PGY-1 General Surgery
Blue – GI/ Colorectal
Purple – Surgical Oncology
Green - General Elective Cases
Red – Transplant
Red Surg clinic is 1-4 on Wednesdays. Clinic is on Purple 5. Red Surgery attendings are Dr. Richardson, Dr. Ney, Dr. Odland
Occasionally you will get called (on Red) to do Pre Op H&P on kidney donors (HFA building 8th floor), and also to refill pain meds on wound clinic patients (burn unit). When you give refills, make sure the request seems appropriate and that they didn’t just get 90 percocet the day before. Use the “refill enc” tab on epic to do a refill.
Finding the list:
Find a computer that has a “My Computer” icon
Go under the public file Pick RedSurg, pick the latest list
Remember to close the list once you are done editing, otherwise it stays open and nobody can edit it.
Make sure the list is updated. The students generally do this, but you don’t want the G2 to have to do it.
Other teams lists-
Green surgery is under “green surg,"
Blue surgery is under “blue surg,”
Where stuff is:
Most surgical patients are in the SICU or on STN 1, 2, 3. These are all on the 4th floor. STN 3 is for patients who need a cardiac monitor. STN 1, 2 do not have cardiac monitoring. The OR is on purple 4 and actually physically located directly above the street on the west side of the hospital.
Rounds: Everyone on the team pre-rounds but the chief. Team rounds with the chief are anywhere from 6-7 am, and they will tell you what time the night before. The G2 sees all ICU and transplant patients (Of note, if you ever get any sort of call on these patients, defer to G2. This is a hard and fast rule.). G1 and med students see floor patients. Have numbers ready for G2 about 10 min before rounds (Tmax, BP, HR, RR, Sats, I/O, BS if they were crazy high overnight). Usually labs and xrays are not back that early. Rounding with staff is dependent on call/OR schedule. Remember to cosign med student notes. Rouding starts at the high acuity patients, starting with SICU-1, then STN3, 2, 1, and then other patients in the hospital.
After rounds, I would suggest paging or finding Karen Lewis, the clinical coordinator for red surgery, and updating her on the plans for everyone for the day. She has surgery schedules for the week, and she is also instrumental for disposition. Make sure she is paged for rounds with the attending too.
Call:
If you are the Call I G1, then you are cross cover
If you are the Call 2 G1, then you are trauma (you need to get the pager from the post call G1) and sometimes urology, in which case somebody should be signing urology out to you. There is a urology sign out list on epic under shared patient lists.
If you are the trauma G1, your role is to fill out the trauma H&P (which often the med student does). The G2 does the physical and calls their finding out to you. A monitored trauma patient must have a physician with them until they get to the floor
D/C summary-the little card we got at orientation is very helpful if you choose to dictate. You do not have to do a dictated d/c summary if a patient is here <48 hours.
Name (yours)
Service
Date of dictation
Patient Name, spell it, MR, DOB
Staff
Admission diagnosis
D/C diagnosis
Procedures
HPI (you can say please see admission H&P)
Hospital Course
Labs
D/C Meds
D/C Exam
D/C Instructions
Code status
Dressing changes, if pertinent
Clinic follow up
Nursing homes/skilled care facilities will want your dictation right away (i.e. a copy will be sent with the patient) In this case, do a *1 dictation, which will be faster (within a few hours).
You can also do full d/c summary on epic if patient is here longer than 48 hours and you don’t have to dictate it. Patients require a brief d/c summary on epic if they are here less than 48 hours. There are templates for both of these on epic if you type in “discharge.”
Admission: Under order sets, type in admit, scroll to “Surgery Floor or Int Care Admission” Discharge: Under order sets in discharge navigator, type in discharge, scroll to “Surgery Discharge” orders
When you prescribe narcotics, remember you have to sign the prescription in red ink, and also it will print out to the computer nearest to you when you sign the order. Any pharmacy outside of HCMC will require a DEA number if you prescribe narcs (vicodin, codeine are ok).
Remember that when you sign the discharge orders, often the patient still has to wait for their meds to come up from the pharmacy. Often, I release the med orders and sign the scripts and send them to the pharmacy before the patient is actually going so when the nurse releases your discharge orders, the patient is all ready to go.
If you need the DEA number of your attending, just call the pharmacy and they will give it to you.
Type in “surgery” under notes template for surgical progress notes, tertiary exams, trauma h & p
Post op checks: Check on patient 4-6 hours after surgery
For these, document 1. Vital Signs 2. Pain control 3. Dressing clean/dry/intact and isn’t soaked in fresh blood.
Consent for procedures: Only do consents for procedures that your team does (no IR/GI lab procedures):
Risks usually include 1. Bleeding 2. Anesthesia 3. Infection 4. Convert to open if it is a laparoscopic procedure 5. Damage to nearby structures
Taking them out: Rule of thumb for being able to take them out is <50 cc per nursing shift.
Always check with your chief before pulling one. Generally you will want a CXR from the morning of the day you are pulling the chest tube. Usually you do not need a CXR after you pull it unless the patient worsens clinically.
The key to this is being FAST.
Re-enforcing-
1. Take all of previous dressings off
2. Assess wound and tube. Replace anchoring stitch if needed or add another if cut appears bigger than the tube. Use 3-0 silk.
Dosing for PCA aka CADD pumps-this obviously varies by patient, but here are some good starting doses
Advancing diet:
Any patient with head injury or LOC needs an OT order for cognitive evaluation while they are in the hospital. They also need a follow up appointment in TBI clinic usually 2 weeks after hospitalization- schedule the appointment under Dr. Sarah Rockswald’s name (PMR), and type in TBI clinic. If you just type in TBI clinic, nothing pops up.
Evaluating agitated patients:
If you get a call about an agitated patient, go see them. Make sure there is not a life threatening cause to their agitation. Do not order benzos, etc over the phone.
Clearing C spines:
The procedure for doing this is posted on the back of the surgery lounge door.
IF in doubt, consult with G2!
Tertiary Exams- need to be done on all new trauma admits within 12-36 hrs of admission. This includes non stab trauma admits. You can find the template on epic if you type in “tert.”
The purpose of these is to do a head to toe exam and make sure that no injuries were missed. This includes things like looking at patient’s skin from head to toe, examine all joints, look for lacs that need to be sewn, look for loose/broken teeth, look at TMs, note areas of swelling/ecchymosis, etc. If there is a lac that needs to be sewn, your responsibility as the trauma GI is to make sure it is done before morning rounds. My G2 wants me to tell you all that mandibular fractures are often missed, so look out for these.
You also need to compile all of the imaging that has been done and write notable findings in your note. If a study if pending, make sure to follow up on the result. Injuries do get missed, so make sure to be thorough and complete.
Tell your G2 if you find anything new on your exam! Med Students cannot do terts by themselves.
Sign Outs:
Make sure to give the cross cover a list, and go over it with them before you leave. Things like following up labs, post op checks , xray results are fine to sign out. If you are taking a sign out and know that a floor patient on another service is sick, give your G2 a heads up. You do not sign out ICU or transplant patients.
Have fun!
Remember, there are three rules in surgery: