1 uw ossmig harborview trauma call guide ortho trauma call guide 201… · uw ossmig harborview...
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CMP 12/2015
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UWOSSMIGHarborviewTraumaCallGuideSpendinganighthelpingtheOrthopaedicSurgeryserviceevaluate,mangeandtreatpatientswithinjuriesintheEDisgreatchancetogettoknowtheresidents,gainrealworldexperiencewithOrthopaedics,learnmusculoskeletalmedicineandgetinvolvedoutsidetheclassroom.OrthoCallatHMCcanbeverybusywiththeshearvolumeofpatientsthattheresidentsseeastheconsultresident.Mostoftheseconsultsrequireareductionofafractureorrelocationofajoint,andthensplintingand/orpinningtostabilizethelimb.Eachconsultcanthusbeverylaborintensive.Inthefirsthalfoftheyear,4thyearmedicalstudentscomefromalloverthecountrytodosub-internshipsatHMCandhelpoutthepersononcalltoseeifthisisthekindofprogramforthem.Thesecondhalfoftheyearwedon'tusuallyhaveanyonetohelpusout.ThisiswhereyouasUWmedicalstudentscomein.Thisguidewillhelpyouonceyou’reinthethickofthings.Hereweattempttobreakitdown,highlightkeythings,answerfrequentlyaskedquestionsandhelpmakingthiswholeprocessbiteasierforyou.GENERALINFO
• Carrynotecards&takenotesonimportantinfo/pearls/questions/patient/operations• Bepreparedtoworkhard!
o It’sguaranteedtobeabusybutfunnight.Manysayitisthemostrewardingthingthey'vedoneintheirpreclinicalyears.
• Beenthusiasticwithagoodattitude.Beyourselfasmuchaspossible.• Takeasmuchcallasyouarecomfortablewith.
o Youcancomelateorleaveearly.Thisisforyourlearning.• Knowyouranatomyandphysicalexam.• ConstantlyAnticipate
o “WhatcanIdotomaketheteammoreefficient.”§ E.g.havetapeanddressingsreadybeforetheasked§ Knowwhichformstoalwayshaveonhand
• Rotationsareablendofserviceandeducation.o Service=beingateamplayer,workinghard,etco Education=learningfromresidents,patients
• Don’ttryandshowupfellowmedicalstudents.Don’ttrytoshowupresidents.o Thatbeingsaid,askquestionwhenyouhavethemandanswerthemwhenasked
• Benicetoancillarypersonnel.Theyknowalotandhavebeenaroundlonger.CALLSIGNUP&SCHEDULINGStudentschedulingiscoordinatedviaanestablishedCalendarontheOSSMIGWebsite:http://www.orthop.washington.edu/?q=ossmig/harborview-trauma-call.html
Pleasebeconsideratetoyourfellowstudentsandsignupforamaximumof2daysatonetime(thismeansyoucanonlyhave2futuredatesatonetime).Donotsignupfor2consecutivedaysor2consecutiveweeksonthesameday(ie.2consecutiveFridays).For2016,twostudentscanberegisteredtotakecallforagivenday.
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2 Ifyoucannotmakeyourdateanylonger,pleaseemailthelistserv([email protected])atleast1weekpriortoyourscheduleddate/timetoletothersknowofthatavailabilityandremoveyournamefromthecalendar!RememberthatResidentsarecountingontheassistancemedicalstudentsprovide,itisimperativethatyouhonoryourcommitments.Tosignup:1)Loginat:https://depts.washington.edu/orthodev/drupal/?q=ossmig/ossmig-htc-calendar.html
username:htc(alllowercase) password:htc@00SMIG(thosearezeros)
Afteryou'reloggedinToaddadate:
1) Clickonthe"Add+"linkatthetopofthecalendar.2) Enteryournameandclassandthedateyou'resigningupfor.3) Click"Save".Yournameshouldappearinthecalendaronyourscheduleddate.Donotchangeany
oftheothersettings.
Toeditordeleteadate:1) Clickontheeventtitlelink(shouldbeyourname).2) Thiswillopenanewwindow.Clickonthe"more"link.3) Clickthe"Edit"tab.4) Todelete,click"Edit",then"Delete".Itwillaskifyouaresureyouwanttodelete.Click"Delete"
again.Ifyouhaveproblemslogginginoraddingadate:Fortechnicalsupport,pleasecontacttheWebmasteratosmweb@uw.edu.BASICSEQUENCEOFEVENTSHowdoIpreparethedaybefore?Eatwellandgetplentyofsleepthenightbefore.Residentsreallyappreciateitifthemedicalstudentsplannedtotake12(weekday)or24hour(weekend)shifts.Thisallowsthemtospendmoretimeteachinginsteadoforienting,andshouldprovidethebestexperienceforeveryone.Anotherkeypieceofadvicetomakeitthroughalongeveningistostayhydrated.It'seasytoforgettodrinkwhenthere'salotgoingon,butit'saloteasiertostayawakeandfunctionalwhenyou'rehydrated.WhatshouldIreadaboutbeforehand?Themostcommonconsultsareanklefracturesandboxer's/distalradiusfractures.Prioritizereadingaboutthemechanism,presentation,diagnosis,andtreatmentofthesemostcommonfracturesaheadoftimesoyouwillhaveageneralideawhatisgoingon.Therealityisyoumayseejustaboutanything,fromfemurandtibiafracturestopelvicandacetabularinjuries,tospineinjuries.Youwillbeabletopickupinformationregardingtheseconditionsonthefly.Feelfreetoaskquestionsandpursuesuggestedreadingarticles.Ifthere'ssomethingthattheResidentmaynotknowaswellastheywouldlike,sometimesthemosthelpfulthingisforyoutoassistinlookingitup.
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3 WheredoIgowhenIarrive?WhenyouarriveatHarborview,thebestplacetoenteristheEmergencyDepartment.Youcanheadtothefrontdesk,andaskthemtousethephonetopagetheOrthoresidentoncall,orpagetheresidentfromyourcellphone(instructionsinthenextsection).Ultimately,theresidentwilltellyouwheretogo(The“On-Call”roomor“FishBowl”)afteryouhavegottenincontactwiththem.WhenshouldIarriveandwhatshouldIdowhenIgetthere?Onweekdaysyoushouldplanonshowingupbetween6and7pm.Onweekendspleasearrivearound6:45am(NOlaterthan6:55am),assign-outoccursat7am.Sign-outcanbeanexcellentlearningexperience,asResidentswillgoovercasesinthemorningthatwillbehandedofftotheoncomingteam.ThesediscussionsoftenrevolvearoundERworkup,management,andindicationsforsurgery,etc.TopagetheOrthoresident,dial4-3000(or744-3000fromanoutsideline)andasktheoperatortopagetheorthopedicconsultresidenttowhatevernumberyouareat.TellthemyouareaUWmedicalstudentwhoissigneduptofollowthemaround.Whoeverisoncallcandirectyouandgiveyouaquickorientation.Ifitisbusy,theymayhavetheinterndothosethings.Ifyouwanttomakeyourliveseasier,pickupscrubsanddropyourstuffoffinthesixthfloorOrthoResidentroombeforehand(see“GoodPlacestoKnow”sectionfordirections).WhataretheexpectationsandwhatwillIbedoing?Residentsreallyneedyourhelp.Sometimesthatmeanshavingyouscribewhiletheyperformahistoryandphysicalexam,andsometimesthatwillmeanhelpingholdalegand/orgettingsplint/localanestheticmaterialready.Anythingthatyoucandotoexpeditetheteamsabilitytoseepatientsmakesyouinvaluable.Justbeawarethatdifferentresidentswillhavedifferentcomfortlevelswithhavingyoudothings.Themoreyouworkwithusandthemoreyouseemtoknow,however,thenthemorecomfortabletheywillfeelgivingyousomelevelofresponsibility/autonomy.IMPORTANTRESOURCES
• HandbookofFractures(Koval)o “Thebook”fororthopedictrauma.Greatprepforfractureconference.
• Netter’sOrthopaedicAnatomyo Greatresourcetobrushuponyouranatomy.
• Hoppenfeld’sSurgicalExposureinOrthopaedicso AmustforORpreparation.Programshouldhavesomelayingaround
• Miller’sReviewofOrthopaedicso Goodoverview.Probablyabittoomuchforbutcouldbehelpful
• JAAOS“YellowJournal”Articles• OtherResources:
o WheelessOnlineOrtho–http://www.wheelessonline.com/o Yoursmartphone-Goodorthoapps&easytosearchforquestions.
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4 GOODPLACESTOKNOWATHMC
• HarborviewOrthopedicsResidentRoomo CentralHospital,6thflooro Code:198419
• OrthopedicsLibraryo Easthospital6thfloor,downcentralhallonright.Roomxxx
§ Meetherebeforeroundsandforsignout§ Code:1234
• HarborviewEmergencyRoomo Easthospital,1stfloor
• Cafeteriao Easthospital,Basement
§ Bestiftakecentralelevators(backofER)downtoB.TheORwillbeoneway,thecafeteriatheother.
• OperatingRoomso Easthospital,Basement
§ Bestiftakecentralelevators(backofER)downtoB.TheORwillbeoneway,thecafeteriatheother.
§ LockerRooms-Ask.Theyaregenderspecific.• ScrubSupply
o Canborrowfromlockerrooms(1WnearERforwomen,orGfloorbelowERformen).Alsoeasilylocatedon9Einunlockedsupplycloset.
EMERGENCYROOMDETAILSWhat is the Harborview ER like? HarborviewERislikenootheremergencyroom.YoucanseemorehereinanightthanmanyotherERsseeinamonth.TheERisbuiltinsections(Medicine[blue],Triage[green],andTrauma).Radiologyisinthemiddleofitall.YouwillspendmostofyourtimeontheTraumaSideoftheER.ThetraumasideismadeupofRooms:Med(bed1&2),Resus1(beds1&2),Resus2(beds1-4)&Resus3(beds1-4).Thereisafrontdeskwherelabsaresent.Theycananswermostofyourquestions.The‘fishbowl’istheworkareawheretheERresidents,attendings,andmedstudentswork.TheOrthoconsultandSurgeryconsultalsohaveastationhere.WhatformsandprocessesshouldIhaveknowledgeof?Aftertransitioningtoanall-electronichealthrecordsystem,Harborviewhasdoneawaywithmost,butnotallforms.YouwillbeallowedtoseeandassesspatientswhoneedanOrthoconsult.Residentswilllikelyinitiallyassignyoupatients,butasyougainexperienceyoumaybeinvitedtopreemptivelygoseepatientsandstarttheworkupandassessment.Withthatsaid,youwillinteractwiththefollowing:
• AllpatientsneedanOrthoH&Psheet–fillingtheseoutreallyhelpstheResidents.Theyaremadeupofthefollowing:
o GeneralOrthoConsultSheet–usedformosttraumas
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5 o SpineConsultSheet–usedforspinepatients
§ Spinecallissharedwithneurosurgery&thusOrthowillnotalwaysbeconsultedo HandConsultSheet–usedforhandpatientso ConsentForms
§ Neededfortractionpinandforthosewhowillgotosurgery§ Listallpossibleprocedures(noabbreviations).§ Listallpossiblesurgeons§ Mustbesignedandconsentedbyresident
• WhenthereisabreakandtheResidentisrunningtheirlistofConsults.SeeiftheyneedhelpaddingtheconsultstoCORES.
o Youwillbeshownhowtodoitthe1sttime.InORCAgotoCORES,findthelistfortheteamthatisonthatnight(Red,Blue,Green),orSpine,Hand,etc.Addpatientfrommenu,addfromEDcensusandmake1’or2’dependingontheconsultandadmittingteam.
WhereisstufflocatedandhowdoIgetit?CollectingandpreparingresourcesforResidentswhenneededisaprimaryroleformedicalstudentsparticipatinginTraumaCall.Withexperience,youwillhopefullydeveloptheabilitytoanticipateneedbepreparedbeforecalledupon.Alwayshavethefollowinginyourpockets:
Ø GlovesØ ShearsØ PaperTapeØ LidocaineØ X-Ray,H&P&ConsentFormsØ Notebook/Notecardstowritedowninfo/questions
Necessaryresourcescanbefoundinthefollowingsupplylocations:
• OrthoERSupplyRoom:Locatedatendofhallonleftbeforeelevators.Code:7-3-1-7-3-1o Splintingtubs:Volunteersshouldhaveplentymadeup.Very
helpfulifrunninglowandERislowtoanticipateandhelpprepareafewifyou’rebored.
§ Plaster• Youknowwhatthisis.Getwetandithardens.
Warmerwater=fasterhardening§ Webril
• Cushioning.Wraparoundextremitybeforeapplyingplaster.Extraaroundanybonyprominences
§ Bias• Tanwrapforwrappingsplintandmakingit
lookgoodandcomfortable.o OtherSupplies:Slings,Crutches,etc.CamBootslocated
underPTdesk.
• ERSupplyRoom#1:LocatedinthebackbetweenEDBlue&Green.o SuppliesnotlocatedinEDSupplyCartsorSupplyRoom#2o Mediporetape,crutches,etc…
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6 • ERSupplyRoom#2:LocatedinthebackcornernearradiologyMRI–1WH408.
o SuppliesnotlocatedinEDSupplyCartsorSupplyRoom#1o Nonstickdressing,kerlex,etc…
• ERSupplyCarts:LocatedaroundER&ateveryResusbaybed.
o Holdsmostcommonlyusedsupplies.Labelsondrawerso Needles,sterilegloves,waternozzles,suturingset,stapler,etc.
• Warmerator:LocatedinhallwaybetweenResus2&3.
o Warm1LSalinebottlesfoundhere.§ Willuseplentyforirrigatingwounds.§ Usenozzlesorpuncturemulti-holesintopwithan18gneedle.
• MedRoom:LocatedoncornerjustdownfromOrthoSupplyRoom.Codeiswrittenon
whiteboardcornerinsideo Stockuponlidocaineinyourpocketforusewithsuturingorpinplacement.o Food&drinkforpatientsalongbackofwall.
• UtilityRoom:LocatedoncorneracrossfromMedRoom.
o Placeusedtoolsandpinsetsinthebinsontheleft.o PlasterwatercanONLYbedumpedintothesinkinthisroom.
Othercommonlyusedsuppliesnotfoundintheabovelocationsare:
• SteinmannPinSet:o LocatedinResus2onbottomofbackLeftwallo Usedforplacingdistalfemoralorproximaltibialtractionpins
• Sutures:
o LocatedonshelvesabovesinksinResusroomso Alsoinsupplycartbackinhallnearsocialwork
• LargeClamps:
o LocatedonbackleftwallofResus2o Inbinonwall,commonlyhiddenunderSteinmannPinPetsinbino Usedforsheetingpelvis
• MiniC-Arm:
o Locatedinhallbacknearsocialworko Plugin,turnon(greenswitch),andlogin(password=x-ray).Fillinanythingforrequired
forandproceedtoperformevaluation.Seton‘continuous’.o Usedforassessmentandreductionoffractures.
• TractionCart:
o Locatedinhallbacknearsocialworko Usedtosetuptractionandhangweights
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• Stickers:o Locatedbyeachpatient,ondesk,orattachedtoclipboardo Alwayshaveafewextrainyourpockettouseo GiveonetotheResidentifyouarepresentingpatientyousaw.
§ Cutitdowntofitintheirlogsheetifyouwanttobequietlyhelpfulo PrintStickers–theymayrunoutofstickerswhenyouneedabunchtoorderX-Rays.Goto
thoseseatedatcomputersatthewallbehindthebackERdeskandaskthentoprintupstickersforthepatient.Grabsomeandreturnthemtothebedside.
• BoxSplints:
o LocatedintheOrthoSupplyRoom.o PriortoproceduresandbeforeX-Rayevaluationslikelyfracturedorknownfractured
extremitiesarealwaysplacedinaboxsplintoncethepatient’sprimarysurveyiscompletedbythetraumasurgeryEDteam.Helpbytakingdowntheclothingandremovingcurrentsplints/supportsandplacingthemintoboxsplints.
o Placetowelinthemforpatientcomforto Tapethemintoplace
HowcanIhelpprepareforcommonprocedures?ThisisanothergreatopportunitytoanticipateandhelpmaketheResidents’liveseasier.WhiletheResidentisbusyrunningaroundtakingcareofbusiness,alwaysaskyourselfifthereisapatientthatwillsoonneedareduction/splint/tractionpin/suturing.Ifso,looklikeanallstarandstartsettingupeverythingsotheResidentandyoucanjustjumpinandperformtheprocedurewheneveryoneisready.Regardlessoftheprocedurebeginbygettingconsentformsprepared,stickered,andworkonH&P.After,youcanbeginprocedurespecificpreparations:SuturingOrthoResidentsarenotcommonlyneededforthis.TheERresidenttakingprimarycareofthepatientcandothis,butifsplintingisdelayedthenwecommonlyhelpoutanddoit.Ifyouknowhowtodothis,youcanwithResidentpermission.Candothisyourselfafterthesmallwoundsareirrigated.Checkwiththeresident.Especiallylocatedwitharesplintwillsoonbeapplied.Need:
• Sutures,suturingset,gauze,etc.(Seeabovewherethisstuffis)o OverheadlightsareateachResusbed.Knobtoturnonishiddenonbackwall.
DistalFemoralTractionPinNeed:
• SteinmannPinSeto Setupsterilesetonstand
• SterileGloves(forresident&you)• 4x4tubwithbetadine• Lidocainedrawnupwith18g.Label&getnew22gneedle.• TractionCart
o Willneedtosetupatendofbedoncepinplaced.2vertical,onecrossbar,(+/-)extensionpiece,pully,weight(10-15lbs),rope
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8 SplintsNeed:
• C-Arm(ifreductionneeded)• Tubwithwarmwater.Placeontowelstomakecleanupeasier• Shears• Mediporepapertape(4”usually,though2”forUEsometimes)• SplintingSupplies(differsdependingoninjury)
o TheTUBSforShortLegSplintsalreadymadeupinOrthoSupplyRoomo MakeownTUBoraddtothemdependingonwhatsplintyou’remakingo UpperExtremitySplints
§ 4”wideplasterused-cornersofplasterroundedorbendin§ ShortArmSplint
• 4”x15”plaster.7-8piecesthickx2(1anterior&1posterior)• 3”&4”webril• Bias&tape
§ LongArmSplint• Sameasshortarm+2more7-8thickplasterslabs(4slabstotal)• Extrawebril&bias
o LowerExtremitySplints§ 5”wideplasterused.30”and2extra15”orlongleg§ ShortLegSplint
• 4”x30”plaster.5piecethickslabsx2(sides)+10thick(posterior)• 4”&6”webril• 3layerdwebrilslabswithedgestorn• 6”Bias&tape
§ LongLegSplint• Sameasshortleg+2extra5”x15”5-8thickplasterslabs(sidesoflongleg)• Extrawebril&bias
HowcanIhelpafterprocedures?Splintingandpinningcangetmessy.Afteryoufinishitiseasytohelpcleanupthearea.Towelsandsheetsgointothewhitesquarelaundrybins.Bloodyandsoileditemsintothebiowasteredcontainers.Scrapsoftrashintothegarbagecans.Tractionpinsuppliesareplacedintheutilityroombins.Plasterwaterintotheutilityroomsink.TractioncartorC-armreturnedtothehallway.IsthereanythingelseIcando?BEHEALTHY-Getsomeexerciseortakeawalk.Usethestairswhengoingonlyafewfloorsinsteadoftheelevator.Mostimportantlystayhydratedwhenoncall.You’llbesurprisedhowyouforgettoeatanddrinkovernightwhenyouaresuperbusyintheER.Takeaquickbreakandgrabsomewaterthroughoutthenight.DuringabreakorwhenwaitingforapatienttogetX-Raystelltheresidentyou’reheadingdowntothecafeteriaandgrabaquickbite.