Plastics

Dr. Michael Gordon
Dr. David Mathes

VA Templates

VA Prefixes: 720-857-xxxx or 720-723-xxxx. Use this last number to call back pages. ie. 1-2345, call 720 723 2345 skipping the 1.
Vocera: 720-723-7997 or 1-7997 (in-house), then say the name of the person you want to call (example: Pre-op charge nurse, K3 [room number] nurse, OR 1 nurse, radiology, outpatient pharmacy, etc.)

Welcome to the VA. The senior resident has good autonomy at this location and you are expected to run the service. Krysta Bearish is the PA who helps coordinate for Breast Surgery as well. She works Tuesday through Friday and is present at clinic and available if needed for the operating room. The interns rotate and cover multiple services and can be scarce. Somebody should be provided each week to come to clinic but that's about it. If this becomes an issue, let Dr. Mathes know, because the service really is starting to get busier especially with us starting hand. DJ is the plastics scheduler but easy to go through Krysta for most things. For cases at the VA, it is VERY important to make sure you have everything ordered beforehand. They won't have anything like integra or implants on consignment.

Signing up for the VA can be a huge hassle. When signing up make sure you have the following things:

• Access Code
• Verify Code
• PIN
• Signature Code
• Dictation Code (45 followed by the last 4 of your social. ie. 45XXXX)

Clinic - Tuesday AM 8-11:30. We are in Maroon Peak clinic. 3rd floor specialties clinic in Building E, in rooms 224 - 228. 3-2-4 “enter” is the code to the door to get back into the clinic from the waiting room. They're using this VetLink program now to show when patients arrive. Once the vital signs are taken, you call for the patient yourself and bring them to your room. You can edit the memo to say you are seeing the patient by adding your name/initials or adding “done” in the memo if the patient has been seen so everyone else is on the same page. The attendings have been using the 3rd room (room 228) from the main door as his office. Since we only have 3 assigned rooms, Krysta will often use one of the Thoracic rooms if an intern is helping in the clinic. Krysta will typically see the pre-ops, and the fellow/resident will see the new patients, and the intern will see everyone else. Obviously, if things fall behind, you see anyone. I also encourage you to at least peek in on your post-ops, as you are afforded quite a bit of independence in the OR and it’s a good way to learn from your mistakes. Because of COVID, we are disinfecting the rooms ourselves between patients).

If you have a case to schedule, the patient should be provided a business card with the contact information for the office (Krysta has those available). Sometimes we can offer them an OR date same day, but most of the time she will call them later in the week to get them onto the schedule.

For pre-ops, patients need: an H&P, pre-op labs (under pre-procedure labs), signed consents (consents are electronic: under “Tools” → iMed Consents → Plastic Reconstructive Surgery → Consents Basics → then select appropriate consent and follow prompts).

Make sure you always set up an encounter, a primary provider, and a diagnosis (The first 2 tabs when you set up the encounter). Then write the note - there are specific plastic surgery headings to select. You can create your own template or use a pre-populated one. Before I made my own templates, I often used the Urology clinic note template). When you sign the notes - add the attending and Krysta as co-signers. Also order clinic follow up appoints (RTC - specialty clinic - plastics).
If you are seeing a NEW patient consult: “Plastic Resident/Fellow Consult Note”
If you are seeing a patient for follow-up, post-op: “Plastic Resident/Fellow Clinic Note”
If you are seeing a pre-op: “Surgical pre-op H&P” then follow the prompts and check all the boxes

The plastic surgery operating room day is Thursday. The first case is supposed to roll into the room before 08:00 AM to not be deemed “late.” Start time is supposed to be 07:45 AM. The operating room is on the 3rd floor of the D building. There are locker rooms in the back of the resident call room.

Residents wear blue scrubs at the VA. There is a scrub card that can be obtained from the administrator's office and Krysta can help you obtain that. In a bind, you can sign out a pair of scrubs from the office as well.

Prior to procedure patients need orders, a pre-op H&P and a consent. Krysta typically handles all of this when she sees the patient pre-operatively. I recommend letting Krysta do the pre-ops while you see new patients and post-ops. If you had an intern for clinic they are typically also with you on your OR day. (Good luck! Starting in July 2021, there is one less intern and plastic surgery has gotten the short stick of this deal. There was no intern for the entire month of July.)

Admitted patients will go to the Building K - 3rd floor.

Prior to discharge, the patients will need:

1. Discharge order
2. Discharge Instructions
3. Pain medication
4. Brief-Op Note
5. Operative Note must be dictated the same day

You can either dictate (see below) or type your operative notes. However if you type, make sure it goes into the right encounter (it is often easier to simply dictate).

The attendings expect us to dictate all of the operative reports. Attached below are the dictation instructions. Your dictation code is 45 followed by your pharmacy ID.

DENVER VAMC Dictation Instructions

1. To access dictation system:

      From within the facility, dial x15075
      From outside the facility, dial 800-394-3845

When the call is answered, you will be greeted with a voice prompt which gives you instructions. 2. Enter your USER ID, followed by the # key. 3. When prompted, key in the patient’s full 9-digit SS number, followed by the # key. 4. When prompted, key in Work Type, followed by # key.

WORK TYPE REPORT TYPE 1 DISCHARGE SUMMARY 2 OPERATIVE REPORT 3 CONSULT & PROCEDURE 8 PROGRESS NOTE

At the sound of the tone, please begin your dictation.

* THE FOLLOWING MUST BE DICTATED DURING THE BEGINNING OF DICTATION* • IDENTIFY PATIENT NAME (SPELL THE LAST NAME AND FIRST NAME). • ENTER FULL SOCIAL SECURITY NUMBER • CLINIC SPECIALTY TITLE (i.e., ORTHOPEDIC, NEUROLOGY, PRIMARY CARE, ETC.) • DATE OF SCHEDULED APPOINTMENT • NAME OF CO-SIGNATURE (ATTENDING) IF APPROPRIATE.

3. If you wish to dictate multiple reports, press ‘8’ to end one and begin another. 4. To obtain a job number for the report you just dictated, press ## before hanging up. KEEP THIS NUMBER UNTIL THE DICTATION IS AVAILABLE FOR ELECTRONIC SIGNATURE. 5. To disconnect, simply hang up.

DICTATION KEYPAD FUNCTIONS PRESS 1 To pause dictation. 2 To resume dictating after pausing. 3 Rewind – rewinds approximately 3 seconds. Press ‘2’ to resume dictating. 8 To end current report & begin another ## To get job number of report just dictated before hanging up To disconnect, simply hang up.

‘LISTEN’ ACCESS 1. DIAL 800-394-3845 2. Press 333, followed by the # key. 3. Enter the patient’s full 9-digit SSN or Report number, followed by the # key. 4. The latest dictation or selected report will begin to play.

‘LISTEN’ KEY FUNCTIONS 1. PLAY 4. WILL GO TO END OF REPORT 2. PAUSE 6. NEW SEARCH 3. REWIND AND PLAY

SCI - This is the inpatient spinal cord unit (first floor of H).

• First Tuesday of every month there is a multidisciplinary meeting at 715 with us and PMNR
• Krysta typically gets first call. Whoever you are in clinic or OR that day is who I tend to staff the patient with.
• Our criteria is that their co-morbidities are relatively well-controlled, osteo has been addressed, and their albumin is 3 or above.
• Intraoperatively, Dr. Mathes typically does V-Y advancements, and Dr. Gordon does rotational flaps.
• Postoperatively, Dr. Mathes typically likes to keep the patients on antibiotics until the bone biopsies result. Dr. Gordon likes to keep dressings on for as long as possible (2 weeks) and sutures in for 4 weeks. Drains stay in until nothing consistently draining. Once sutures are out can start on movement protocol (led by PMNR).
• Patients are typically seen every tuesday after clinic. Will see with krysta. Have her or the charge nurse call for wound care nurse (Jen) to help you turn and go over what they have been doing for wound care. Unless ongoing concern for a wound, we typically stop following a week or two into their motion protocol.

Instructions for installing a card reader can be found at Military CAC. There is a section for buying a card reader and installing the required certificates.

See Aline's guide here: plastics_va_.docx

Dr. Mathes Post-Operative Instructions
Breast Tissue Expanders

Dressing

• You have a soft surgical bra in place. You may change the gauze or pads inside the bra as needed if they become damp or soiled.
• 48 hours after surgery, you may remove the surgical bra and dressings, and shower. Leave Steri-strips in-place, and pat them dry after showering. Do not submerge in water (tub bath, pool, hot tub) for 4 weeks after surgery.
• You may wear the surgical bra as needed for comfort, or you may go bra-less.
• If needed, apply antibiotic creme to any blistered areas, twice a day.
• NO ICE to the breasts.

Drains

• You will be sent home from the hospital with drains in place. Empty the drains as instructed twice a day, and record the amount emptied each time, for each drain.
• Bring the record with you to your post-op appointment, as this will determine if the drains may be removed. Drains are removed when draining less than 30cc per day.
• Make sure the bulbs are collapsed on suction after you empty them.
• You may shower with your drains, but be careful not to accidentally pull them out. Do not take a tub bath until after your drains are removed and the drain sites are healed.

Pain

• You will have some pain and discomfort from your surgery
• Take the pain medication that you have been prescribed
• If you have extreme pain not relieved by the pain medicine, or if you have swelling, fever, redness or drainage from your wound, call immediately

Activity

• You should begin walking as much as possible immediately after surgery.
• Refrain from lifting greater than 10 pounds, and strenuous activity or exercise, for 4 weeks after surgery.
• Do NOT sleep on reconstructed breasts—sleep on back, only.

Post-operative appointment:
7-10 days after your surgery day. If you don’t already have your post-op appointment scheduled, please call the number below to schedule with Dr. Mathes:

The Plastic Surgery clinic, E building 3rd Floor - Maroon Peak
720-857-5817

Date:
Time:

Prescriptions given:
Pain Medicine:
Antibiotics:
Anti-nausea medicine:

If you have further questions, please call the Plastic Surgery Clinic at 720-857-5817. If you require immediate attention after business hours, call the hospital 24-Hour Emergency Nurse Line at (866) 369-8020.