1. Ward & On Call Survival Skills

2. By: Gen Surg R2sLaura VanderBeek Carmen Barnette Heather MacLeod Jola Omole Plastics R2 Colin White Urology R2s Jason Kovac Zak Klinghoffer ENT R2 Rajveer Hundal Ortho R2s Ted Scriven Jihad Abouali Vick Khanna

3. General Ward Management Electrolyte imbalance Post Op Fever Chest pain/SOB ECG Acute MI

4. Common General Surgery Consults Appendicitis Acute Cholecystitis Ascending Cholangitis Acute Pancreatitis Small Bowel Obstruction Ischemic Bowel

5. Helpful Pointers Urology Orthopaedics ENT –Epistaxis –Peritonsillar Abscess Plastics Useful #s and General Tips

6. Hypokalemia What is the cause? –Diuretics (lasix) –Metabolic / Respiratory Alkalosis –Hyperaldosteronism –Diabetic ketoacidosis (with osmotic diuresis) –Loss through GI tract (diarrhea,vomiting) –Other renal losses - eg. various renal tubular acidoses

7. Hypokalemia ECG (PAC, PVC, flat Ts, U waves, ST depression) Replenish Potassium: –IV: Add 20-40mEq KCl/L to IV solution 10 mEq in 100cc H2O (x 3) ~> each over 1 hr hurts, remember KCl scleroses veins –Oral: KCl elixir 20 mmol/15ml K-lyte 25mmol/packet i-ii Slow K tabs (8mmol) –Replace Mg if deficient Repeat lytes

8. Hyperkalemia What is the causes? Pseudohyperkalemia: –Hemolysis Excessive Intake: –K+ supplements (oral or IV), Blood transfusions Decreased Excretion: –Renal failure (acute or chronic) Drugs: –K+ sparing diuretics (spironolactone) –ACE inhibitors –NSAIDS –Trimetoprim / sulfamethoxazole (TMP/SMX) –Cyclosporine –Renal tubular acidosis Redistribution: –Acidosis –Cellular breakdown (Rhabdomyolysis, Hemolysis, Tumor lysis syndrome, Burns) –Drugs (digoxin, beta blockers, succinylcholine) –Insulin deficiency

9. Hyperkalemia Repeat lytes Stat IV ECG –Peaked Ts, ↓ R waves, prolonged PR, no P waves, sudden VT Stop any K+ or contributing drugs Notify your chief resident/SMR Continuous cardiac monitoring 1 amp CaCl or Ca gluconate 10% 1 amp D50W IV then Humulin R 10 units IV Ventolin Lasix 20-40mg IV 1 amp sodium bicarbonate (NaHCO3) kayexalate: 30 g PO/PR q4h Persistently high, call nephrology for dialysis

10. Post-Op Fever The 5 W’s: –Wind (pneumonia) –Water (UTI) –Wound –Walk (DVT, PE) –What did we do? (surgery, drugs, IV sites, blood products)

11. Chest Pain &/or SOB Assess pt: –ABC’s, vitals –Hx –PE Do you need further investigations: –CXR –CK and Trops –ECG Remember: –Call for help early if pt unstable or you feel uncomfortable: chief resident / SMR / CCRT/ RACE team

12. ECG Rate –300-150-100-75-60-50 Rhythm –P before every QRS, QRS after every P –PR interval (AV blocks), QRS interval (BBB) Axis –Positive QRS in leads I and aVF Intervals –QRS <0.12, PR 0.12-0.20 Hypertrophy –RVH: R wave progression decreases from V1 to V6 –LVH: S in V1 + R in V5 > 35 mm Infarct –ST depression, ST elevation –T wave inversions, Q waves

13. Acute MI ABC’s MONA –Morphine –Oxygen –Nitroglycerin –Asprin (160mg chewed) ECG 2 large bore IVs CK and Trop q8h x3 CXR Meds: ASA, anticoagulation, ACEi, B-blocker, CCB, Statin, Diet Call Race team, CCRT or SMR, ?PCI

14. Gen Surg Consults Constipation –Does not have to be a referal –ER docs can manage them, but they often are referred and hard not too accept as they could be a more serious underlying problem GI Bleeds –Go to GI, some exceptions Abd pain and Crohns, even if it is SBO –Go to GI, some exceptions

15. Appendicitis Symptoms: –anorexia usually first symptom, followed by vague peri-umbilical  RLQ abdo pain, then vomiting occurs after the onset of pain; if no anorexia or if vomiting before pain, then question the diagnosis Signs: –fever, localized RLQ peritonitis, increased WBC Imaging: –Plain film – may see ileus –U/S – (sens 55-95%; spec 85-98%) look for non-compressible appendix, > 6mm diameter, presence of a fecalith, peri-appendiceal fluid, and thickened appendiceal wall –CT – (sens 92-97%; spec 85-94%) dilated appendix > 5mm, thickened appendiceal wall, fat-stranding, thickened mesoappendix, and obvious phlegmon Management: –IV fluid resuscitation, antibiotic coverage (cipro/flagyl, 2nd gen cephalopsporin), NPO, analgesia, prepare for OR (consent, book OR), lap/open appendectomy equivalent. If perforated with abscess, treatment is percutaneous drain and interval appendectomy.

16. Acute Cholecystitis Symptoms: –steady RUQ pain (usually > 12 hr duration), bloating, nausea/vomiting, onset after big/fatty meal Signs: –Murphy’s sign, distended abdo, fever, increased WBC, may see increased conjugated bili and alk phos/GGTs – may indicate passed stone Imaging: –CXR – exclude RLL pneumonia, may be able to see calcified stone –U/S – (sens 88%; spec 80%) gallstones, distended gallbladder, thickened wall ( > 3mm), pericholecystic fluid, and sonographic Murphys sign –CT – wall thickening, pericholecystic fluid, subserosal edema –HIDA – (sens 97%; spec 90%) failure to see contrast in gallbladder/cystic duct Management: –IV fluid rehydration, NPO, antibiotics (cipro/flagyl, amp/gent/ flagyl), analgesia (toradol/morphine), conservative management or cholecystectomy if presentation within first 48 hrs or if patient deteriorates. May consider percutaneous cholecystostomy tube if patient not good operative candidate.

17. Ascending Cholangitis Symptoms: –RUQ pain, jaundice, fever – Charcot’s triad; plus hypotension and confusion – Reynold’s pentad (indicates shock state); may also have nausea/vomiting Signs: –jaundice; Murphys sign; increased WBC; fever; increased conjugated bilirubin, alk phos/GGT, and transaminases Imaging: –U/S – distended gallbladder, dilated bile ducts, choledocolithiasis –CT – dilated biliary system, pancreatic head masses –ERCP/PTC – dilated biliary system, choledocolithiasis, site of biliary tree obstruction Management: –Aggressive IV fluid resuscitation, blood cultures, antibiotics, analgesia, NPO, urgent biliary tree decompression (ERCP/PTC drain), may require ICU admission

18. Acute Pancreatitis Symptoms: –severe, steady epigastric/LUQ pain that radiates to the back, nausea/vomiting, pain may be relieved by leaning forward Signs: –epigastric tenderness with voluntary/involuntary guarding, fever, leukocytosis, increased amylase/lipase, LFTs may be increased if gallstone disease Imaging –U/S – R/O gallstones –CT – use to differentiate between mild and severe pancreatitis and to monitor for complications of severe pancreatitis Management: –Aggressive IV fluid resuscitation, correct electrolytes, foley in, analgesia, NPO/clear fluid diet, antibiotics in severe pancreatitis, monitor lab markers as per Ranson’s Criteria or APACHE-II score, may require ICU admission

19. Small Bowel Obstruction Symptoms: –colicky abdo pain, nausea, vomiting, and obstipation Signs: –abdo distention (esp. if distal obstruction), dehydration, mild leukocytosis Imaging: –Plain films – (sens 70-80%; low spec) dilated small bowel loops (>3cm), air-fluid levels ( > 5), absence of gas in the colon/rectum –CT – (sens 80-90%; spec 70-90%) transition zone with dilated bowel proximal and collapsed bowel distal, intraluminal contrast not present distal to transition point, and little gas or fluid in the colon Management: –IV fluid resuscitation, electrolyte correction, foley catheter in, NG tube esp. if vomiting, NPO, urgent OR if suspect strangulation/ischemia, otherwise trial of conservative management with serial abdo x-rays

20. Ischemic Bowel Symptoms: –mid-abdominal pain out of proportion to physical findings, nausea/vomiting, diarrhea, blood per rectum Signs: –abdo distention, diffuse peritonitis, fever, +ve FOB, increased WBC (often > 20 000), increased lactate, metabolic acidosis Imaging: –Plain films: ileus, thumbprinting, gas in bowel wall or portal venous system –CT (with IV contrast)– (imaging modality of choice) bowel wall edema, gas in the bowel wall, decreased bowel wall enhancement, occlusion of SMA/LMA, gas in the portal venous system –Angiography – site of occlusion of mesenteric vessels, can determine whether embolic occlusion, thrombotic occlusion or vasospasm, Management: –Aggressive IV fluid resuscitation, foley in, analgesia, correction of electrolyte imbalances, antibiotics (tazocin), +/- CTA of abdo/pelvis, ICU admission, urgent laparotomy for resection of necrotic bowel – if entire small bowel compromised patient is palliative, revascularization may be required intra-op or via anti- thrombolytics depending on etiology. Second look laparotomy in 24-48 hours to check for further necrotic bowel, esp. if during first laparotomy bowel was resected or there were areas of questionable viability.

21. General Surgery Topics Hernias Breast cancer Colon Cancer Soft tissue and Skin Malignancy GERD and esophageal diseases Hepatobillary Diseases (very brief and only if at St. Joes or MUMC)

22. Urology Ward : –Difficult catheters –Suprapubic catheters –Post-op retention ER : –Stones (office apt. vs. consult) –Hematuria –Trauma –Pyelonephritis

23. Orthopaedics Site Specialties: –HGH: Trauma, Upper Extremity, Foot&Ankle, Spine Lots of ‘Barton Street Specials’ –MUMC: Peds, Sports Lots of ‘entitled’ local residents –HDGH: Mainly arthroplasty, Sports (just a bit) Lots of old people with broken hips –SJH: Arthroplasty, Upper extremity, Spine, Foot&Ankle Lots of ‘crazys’ thanks to psych

24. Orthopaedics On Call: –Weekdays: Day call 8-5, Night call 5-8 –Weekends: 8-8 (check for 8am OR’s 1 st !!) –Always 2 nd call backup by Sr – don’t hesitate to call them (esp before calling staff)! –Consults: get a copy of the bradma to give to staff with dictation jobid on it –Post-call: get a feel for things, use your own judgment Similar for Gen Surg

25. Orthopaedics On Call: –HGH: in house, terrible call rooms, very busy with trauma –HDGH: home call, check with wards before leaving, lots of hip #’s –MUMC: VERY busy with ER consults, lots of reductions, issues with RNs, conscious sedation in ER –SJH: Home call –Make SURE you handover all issues/admits in the a.m.!

26. Orthopaedics Ortho Emergencies: –Open #’s –Compartment Syndrome –Lower Limb Nec Fasc –# Dislocations –Cauda Equina –Septic Joints –NV Compromise –C-Spine Injuries

27. Orthopaedics Common Ortho Meds to Know: –Ancef –Percocet –What else could you possibly need???

28. Orthopaedics Admissions: –Never admit without 1 st talking with Sr or Staff –Many sites have pre-printed order sheets (ex: HDGH, 6W @ HGH) –Don’t forget NPO, abx oncall, pre-op consults (medicine, thrombo, anesthesia) –Many medicine consults, but use your head 1 st !!! (ex: timing, appropriateness)

29. Orthopaedics Department Activities: –Wednesday a.m. Grand Rounds 7-7:30am: spine or oncology 7:30-8:30: Grand rounds –Each resident assigned a staff for 1 presentation/year –Staff presents cases and grills chiefs, resident presents ~15min at the end –Try to find out case details from staff to pass along to residents (esp chiefs) in advance! –Journal Club: Monthly, different staff’s house each month. Schedule out in advance, R3’s coordinate May be excused from call to attend!

30. Orthopaedics Department Activities: –Quarterly JBJS MCQ Subscriptions given out in July/Aug (Candice) Quarterly quizes found online (jbjs.org?) Submit to Dr. Bednar on due date (Wednesdays) Must complete ¾ yearly –OITE Novemberish Everyone fails BADLY!

31. Orthopaedics Department Activities: –Funding: ~$1200 yearly for courses/books – use it or lose it! –Research: Present twice in 5 years Coordinator is Dr. Ghert Need ideas/proposals by fall of R2

32. Orthopaedics Resources: –JAAOS online – good reviews –Hopenfeld – surgical approaches –AO Foundation for Trauma –Wheeless online –Rockwood – wordy but comprehensive for #’s –Campbells – good luck! Good insomnia tx –Miller Review – good for review, very brief

33. Epistaxis When assessing a patient in the ER, it is important to determine if the patient is still bleeding, is this an anterior or posterior bleed?

34. Anterior Bleeds Very common, occur from vessels which anastomose & create Kiesselbach’s plexus 1.Ask the patient to gently blow the nose to clear out any clots. 2.Use suction if needed to rid yourself of clots/excess blood. 3.Use cotton swabs with lidocaine and epinephrine to achieve a vasoconstrictive effect. 4.Take a look with your nasal speculum and see if there are areas of bleeding. 5.Use silver nitrate cautery if there is a bleeding vessel, do NOT! Cauterize both sides of the septum. 6.If bleeding does not stop move on to packing with Vaseline gauze or murocel packs. 7.Remember to give medications for pain (Tylenol 3/Percocet) and Keflex to prevent toxic shock syndrome from the packing. Have the patient return in ~2 days to remove packs. 8.Sometimes the bleeding still doesn’t stop and you may have a posterior bleed which will require a nasal pack. Posterior bleeds are usually caused by the sphenopalatine artery.

35. Posterior Bleeds Technique - Foley catheter (10-14F 30-mL balloon) a)Apply ‘muco’ nasal ointment 2% to the catheter. b)Insert the catheter into the nostril. c)Visualize the catheter tip in the back of the throat. d) Inflate the balloon with up to 10 mL of sterile water. (Do not fully inflate the balloon to 30 mL.) e)Withdraw the balloon gently until it seats posteriorly. f)Pack the anterior nasal cavity with a balloon device, nasal tampon (eg, Rhino Rocket), or layered ribbon gauze. g)Apply a padded umbilical clamp across the catheter to prevent alar necrosis and to keep the balloon from dislodging.

36. Peritonsillar Abscess  Needle aspiration: Needle aspiration is used for symptom relief and is the criterion standard for diagnosis. Lidocaine with epinephrine should be used to anesthetize the area. A 16- to 18-gauge needle with a 10-mL syringe should be used to aspirate from the area that is most fluctuant. A needle guard may be used to prevent accidental carotid artery puncture due to the tip of the needle migrating too far posteriorly. Only 0.5 cm of the needle needs to be exposed. If a needle guard is unavailable, a curved clamp can be used to expose a small portion of the needle before inserting it into the area for aspiration. Since the superior pole is the most common place for the abscess to develop, that is usually the first place aspirated if the entire tonsil looks or feels boggy. Aspiration of the middle one third and then the lower one third should then be attempted if pus is not returned from the superior pole.

37. Peritonsillar Abscess Abscess I&D: –After lidocaine with epinephrine local infiltration, a No. 11 blade scalpel may be used to incise a very large PTA, allowing the purulent drainage to flow freely as the abscess cavity decompresses. Allow the patient to hold the Yankauer catheter tip and to suction the pus, rather than swallow it. Give analgesia medications and Clindamycin 600 mg po TID for ~10 days. Tonsillectomy: –may be used for recurrent peritonsillar abscesses

38. Plastics First year of plastic residency is mostly off service: Ortho, Medicine, Plastics, ER, Gen Surg (4 mths) Plastics rotation is based out of SJH Journal Club each month (don’t miss this) Core and Plastics rounds (don’t be late) Call at SJH

39. Plastics Off service residents going thur plastics: Gen Surg – usually at General - trauma, hand fractures Ortho – usually during second year at SJH - know hand and breast anatomy Ways to prep Toronto Notes & The little red book of plastics secrets

40. Plastics Need to know how to do… –extensor tendon repairs –manage various hand fractures (ie the different ways of casting) –local hand nerve blocks –drain abscesses appropriately –Expected to be able to conduct procedures independently in ER (ie sterile technique etc)

41. Plastics Know the plastics emergencies Know the reasons for referrals Get meditech at home for looking at Xrays Know different dressing types and associated +/- of each Consults – wide range of cases Have office phone numbers & addresses on hand for arranging follow up

42. Plastics SJH staff are very particular with punctuality and dress for clinic White coats must always be worn if in greens and outside of the OR Always be on time for the start of staff clinics and especially for SJH resident clinics Friday mornings Its a preceptor based system at SJH so if you are sick make sure you let your staff or staff office know

43. Phone #s Dictation:5000 MUMC Main #: 905-521-2100 Paging:76443 HGH Main #: 905-527-0271 Paging:46311 HDGH Main #: 905-389-4411 Paging:42111

44. SJH Phone #s Main #:905-522-1155 Paging:33311 Admitting:33183 Dictation:32078 –doesn’t give you prompts so use the yellow card the first few times

45. Paging HHS –87 – pager # * priority Online Text –“corpweb” –Far right of screen, link to “PHONEBOOK” –Type in last name of person to be paged

46. Turning Off Your Pager Turning your pager off does not work Call paging and let them know you are post call, on vacation, at teaching… etc Call 905-521-2100 –Ext 87 –Enter your pager # –Enter 08 Do the same thing to turn pager back on

47. General Tips Keep up with reading/knowledge, you won’t operate if you don’t know what you’re talking about Be on time Get to the OR before your staff does Work hard, don’t be lazy Enjoy time off when you get it RNs can be your best friends or your worst enemy!

48. General Tips Teach the Clerks Take advice from your seniors Make sure to vent often, and if necessary loudly! If you think about calling your senior or staff, CALL them If you are overwhelmed with a sick pt call your senior, the CCRT, RACE team, and/or the SMR If someone is nasty to you, chances are they are nasty to everyone! Keep a balanced life –family, friends, physical activity, hobbies, etc Take all your vacations!!! Have Fun!!!