1 uw ossmig harborview trauma call guide ortho trauma call guide 201… · uw ossmig harborview...

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(ossmig_members@uw.edu)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.