemistry 25242
Ortho Clinic 21590
Help Desk 63777
MICU Access 159
CT 24149
X-ray 24144
Pediatric Intern 21883
Surgery social worker 21415
U/S 24135
RT 23955
Radiology reading room 24142
MTT (pharm reconciliation) 25442

4B 21250
5A 23810
6A 28900
7A 27300
8A 28800
SICU 25800