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Surgical Rotation Handbook

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Surgical Rotation Handbook Powered By Docstoc
					

                                         

    The UNIVERSITY of WESTERN ONTARIO


      SURGICAL ROTATION HANDBOOK

           A PRACTICAL GUIDE FOR
                     

                     Medical
Students

                              

                       Military
PA’s

                              

                Visiting
Elective
Students

                              

             International
Medical
Graduates

                                         







                          Suggestions
or
Copies
Contact:

        Christine
Ward,
Program
Administrator,
Division
of
General
Surgery

                             christine.ward@lhsc.on.ca

                               Revised:
August
2010

                                              TABLE OF CONTENTS
    SECTION 1: CONTACT NFORMATION                                           PAGE                SECTION 6: URGENT SITUATIONS
                          PAGE                Prescribing Privileges          44                                               PAGE
    Surgical Rotations   7-8                                                                    Just the Facts - Critical Care
                                              SECTION 5: GENERAL SURGICAL                         OutreachTeam (CCOT)          63
    Division of General Surgery London        INFORMATION
    Consultants & Secretaries 10                                                                Respiratory Status            64
                                              The Operating Room                 47
    Telephone Extensions –UH/VH/SJH                                                             Cardiovascular Status         64
                              11-13           At Time of Operation               47
                                                                                                Neurological Status           64
    LHSC One Number Patient Access            Pre-op Orders                      47
                                  14                                                            ACLS Protocol                 65
    Division of General Surgery – Windsor     OR Note                            47
                                  15-16                                                         CXR Approach                  66
    Windsor Community Surgery Program         Post-op Orders (major surgery) 48
                                  17                                                            ECG Interpretation            66
    SECTION 2: POLICIES                       Post-op Orders (minor surgery)          48
                                                                                                Acute MI                      67
    Call Policy                  20           Patient Order Guidelines           49
                                                                                                Cardiac Enzyme Profile        68
    Fragrance Free               21           Admission History             50
                                                                                                Trauma/Emergency Surgical Patient
    LHSC Mission                 21           Admission Orders              51                                             68
                                                                                                Surgical Abdomen: Indications for
    Shared Values                21           Abdominal Pain DDx            52                  Urgent OR                  68

    Code of Conduct              22           Common Causes of Post-op Fever 53                 SECTION 7: MISCELLANEOUS

    Resolving Conflict           22           Daily Progress Note POD#       53                 Thyroid CA                    71

    SECTION 3: ROTATION GUIDELINES            Discharge Dictation           54                  Thyroid Nodule Workup         72

    General Surgery Guidelines 26             Commonly Ordered Meds         54                  Surgical Wound Classification 72

    On Call Guidelines           27-28        Insulin Sliding Scale        55                   Infection Prevention and control really
                                                                                                starts with YOU!              73
    Rocket Rounds                28           Blood Transfusion Risks      55
                                                                                                Management of Coroner and Non
    Anesthesia Guidelines        29           Clinical Pearls               56                  Coroner Case Deaths       74

    Radiology Guidelines         30           Upper GI Bleed                56

    ENT Guidelines               31           Lower GI Bleed                56

    Ophthalmology Guidelines      31          Acute Cholecystitis           57

    Orthopedic Guidelines        32           Ranson’s Criteria for Pancreatitis           57

    Dictaphone Dictating Instructions    33   Appendicitis                  58

    SECTION 4: PHARMACY                       Bowel Obstruction             58

    LHSC Pharmacy Services: What You          Hemorrhoids                   59
    Need to Know             37-41
                                              Groin Hernias                 59
    Writing Orders               42
                                              Inflammatory Bowel Disease         60
    Order Signing                43



2                                                                   3
2                                                                     3
    SECTION 1:   CONTACT INFORMATION

            Surgical Rotations
            Division of General Surgery London - Consultants & Secretaries
            Telephone Extensions UH/ VH/ South Street
            LHSC One Number Patient Access
            Division of General Surgery Windsor Consultants
            Windsor Undergraduate Education Contacts
            Windsor Community Surgery Program




                                     5
4
4                                     5
                   SURGICAL ROTATIONS CONTACT INFORMATION
                          Be sure to call the contact person the Friday before starting that rotation.

    Anaesthesia                  Contact: Linda Szabo #33283, Room B3-218
    Dr. I. Inglesias             email: linda.szabo@lhsc.on.ca
    University Hospital

    Anaesthesia                  Contact: Christina White #58525, Room D2-315
    Victoria Hospital            email: christina.white@lhsc.on.ca

    Anaesthesia                  Contact : Valerie Rapson #64218 , Room A1-609
    Dr. P. Armstrong             email: valerie.rapson@sjhc.london.on.ca
    St. Joseph’s

    Cardiac Surgery              Contact: Liz Millar #33181, Roo m B6-102
    Dr. R. Guo                   email: liz.millar@lhsc.on.ca

    Diagnostic Radiology         Contact: Christine Koustrup #32615, Room B6-667A
    St. Joseph’s                 email: christine.koustrup@lhsc.on.ca

    ENT                          Contact: Angelika Edwards # 55807 Room B3-C46
    Dr. Kevin Fung               email: angelika.edwards@lhsc.on.ca
    Victoria Hospital            Reporting instructions will be emailed to you.
                                 Please view the Clerkship Lecture: http://www.uwoent.ca/files/Clerkship_Lecture.pdf, and
                                 review the web-based Clerkship Learning Modules: http://www.uwoent.ca/node/30,
                                 before your rotation begins.

    Ophthalmology                Contact : Lyn Clark # 66382, Room B2-072
    Dr. Ian McIlraith            email: lyn.clark@lhsc.on.ca
    Rotation Director
    St. Joseph’s Health Care

    General Surgery              Contact: Christine Ward #33269 Room C8-114
    Dr. P. Colquhoun             email: christine.ward@lhsc.on.ca
    Site Coordinator             Friday before starting rotation page Sr. Resident on the team you have been assigned to.
    University Hospital

    General Surgery              Contact: Liz Radford #75435, Room E2-619
    Dr. N. Parry                 email: liz.radford@lhsc.on.ca
    Site Coordinator             Friday before starting rotation page Sr. Resident on the team you have been assigned to
    Victoria Hospital

    Neurosurgery                 Contact: Nicole Farrell #33696, Room B7-005
    Dr. D. Steven                email: nicole.farrell@lhsc.on.ca
    University Hospital

    Orthopedic Surgery           Contact: Kathy Stead #33689, Room C9-126
    Dr. S. MacDonald             email: kathy.stead@lhsc.on.ca
    University Hospital

6                                                              7


6                                                               7
Orthopedic Surgery       Contact: Martha Boertien #66312, Room D0-203A
Dr. K. Faber             email: Martha.Boertien@sjhc.london.on.ca
St. Joseph’s Health Care

Orthopedic Surgery        Contact: Kathy Stead #33689, Room C9—126
Dr. S. MacDonald          email: kathy.stead@lhsc.on.ca
University Hospital

Orthopedic Surgery        Contact: Sarah Smith #58525, Room E4-120
Dr. C. Bailey             email: sarah.smith@lhsc.on.ca
Victoria Hospital         The week prior to starting rotation page senior resident on team you have been assigned

Plastic & Reconstructive Surgery
Dr. B. Evans             Contact: Karen Heyda #32919 , Room B8-030
University Hospital      email: karen.heyda@lhsc.on.ca

Plastic & Reconstructive Surgery
Dr. B. Richards          Contact: Melanie Johnson #66046, Room D0-201
St. Joseph’s Health Care email: melanie.johnston@sjhc.london.on.ca

Plastic & Reconstructive Surgery
Victoria Hospital        The week prior to starting rotation page senior resident on team you have been assigned

Thoracic Surgery          Contact: Maria Silveira #58777, Room E2-120
Dr. D. Fortin             email: maria.silveria@lhsc.on.ca
Victoria Hospital

Urological Surgery        Contact: Amanda Travers #33180, Room C4-207
Dr. P. Luke               email: amanda.travers@lhsc.on.ca
University Hospital

Urology                   Contact : Michelle Demaiter #66384 , Room B4-673
Dr. S. Pautler          email: michelle.demaiter@sjhc.london.on.ca
St. Joseph’s Health Care

Vascular Surgery          Contact : Traci Devulgt #76794, Room E2-119
Dr. T. Forbes             email : traci.devulgt@lhsc.on.ca
Victoria Hospital




                                                        8                                                           9


                                                         8                                                          9
               DIVISION OF GENERAL SURGERY – Consultants & Secretaries                                                     TELEPHONE EXTENSIONS – University Hospitall

NAME                             PAGER   ADDRESS       TELEPHONE   FAX     SECRETARY             Admitting                35191/33191               Preadmit Clinic
Muriel Brackstone                15770   LRCP - A3-    58712       58744   Davina Menard
                                                                                                 Bed Booking              35849/35845               Main                    33709
                                         931
                                                                                                  th
Andreana Butter                  19188   VH - E6-311   58401       58421   Joy Chapman           8 Floor Clinic                                                       Fax   33495

Patrick Colquhoun                14498   UH - C8-128   33287       33906   Katherine Pereira     Maureen – Clerk          33188                     Preadmit Nurse          33923/34750
                                                                                                 Nurses                   33192                     Customer Support        35959
Ward Davies , Chair/Chief        10433   UH - B8-007   33458       33457   Christine Stephan
                                                                                                 Operating Room                                     Computer Help Desk 44357
David Girvan                     14606   VH - E2-218   76772       76605   Carol Breen           Main Desk                33310                     Security                32281
                                                                                                 OR Booking               35846                     Clerk Seminar Room 35423
Daryl Gray                       14610   VH - E2-217   76583       76546   Jo-Anne Brodie
                                                                                                 OR Lounge                34893/34894               Urology – Dr. P. Luke
Roberto Hernandez                13812   UH - C4-212   32920       33858   Lois Cloutier         PACU                     33290                     Amanda Travers          33180
                                                                                                 Radiology                                                            Fax   33858
Steve Latosinsky                 17670   LRCP - A3-    58740       58744   Judy Butler
                                         931C                                                    Bookings                 33212                     Plastics
Ken Leslie, Program Director     17639   VH - E2-213   76778       76764   Shelley Coad                                                             Dr. B. Evans
                                                                                                                    Fax   33034
                                                                                                                                                    Karen Heyda             32919
Vivian McAlister                 17712   UH - C4-212   32920       33858   Lois Cloutier         Film Library             32901
                                                                                                                                                                      Fax   33748
                                                                                                 ERCP Room                35232
Tina Mele                        15973   UH - C8-005   33970       33459   Trudy Bain                                                               Dr. A. Fortin
                                                                                                 UH Health Records
                                                                                                                                                    Arlen Bermudez          32921
Neil Merritt                     15997   VH – E6-311   58401       58421   Joy Chapman           Main                     35841
                                                                                                                                                                      Fax   32907
                                                                                                 Transcription            35131
Mike Ott                         15966   VH - E2-211   58260       58378   Marcie Vandenberghe                                                      LRCP Health Records
                                                                                                 SJHC Health Records
                                                                                                                                                    Main                    58630
Neil Parry                       14883   VH - E2-217   76583       76546   JoAnne Brodie         Main                     64296
                                                                                                                                                    Correspondence          53254
Doug Quan                        13831   UH - C8-122   33355       33906   Evelyn Belanger       Transcription            65584
                                                                                                                                                    Transcription           53248
                                                                                                 Inpatient
                                                                                                                                                    Patient Referral        58602
Chellappa Rajgopal               10453   UH- C8-005    33460       33459   Trudy Bain            8th flr Desk             32400/32401
                                                                                                                                                                      Fax   58664
                                                                                                                    Fax   33056
Elizabeth Saettler               17075   LRCP- A3-     58740       58744   Judy Butler
                                                                                                                                                    Surgical Education – VH Rm E2-619
                                         931C                                                    4th flr Medicine         32430
                                                                                                                                                    Terri MacDougall         77104
Leslie Scott                     14223   VH - E6-204   58571       58241   Marcie Simmonds
                                                                                                 5th flr CCU              33356
                                                                                                                                                    Liz Radford             75435
Christopher Schlachta, Medical   17585   UH - B7-216   33478       33481   Teresa Vanderhoek     6th flr Cardiology       32444
                                                                                                                                                    Rachel Annett           76779
Director, CSTAR                                                                                   th
                                                                                                 7 flr CNS                32424
                                                                                                                                                                      Fax   58493
Brian Taylor                     14803   UH - C8-116   33209       33906   Brenda Campbell
                                                                                                 9th flr Ortho            32454
                                                                                                                                                    Department of Surgery – SJ Rm A2-017
Chris Vinden                     16803   VH - E2-215   58407       58408   Sharon Fountain       Emergency                33197                     Dinah Frank              32361
                                                                                                 ICU                      33870                     Kris Schroeder          33349
Bill Wall                        18792   UH - C8-002   32940       33067   Karen Sabine
                                                                                                 Endoscopy Clinic         33543                     Tricia Toderick         34773
Christine Ward, Program          17765   UH - C8-114   33269       33068   Janet Fenech                             Fax   33020                                       Fax   33076
Administrator                                                              32674
                                                                                                 Pathology                32956                     Complete Messenger Service
                                                                                                                                                                  519-679-3430
                                               10                                                                                              11


                                               10                                                                                              11
12   13
12   13
                            DIVISION OF GENERAL SURGERY – Windsor Consultants

         NAME            TELEPHONE          FAX           PAGER                               E-MAIL
                                           519-256-                    a.elalem@utoronto.ca
     Dr. A. Elalem        519-256-6590                519-561-1876
                                             8064
                                           519-252-                    gkgyetvai@hotmail.com
     Dr. K. Gyetvai       519-252-6538                519-561 2679
                                             3389
     Dr. B. J.            519-258-4433     519-258-                    bheartwell@cogeco.ca
                                                      519-255 6087
     Heartwell            519-258-8104       8793
     Dr. B. S.                             519-255-   Cell: 519-990-   laschuk@mnsi.net
                          519-255-9792
     Laschuk                                 9908     9044
     Dr. S. M.                             519-255-                    sliebman@cogeco.ca
                          519-255-9584                519-259 4099
     Liebman                                 9908
                                           519-973-                    yluo@uwo.ca
     Dr. Y. Luo             519-973-4693
                                             4693
     Dr. R. K.                             519-252-                    Alileen Cell: 519-890-9869
                          519-252-4049                519-563 1670
     Parashar                                3389
                                             519-                      mailto:apetrakos@cogeco.caapetrakos@cogeco.ca
     Dr. A. Petrakos      519-255-9616                519-259 6742
                                           2859908
     Dr. A. Ravid-                         519-258-                    ravideiny@hotmail.com
                          519-258-4433                519- 258 8104
     Einy                                    8793
     Dr. T.                                519-419-                    drttakahash@yahoo.ca
                          519-419-0792                519-225-8986
     Takahashi                               0793


      Student Counsellor

                     NAME                     PHONE                    FAX                          E-MAIL
     Dr. Arthur Kidd
                                                                                     akidd@hdgh.org
     Chief of Staff at Hotel Dieu          519-258-1335        519-258-8936
     Grace Hospital




14                                                    15
14                                                    15
UNDERGRADUATE EDUCATION
                                                                          WINDSOR COMMUNITY SURGERY PROGRAM
Ann Sovan [asovan@uwindsor.ca]
Manager - Windsor Undergraduate Programs                                  (1)   Surgery Rotations
                                                                                Surgery rotations will be at Hotel Dieu/Grace Hospital (228 beds, 16,400 surgical cases
Jeanne Hickey [jeanne.hickey@schulich.uwo.ca]
                                                                                per year, 2399 general surgical cases per year and 56,520 Emergency visits), and
Program Coordinator, Windsor
                                                                                Windsor Regional Hospital – Metropolitan Campus (320 beds, 1,431 surgical cases per
Christine Gignac [cgignac@uwindsor.ca]                                          year, 1,586 general surgical cases per year, and 56,515 Emergency visits).
Education Assistant - Postgraduate
                                                                          (2)   Clerkship and Surgery
Linda Wright [lindaw@uwindsor.ca]                                               Surgery Clerkship will consist of a twelve week block with four mandatory weeks in
Education Assistant - UGE - Psychiatry, Family Medicine and Paediatrics         General Surgery, two mandatory weeks in Emergency, as well as 3-2 week electives in
                                                                                Anesthesia, ENT, Ophthalmology (1 week plus 1 week in General Surgery), Vascular
Bev Nicholls [beverlyn@uwindsor.ca]                                             surgery, Urology, Neurosurgery, Orthopedics, or Plastics.
Education Assistant - Surgery and OB/GYN
                                                                          (3)   Services
NadiaHachem [nadiah@uwindsor.ca]                                                Hotel-Dieu/Grace Hospital provides services in General Surgery, Trauma, Plastics,
Education Assistant - Medicine                                                  Vascular Surgery, Ophthalmology, Urology, Orthopedics, Neurosurgery, Maxillofacial
                                                                                Reconstructive surgery. Windsor Regional Hospital provides services in General Surgery,
                                                                                ENT, Plastics, Orthopedics, Urology, and Maxilla Facial Reconstructive Surgery. The
                                                                                Maternal Newborn-Pediatrics program is located at Windsor Regional Hospital, providing
                                                                                exposure to the Neonatal Intensive Care Unit as well as Pediatric surgery.

                                                                          (4)   Gastroenterology Coverage
                                                                                There is gastroenterology coverage at both hospitals.

                                                                          (5)   Preceptor Assignment
                                                                                Clerks will be assigned a single preceptor during each of their rotations who will be
                                                                                responsible for their ward – O.R. evaluations. On-Call will be arranged with the clerk’s
                                                                                preceptor and is usually one in three to one in four. Overall evaluations will consist of
                                                                                assessment of ward performance (50%), as well as oral (25%) and written (25%)
                                                                                examinations. During each twelve week rotation clerks will have 46-50 mandatory
                                                                                lectures given by SWOMEN preceptors. There is an award for the best overall
                                                                                performance by a clinical clerk in the Windsor-SWOMEN surgery program given out at the
                                                                                end of each clerkship year.




                                               16                                                                      17
                                              16                                                                       17
     SECTION: 2       POLICIES

         Call Policy
         Fragrance Free
         LHSC Mission
         Shared Values
         Code of Conduct
         Resolving Conflict: what you can do




                                          18
18                                        19
CALL POLICY:                                                                                                attend the Half Day, they may be excused if they notify the Clerkship Coordinator (x86230)
                                                                                                            before the Half Day begins, although the clerk would still be expected to be familiar with the
As part of clerkship, clinical clerks are required to take call on some rotations. Some of these            material – PowerPoint slides and audio recordings are posted on WebCT within a day or so
rotations will include “in house” call and others will involve call from home. On call experience is        following the session. A clerk on call the night before an oral or written exam is excused at
considered to be an important learning opportunity. Being on call does not necessarily entitle a            10:00 pm.
student to be excused from clinical duties because they are “post-call” subject to the specific
policies outlined below.                                                                                � A clerk who has been on-call the day before leaving a service will not be required to take call
                                                                                                          on the first day of a “new” service.
This on-call policy, as approved by the CEC, applies to all rotations.
� A weekend call is defined as Saturday morning to Monday morning; Friday is not a weekend              � On the last day of a block, call will be over at 1800 hours.
  day.
                                                                                                        Any questions or conflicts with respect to the call policy should be reviewed with the
�       Clinical Clerks will not be scheduled for in-hospital duty more than:                           Clerkship Coordinator, Dr. Robert Stein, or brought to the attention of the student
             one night in three                                                                        representatives on the CEC.
             one weekend in three; the weekend duty will be calculated over the average
                 length of the block                                                                    FRAGRANCE FREE
� Requests from residents or others to do call more frequently than this should be discussed            London Health Sciences Centre supports the creation of a fragrance-free environment so that
  with the consultant(s) on the particular service and/or the Clerkship Coordinator for the             chemical barriers will not prevent access to LHSC for people having chemical sensitivities.
  hospital.
                                                                                                        All staff, contractors, patients and visitors are asked to refrain from using, wearing, and bringing
� Should the clinical clerk be called upon to furnish call of an intensive nature during on-call,       scented products and materials into LHSC properties and buildings. Compliance with this policy
  he/she will be relieved of further clinical duties after an adequate time for handover of patient     initially relies on the goodwill of staff, contractors, patients and visitors
  care responsibilities. This does not apply to educational responsibilities (e.g. lectures and
  seminars). Students should be aware that during holiday periods, the expectations for call may        "Scented products can cause allergic reactions and respiratory distress. Staff, patients and visitors
  be heavier.                                                                                           are asked not to wear or use any scented products while at LHSC."
� In those departments where the clerk is required to do shift-work (emergency room, ICU,
  etc) the guideline is a maximum work week of 6 0 h o u rs o r 5 shifts o f 1 2 h o u r s
  each.
                                                                                                        LHSC MISSION

� A clinical clerk will not be expected to take call “from home” for two consecutive weekends.          London Health Sciences Centre, a university teaching hospital, is
                                                                                                        committed to improving health. Building on our tradition of leadership
� Home-call will not exceed more than one night in two.                                                 and partnership, we champion patient-centered care, a spirit of inquiry
                                                                                                        and discovery and a commitment to life-long learning.
� For students doing call from home, they may be excused from clinical duties the day
  following call if they have had less than 4 hours of sleep due to their clinical duties while on      SHARED VALUES
  call. If such an occasion arises, the clerk must notify the most senior resident on the service
  prior to leaving the hospital and review why they need to be excused from clinical duties.            We will be guided by the following shared values:
� All students must round with their teams the morning following call and should be
  excused from clinical duties once morning rounds are complete.                                                Caring and Compassion

� All students must attend the teaching seminar for that day if the seminar commences at 9:00                   Collaboration and Teamwork
  a.m. or earlier. If the seminar occurs later in the day, they are excused from the seminar for that
  day. Students are still responsible for the educational content taught during sessions post-                  Integrity and Responsibility
  call.
                                                                                                                Innovation and Achievement
� Clerks who are on call before an Academic Half Day are on call. If the clerk is too tired to
                                                                                                                Excellence and Professionalism


                                                  19
                                                  20                                                                                                      21
                                                  20                                                                                                      21
CODE OF CONDUCT

London Health Sciences Centre is committed to providing a safe and
healthy work environment that inspires respect for the individual,
collaboration and teamwork.

R   Respect and consider the opinions and contributions of others.

E   Embrace compassion and show genuine concern for patients
    and their families.

S   Share your suggestions and concerns with discretion and tact.

P   Protect privileged information.

E   Engage in honest, open and truthful communication.

C   Create and foster a collaborative and caring work environment.

T   Treat everyone with dignity and respect.


RESOLVING CONFLICT: WHAT YOU CAN DO
Disagreements are expected to be handled in a courteous, respectful
and dignified manner. Public disputes or arguments with any other
individual which may be overheard by patients, visitors, staff or other non-
involved individuals are inappropriate.

If you have questions or wish to speak confidentially with someone
About conduct in the workplace, please call:

                Human Resources ext. 35222
                        Or
         Occupational Health & Safety Services ext. 77707

If you believe you have experienced inappropriate conduct, you have
several options to resolve the problem. Depending on the situation,
you may wish to discuss the inappropriate conduct with the person directly.
Or you may wish to discuss it with a leader or Human Resource professional.

There are a number of individuals throughout our organization who can
support you through this process. If you wish to have a confidential discussion,
prior to commencing a complaint, please refer to the website for a current list of
staff available to assist you.


                                                 22
                                                 22                                  23
     SECTION 3:       ROTATION GUIDELINES

          General Surgery Guidelines
               Goals and Objectives
               Ward Rounds
               Formal Teaching Rounds
          On Call Guidelines – University Hospital
          On Call Guidelines – Victoria Hospital
          On Call Guidelines – Pediatric Surgery
          On Call Guidelines – Acute Care Emergency Surgical Service Call
     Coverage
          Rocket Rounds
          Anesthesia Guidelines
          Diagnostic Radiology Structure
          ENT Guidelines
          Ophthalmology Guidelines
          Orthopedic Guidelines
          Dictaphone Dictating Instructions




23                                       24
24                                       25
GENERAL SURGERY GUIDELINES                                                                          ON CALL GUIDELINES: General Surgery (applies weekdays & weekends)
                                                                                                    University Hospital
Goals and Objectives:
                                                                                                    0700 to 1700          Ward Work: Page the clerk on that team during the day. If nurse is
� To gain an understanding for basic general surgical disease process and their management                                concerned about patient’s disposition, the call should go to junior resident
� To be ale to obtain a comprehensive yet concise history and physical                                                    for that team.
� To independently write patient orders, progress notes, admission notes and operative notes
� To gain basic technical skills in the operating room, in the ER and on the floor; for example,                          ER consults, Inpatient consults, Outside calls for team
  suturing, inserting Foley catheters, inserting NG tubes, starting IV’s                                                  1st call: junior resident
� To function effectively and efficiently as a member of a general surgical team                                          2nd call: senior resident
                                                                                                                          Do not page clerks for consults
� To manage common pre-op and post-op surgical problems
                                                                                                                          Outside Consults/Calls: If the call is from outside the institution (i.e.
Ward Rounds:                                                                                                              another surgeon or family physician) and it is an emergency then the
                                                                                                                          senior resident for the team on call for that day should be the one who
� Be on time
                                                                                                                          gets 1st page.
� Always make the daily morning rounds with the residents. Try to join the rounds with the staff
  and residents later in the day.                                                                   1700 to 0700          Ward Work: Page the clerk on call. If nurse is concerned about patient’s
� Ask the residents to explain aspects of the patients' illness or treatment that you do not                              disposition, then page the junior resident on call.
  understand. Residents assume you know unless you ask.
� Make sure that the team list is up to date, admission and discharges happen daily.                                      ER Consults/Inpatient Consults: Page junior resident on call.
� Know the results of all lab and x-ray investigations for morning rounds so you can follow the
  progress of each patient.                                                                                               Outside Consults/Calls: If a call is from outside the institution (i.e.
� Look at the lists on the chart racks and act on any requests.                                                           another surgeon, family physician, or patient) the senior resident on call
� When doing progress notes keep them short and simple.                                                                   should be paged.

Formal Teaching Rounds                                                                              Clerks:               If you are post call you are expected to go to your teaching seminar that
                                                                                                                          morning and then you are to be relieved of your duties. If the seminar is
University Hospital                                                                                                       scheduled for the afternoon, then you can decide whether you come back
General Surgery Rounds:         Thursday 0700-0800                                                                        for the afternoon seminar. It is your responsibility to notify your senior
M&M rounds:                     Last Thursday of month 0700-0800                                                          resident on the service prior to leaving the hospital.
Inter-hospital Grand Rounds:    3rd Wednesday of month 0700-0845 (alternate between sites)
                                                                                                    ON CALL GUIDELINES: General Surgery (applies weekdays & weekends)
Victoria Hospital                                                                                   Victoria Hospital
General Surgery Rounds:         Tuesday 0700-0800                                                   DAYTIME GENERAL SURGERY PAGING INSTRUCTIONS
Trauma Rounds:                  4th Tuesday of month 0700-0800                                      0700-1700         Ward work page team clerk
                                (All general surgery residents & medical students are expected to                     Outside calls for team 1st page jr. resident
                                attend.)                                                                                                      2nd page sr. resident
General Surgery M & M:          4th Thursday of month 0700-0800 & 3rd Tuesday of month (in                            DO NOT PAGE THE CLERK
                                place of general surgery rounds)                                    0700-1700         Emergency & consults: 1st call the ACCESS jr. resident
                                                                                                                                               2nd call the ACCESS sr. resident
                                                                                                    1700-0700         ER, inpatient consults: 1st call jr resident
                                                                                                                      Outside consult/call: 1st call jr resident on call
                                                                                                                                              2nd call sr. resident on call




                                               25
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                                               26                                                                                                 27
ON CALL GUIDELINES: Pediatric Surgery (applies weekdays & weekends)                                     ANESTHESIA GUIDELINES
0700-1700              1st call junior pediatric resident                                               Dr. Ivan Iglesias, Coordinator, Undergraduate Medical Education,
                       2nd call senior pediatric resident                                               LHSC-UC, Department of Anesthesia & Perioperative Medicine
1700-0700              1st call junior resident listed on call for that evening
                       2nd call senior resident listed on call for that evening                         Secretary:      Linda Szabo, Room 31R9, Ext. 33283
NOTE: If there is no senior or junior resident listed page the peds junior resident
                                                                                                           1. Report to your assigned consultant (or alternate a booked), in greens, in the Operating
Clerks:                   If you are post call you are expected to go to your teaching seminar that           Room after your seminar. (First day – report to Linda’s office (B3-218) for assignment.
                         morning and then you are to be relieved of your duties. If the seminar is            For remained days – follow OR list.)
                         scheduled for the afternoon, then you can decide whether you come back
                         for the afternoon seminar. It is your responsibility to notify your senior        2. Pick up the Anesthesia for Medical Students textbook on the Friday prior to your rotation
                         resident on the service prior to leaving the hospital.                               and read prior to starting. (Pick up in Room B3-218). This book must be returned to the
                                                                                                              Department of Anesthesia in order for your rotation to be considered complete.
ACUTE CARE EMERGENCY SURGICAL SERVICE CALL COVERAGE
0700-1700                1st page the junior ACCESS resident                                               3. An evaluation form will be provided to you at the beginning of the rotation.
                         2nd page senior ACCESS resident
                         Emergency patients & consults will be seen by the ACCESS TEAM                         Clinical Evaluation:     Your assigned consultant will assess your clinical
1700-0700                1st page the junior resident listed on general surgery call for that evening                                   performance and your case report and record this on the
                         Refer to the general surgery portion of this call schedule & follow those                                      evaluation form.
                         guidelines

ROCKET ROUNDS                                                                                              4. The Anesthesia education office is located in Room B3-218 (3rd floor, Visual Services
                                                                                                              Area, directly behind Creative Copy). If you are experiencing any difficulties or have
Rocket Rounds are a quick 5 minute session that takes place behind the nursing station at the                 questions regarding your anesthesia rotation, please contact Linda.
Red/Yellow/Green Discharge Status Tracking Board. A designate from each of the surgical teams
(usually junior resident), coordinator or in charge nurse attends at 0730 (or as soon as rounding on       5. Tell your assigned consultant of any special interests you have, i.e. cardiac, neuro,
patients is completed) to review the discharge status of each of their patients. The magnets on the           transplant. A half-day in these areas can be arranged for you.
discharge status tracking board indicates when their discharge is likely to happen. Red: greater
than 3 days, yellow is 2-3 days, green is within 24 hours. These magnets are updated based                 6. Remember…ask lots of questions.
on their status.
• This white board is a visual management tool to track discharge planning on each patient using           7. Objectives:
the red/yellow/green status tool, therefore improving communication between team members.
                                                                                                                      Preoperative assessment and anesthesia in patients with medical illness.
Benefits to Patients:                                                                                                 Learn applied physiology and pharmacology related to anesthesia drugs and
• Promote smooth continuum of care                                                                                     techniques
• Improve communication between all health care disciplines                                                           Technical procedures related to airway, ventilation and IV access.
• Reduce wait times during their hospital stay

Benefits to Staff:
• Provide quick overview of patient’s progress as it relates to plan of care
• Increase in discharge predictability and improved coordination of care
• Increase patient/family satisfaction - less complaints
• Assist in planning their day
• Provide overview of planned inpatient activity and staff workload

Impact on Other Areas:
• Enhanced patient flow leading to increased inpatient bed availability


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DIAGNOSTIC RADIOLOGY                                                                                 ENT GUIDELINES
Structure of the Rotation
Radiology is a two week selective in the Surgery rotation.                                           A schedule with reporting instructions will be emailed to you
Assessment                                                                                           by Ms. Edwards on the Thursday preceding your rotation.
    � Direct observation and feedback by the attending radiologists and radiology residents          Please view the Clerkship Lecture:
    � Written examination                                                                            http://www.uwoent.ca/files/Clerkship_Lecture.pdf,
                                                                                                     and review the web-based Clerkship Learning Modules:
Duties of the Clerk - The students will be assigned to attending radiology preceptors or radiology   http://www.uwoent.ca/node/30, before your rotation begins.
residents for half-day blocks within the subspecialties/modalities of radiology, including time in
nuclear medicine. They will participate, along with the resident and attending staff, in the
interpretation of diagnostic imaging, and observe various interventional radiology procedures.       OPHTHALMOLOGY
During their rotation, they may be asked to present on small topics around their learning.
                                                                                                     Duties of the Clerk
Teaching Sessions - During their rotation, they will attend daily teaching rounds for radiology      Daily duties, attendance at clinics, attendance in OR, skills practice (eg fundoscopy / slit lamp)
residents, along with the academic half-day on Thursday afternoons, and participate in an
interactive seminar series directed at the students to cover the basics of the subspecialties and    Teaching Sessions
modalities of radiology.                                                                             Attendance at Ophthalmology Grand Rounds (Wednesdays 0730 to 0830 Sept to June)
                                                                                                     Attendance at Clinical Skills Teaching Session (Tuesdays 0830 to 1100)
Separate lectures on subspecialty radiology topics will be incorporated into the Internal Medicine   Attendance at Surgical Teaching Sessions (as scheduled)
clerkship seminar series (neuroimaging and cardiopulmonary imaging) and into the Surgical
Clerkship seminar series (orthopedic imaging and abdominal imaging/interventional radiology).        Resources Required:
                                                                                                     Basic Ophthalmology, 8th edition, 2004. American Academy of Ophthalmology
Resources                                                                                            (Mandatory text book is available at the University Bookstore)
Squire’s Fundamentals of Radiology - Available in the UWO Health Sciences library




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ORTHOPEDIC GUIDELINES                                                                                 DICTAPHONE DICTATING INSTRUCTIONS - University / Victoria Hospital
                                                                                                      Important:
Dr. Steven J. MacDonald, MD, FRCSC, Site Chief, Division of Orthopedic Surgery
                                                                                                      All dictators must obtain a personal dictator ID number from Health Records Transcription, ext.
 GOALS & OBJECTIVES                                                                                   35131.
                                                                                                      Dictating Instructions:
    � To have the orthopedic rotation, fulfill all of your learning and educational objectives
      through your education on the wards, in the operating room, in the outpatient clinics and in        1. Dial extension 66080 or 519-646-6080 from outside the hospital
      the emergency department.                                                                           2. Enter your 5 digit User ID number followed by # key
                                                                                                          3. Enter the hospital site code followed by # key
    � Orthopedic rotation time will be split evenly with one week on the Sports Medicine clinical                  1 University Hospital
      teaching unit and one week on the Arthroplasty clinical teaching unit. The senior resident                   2 Victoria Hospital
      on each of those clinical teaching units will help facilitate your orientation.                     4. Enter the work type followed by # key
                                                                                                                                City-wide Work types
 FORMAL TEACHING OUTLINE
                                                                                                              30   Preadmission Clinic Note                     35   Emergency Room Report
                                                                                                              31   History and Physical                         36   Delivery Report
The Orthopedic Service highly values and is committed to excellence in its teaching program. A                32   Operative Report                             39   Procedure Report
desire to continually improve this program we welcome your feedback.                                          33   Discharge Summary                            40   Death Summary
                                                                                                              34   Consultation                                 41   Telephone Correspondence Note
Monday (7:00 am)                 Tumor Teaching Rounds
                                                                                                                                Site Specific Work types
Tuesday (7:00 am)                Sports Medicine Teaching                                                     80 Clinic Report                       87 Urgent Neurology Clinic Note
                                                                                                              81 Adult Psychiatry Note               88 John H. Kreeft Clinic Note
Wednesday (7:15 am)              Grand Rounds                                                                 82 Child / Adolescent Psychiatry              89 General Medicine Clinic Note
                                 3rd Wednesday of each month (not during summer)                              83 Women’s Health Clinic Note                 90 Geriatric Mental Health
Thursday (7:00 am)               Arthroplasty Teaching                                                        84 Trauma Resuscitation Note                  91 TIA Clinic Note
                                                                                                              85 Trauma Clinic Note                         92 Thoracic Surgery Clinic Note
Friday (7:00 am)                 Case Based Problem Learning,                                                 86 Speech Pathology Note                      93 In-hospital Transfer Note
                                                                                                          5. Enter the PIN (Medical Record Number) followed by # key
 DAILY ROUTINE                                                                                            6. Enter 2 to begin dictation: Dictate and spell patient’s name, PIN (Medical Record
                                                                                                             Number), your name and required copies (indicate address for out-of-town providers.
Your day will begin with ward rounds accompanying the residents prior to the morning’s teaching
                                                                                                      Keypad Functions
sessions. Following that normally you will then have your own clinical clerk teaching seminars. On
completion of these seminars you will then be either attending in the operating room or the               2 To begin, pause or resume dictating
outpatient clinic depending on the day of the week.                                                       3 To replay dictation
                                                                                                          4 Continuous forward
 ON CALL GUIDELINES                                                                                       44 Fast forward to end of report
                                                                                                          5 To end last report and dictation session
You will be on call three or four times during your two weeks on the orthopedic service and will be       6 Priority dictation
provided a pager for those responsibilities. Many of the learning opportunities will occur while on       7 Continuous rewind
call including management of patients in the emergency department under the supervision of the            77 Go to beginning of dictation
resident on call, as well as after hour trauma operative experience and the management of patients        8 Go to next report
on the ward. The call is in-house call, and call room C10-132 is the orthopedic clinical clerk call       0 To open / interrupt report that cannot be finished during the current dictation session. When
room for your use.                                                                                        beginning a new session and after entering the site code, you will hear “you have an open
                                                                                                          report”. To retrieve it, enter 1 and continue to dictate. To ignore it, enter 2.
                                                                                                      Help Line: 35131


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     SECTION 4:     PHARMACY

       LHSC Pharmacy Services: what you need to know
       Writing Orders
       Order Signing
       Prescribing Privileges




                                    35
34                                  35
     LHSC PHARMACY SERVICES: WHAT YOU NEED TO KNOW!!!
     LHSC Pharmacy Services operates as a single department across all sites of the London Health
     Sciences Centre. LHSC Pharmacy is committed to excellence in patient care and service.

     Our mission statement is:
     Each member of the Pharmacy Team supports the goal of improving the quality of life for all
     patients. Through innovation and collaboration we are dedicated to providing pharmaceutical care
     and supportive practices with an emphasis on excellence in service, training, education and
     research.
     Your pharmacist for the service: _________________________________ Pager#: ___________

     PHARMACY SERVICES

     LHSC Pharmacy provides the following services:
     � Inpatient Unit Dose/IV Additive Drug Distribution Service (Ext: SSH 74756,
       UH 35623, & VH 52162)
         � Specially trained pharmacy technicians work with pharmacists to ensure that medication
           doses are prepared and dispensed in a ready to use format for administration by nursing or
           medical staff. The Pharmacy also prepares Leave of Absence Prescriptions (LOA’s) for
           patients who will be leaving the hospital for a short period of time in accordance with their
           medical therapy.
         � Pharmaceutical Care Services
         � Pharmacists at LHSC are integrally involved in the interdisciplinary care team. They
           identify and resolve drug related problems for patients in a variety of settings. They work
           with medical, nursing and other allied health staff in areas such as inpatient wards, pre-
           admit clinics and outpatient clinics.
     � Prescription Centre Retail Pharmacy Services (Ext: UH 33231 & VH 58172)
         � LHSC operates accredited retail pharmacies located in the lobby at the University
           Campus and on Level 2 of the Westminster Campus. These pharmacies provide retail
           pharmacy services to patients, staff and visitors of LHSC.
     � London Regional Cancer Program Pharmacy Services (Ext. 58606)
             • LHSC Pharmacy operates the pharmacy in the London Regional Cancer Program. The
                 pharmacy prepares and dispenses chemotherapy doses for the patients of the LRCP
                 and also offers a variety of prescription services to the patients in the LRCP.
         � LonDIS Regional Drug Information Centre (Ext. 33172)
         � LHSC Pharmacy operates a regional drug information service. This service is available
           FREE to staff within LHSC and is offered on a fee for-service-basis to other organizations
           and individuals. The pharmacists in the centre are specially trained in information retrieval
           and interpretation.
     PRESCRIBING DRUGS AT LHSC
     While there are thousands of drugs available on the market, it is neither feasible nor necessary for
     the hospital pharmacy to have all drugs available. This is particularly true for "me-too" drugs within



36                                                     37
36                                                     37
the same class. For this reason, the hospital formulary was created, in order to list the medications           full post-operatively or on transfer
available for prescribing within the London Health Sciences Centre.
WHICH DRUGS CAN I ORDER AT LHSC?                                                                        WHO CAN PRESCRIBE?
Through the Drug & Therapeutics Committee (DTC) a sub-committee of MAC, Medical, Pharmacy               In addition to licensed physicians, within the hospital many individuals of different
and Nursing staff evaluate and select from the numerous available medicinal agents and drug             health care disciplines (e.g. nurse practitioners, pharmacists) have been granted authority to
products those agents considered most efficacious. These agents are contained in a list known as        prescribe medications through such vehicles as Medical Directives, Corporate Policy etc. These
the Formulary. The LHSC PTC will objectively appraise, evaluate, and select drug products for the       authorities are ONLY applicable for inpatient and some ambulatory patient uses and do NOT apply
LHSC formulary according to the tenets of evidence-based medicine (EBM). The LHSC formulary             for prescriptions issued at discharge to be filled at a retail pharmacy. In the case of discharge
is tiered as follows:                                                                                   prescriptions, the Regulated Health Professions Acts and Regulations govern prescribing authority.
                                                                                                        For example, a medication written by a nurse practitioner under a medical directive is only valid
� TIER 1: General use at LHSC                                                                           while the patient is under the direct treatment of LHSC as defined in the Public Hospital Act and
� TIER 2: General use with monitoring by DTC to provide drug use evaluation                             Health Insurance Act and cannot be validly filled by a retail pharmacy including LHSC’s
� TIER 3 (RESERVED): limited to specific prescribers/clinical services or                               Prescription Centre Pharmacies.
     reserved for use on specific nursing units (extreme toxicity, extreme cost, or extremely rare
     use). These restrictions will be listed as a link in the online formulary.                         What Should LHSC Healthcare Professionals Know About the LHSC Drug Formulary?

ONLINE FORMULARY                                                                                        What is the Formulary?
http://appserver.lhsc.on .ca/Formulary1.0/public/index.php                                              The LHSC formulary is the list of drugs and related products available for use within LHSC.
From the LHSC Intranet Page, Select “Manuals/Guides”, under Guides Column is the link to the            Prescribers are expected to limit their prescribing to the Formulary, except under exceptional
LHSC Drug Formulary                                                                                     circumstances (special approval required). Formulary drugs are commonly stocked by the LHSC
Click on “Search” from the Blue index bar at the formulary home page. The FIRST search box is           pharmacy and are widely available for patient use.
where you can enter a drug name to see if it is Formulary or non-formulary at LHSC.
Pharmacy/Medication-related Policies & Procedures, Therapeutic Information, DTC documents               Where is the Online Formulary?
and Evidence-Based Medicine Summaries are also available as links from the online formulary               o From the LHSC Intranet, select “Manuals/Guides”
homepage                                                                                                  o Under the Guides Column, click on the link to “LHSC Drug Formulary”
                                                                                                               (http://appserver.lhsc.on.ca/Formulary1.0/public/index.php )
NON-FORMULARY DRUGS
  � If a non-formulary drug is written at LHSC, pharmacists will assist MDs in determining if
      viable formulary alternatives or patient's own supply exists
  � If patient’s own supply is considered the best option, consent MUST be obtained from the
      patient (the pharmacist or nurse can assist in this and document the consent)
  � If the non-formulary drug remains the best choice, the Non-Formulary Approval Process
      is outlined in the online formulary under the “Drug & Therapeutics Committee Section”
      under Interim Drug Approval Forms:
          o A call/page/email (depending on urgency) to one of the three contacts on DTC: Dr.
               Dave Massel, OR Richard Jones, OR Dr. Janet Martin (please check online for the
               most current contact list/information)
          o Rationale and evidence will be requested & requests are documented and tracked
               by DTC
          o Obtaining a non-formulary drug supply for a patient may take up to 48 hours
                                                                                                        What Drugs Can Prescribers Order at LHSC?
WRITING PRESCRIPTIONS                                                                                   Through the Drug & Therapeutics Committee (DTC) a sub-committee of MAC, Medical, Pharmacy
   � Prescriptions from a prescriber must be clear, legible and complete                                and Nursing staff evaluate and select from the numerous available medicinal agents and drug
   � Use a ball point pen to ensure a legible copy                                                      products those agents considered most efficacious. These agents are contained in a list known as
   � It is hospital policy that prescribers must complete the initial order documenting any             the Formulary. The LHSC PTC will objectively appraise, evaluate, and select drug products for the
      allergies and/or adverse drug reactions before pharmacy can dispense medication.                  LHSC formulary according to the tenets of evidence-based medicine (EBM). The LHSC formulary
   � Since surgery and transfer in-and-out of critical care areas (e.g. ICU, CCU)                       is tiered as follows:
      automatically cancels all medication orders, medication orders must then be rewritten in          ~         TIER 1: General use at LHSC


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                                                 38                                                                                                    39
~       TIER 2: General use with monitoring by DTC to provide drug use evaluation                        What other Useful Information found in the Online Formulary?
~       TIER 3 (RESERVED): limited to specific prescribers’/clinical services or reserved for use        Medication-related policies & procedures (see “Policies & Procedures section):
        on specific nursing units (extreme toxicity, extreme cost, or extremely rare use). These            o Automatic Substitution Policies
        restrictions will be listed as a link in the online formulary.                                      o Automatic Stop Order Policies
                                                                                                            o Prescribing Restrictions
How are Non-Formulary Drugs Accessed For a Patient at LHSC?
~      If a non-formulary drug is written at LHSC, pharmacists will assist MDs in determining if         Helpful therapeutic information can also be found here (Therapeutic Information):
       viable formulary alternatives or patient's own supply exists                                          o Comparison Charts of Drug Classes e.g. beta blockers, insulin
~      If patient’s own supply is considered the best option, consent MUST be obtained from the              o Compatibility of medications in syringe
       patient (the pharmacist or nurse can assist in this and document the consent)
~      If the non-formulary drug remains the best choice, the Non-Formulary Approval Process             Evidence Based Medicine Resources (see EBM section):
       is outlined in the online formulary under the “Drug & Therapeutics Committee Section”                 o EBM Drug Summaries (approved by PTC)
       under Interim Drug Approval Forms:                                                                    o EBM Tools e.g. critical appraisal worksheets
~      A call/page/email (depending on urgency) to one of the three contacts on DTC: Dr. Dave
       Massel, OR Richard Jones, OR Dr. Janet Martin (please check online for the most current           Pharmacy & Therapeutics Committee (PTC) information:
       contact list/information)                                                                            o Meeting minutes & agendas
            o Rationale and evidence will be requested & requests are documented and tracked                o Formulary decisions (Additions & Deletions to LHSC Formulary)
                by DTCO                                                                                     o Interim Approval forms e.g. Non-formulary drug approval for use forms, Interim Approval
            o Obtaining a non-formulary drug supply for a patient may take up to 48 hours                      for Parental Administration forms

How do I Search for a drug in the Online Formulary?                                                      Links to Commonly Used LHSC Resources:
                                                                                                             o CPS (need LHSC library username & password)
From the Formulary Homepage the 1st option on the blue navigation bar on the LEFT is “Search”                o Micromedex
        “Site Search” searches both the documents AND the drug database                                      o LHSC Parenteral Drug Administration Manual (PDAM)
Click on “Advanced Search” to search the two databases separately
~       1st search box “Formulary Search” to search the drug database
~       2nd search box “Document Search” searches documents posted online in the formulary
                                                                       Approx LHSC Cost


How do I Search for therapeutic alternatives within a drug/therapy class?
Using the Search function, underneath the “Formulary Search” is the option to do an Advanced
Search. Once in the Advanced Search screen, you can search by AHFS (American Hospital
Formulary System) Classification and Therapeutic Classification. These are the 2 ways that the
online formulary classifies drugs. By clicking on either option you can use the links to select a drug
class by AHFS or by Therapeutic Classification and your results will be all the drugs in the online
formulary that match that classification.




                                                  40                                                                                                     41
                                                 40                                                                                                      41
WRITING ORDERS
                                                                                                    Common Calls:
                                                                                                    � Low urine output:             Foley, consider fluids (bolus 1liter over 1/hr if young, 1 Liter over
            Use the ADDAVIDDD format:
                                                                                                                                    2 hrs if old),
            A:       Admit to: Dr __________
                                                                                                                                    Blood work – CBC, lytes, BUN/Cr
            D:       Diagnosis:
                                                                                                                                    Always check for significant blood/fluid loss (tachycardia,
            D:       Diet:           NPO → sips → clear fluids → full fluids → transitional → DAT
                                                                                                                                    hypotension, agitation vs. confusion)
                                     Gallbladder – low fat DAT
                                     Local – DAT
                                     Diabetic – 1800 kcal                                           � Low potassium:                10 mEq KCI in 100 cc NS over 1 hr
            A:       Activity:                AAT or up tomorrow unless contraindicated
            V:       Vitals:         VSR =q4h for 48 hrs post-op                                    � Short of breath:              examine pt, portable CXR, consider Lasix, Chest physio, puffers
            I:       Ins & outs:     IV NS with 20 mEq KCI/L @50 cc/hr→ D5/45 with 20 mEq
            KCI/L @ 125-175 cc/hr (wt dependent) → d/c IV WDW or SL                                 � Chest pain:                   examine pt, portable CXR, ECG, consider ASA
                                     WDW or TKWO IV
            Titrate 0� sat to > 92%
                                     Accurate ins and outs                                          ORDER SIGNING
                                     Foley to urometer (call MD if U/O <60 cc/2hrs)
                                     Hemovac to S.D.                                                Residents and Consulting Physicians:
                                     J.P. to hemovac                                                   - All orders written on the order sheet must be signed before the order is faxed or the yellow
                                     NG to low wall suction                                                copy sent to Pharmacy.
                                     Replace NG losses with NS with 10 mEq KC1/L 1:1 q shift           - Pharmacy and nursing will no longer take a telephone order from a medical student.
                     Investigations: CBC, lytes, BUN, Cr – POD#1 and as needed                         - In the event you are not present at the time of the order, you will be paged or called by the
                     Other:          Chest physio                                                          medical student to sign the order so that it may be processed.
                                     Incentive spirometry
                                     DBOC – deep breathing and coughing                             Medical Students:
                                     TEDS stockings – SCD                                              - You must discuss all orders (medicine, laboratory, radiology, nursing, allied health orders
                                                                                                           etc.) and then have them immediately signed by a supervising resident, fellow or attending
D       Drugs:             Cover all the A’s that are appropriate                                          physician. It is the responsibility of the medical student to obtain this signature.
Anti-pain                          PCA as per anesthesia
                           Morphine 5-10 mg IM/SC q4h prn                                           Nursing Staff:
                           Demerol 25-75 mg IM q6h prn (100-150 mg in big people)                      - A signature of a supervising physician must be present before processing the order.
                           Codeine 15-30 mg PO/IM q6h prn                                              - Nursing will not administer medications or perform any other treatments from an order that
                           Tylenol #3 1-2 tabs q4h prn (usually 1 narcotic + Tylenol)                      is not counter/co-signed by the supervising physician
                                                                                                       - Once the signature is obtained by the medical student, the order can be processed.
Anti-puke                  Gravol 25-50 mg PO/IM/IV/PR q4h prn                                         - Nursing will no longer accept a telephone order from a medical student.
                           Maxeran 10 mg IV q6h prn (=metoclopramide)
Anti-reflux                Rantidine 50 mg IV q8h or 150 mg PO BID                                  Pharmacy Staff:
(anybody NPO)              Pantoloc 40 mg IV OD (= pantoprazole)                                       - A signature of a supervising physician must be present before processing the order.
                                                                                                       - Pharmacy will not dispense or fill medication orders written by Y3 or Y4 (aka clinical
Anti-clot                  Heparin 5000 units SC BID/TID until ambulating (7500 units if obese)        clerks) unless it is counter/co-signed supervising physician first.
                           OR Fragmin 5000 units SC                                                    - Pharmacy will no longer accept a telephone order from a medical student.

Antecedent                 All drugs they were taking before (ask about exceptions)                 Communication Clerks/Unit Secretaries/ Medical Secretaries
                                                                                                       - A signature of a supervising physician must be present before processing the order.
Antibiotics                eg: Ciprofloxacin 400 mg IV q12h + Flagyl 500 mg IV q12h 2 doses
                           or Ancef 1 g IV q8h x3 + Flagyl 500 mg IV q12 x2} for colonic surgery
                           wound infection prophylaxis
Anti constipation          Stool softeners – Colace 100 mg PO BID or Fleet


                                                  42                                                                                                43
                                                  42                                                                                               43
For more information                                                                                   SECTION: 5 GENERAL SURGICAL INFORMATION
Physicians: contact your Department Chief
LHSC Nursing staff: Deb Karcz ext 74700, Professional Practice Specialist
SJHC Nursing staff: Brenda Merrifield ext 47382, Professional Practice Consultant                       The Operating Room
SJHC Pharmacy: Chris Judd, Director Pharmacy Services #65526/42562
                                                                                                        At Time of Operation
                                                                                                        Pre-op Orders
PRESCRIBING PRIVILEGES                                                                                  OR Note
Drugs shall be administered only upon the order of an individual who has been assigned clinical
                                                                                                        Post-op Orders (major surgery)
privileges or who is an authorized member of the house staff.                                           Post-op Orders (minor surgery)
                                                                                                        Patient Order Guidelines
Residents on the educational register may write drug orders within the hospital. They may also
give prescriptions to outpatients of the institution where they are training. This includes patients
                                                                                                        Admission History
who have attended the Emergency Department or an outpatient clinic; such prescriptions can be           Admission Orders
dispensed by a pharmacist within or outside the hospital. You must include your pager # on all          Abdominal Pain DDx
prescriptions.
                                                                                                        Common Causes of Post-op Fever
The clinical clerks are encouraged, wherever possible, to write orders for investigation,               Daily Progress Note POD#
medications, etc. directly on the patients order sheet. It is to be clearly understood that these       Discharge Dictation
orders are to arise out of the discussion of the case with the resident, or the attending physician
responsible for the patient. Such orders are to be written and signed clearly and legibly. The
                                                                                                        Commonly Ordered Meds
signature of the clinical clerk must be followed by the annotation Meds lll or Meds lV for Dr.          Insulin sliding Scale
____________, the latter being the resident or attending physician with whom he/she has                 Blood Transfusion Risks
discussed the order, on the understanding that such discussion did in fact take place. Ideally this
action should be recorded on the progress notes. Orders are required to be countersigned by
                                                                                                        Clinical Pearls
the licensed physician with whom the above order was discussed or in that person’s                      Upper GI Bleed
absence by the attending physician, before they can be implemented.                                     Lower GI Bleed
All visiting elective medical students, after acceptance by the UCE office, operate under the same
                                                                                                        Acute Cholecystitis
rules.                                                                                                  Ranson’s Criteria for Pancreatitis
                                                                                                        Appendicitis
                                                                                                        Bowel Obstruction
                                                                                                        Hemorrhoids
                                                                                                        Groin Hernias
                                                                                                        Inflammatory Bowel Disease




                                                44                                                                                   45
                                                44                                                                                   45
     THE OPERATING ROOM
     A critical and large part of surgery has to do with what occurs in the operating room. The surgical
     team has a heavy time commitment to the O.R. and daily routines are planned around the O.R.
     schedule. For this reason, the clerkship duties and routines on surgery are different from those of
     other specialties. Although students need not spend excessive time in the O.R., this experience is
     an absolutely essential part of the clerkship. Clerks should make every attempt to scrub in on the
     patients they have admitted.

     AT TIME OF OPERATION
     � Fill in operation and diagnoses on front sheet.
     � Read the chart before the OR – for the patient history
     � Write post-op orders - residents will countersign.
     � Write O.R. report in progress notes.
     � Check the OR list the night before so you can read up on the cases

     PRE-OP ORDERS (not necessary for all surgeries)

     �     NPO
     �     Abx (Ancef 1gm IV + Flagyl 500 mg IV)
     �     IV (bolus and maintenance)
     �     Blood on reserve
     �     B/W, CBC, lytes, BUN/Cr, INR/PTT
     �     Heparin or Fragmin 5000 units SC on call (if sx > 3hrs)
     �     CXR
     �     ECG
     �     Teds/ScDs


     OR NOTE

     Put in progress note - start filling out in the OR before you scrub (if you have time)

     1.    Pre-op Dx:
     2.    Post-op Dx
     3.    Procedure
     4.    Surgeons
     5.    Anesthetist
     6.    Findings: (most important)
     7.    EBL: (estimated blood loss)
     8.    Drains:
     9.    Disposition: stable, extubated to PACU or intubated to ICU
     10.   PLAN (next most important)




46                                                     47
46                                                     47
                                                                                                 PATIENT ORDER GUIDELINES
POST-OP ORDERS (major surgery)
                                                                                                 � Low K+ 10meq KCl in 100cc NS x3 doses
Admit to floor under Dr.______                  IV RL 125cc/h until midnight then D5/0.45NS        Repeat Lytes after last dose.
Dx Colon Cancer                                 with 20meq KCl @ 125cc/h                           or
                                                                                                   K+ 40meq po q4-6h
NPO or fluids if enhanced recovery              PCA as per anesthesia
Up and about                                            or                                       � High K+ (>4.9) : Repeat sample, ECG,
                                                                                                   Calcium gluconate 1-2amp IV, Insulin R 10u +
VSR                                             Morphine 2.5-7.5mg IM/SC q4h prn                   1amp D50W, B2 agonist, Kayexalate 30g PO,
Foley to Urometer                               Tylenol #3 I-II tabs PO q4h prn                    Lasix 40mg IV, Hemodialysis if refractory.

Accurate Ins and Outs                           Gravol 25-50mg IM/IV/PO q4h prn                  � Ileus
Call MD if UO<60cc/2h                           Heparin 5000u SC q12h OR Fragmin 5000              NPO
                                                                                                   NG to low wall suction
Blood work POD 1 & 3: CBC, Lytes, Bun Cr        sc od                                              Abd x-ray 3 views
Chest Physio                                    Ranitidine 50 mg IV q8h or Pantaloc 40 mg          (r/o obstruction pg#*****) (always give the radiologist the patient’s surgical history)
                                                IV od
Titrate 02>92% sat. r/a                                                                          � Anxious Ativan 1mg SL prn
NG to low wall suction
                                                Antibiotics (if indicated)                       � Cardiac Arrest DIAL x55555 - Give floor and room number
Replace NG loss with NS (if present)            Maxeran 10 mg IV, POq6h, prn or Atl
                                                                                                             Start CPR
TED/SCD until patient ambulating
Chewing gum – 1 piece TID
                                                                                                 � Hypertension : Hydralazine 10mg IM/IV/PO prn
                                                                                                   *Ideally you want to optimize the patients
POST-OP ORDERS (minor surgery)                                                                     current anti-hypertensives

Admit to floor under                                                                             � Hypotension : IV bolus NS 1L/1h if young or
Dr.______                                                                                          1L /2 hrs if old – look for cause of hypertension

Dx Appendicitis                                                                                  � Low urine output: Foley, give fluids (bolus
                                                                                                   1L/hr if young, 1L /2 hrs if old), Blood work –
DAT                                                                                                CBC, lytes, BUN/Cr
Up and about                                                                                       Always check for significant blood/fluid loss
                                                                                                   (tachycardia, hypotension, agitation vs.
                                                                                                    confusion)
VSR
                                                                                              Pulmonary Edema: ABCs, O2,
IV D5/0.45NS with 20meq KCl @ 100cc/h, SL WDW                                                 Diuretics (Lasix etc)
Morphine 2.5-7.5mg IM/SC q4h prn
Tylenol #3 I-II tabs PO q4h prn
Gravol 25-50mg IM/IV/PO q4h prn
Antibiotics (if indicated)



                                           48                                                                                                 49
                                           48                                                                                                 49
ADMISSION HISTORY                                               ADMISSION ORDERS
Gen Sx Admission Note                                           Use ADDAVID format                       IV D5/0.45NS with 20meq KCl @ 100cc/h
ID 46yo male                                                    Admit to __ floor under Dr.______        Drugs:
PMHx                                                            Dx Appendicitis                                   Pearl (admission meds)
                 Surgical               Medical                 Diet: NPO                                         Pain
                 1) Appendectomy        1) HTN                  Activity: Up and about                            Puke
                 2) Tonsilectomy        2) GERD                 Vitals: VSR                                       Prophylactic (abx and anti-
Meds                                    Allergies               Ix: CBC, Lytes, BUN, Creatinine                   coagulation )
Soc.Hx           Smoker, EtoH, lives alone                        Abd x-ray 3 views                               Personal
HPI
O/E
                                                                Drains – Foley – Urometer
Vitals                                  Abd
                                                                        Call if Vol 60cc/2hrs
CVS                                                                 - NG –> low gamco
                                                                    - Drain –> HVC
Resp
Ix                  Na+       K+        BUN          WBC        Disposition – Chest physio
                                                                            - Consult …
                                                    Hb   Plts
                   Cl-       HCO�        Cr




Abd x-ray 3views: 0 air-fluid levels   INR
                                        PTT
Impression (Diagnosis and DDx)
Plan (Investigations and Treatments)




                                              50                                                    51
                                              50                                                    51
ABDOMINAL PAIN DDx                                                     COMMON CAUSES OF POST-OP FEVER
                                                                       (chronologically) – 6 W’s:

 RUQ                                              LUQ                  wind (atelectasis)
 Hepatitis                                        MI
Cl-
 Biliary Colic                                    Pancreatitis         water (UTI)
 Acute cholecystitis                              Splenic infarction
 PUD                                              Pyyelonephritis      wound (healing/infection)
 Pyyelonephritis
                       Generalized                                     walking (DVT leading to pulmonary embolus)
                       Gastroenteritris
                       Obstipation                                     wonder drug (drug reaction)
                       SBO/LBO
                       Mesenteric ischemia                             wein “vein” thrombophlebitis
                       Peritonitis
                       Abdominal aortic
                       Dissection                                      DAILY PROGRESS NOTE POD#

 RLQ                                              LLQ
                                                                       Transcribe everything the senior resident says in this format
 Appendicitis                                     Diverticulitis
 IBD                                              IBD
                                                  Sigmoid volvulous    � Gen Sx heading & POD #/ HD#
 Ureteral Stone                                                        � SOAP format:
 Salpingitis                                      Ureteral Stone
                                                  Salpingitis               o Subjective: no abdo pain, passing gas, no BM etc
 Ovarian torsion                                                            o Objective: AVSS, abd soft, not distended, stoma pink, etc
 Ruptured ectopic                                 Ovarian torsion
                                                  Ruptured ectopic          o Assessment or IMP: stable, unstable etc
                                                                            o Plan: diet as tolerated (DAT), d/c IVF, etc

                                                                       Remember to write orders for everything in the plan section

                                                                       Date/Time

                                                                       It is most important to use the progress notes to document significant lab and x-ray results, and
                                                                       indicate changes to your management plan. Document any significant event (positive or negative)
                                                                       in progress notes. These notes should drive the patient care ahead.
                                                                       Finally – sign your name, print your name and include your pager number!




                                             52                                                                         53
                                             52                                                                         53
                                                                                                For full list: http://www.health.gov.on.ca/english/providers/program/drugs/odbf_eformulary.html

LHSC 58570, SJHC 66200                                                                          INSULIN SLIDING SCALE
ID____
Password__
                                                                                                Blood glucose                        Humulin
DISCHARGE DICTATION
                                                                                                4.0-8.0                                     0
Your name, clinical clerk, dictating for Dr.____.                                               8.1-10.0                                    2u
Patient name, PIN, DOB
                                                                                                10.1-12.0                                   4u
Date of Admission:
Date of d/c:                                                                                    12.1-14.0                                   6u
Most responsible Dx:
                                                                                                14.1-16.0                                   8u
Procedures:
Complications:                                                                                  16.1-18.0                                   10u
Summary:
                                                                                                18.1-20.0                                   12u
         Presentation:
         Course in Hospital:                                                                    <4, >20                                     call MD
         D/C Meds
         Plan: (most important)

Remember to write order for d/c, give script for meds and follow-up in clinic, and sign the     BLOOD TRANSFUSION RISKS
face sheet to indicate you have dictated.
                                                                                                                                    Transfusion
COMMONLY ORDERED MEDS                                                                                      Virus                       Risk
Analgesia                                                Anti-constipation
Morphine 5-10mg IM/SC q4h prn                            Colace 100mg po bid                       Hepatitis C Virus                 1:3,000,000*
 2-4mg IV q15min prn in PACU                             Milk Magnesia 30cc po prn
Tylenol #3 1-2tabs q4h prn
Percocet 1-2tabs q4h prn                                 Antibiotics                               Hepatitis B Virus                     1:137,000
Toradol 30mg IM q6h prn                                  Ancef 1g IV q8h
Demerol 25-100mg IM q3-6h                                Ciprofloxacin 400mg IV(500mg PO) bid
                                                         Flagyl 500mg PO/IV q12h                   EHTLV I and II                    1:641,000
Antiemetics/Prokinetics                                  Piptazo 4.5 g IV q8h
Gravol 25-50mg PO/IV/IM q4h prn                          Imepenem 500 mg IV q8h
Maxeran 10mg IV/PO q4h prn                                                                         HIV                               1:10,000,000*
Stermetil 5-10mg IV/IMPO bid

For further medication info visit: http://www.lhsc.on.ca/priv/medres/odb/index.htm
Drug Formulary: http://appserver.lhsc.on.ca/formulary/public/index.php                                    * Canadian statistics as per
                                                                                                          Up-to-date 2005

Common “Limited Use” Codes
                                                                                                          Every 1u PRBC =
Losec            294                                                                                      10g/L increase in Hb
Plavix           376
Cipro            332


                                                    54                                                                                                55
                                                    54                                                                                                55
                                                                                                   ACUTE CHOLECYSTITIS
CLINICAL PEARLS
                                                                                                   Pathogenesis: inflammation of gall bladder from gall stone impaction (acalculous in 5-10%)
Corrected Calcium
Normal albumin = 40                                                                                Presentation: RUQ pain, anorexia, N+V, fever, Murphy’s sign, palpable gall bladder.
Every 10 decrease in albumin add 0.2 to Calcium.                                                          If CBD obstructed: = Ascending cholongitis Charcot’s triad (Fever, RUQ pain, jaundice)
                                                                                                          Reynold’s pentad (prev 3 + shock, confusion)
Acid base Compensations
Resp Acid: Acute PCO2, HCO3 ph Chronic PCO2, HCO3 pH N                                       Ix: 1)Labs-leukocytosis w left shift, possible increase in LFTs +bilirubin.
Resp Alk: Acute PCO2, HCO3  Chronic PCO2, HCO3 
Met Acid: PCO2, HCO3                                                                               2)Imaging-U/S distended edematous gall bladder, pericholecystic fluid, stone in bladder neck,
Met Alk: PCO2, HCO3                                                                                      sonographic Murphey’s sign (98% sensitive) consider HIDA scan if U/S negative.
4-2-1 rule for maintenance fluids
4cc/kg/h for first 10kg                                                                            Tx: hydrate IV fluids, NPO, analgesia Surgery and abx coverage (if not responding)
2cc/kg/h for next 10kg                                                                                 Biliary colic TX w analgesia and surgery (urgent or delayed)
1cc/kg/h for every kg>20
Layers of abdominal wall: skin, subcutaneous fat (Camper’s), Scarpa’s fascia, external oblique,
internal oblique, transversus abdominis, transversalis fascia, peritoneum.
                                                                                                   RANSON’S CRITERIA FOR PANCREATITIS
UPPER GI BLEED                                                                                     Use Acronym “A Gall Stone”
Definition: bleeding proximal to ligament of Treitz.                                               At admission:
Causes:
Esophagus-varices(20%), Mallory-Weiss tear(10%), esophagitis, CA                                   Age >55 years
Stomach- ulcer(20%), gastritis(20%), CA                                                            Glucose >11mmol/L
Duodenum-ulcer(20%),aorticoenteric fistula                                                         AST >250IU/L
                                                                                                   LDH >350IU/L
Presentation: hematemesis, hematochezia, melena, FOB                                               Leukocytes > 16x109/L

Ix: Lab-CBC, lytes, BUN, Cr, PTT, INR                                                              During initial 24h

TX: ABCs, 2 large bore IV, NPO, NG tube, endoscopy (if endoscopy not available give IV PPI).       Six L sequestered fluid
                                                                                                   Ten % drop in HCT
                                                                                                   O2 <60 mmHg
LOWER GI BLEED                                                                                     No calcium <2.0mmol/L
                                                                                                   Extra B’s
Definition: bleeding distal to Ligament of Treitz.                                                   BUN increase >1.8mmol/L
                                                                                                     Base deficit >4mEq/L
Causes: IBD, infectious colitis, Hemorrhoids, Angiodisplasia, CA, Diverticular disease, upper GI
bleed
Presentation: hematochezia, FOB, melena, anemia
Ix: Lab-CBC, lytes, BUN, Cr, PTT, INR colonoscopy, sigmoidoscopy
Tx: ABCs, 2 large bore IV, NPO, NG tube




                                                 56                                                                                                  57
                                                 56                                                                                                  57
APPENDICITIS                                                                                       HEMORRHOIDS
Pathogenesis: luminal obstructionbacterial overgrwthinflammationincreased Pischemia            Pathogenesis:
                                                                                                         Complex of dilated veins and arterio venous plexus and connective tissue. Internal: above
Presentation: Fever, Anorexia, Abd Pain (progression from poorly localized periumbilical pain to         dentate line, (portal circulation). External below dentate line (systemic circulation).
       well localized at McBurney’s point).Rovsing’s, Psoas, Obturator signs.
                                                                                                   Presentation:
Ix: 1) Labs-mild leukocytosis
                                                                                                   Internal hemorrhoids: painless bleeding, prolapse, burning pain.
   2) Imaging-U/S (90-94% accuracy), CT (94-100% accuracy)                                         10 No prolapse from anus
                                                                                                   20 Prolapse with spontaneous reduction
Tx: hydrate IV fluids, NPO
                                                                                                   30 Prolapse requiring manual reduction
    1) Surgery
                                                                                                   40 Permanent prolapse
    2) If localized abscessrad. Guided drainage, abx x 14d, consider interval appendectomy in     External hemorrhoids: pain after BM. Very painful if become thrombosed.
       6wks
                                                                                                   Tx.: High fiber diet, steroid cream, sitz bath, band ligation, sclerotherapy, Hemorroidectomy

                                                                                                   GROIN HERNIAS
BOWEL OBSTRUCTION
                                                                                                                               Direct                    Indirect                     Femoral
                                                                                                                               Inguinal                  Inguinal
                             SBO               LBO                           Ileus                 Epidemiology                1% of men                 Most common hernia in        Mostly females
                                                                                                                                                        men and women
Common                       Adhesions,       CA, diverticulitis, volvulus                                                                               Males>females
causes                       hernias,                                                              Etiology                    Acquired weakness in Persistence of process            Increased intra-
                             neoplasms                                                                                         the transversalis fascia vaginalis                     abdominal
N+V                          Early in course, Later in course, feculent      Present                                                                                                  pressure
                             bilious                                                               Anatomy                      Through Hesselbach’s       Passes through deep        Into femoral
Abd distension               +                ++                             +                                                   triangle (inferior       inguinal ring (lateral to   canal below
                                                                                                                                epigastric art.           inferior                    inguinal
Abd pain                     colicky           colicky                       minimal                                            Inguinal ligament,         epigastric art)            ligament
Constipation/                +                 +                             +                                                 lateral rectus sheath)
Obstipation                                                                                        Treatment                    Suture or mesh             Suture or mesh              Suture or mesh
                                                                                                                               (Plug, patch or both       (Plug, patch or both        (Plug, patch or
Bowel Sound                  Normal or         Normal or Increased(borbor Decreased or absent                                  repair)                    repair)                     both repair)
                             increased         ygmi)                                               Prognosis                    3-4% risk of               <1% risk of
                                                                                                                                recurrence                 recurrence
Radiology                  Air-fluid levels, Air-fluid levels, picture       Air-fluid levels
                           plicae circulars frame appearance, small                                                Contents of the spermatic cord
                           pattern, no       bowel air depends on                                  Vas deferens, testicular artery, pampiniform vein plexus, genital
                          colonic gas         competency of ileocecal                              branch of genitofemoral nerve, cremaster muscle, lymphatics
                                             valve




                                                   58                                                                                               59
                                                   58                                                                                               59
INFLAMMATORY BOWEL DISEASE                                                          SECTION: 6     URGENT SITUATIONS
                           Crohn’s disease             Ulcerative Colitis               Just the Facts - Critical Care Outreach Team (CCOT)
Location                   Any part of GI tract “Gum   Continuous from
                           to Bum” skip lesions        rectum to cecum                  Respiratory Status
Rectal Bleeding            Uncommon                    Very Common                      Cardiovascular Status
Diarrhea                   Less Prevalent              Frequent small stools            Neurological Status
Abdominal Pain             Post-prandial/colicky       Pre-defecatory                   ACLS Protocol
                                                       urgency
Fever                      Common                      Uncommon
                                                                                        CXR Approach
Palpable mass              Frequent, RLQ               Rare                             ECG Interpretation
Recurrance after Surgery   Common                      No                               Acute MI
Endoscopic features        Aphthous ulcers, patchy     Diffuse erythema,                Cardiac Enzyme Profile
                           lesions                     friability, loss of normal       Trauma/Emergency Surgical Patient
                                                       vascular pattern,                Surgical Abdomen: Indications for Urgent OR
                                                       continuous lesions,
                                                       pseudopolyps
Extraintestinal Features   1 in 4                      Less common
Radiological features      Cobblestone mucosa          Lack of haustra
                           Strictures and fistula
Histological features      Transmural with skip        Mucosal distribution
                           lesions                     (not transmural)
Complications              Strictures, fistulas,       Stenosis, toxic
                           perianal disease            megacolon




                                        60                                                                          61
                                       60                                                                           61
     JUST THE FACTS

     Critical Care Outreach Team (CCOT)

        �     A critical care Intensivist-led nurse and respiratory therapist-based team
        �     Brings critical care support beyond the walls of the ICU to high-risk patients on inpatient
              units
        �     Provides the opportunity for knowledge sharing and transfer by working in collaboration
              with inpatient ward teams throughout the hospital
        �     Part of the Critical Care Strategy of the Ministry of Health and Long-Term Care, with the
              goal of improving patient safety and access to critical care

     Core functions

        �     Early identification of patients at risk
        �     Prophylactic intervention
        �     Knowledge sharing
        �     Assistance with end-of-life decision making
        �     Facilitating appropriate ICU admissions and utilization of critical care resources, follow up
              for patients being transferred out of ICU

     Resources
     For additional information about CCOTs:

     LHSC Resources:

        �     CCOT Unit/Ward Staff Presentation (PowerPoint)
        �     CCOT PowerPoint Presentation (PowerPoint)
        �     CCOT Fact Sheet (pdf)
        �     CCOT Flyer (pdf)
        �     CCOT Flyer (Word)

     Links:

        �     Safer Healthcare Now!
        �     MOHLTC Critical Care Strategy




62                                                     63
62                                                     63
RESPIRATORY STATUS: Warning Signs                                          ACLS PROTOCOL
- ↑ Respiratory rate
- Dyspnea → shortness of breath
- Air hunger, working hard or fighting for breath
- Stridor
- "Wet" respirations
- ↑ Pallor or cyanosis
- Abnormally slow breathing, apneic spells or Cheyne-Stokes breathing

CARDIOVASCULAR STATUS: Warning Signs
-   Very slow or very rapid pulse rate
-   Bounding or weak pulse
-   ↑ or ↓ B.P.
-   Palpitations
-   Distended neck veins
-   Acute, sudden onset of chest pain - aggravating or relieving factors

NEUROLOGICAL STATUS: Warning Signs
-   Change in level of consciousness
-   ↑ Restlessness
-   ↑ Anxiety
-   Cold sweat




                                                   64                                      65
                                                  64                                       65
CXR APPROACH
                                                             ACUTE MI
ID-name, date etc.
“PERI”                                                       ABCs
Penetration -vertebrae just visible through cardiac shadow   “MONA" =Morphine (2mg), Oxygen,
Exposure                                                     Nitroglycerin (SL or IV), Aspirin (2x 81mg)
                                                             EKG
Rotation -vertebrae centered b/w clavicular heads            2 large bore IVs
Inspiration - 9 ribs visible                                 Serial Trop + CK q8h x3
                                                             CXR
Lines-ETT, PICC etc                                          Thrombolytics (STEMI or LBBB)
Bones                                                        PCA or CABG if warranted
Soft tissue                                                  Prior to d/c:
Trachea/medinistinum                                         A) ASA, Anticoagulation for 48h pain free), ACEi
                                                             B) B-blocker (metoprolol)
Hila                                                         C) CCB (diltiazem), Cholesterol (statin)
Heart-size (1/2 thoracic diameter), shape                    D) Diet
Diaphragm
Pleura -pneumo, costodiaphragmatic angles
Lungs                                                        CARDIAC ENZYME PROFILE


ECG INTERPRETATION                                           Marker                   Initial        Mean time to        Time to
                                                                                    elevation           peak            return to
1) ID                                                                                               elevation after     baseline
2) Rate
                                                                                    after AMI            AMI            after AMI
3) Rhythm
4) AXIS
5) Intervals                                                 Myoglobin                1-4h                   6h          18 - 24 h
6) HYPERTROPHY
7) INFARCT                                                   CK                       6 - 12 h             18 - 24 h     35 - 48 h

1) RATE                                                      Troponin                 3 - 12 h             18 - 24 h   Up to 10 days
Common method: 300-150-100-75-60-50
Mathematical method: 300/# large boxes between R waves       LDH                      6 - 12 h             24 - 48 h    6 - 8 days
2) RHYTHM
Normal sinus:
1. Check for a P wave before each QRS, QRS after each P.
2. P axis normal (-in aVR, +in II)
3. PR interval and P wave morphology constant
3) AXIS
positive in I and aVF Perpendicular to isoelectric lead
4) Intervals




                                                66                                                              67
                                               66                                                               67
TRAUMA/EMERGENCY SURGICAL PATIENT                             Section: 7 MISCELLANEOUS
Initial management
                                                                  Thyroid CA
“ABC, IM FINE”
                                                                  Thyroid Nodule Workup
ABCs                                                              Surgical Wound Classification
                                                                  Infection Prevention and control really starts with YOU!
I-IV: 2 large bore IVs with NS wide open
                                                                  Management of Coroner’s and non Coroner Case Deaths
M-Monitors: O2 sat, EKG, BP

F-Foley catheter

I-Ix: CBC,lytes,BUN,Cr,LFTs,amylase, lactate,type and cross

N- + NG tube

E- Ex rays: abd 3 views



SURGICAL ABDOMEN: Indications for Urgent OR
    •   Diffuse peritonitis
    •   Severe or increasing localized tenderness
    •   Progressive distension
    •   Tender mass with fever or hypotension (abscess)
    •   Septicemia and abdominal findings
    •   Bleeding and abdominal findings
    •   Suspected bowel ischemia
    •   Deterioration on conservative Tx
    •   Radiologic:
                  free air
                  massive bowel distension
                  space occupying lesion with fever
    •   Endoscopic: perforation, uncontrolled bleeding
    •   Paracentesis: blood, pus, bile, feces, urine




                                                  68                                           69
                                                 68                                            69
     THYROID CA

               Papillary           Follicular                 Medullary        Anaplastic    Lymphoma
      Incidence 70-75%             10%                        3-5%             2-5%          <1%
     of all
     thyroid CA
      Route of Lymphatic           hematogenous               Lymphatic
      spread                                                  +hematogenous
     Prognosis 98% @ 10years 92% @ 10years                    50% @            20-35% @
                                                              10years          1year
                                                                               13% @
                                                                               10years
     Treatment Small tumours: Small tumours: near             Total            Small         Radiation
               near total           total thyroidectomy or    thyroidectomy tumours:         and
               thyroidectomy       lobectomy/isthemectomy     median lymph     total         Chemo
               or lobectomy         Diffuse/bilateral total   node             thyroidectomy
               Diffuse/bilateral    thyroidectomy             dissection if    +external
               total                                          lateral cervical beam
               thyroidectomy                                  nodes +ve
               post-op131I                                    modified neck
                                                              dissection
                                                              Post-op
                                                              thyroxine
                                                              Tracheostomy
                                                              Screen
                                                              relatives
     Other     Papillary CA        Follicular CA              Medullary CA
               Popular             Far away mets              MEN IIa or Iib
               Palpable lymph      Female 3:1                 AMyloid
               nodes               FNA (cannot be dx by       Median node
               Positive 131I       FNA)                       dissection
               uptake              Favorable prognosis
               Positive
               prognosis
               Post-op 131I to
               diagnos
               treatments




70                                                   71
70                                                   71
THYROID NODULE WORKUP                                                        INFECTION PREVENTION AND CONTROL REALLY STARTS WITH YOU!
                                                                             Your practices and adherence to certain policies and procedures are a large part of the goals we
                                                                             try to achieve in infection control which is basically to prevent or stop transmission.

                                                                             HAND HYGIENE IS THE SINGLE MOST EFFECTIVE WAY OF STOPPING THE SPREAD OF
                                                                             MICROORGANISMS.

                                                                             Some key points to remember during your day:

                                                                             Use alcohol based hand rub before touching patients OR their environment. The environment
                                                                             includes their bed, the side rails, their over bed table, the curtain around the bed, and even their IV
                                                                             tubing.
                                                                             Use the same product before performing aseptic procedures. These include mouth care, exam of
                                                                             throat, instilling eye drops.
                                                                             Use the product after all contact with body fluids.
                                                                             Using the same product , before you leave the patient environment.

                                                                             Soap and water is required if the hands are visibly soiled but in all other instances, the alcohol
                                                                             products are preferred.

                                                                             Ensure you are well educated on additional precautions on your patients, and follow the
                                                                             instructions for (personal protective equipment ) or PPE as required. PPE is available to protect
                                                                             all staff however it up to individuals to know how to use these items appropriately and properly. If
                                                                             you have not received this training ensure you do by contacting your immediate supervisor or
                                                                             senior leader.

                                                                             Maintain a healthy lifestyle yourself. If you are unwell please do not report for work. Stay home
SURGICAL WOUND CLASSIFICATION                                                until you are symptom free.

Clean (A)          Does not cross a viscus. No     Infection rate 1%         Remember
                   inflammation
                                                                             GOOD INFECTION PREVENTION AND CONTROL SAVES LIVES...IT'S IN YOUR HANDS.

Clean              Crosses a hollow viscus. Acute Infection rate 10 - 20%    Debby Kenny RN CIC COHN(C)
Contaminated (B)   inflammation, no pus.                                     London Health Sciences Centre
                                                                             University Hospital
                                                                             685-8500 ext 36835
                                                                             pager 13440
Contaminated (C)   Acute trauma <6h. Acute         Infection rate 20 - 40%
                    inflammation.
                   Major breaks in
                   sterile technique.

Dirty (D)          Pus. Acute trauma >6h.          Infection rate > 40%




                                  72                                                                                           73
                                  72                                                                                           73
MANAGEMENT OF CORONER AND NON CORONER CASE DEATHS                                                       NOTES:
A. Non Coroner’s Cases
       Licensed MD must pronounce the patient dead

        Physician pronouncing the death must notify the attending physician and next-of-kin

        Decision should be made re need for autopsy and should be discussed with family.

        If Coroner’s case, go to B (Nursing Home patient, unexpected/unexplained death, death in
        OR)

B. There are some key points and actions required when applying this policy, specific to a
       coroner's case:

        There are specific circumstances that require identification and notification of the coroner.

        The Coroner, when notified, makes one of the following determinations:

        A. this is not a coroner's case

        B. it is a coroner's case and that he/she will come in to complete the Medical
                         Certificate of Death, but that no autopsy is required, or

        C. it is a coroner's case and that he/she may come in to view the body,
                  and that an autopsy is required.

There are specific communication and documentation requirements.

Direction regarding the care of the body will be given by the coroner. This includes
any direction regarding organ and/or tissue retrieval and donation.

The body may not be moved, interfered with or altered in any way until the
Coroner so directs.


http://appserver.lhsc.on.ca/policy/search_res.php?polid=PCC024&live=1




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