GOLD SERVICE RESIDENTS AND STUDENTS

ORIENTATION GUIDE

Welcome to the Gold service.

We hope you are going to learn a lot, and perhaps have a decent time  in the process.

This guide is meant to cover some of the administratvie, non-clinical aspects of your rotation, and to make clear what our expectations are.

• ADMINISTRATIVE STUFF

  BEFORE YOU SHOW UP

  www.TeachingSurgery.com

  This website contains basic information on Trauma at WHC and trauma in general. This was written and designed by Dr. Sava. Finish at least module one (orientation), since he will ask you about this. You’re going to have to do them all, so you might as well do them early. Dr. Sava spent a lot of time creating this content, and he gets cranky when residents don’t do all the modules early in the rotation.

  WHEN YOU SHOW UP

  Park in Pavilion 1 or 2.  Hold on to your ticket and you will be validated when you work your parking out.

  Report to GME on the 6^th floor, by taking the B elevators at some point on day 1.  GME will set you up with info on how to get your I.D., parking and ZipThru Card (a.k.a GoCard).  The Trauma office is on 4^th floor and you will need to show your face there on Day 1.

  Ask one of the nurses to orient you to the trauma bays in MedSTAR.  This will be helpful before you have to work your first trauma.

  TRAUMA PAGER

  1)  You have to leave a cash deposit to get a pager and work on this service.

  2)  There are no exceptions.

  3)   It does not matter whether you were here before and didn’t leave a deposit, whether you leave deposits on other services, or whether you got the pager already from another resident.

  4)  You must give the money to the trauma office, not to another departing resident.

  5)  The administrative assistant has no authority to deviate from this policy or make exceptions.  Trainees should not direct any complaints or suggestions toward the admin. assistant.  Refer any questions to Susan Kennedy orDr. Sava.

  6)  If you don’t have cash with you, or are suffering financial hardship, Dr. Sava will personally loan you the money for as long as necessary.

  7)  If you finish your rotation on a weekend, you have two options:

  a) You can leave the pager with the oncoming resident or in the trauma office.  Call the office when it opens on Monday to complete checkout and arrange repayment.  We will not give you your money back until checkout is complete, and we have either a) the returned pager, or b) the deposit from the oncoming resident.

  b) Arrange in advance to have the attending on call on the weekend give you your deposit in exchange for the pager. This will need to be arranged several days in advance through the trauma office.

  The current system arose after a long history of problems and failed solutions. Thanks for your understanding.

• SCHEDULE

  Monday	7 am Trauma M&M in 4B45
  	7:30 am Pass-on rounds in MedSTAR
  	9 am Trauma attending rounds
  Tuesday	7:30 am Department of Surgery Education day begins in True Auditorium
  	11 am Multidisciplinary Rounds on 3E. Attending rounds to follow.
  Wednesday	7:30 am Pass-on rounds in MedSTAR
  	9am-12am Trauma Clinic
  Thursday	7:30 am Pass-on Rounds
  	9am-12am Trauma Clinic
  Friday	7:30am Pass-on Rounds
  	After M&M attending rounds
  Weekend	8am Pass-on Rounds

   

  EVALUATIONS

  We usually evaluate students and residents in a group meeting. We are committed to fair evaluations by people familiar with the evaluee’s work. Please remember two things:

  1) In order to get honors, you must demonstrate independent learning skills, and 2) Any evidence of dishonesty during your rotation will likely result in a failing grade.

• CLINICAL DUTIES

  WORKHOURS

  You are expected to be compliant with all relevant duty hour regulations, and to take responsibility for your compliance. It is expected that when you need to leave to be compliant, you will sign out whatever remaining work you have. Violating duty hour restrictions to clean up your service is not an option, and puts the residency program in jeopardy.

  These days, no description of duties is complete without a discussion of recent resident work hour restrictions. The trauma service is committed to compliance with the 80-hour work week. To avoid erosion of patient care and training, though, you must remember the following:

  Work hour limits are an average over 4 weeks. These regulations are not meant to imply that a resident must go home at a certain time every single day. There are light days, and there are days when all the teams must pull together and stay until the work is done. Work hour limits do not preclude reading (self-initiated or mandatory) during off hours. Work hour limits do not prevent your from calling in to check up on your patients.

  TEAM LEADERS

  You are responsible for all aspects of care of the patients on your service at all times. You must use your judgement in delegating tasks to juniors, and must bear ultimate responsibility for any failures anywhere on the team. When working with a particularly inexperienced or ineffective team, you will be expected to supervise more and delegate less, in order to maintain a tight service.

  You are expected to see every patient every day. By morning rounds, you should be thoroughly up-to-date on all your patients’ problems and plans. Most of the time, this will mean seeing them yourself before rounds. If your service is quite busy, or has an unusual number of ICU patients, you may choose to wait until after rounds to see some patients, but you are responsible for the comleteness and accuracy of your teams’ assessment.

  You are responsible for continuity of care for your patients, even when you are not in the hospital. You are exected to sign out tasks and follow-ups as if it was your own life that depended on it. If the person to whom you sign out doesn’t follow through, you will be held resonsible for the lapse in care. Important sign-out items probably merit a quick phone call that night, to make sure the on-call resident followed through.

  INTERNS/STUDENTS

  You will see the patients assigned to you in the morning and make rounds with the TTL before pass-on.

  You will attend all trauma educational conferences

  You will write a note on each of these patients before morning rounds

  You will fill out the forms for multidisciplinary conference

  You will maintain the problem list

  You will be responsible for completion of H&P and discharge paperwork

  You will be stuck with mopping up incomplete dictations from the person on service before you from your institution. There are usually just a couple discharge summaries that hadn’t worked their way into the system by the time the previous person left.

  VACATION

  Discharges
  All paperwork needs to be filled out before rounds on day of expected discharge. This includes 23h observation patients. Patients going home will require PICC map. Patients going to a rehab facility will need stat DICTATED D/C summary as early as possible. Addendums can always be done on day of discharge. It is best to touch base with SW as often as needed. Patients that have stayed longer than 48 hours will require dictated discharge summaries. You will need to complete these prior to leaving WHC or they will be assigned to the person who follows you. Patients with a CHI will follow-up in the Trauma clinic in 1-2 weeks. Patients with an ICH will follow-up with Neurosurgery. Patients who had no chest or abdominal or CHI injuries DO NOT need to follow up in Trauma clinic unless they have sutures or staples. Have patients with sutures or staples return in 1 week.

  Social work issues/placement is unfortunately a big topic on the trauma service. The best way to keep up with this is with frequent personal communication with the social worker. On 3E this is Karen Levinson. Don’t let her bark fool you. She is often irritated, but usually not at you. Try to talk to her every day so that we get placement stuff rolling early.

  CONTINUITY ROUNDS:

  Weekdays – 7.30am in Medstar Conference Room
  Weekends / Holidays – 8.00am in Medstar Conference Room

  The goal of continuity rounds is to briefly go over each patient in the presence of attendings, the NP, and the social worker. Various attendings can give their input, the social worker can find out what to work on, and the NP can mention safety items like DVT prophylaxis or vaccinations. On Monday, Wednesday, and Friday, continuity rounds will be followed by attending ICU and ward rounds. On Tuesday and Thursday, continuity rounds will be followed by attending ICU rounds.

• DOCUMENTATION

  There must be a note by morning rounds.

  The daily note must have two components: data and interpretation. For the hospital to bill for service, a certain volume of data must be recorded in the progress note each day. However, this painful process is no substitute for an actual discussion of the team’s thoughts.

  Digression:
  Decades of lawsuits and insurance company tricks have ravaged the medical record. Most progress notes simply regurugitate information that is widely available elsewhere in the medical record. The actual plans and concerns of the treating team are rarely evident in the progress notes. While we have learned to practice medicine most of the time without meaningful progress notes, there are several big problems:

  First, lawsuits generally happen long after the patient leaves. We are then faced with a chart that shows, for example, an order for steroids, or a nursing note which documents chest pain. Without a note saying what we were thinking, we are left testifying that “I don’t remember why we gave steroids, but it must have been a good reason” or “I assume that we evaluated the guy’s chest pain at some point, and I really doubt that it had to do with his death, because we’re usually good at that stuff…”

  Second, insurance companies stop paying when they don’t see an ongoing active problem that justifies hospitalization

  Third, in an emergency, it can be nearly impossible to figure out a patient’s problems.

  Therefore, please keep the following in mind:

  Every significant order should be explained in the progress notes.

  The daily note should include the current problems, and the thinking of the team. If we are starting a drug, say why. If we are ignoring some finding, say why. If we are going to tolerate a fever for one more day and then order a CT, put that in the note.

  Get in the habit of writing quick additional notes when something happens. Don’t feel that each note has to be long or formal. The following brief notes convey critical information:

  “09-04-03 2pm Breathing comfortably now. Abd exam unchanged”
  “05-03-02 11am Reviewed CT with Dr. Wang. The spleen doesn’t seem to have bled. Source of HCT drop not clear, will continue to follow.”
  “12-23-02 830pm Tenderness now completely gone”

  Most importantly, never EVER write down a finding that you didn’t actually test. If you can’t find the ankle reflex, but are pretty sure there is no neurological damage, DON’T WRITE IT IN THE CHART. If you are were in a rush and didn’t listen to the heart, DON’T SAY THAT IT WAS NORMAL. These little errors are fuel for legal trickery that can be used to sue good caregivers, and to get violent criminals off the hook. The game is to find internal contradiction in the chart (e.g. the echo says severe AI but the trauma team says “Normal S1S2”) and thereby discredit everything else we said. In the hands of a clever lawyer, its devastating. If you don’t have confidence in some finding, either ask your senior, or write that you are having trouble with the exam.

  The clerk will print out paperwork for each patient that comes in. All of the H&P forms must be filled out(Pages 1-4). If parts of the history or physical are impossible, write why you can’t do them on the form. Page 5 is filled out by the Team Leader and attending. Page 6 (procedures) is filled out as necessary. The are yellow sheets in the clerks area, which is for the list of injuries and procedures performed on every patient. Burn diagrams need to be filled out on all burns admitted through MedSTAR. Order sheets for the floor and 23 hour observation can be found in the clerk’s area. ICU orders will often be filled out by Team Leaders unless they are in OR and you may need to fill them out. Every patient seen and evaluated (traumas, burns and consults) should have a sticker placed on the log, which is located at the nurses station in MedSTAR.

• MEDSTAR

  Medstar can be a challenging work environment, especially for senior residents. In addition to the occasionally frantic pace and clinical urgency, there is occasionally friction between residents and nurses. Usually the problem involves the team leader’s impression that their authority is not being respected. Some of these conflicts are due to personality clashes, and are inevitable. However, please consider the following general rules:

  1) We expect that the trauma team leader will run trauma resuscitations, and that their orders will be followed. They should not be bypassed.

  2) Many Medstar nurses have a wealth of experience, and have been here long enough to have seen a few dangerous residents. If they don’t know you, they are in a difficult position.

  3) A nurse who feels a resident’s plan is dangerous must have recourse. They may sometimes be wrong, but they have a moral resonsibility to confirm a plan that they think is really bad. This should not be taken as an insult.

  4) Residents and nurses must maintain a professional demeanor, and speak with respect. Sarcasm, name-calling, unpleasant tones of voice, and passive aggression are unprofessional.

  You need to get official reads on ALL studies done on each patient. If patient is going home, this becomes even more important. We need to prevent missed injuries at all costs. Sometimes the radiology-attending read will differ from consultant’s read. Please bring this to their attention in tactful way. The radiologists are located next to x-ray on way to ER. A radiologist will be there from 8am until 1am. Starting at 3am there is a radiologist, although they are usually hidden somewhere else. You can get the pager number for the radiologist on call from the techs in the CT room. Out of courtesy, don’t page the radiologist until all of the studies are done. There is no radiologist in house from 1am to 3am. You must look at every x-ray with a radiologist or your Team Leader. Your own read is not acceptable.

  SPECIALTY SERVICES

  Service Transfers.

  Review the document hanging on the wall in MedSTAR. Injured patients are managed according to the injuries they have that require inpatient care.

  If the patient has injuries requiring inpatient management by several services, they stay on the Trauma Service.

  If they have injuries requiring only one specialty, they will be managed by that service.

  Some single-specialty injured patients will be observed on the trauma service overnight, then transferred to the appropriate service. The attending and team leader will identify these patients (examples include proximal bony injuries like pelvic fracture or L-spine fracture)

  No transfer should be ordered w/o documentation of discussion w/ an off service resident

  Items to have / known where to find

  Trauma Shears

  Stethescope

  Opthalmoscope (usually on the multifunction posts in one of the bays the patient is not in)

  Wound markers (paperclips on tape – on the windows or above the sinks in the bays)

  Patients with blunt thoracolumbar spinal injury go to ortho. All c-spine, and all penetrating spinal injury go to neurosurg. This is an absolute rule.

  We take care of trauma patients with orthopedic, neurosurgical, maxillofacial, and plastic problems. After trying it several different ways, we have come back to this arrangement for reasons of patient safety and resource management.

  If a patient has injury isolated to one of these subspecialties, and they operate on him/her, you may approach that service and find out if they feel comfortable transferring the patient to their service. If they agree, you may transfer, but if they are reluctant or uncomfortable, keep the patient. RESOURCES

  We have some trauma manuals which are easy reading, and quite helpful. We will loan them.

  Trauma attendings have a number of trauma/critical care texts that we are happy to share

  Ovid access is widespread throughout the hospital.

  We would be happy to direct you to our favorite book or review article on any topic. Just ask.

  CLINIC

  Wednesday and Thursday 9-12, in the Surgery Clinic area, ground floor. Patients call 877-7103 for appts.

  Tell patients to bring the yellow copy of the discharge instruction sheet to their clinic appointment to ensure proper identification. Patients should be provided with adequate prescriptions (at least enough pain medication to last until their next clinic appointment) before they are discharged. Avoid giving any narcotics over the phone for patients who you don’t know personally. If you must, provide only enough to last until the next clinic day.

  All scheduled elective surgeries must be done through the Surgery Clinic and requires financial approval. The attending of record should be contacted prior to scheduling surgery. If the attending is unavailable, the on call attending for the day should be contacted.

  Don’t send patients with large posttraumatic ventral hernias to plastics, unless an attending directs you to do so. We generally prefer to manage these hernias ourselves.

  A resident physician should remain in the clinic until all scheduled patients are seen.

  CLINIC 12pm Wed & Thurs – On Call Team and NP attend. The attending on call for new admits is responsible for clinic.

  All vacations need to be cleared by Dr. Wang, Sava, or Williams.

  Only one team leader can go at a time

  We expect you to take time off your trauma rotation in proportion to your yearly vacation allottment. In other words, if your program gives three weeks/year, and you spend four months on trauma at WHC, then you are entitled to one week off during your rotation here.

  When a team leader goes on vacation, his/her patients should be assigned fairly to the other team leaders, who will “own” them for the duration of the vacation. Individual patients should not be shuttled back and forth between the remaining team leaders.

• LEARNING

  It is a minimum expectation that residents on this service will:

  1) Identify clinical problems (Every patient on service has at least one book chapter written about them…)
  2) Pick appropriate learning resources (We are happy to help and suggest)
  3) Read
  4) Present what they’ve learned to the team and attending

  We will NOT give a resident or student honors unless they demonstrate a consistant pattern of self-directed learning, no matter how cheerful and hardworking they may be.

  PREPARATION FOR EDUCATIONAL CONFERENCES

  Each team should have a few xrays/CT’s in mind to use at Wednesday xray rounds. It wastes everyone’s time if we have to sit and think of cases to discuss. They don’t have to be fascinating or unusual films.

  Proper preparation for M&M takes some time. The basics are:

  Thorough review of the patients’ course. Data related to the event should be memorized. Use notes if necessary. Anticipate where the discussion will go, and gather the data. Talk to people who were involved, and review ALL pieces of the medical record (e.g. nursing notes, respiratory flowsheeet).

  If films are relevant, know which specific image to open. We don’t want to watch you flip through 600 CT images to find the important one.

  Review the literature. You should not only become expert in the complication, but also in any other directions the discussion may go. You are there to educate us on what you have learned.

• RANDOM SURVIVAL INFO

  All door access codes are 1000*

  Supply room combination on 3E is 2-4-3

  Trauma Attendings include: Sava (WHC), Williams (WHC), Light (WHC), Dunne (Navy), Bowyer (Navy), Daza (GS WHC), Paul (GS WHC), Jordan (BURN WHC), Jeng (BURN WHC)

  Pages:
  All traumas will come across your pager as code yellow. The letters after code yellow indicate which level of response: cy = code yellow (severe injury) and tr = trauma response (more stable patient). Sometimes this is not accurate so show up ASAP. If response is 1 minute, this means they are already in MedSTAR waiting for you.

  MISCELLANEOUS

  In D.C., giving an addict methadone constitutes a commitment to manage ongoing methadone therapy, which we can’t do. So don’t give methadone unless you can speak to a methadone clinic and confirm a patient’s dose, or unless psych orders it. You can judiciously use other narcotics to manage pain in these situations, just not methadone.

  KEY NUMBERS (make a card and keep with you)

  OR 7-6411	MedSTAR 7-7210/7-3258/7-7272
  PACU 7-6724	CT 7-5301
  ER 7-5515	X-ray 7-3616
  Amb care in ER 7-5516	U/S 7-6030
  3E 7-6351/7-3151/7-6352	IR 7-6495
  3NW 7-3391	Fluoro 7-6469
  Vasc tech (p) 2524	Neuroradiology 7-3139
  PT/OT 7-6316	Weekend PT/OT (p) 2840
  Neurosurgery (p) 0009	NASCOT 877-1497
  Cardiology (p) 5757	Team Leader GT (p) 9828
  Trauma/Ortho clinic 7-7103	OMFS Clinic 7-7332
  Ophthmology Clinic 7-3937	Neurosurgery Clinic 7-0333
  Urology Clinic 7-7011	ENT Clinic 7-6733
  Posting 7-6405	Trauma office 7-5190
  Lab 7-5242	Medical Records 7-7173