Plastics

Connect to TCH family network for link to work. Haiku Setup Link:
https://haikusetup.childrenscolorado.org

Dr. Brooke French
Dr. David Khechoyan
Dr. Jason Yu

This page contains a wealth of information about University of Colorado Children's Hospital. The rotation includes high volume pediatric plastic surgery and craniofacial surgery. Plan to meet with Dr. Mason at the beginning of the rotation and he will go over his Welcome Packet that includes introductory information, weekday and weekend workflow, resident responsibilities, Day Call, The List and Transition of Care and Children's Specific Conferences including Oral Boards. You are encouraged to read this prior to starting your rotation.

This page contains other informal tips and tricks from prior residents.

Important phone numbers:
Maureen Andrews: 303-929-7929
OR charge: 64890
OR Desk: 76492
ED: 76888
OneCall: 73999
Yellow Team: 79247
IT: 74357
Phone stems: 720-777-XXXX. 720-752-XXXX. Numbers that start with 6 are all internal (usually nurse PCD). The only way to call back from outside is to call OneCall and ask them to connect you.

On call: either call OneCall or go to the Children's home page, click on Quick Links, then Amcom (must be at the hospital or remotely using the CHC Desktop).

Lounge space (ONLY Independents have access): There's a surgeons lounge on the 2nd floor with food and drinks.

OR Lockers: There is a designated PRS locker in the Men's and Women's locker rooms.

Expectations: OR takes precedence over clinic. However, if you are not in cases, you are expected to attend clinic. If simultaneous cases, cover cases in order of seniority (Dr. French's cases covered first, then Khechoyan). Of course, if one of the more junior attendings is doing a really cool case, talk to French about covering those instead. Please look ahead and coordinate coverage as needed. Some cases require extra hands (ABG, breast reduction, etc).

Rounding: You will see all the necessary patients yourself and update the attendings. Maureen will also see the Cleft/Craniofacial patients, but this should not replace your rounding.

Children's is all electronic consents. In order to make a consent, you click on the Pre-op Consult tab in Epic and then click Consents. To make a consent - you click on New Surgical Informed Consent (or Panel 2 or Panel 3 if it's a combo case) and fill in the correct information in the boxes on the right. .MOMSNAME or .DADSNAME in the first box and then whatever parent (or patient) is signing for the kid. This MUST be accurate and only have one parent's name spelled correctly. They will hold the case if this is done incorrectly. You can add extra procedures and whatnot in Additional Procedure Information. Fill in your name as Provider Performing Consent. Often the procedure etc will already pre-populate. If you're consulted for a spine closure, etc, you'll have to type in all the stuff yourself.
-After the form is filled out, the parent can sign on the computer's signature pad or on the patient's iPad. To log into the iPad you put in the patient's DOB (MMDDYY). The consent must be closed (close the patient's chart) to access the consent on the iPad. Click submit after you and the patient have signed the consent. The attending can sign the consent when they're back in the OR.
Caveats:
-If the patient is over 18 and otherwise legally able to consent for themselves, THEY must sign the consent and not a parent. Parent should sign if they are the legal guardian of an otherwise >18 year old patient (delayed, etc).
-Transfusion consents are separate than the surgical sent. There is another box to click for the transfusion consent (fill out as above).

• Maureen is an awesome resource. She will seeing everyone herself too, and will write her own note. She'll also check in with people postop. Text her and the attending after any craniofacial or cleft case so she knows how it went. She provides teaching to all the families while in house, and is their main point of contact after they get discharged. If she's ever not there, you can get the teaching handouts for patients on discharge on the Children's home page - Resources - Patient Handouts.
• If you put in cranial distractors, Dr. French usually likes to teach the parents pretty quickly on how to turn the distractors themselves. However, for the first day or two, you and Maureen are responsible for distractions. Coordinate with her on who will do the AM versus PM turns.
• All of the craniofacial patients are neurosurgery primaries post-op. They are responsible for drains and everything. The only thing we are responsible managing are distractions.
• Consents - these cases are always booked under the neurosurgery attendings. The fellows are usually slammed in the mornings, so you are responsible for the consents. All the kids need a regular procedural consent as well as a transfusion consent. The plastics attendings are typically not on the consents– Include under Additional Procedure Information: “Co-surgeon: Dr. Brooke French, MD” as appropriate.

• Maureen helps to manage these patients pre- and post-operatively as well.
• There are multiple applicable ordersets (Plastics IP Alveolar Bone Graft Admission; Plastics IP Cleft Lip Repair Admission; Plastics Cleft Palate Admission)
• These cases are now being admitted to the hospitalist service Yellow Team post-operatively. Since they are non-surgical and rotate every week, they need a lot of hand-holding. Call them after the OR to sign out the patient to them (number above). Be VERY explicit about all instructions, nursing care, diet, pain meds, antibiotics, etc.
• For Dr. Khechoyan - all primary palate repairs go to PICU postop for airway monitoring (French's patients typically go to the floor). Khechoyan will also do a tongue stitch and sometimes a nasal trumpet sutured in that you have to remove the next morning. Sometimes Mo is able to remove these when she does her rounds. Coordinate with her as needed.

Cleft and Craniofacial patients: Once done in the OR, text Mo so she can meet you in PICU for handoff Mo rounds and manages these patients along with you, so please keep her in the loop on all things pertaining to these patients Outpatient visits and EPIC messages are generally Mo’s territory as well

Khechoyan has a big postop pathway, see separate document.

• The clinics are on the second floor of the outpatient side of the hospital. PRS patients are usually in Hallway B. There's a work room in the back hall that is shared with gyn and ID. Multi-D clinics are behind these. Sometimes you're in the clinics at one end of the hallway or the other (rooms starting with J versus rooms starting with K).
• There are several Multidisciplinary clinics that we attend: Craniofacial, cleft, brachial plexus, vascular malformations. You are mostly observing and writing notes (for some MDC clinics, Dr. Khechoyan will do his own notes).
• Plastic Surgery clinic: You are expected to see the patients yourself and then staff as usual. Notes are your responsibility.
• Brooke Jacobson is the go-to person for outpatient Plastics stuff. She'll also help you with wound care stuff on the floor if you ask her.
• Sometimes you will be called by Brooke to help with the odd clinic patient (usually for tissue expander fills, steroid injections, vac changes, etc.).

• You are first call for all consults (Face on even days, gen plastics, wound).
• For arranging outpatient follow-up, message the corresponding scheduler and the attending of record. See below
• NEW cleft lip/palate consults: Sometimes if the baby has a prenatal diagnosis, they have seen Mo to get information and to be plugged into the MDC system. I would let Mo know the baby has been born. The consult should go to the attending on call (or whoever is next) between French and Khechoyan. The primary team should consult OT for feeding. Mo can coordinate NAM/lip taping/follow-up with Dr. Lowe as needed.

ED Laceration Repairs

• Ask the ED to obtain supplies/local/baci ointment for you. They have a poor selection of sutures. I will go to the OR to select instruments I want (0.5 pick ups, small needle driver or Castros, small Iris scissors or tenotomies) and sutures.
• For ED facial lacerations, be mindful of absorbable versus non-absorbable sutures based on patient age and location of laceration. Discuss with attending if you are unsure.
• See above to message scheduler for follow-up. If using nonabsorbables that need to be removed in a patient that will require sedation, coordinate this beforehand. They can be scheduled for suture removal in the Procedure Center without coming to clinic.

Coordination of outpatient visits: - Send an EPIC Staff Message (does not need to be Secure Chat unless it is urgent) to Lindsay, Jordan, Marquise Sanford, Melinda Bond, and Brooke Jacobson RN. Include any relevant scheduling needs (ie, ‘s/p xxx procedure w/xxx MD, needs clinic follow up in 7-10 days’). Most of these visits will be scheduled with a PA, however if Dr. Khechoyan is on call please be very clear when staffing with him whether he wants them scheduled with a PA or with him - ED follow up visits: can be scheduled with Lindsay or Jordan. Again, if Dr. Khechoyan is the attending, they should all be scheduled with him unless he specifies that he is OK with them being with a PA. He will authorize overbooking his clinic to accommodate if necessary. - If a patient will require sedation for suture removal, please place an order for suture removal under anesthesia: Plastics Case Request–> Suture Removal, location PC, provider either Lindsay or Jordan (can be changed after it’s placed if needed) Still need to send an EPIC Staff Message to the team to notify them of the scheduling need If a patient does not require sedation for suture removal, can be scheduled as a regular clinic visit

Follow Up: cc Jordan and Lindsay French: Marquis Sanford Khechoyan/Yu: Melinda Bond

• Complex patients or possible non-op observation: If there's a complex medical patient coming in or if you want to have a patient stay overnight from the ED (ie lip hematomas etc that we may or may not operate on), you can have medicine admit them. Discuss with the attending. Call the One Call people and then select Admissions/Transfers and to be connected to the admitting attending and senior resident to discuss the admission.
• Yellow Team: In addition to our new collaboration with Yellow Team for Cleft patients, they admit post-op breast patients as well. There are certain other cases where you can admit post-op patients to them. Discuss with our attendings.

• __Liquid oxycodone is the one med that impacts our kids as it is hard to find outside of CHCO. Attaching the work around in case you think this is work sharing with the rest of the team. If not—feel free to discard and no reply back to me is needed. Happy Friday! Mo

*Walgreens Pharmacy at Anschutz Medical Campus: Hour of Operation Changes starting Thursday, April 14.

*New hours: pharmacy will be open Monday – Friday from 9 a.m. to 6 p.m. Closed on Saturdays and Sundays. *Plan: wallgreens will be directing patients with after-hours pharmacy needs to the following locations closest to Children's Colorado

*From CHCO Pharmacy team:

*15310 E Colfax Ave (M-F 9a.m. - 9p.m., Sat. 9a.m. - 6p.m., Sun. 10a.m. - 6p.m.) *Yes – 380 mL oxycodone liquid in stock (don’t typically use that much and could get quickly if ordered for the weekend) *10501 E Colfax Ave (M-F 9a.m. - 9p.m., Sat. 9a.m. - 6p.m., Sun. 10a.m. - 6p.m.) *No – NO oxycodone liquid in stock *10601 E Alameda Ave (M-Sat. 9a.m. - 6p.m.) *Yes – 257 mL oxycodone liquid (wouldn’t be able to get any in stock until Tuesday) *12051 E Mississippi Ave (M-F 9a.m. - 9p.m., Sat. 9a.m. - 6p.m., Sun. 10a.m. - 6p.m.) *Yes – 63 mL oxycodone liquid in stock

*The last alternative is to use the Afterhours dispense of critical medications policy. In this policy, critical medications can be dispensed for discharge by the inpatient pharmacy. However, some rules apply: *Only use if absolutely necessary on critical meds that can’t be obtained at another pharmacy *All meds have to have a specific dispense quantity as noted below *For non-narcotics like decadron, can dispense up to 72 hour supply *For Schedule IV drugs like Valium, can only be up to 24 hours *Schedule II drugs like oxycodone CANNOT be dispensed this way at all

*For 24 hour options:

*19028 Lincoln Ave Parker, 80134 *4001 E. 120th Ave Thornton, 80233

The language in these is geared toward parents, but includes lots of good information about care. These are helpful to refer to when parents call in about what they're supposed to do.

• Cleft Lip Surgery: cleft_cleftlipsurgery_eng.pdf
  
• Lip taping before unilateral cleft lip repair: cleft_liptapingbeforeunilateraloronesidedcleftliprepair_eng.pdf
  
• Lip taping before bilateral cleft lip repair: cleft_bilateralcleftlipandpalateliptaping_eng.pdf
  
• Feeding a baby with cleft lip/palate: cleft_feeding_your_baby_with_a_cleft_lip_or_palate_eng.pdf
  
• Cleft palate handout: cleft_palate_handout.pdf
  
• Cleft lip and nose revision: cleft_cleftlipnoserevoldchild_eng.pdf
  
• Mouth care instructions for ABG: cleft_mouthcareinstructionsforalveolarbonegraftsurgery_eng.pdf

As part of your rotation at children's, on the last Friday you will have oral boards. Dr. Mason tries to make these as straight forwarded as he can. The cases come from the book Plastic Surgery Case Review: Oral Board Study Guide. He gives you 5 cases: Unilateral cleft lip (French), bilateral cleft lip (Mason), cleft palate (Khechoyan), facial paralysis (Domeshek), and syndacytly (Domeshek).

Unilateral Cleft Lip (French):

• Make sure you understand the 3 phases of non-invasive intervention before surgery: Lip taping, Naso-alveolar Molding and palatal lift.
• Explain what Nordoff's point is (thinning of the white roll)
• You will want to have frequent appointments to make sure the baby is feeding well. So see the baby 1 week after leaving the hospital. Don't just schedule surgery at 3 months and trust other services.
• You will be asked about special bottles and how they work. They all use a gravity fed reservoir that squirts the milk into the mouth as the baby bites.
• You will be asked to draw a cleft lip repair. You have to practice drawing the lips and the markings. You also should do this quickly. I suggest learning to draw the Fischer Repair. They will give you a hard time if you don't draw this quickly and explain your markings as you draw. It isn't a horrible idea to draw your lip templates during the time you have to look over the pictures before starting.

Bilateral Cleft Lip (Mason):

• What is ideal lip height? 9-10 mm
• If you are lax, you will get worse complications. When the baby has cellulitis after surgery, bring them into the emergency room. If you see them in clinic the next day, you will have an abscess. JERRY, YOU HAVE TO SEE THE BABY.
• He sticks to the script pretty well.

Cleft Palate (Khechoyan):

• Asks for two syndromes associated with cleft palate: Van der Woude (Lip pits), Stickler Syndrome (Retinal detachment)
• Then asks for a sequence - Pierre Robin Sequence. This patient will need a sleep study and maneuvers for breathing: prone positioning, nasal trumpet, lip tongue adhesion stitch vs distraction
• Asks to explain the aberrant anatomy

Facial Paralysis (Domeshek):

• Sticks to script on this one
• Will ask for pros and cons on different nerve transfers and timings of surgeries

Syndactyly (Domeshek):

• Also sticks to script on this one and very straight forward
• Basically goes through all the complications at the end. TAKE THE KID BACK TO THE OR and fix whatever problem came up.
• Make sure to splint in your post op care and get OT involved