Plastics

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Plastic Surgery at Denver Health\\

**Denver Health Faculty**\\
[[resident:corrine_wong|Dr. Corrine Wong]]\\
[[resident:stephanie_malliaris|Dr. Stephanie Malliaris]]\\
[[resident: haley_desjardins | Dr. Haley Desjardins ]]\\

==== Contact Information ====

PRS NP: Rosa DiPrima. 256-558-3028\\
PRS Clinic RN: Aimee Harmon. 719-661-1555 (MESSAGE FOR FU)\\

Attendings:\\
Stephanie Malliaris: 617 970 7590\\
Corrine Wong: 972 322 2078\\
Haley Desjardins: 207 838 1957\\

Surgery Schedulers:\\
Ortho: Jacob Geesling\\
Plastics: Christine Archuleta

==== Haiku Setup ====
{{ :medical_student:dh_haiku.pdf |}}\\
{{:medical_student:initial_patient_activity.png?400|}}

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==== Replant/Fellow Hand call ====
There is a google calendar that is shared that has the schedule of fellow call. Reach out to the 6s to get added to the calendar. It is shared amongst the three ortho hand fellows and the senior plastic surgery resident. Please reach out to the fellows directly and let them know that you put in your dates and to contact you if there are issues. More communication is better to have a good working relationship with them. Add yourself to 1 weekday per week and 1 full weekend for the month you are on. Can be any dates of your choosing. If you have a vacation you have to make up that week day in another week. Weekend call starts Friday at 5 pm to Monday 6 am. \\ 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, pus/washouts. All attendings take 1 week at a time starting at 5pm Friday\\


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All hand patients admitted while Malliaris or a PRS attending are on call get admitted to PRS team after the initial ortho consult.\\

{{ :resident:hand_fellow_excused_days.png?nolink |}}

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{{url>https://calendar.google.com/calendar/embed?src=dcj4rv5tr4ng8vdhk8ssrv7o7o%40group.calendar.google.com&ctz=America%2FDenver,800,600,noborder}}


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


==== Intern Information ====

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.\\
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There is a new outpatient urgent care that we have limited ability to go see the patient in person. Any time a plastic surgery patient is involved (ie. breast reconstruction where both gen surg and plastics are involved) the plastic surgery senior on call should be called.\\
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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 that can be found on this wiki. The night intern is also welcome to the wiki. If they do not have access, please have day PRS resident add night intern. It is the day intern's responsibility to make sure that the night intern has read the [[resident:nightfloat|nightfloat responsibilities]]. The ON CALL resident rotates and is the name on the calendar on the [[:start|start page]].\\

Every day at 6am, you must log into the plastic surgery service team and plastic surgery consult team on Epic. If patient's get admitted during the day, you must unassign yourself, and re-assign yourself to the team for nurses to know who to contact. All consults come through Epic. If nurses message you with concerns, please try to address or discuss with a senior prior to adding senior resident or attending to Epic chat.\\

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\\ 
- 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 (update H&P, 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 (not hand) patients: send EPIC basket message to PRS Clinic RN named above 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\\

==== Rounds ====
- The residents on service at DG will round on the plastic surgery service. The senior resident will communicate with the primary attending regarding patient care. \\

- Almost daily needed wound dressings: xeroform, bacitracin/vaseline, kerlex, ABD pads, ACE wraps, scissors, tape. Get more than you need. You can also ask the day before what kind of dressings to have ready on rounds\\
-If there are rotating sub-I students, you can have them collect necessary supplies and prep consents for the day. Often the attendings will have the exact procedure and associated risks noted in their attestations on the clinic note. You also should feel free to confirm the consent with the senior.\\

- 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.\\

-The weekend is split between Urology and Plastics, so as the intern you will cover both of these services. Additionally, the plastics intern now covers the RGB patients after they have rounded. Please let the weekend intern know who is rounding and pass along the rounding resident's number. Please also signout any patients on the list to the XCV intern\\

-The rounding resident will signout patients to on call PRS resident.\\

==== Cases / Clinic ====

Monday: Dr. Wong Pav A, Dr. Malliaris Clinic
Tuesday: Dr. Wong Clinic, Dr. Malliaris Pav A
Wednesday: Dr. Wong Pav L
Thursday: Dr. Wong Clinic, Dr. Malliaris Pav L
Friday: Dr. Malliaris Clinic


Dr. Wong has clinic on Tuesday AM and Thursday AM. Dr. Malliaris has Ortho Hand clinic on Monday all-day and general plastics on Friday morning.\\

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.  \\

Discharge instructions can be found in most senior resident's smart phrase list, or under Kendra Keene where 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: Aimee Harmon, 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 and patient's "wish photo". Black and white is fine.\\

==== CONSULTS ====
- The plastics intern takes first call during the day for any plastics consults. We do not see hand or face consults. \\
- 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 midlevel resident on-call who may ultimately assume care of that patient. The resident will generally staff directly with the attending  \\
- Dr. Wong covers all PRS consults unless Dr. Malliaris is on call for hand that week. When Dr. Malliaris is on hand call, she also covers PRS call.\\

=== Pressure Ulcers ===

MOST PRESSURE SORES ARE NON-OPERATIVE.\\

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. Below can be copied into the PRS consult note for all pressure sores and contains all required criteria to be optimized prior to surgical intervention. \\

Surgical closure of pressure sores has a high rate of failure. To maximizing the patient's chance for success, the following criteria must be met prior to consideration of soft tissue closure or reconstruction for chronic pressure ulcers: \\

- Wound:\\
The patient must have source control. Staged reconstruction can be considered for a clean wound after adequate debridement and antibiotic therapy optimization.\\
Debridements should be performed by the patient's primary surgical service or by the general surgery service. \\
If evaluation for osteomyelitis or bone biopsy is desired, the orthopedic service should be consulted. Often an MRI is necessary.\\
The infectious disease service should be involved for antibiotic recommendations. \\
The clean wound should be managed with a wound vac whenever possible until ready for soft tissue closure. There should be evidence of the ability to form healthy granulation tissue in the wound. If wound care recommendations are needed in the interim, please consult the wound care team.\\

- Nutrition:\\ 
Albumin > 3.0 gm/dl\\
Prealbumin >16 mg/dl. \\
In general, patients with osteomyelitis and inflammatory processes do not have a normal prealbumin (negative acute phase reactant). However, if they can show consistent elevation in prealbumin over 3 weeks, they can be considered candidates for reconstruction. A nutrition consult should be ordered if these goals are not being met.\\

- Medical comorbidities: \\
Medical comorbidities, such as diabetes, must be well controlled.\\
Control of any spasms or release of fixed contractures that may impair flap mobilization should be obtained prior to soft tissue closure.\\
A bowel regimen must be well established and urinary control must be obtained. If necessary, stool diversion must be arranged prior to soft tissue closure. \\

- Postoperative disposition: \\
Pressure relieving surfaces should be used during hospitalization and should be obtained for outpatient use prior to closure (e.g. mattress, wheelchair). \\
Outpatient wound care, if needed, should be arranged.\\
Medical management follow up and rehabilitation plan should be set up. \\
Physical therapy, occupation therapy, and social work should be involved with the disposition process.\\
　
Once these parameters have been met, the patient can follow up with Dr. *** in outpatient plastic surgery clinic for evaluation. \\


==== Replant Protocol ====

__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

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==== Discharge Summary ====

Discharge summaries need to include a complete list of every diagnosis or medical issue that impacted your patient’s care during their hospitalization in the discharge summary. The discharge summary is the first documentation that coders review. If the diagnosis is not present in the DC summary, even though it was treated during the hospital course, payers use this discrepancy to deny payment.

 

Ways to phrase things: Apparently there is  widespread use of the words “in the setting of” to possibly link conditions together.  For coders to link conditions together, the physicians and APPs need to use linking verbiage like “due to”, “secondary to”, or “with”.  Do not use “iso” or “in the setting of”.



==== Denver Health Phone Numbers ====

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\\