Welcome to the Limb Service!

Limb Team Attendings

Plastic Surgeons Dr. Attinger Podiatrists Dr. Steinberg

Dr. Kim-Evans (Wednesdays)

Dr. Paul Kim

Limb Team NPs

Inpatient NPs Margaret Kugler Clinic NP Allison Chappell

Nancy Megas

Clinic Boss Catherine Hubley

Limb Team Official Scrub Tech

Brian Phillips CST

Limb Team Residents

Georgetown Plastic Surgery R3 (The Limb Chief) Georgetown Plastic Surgery R2 Fairfax Podiatry P3 Washington Hospital Center Podiatry P2 Georgetown Surgery Intern (Plastic/General/Ortho)

Plastic Surgery R3 (LIMB CHIEF)

On Service for 4 consecutive months Takes 1 week of vacation during the 3rd month Takes care of OR stuff, sends out Bible every night Is back-up for ALL residents at ALL times, is ALWAYS available Takes primary call 1 day per week, 1 weekend per month, rounds that weekend Calls Attinger around noon on Sat/Sun to run the list In OR 21 T/W/F In Clinic with Attinger M/Th Rounds on M43 in the morning

Plastic Surgery R2
On service for 3 months No vacation Is the General of the inpatients and consults Checks in with intern throughout the day In charge of call schedule Looks at OR schedule night before, making sure we dont miss combo cases Takes 1-2 nights of call per week, call 1 weekend per month, rounds 2 weekends per month. In OR 21 most of the time, sometimes OR 22 In Clinic with Attinger M/Th Rounds on the CCC building with 4th yr med students

Fairfax Podiatry P3
On service for 3 months No vacation Takes call 1 night per week, 1 weekend per month, rounds that weekend OR Clinic on Wed with Steinberg Rounds on the Bles patients every morning

WHC P2
On for 3 months No vacation Takes 1-2 nights of call per week, 1 weekend per month, rounds 2 weekends per month OR Clinic with Steinberg on Tuesdays Rounds on M63 every morning with a 3rd year medical student

Intern
On service for 1 month USED to take 1 night of call per week, 2 weekends per month NOW cannot take any call Will be at the hospital from 5:30AM to 7PM M-F
13.5 x 20 = 270 hrs

Will be at the hospital from 5:00AM to 5:30 PM Sat/Sun

12.5 x 4 = 50 270 + 50 = 320 320/4 = 80

Yes, that is legal.

duty. VI.G.5. VI.G.5.a) Minimum Time Off between Scheduled Duty Periods PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods.

VI.G.5.b)

Intermediate-level residents [as defined by the Review Committee] should have 10 hours free of duty, and must have eight hours between scheduledRequirements 17 Common Program duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty.
At-Home Call Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum weekly hour limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one-day-in-seven free of duty, when averaged over four weeks.

VI.G.8. VI.G.8.a)

VI.G.3.

Mandatory Time Free of Duty Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). At-home call cannot be assigned on these free days.

Intern
Rounds on M61 with a 3rd year medical student Brings FRESH lists to PACU in the morning MOST IMPORTANT JOB IS POSTING OR CASES VIA VELMA
0730 START TIMES M/W/F 0830 on TUES 0800 on THURS

2nd most important job is keeping the list up to date. Make time so that around 3-4pm you can go through list and update micro results, path results, medications (ABX, anti-coag, etc.) Meets with inpatient NP and Medicine Doc at 8AM in Limb Center M-F Pre-op and Consent patients

Pre-op Order Set

Consent Form

Blood Consent

The Famous White Sheet

WOUND CARE RECS

Home VAC Order Set

Intern
Forwards all consults on to the R2 via text page or coming down to OR 21/22 area Takes care of floor work (dressing changes, PICC lines, consults, DC ppw etc.) Does all discharge summaries MAKES SURE EVERY PATIENT WHO IS DISCHARGED HAS A WHITE SHEET Carries debriding tools during rounds (Curette, Scissors, Forceps, Silver nitrate, Suture, Hemostat) Does all drainage amputations in OR 21 and OR 22

Daily Routine
AM rounds Meet in PACU at 7AM to run list (M/W/F) Meet in Limb Center at 7 AM to run list on Tuesdays Meet in Limb Center at 6:30 AM to run list on Thursdays OR/Clinic Attending Rounds Run list as team in Limb Center Finish work as a team Walk through ER as a team, looking for rotting feet

AM Rounds
LOOK THROUGH VITALS
Can write AFVSS (if true)

Talk to patient Undress, examine and redress ALL wounds

except those that are VACd Closed incisions checked on POD 2 then QOD

Is/Os
Adequate UOP (>30mL/kg/hr) Bring drain outputs to PACU

Med Profile
ABX DVT ppx Stool Softner

Pull ON-Qs when empty Read Consultant Notes Write SOAP Note
Ask Hospitalist GIM for help on issues

Labs Micro Path Radiology

Write Orders
Order dressing supplies

Attending Rounds
The on call attending will round on the service and see the consults Attinger will likely go see a few select patients When rounding, assign someone to peruse through chart looking for consultant recommendations Order what consultants want (after thinking about it and making sure it is reasonable)

OR
Be respectful to scrub techs and nurses Help move patients Help clean the room Help move things along! Help start IVs Help prep the field by holding a leg, painting, etc.

WEEKDAY CALL
Call Schedule is on a Google Calendar which you should have access to R2 makes call schedule Intern caries the LIMB pager whenever they are in the hospital. Gets forwarded pages from LIMB pager on weekends while in the hospital. 405-PAGE Weeknight call person takes call pager home with them Fields inpatient and outpatient phone calls
Enters Centricity phone notes for outpatient phone calls the next morning

Goes to the hospital to evaluate inpatients as needed Sees ER consults Calls limb chief with any questions AFTER gathering all the info, examining the patient, etc. If one of our patients is dying, you better be at their beside calling the limb chief.

Weekend CALL
R2/P2 for two weekends per month Take care of all inpatient pages, outpatient phone calls, inpatient consults, outpatient consults Calls the R3 by 11am to run the list R2 calls Attinger & Evans by noon to run list P2 calls Steinberg or Kim (whomever is on call) to run list The primary call person calls the ID attending on call to run the list

R1/R3 for one weekend per month Intern stops page forwarding to the R3 and answers pages starting at 5:00AM Intern tries to round on all patients by 10:30AM Intern rounds with R3 on selected patients at 10:30AM Runs the list with the R3 R3 calls Attinger & Steinberg/Kim Intern calls the ID attending on call to run the list Intern answers pages and does floor work until 5:30PM, calling R3 with any questions Start page forwarding at 5:30PM, pages go back to R3

R1/P3 for one weekend per month Intern does same routine as with R3 P3/R1 call the R3 by 11am to run the list R3 Calls Attinger P3 Calls Steinberg/Kim

Patient Phone Calls

Return promptly from hospital phone, via operator or after dialing *67. You do not want these people to have your cell phone number. Answer their questions as best as you can. Do not tell them to go to clinic. However, you can tell them to call and make a clinic appointment. Give them ER warnings (i.e. when they should go to the ER) Document the conversation at your earliest convenience in Centricity via a phone note.

Consults
Wound
Size Depth Base Border Tunneling MARK/TIME/D ATE cellulitis Take a photo

Blood Flow Biomechanics Microbes Systemic illness X-ray

Gas Osteopenia

Clinic Admissions
Admit them yourself. Intern can help if they are able to. H&P Blood Consent / OR Consent Admission Orders Call ID Call Hospitalist or GIM Consult Add to list USE THE CORRECT ACCOUNT. If the account for this admission not started yet, fill out blank forms, write patients name/dob/MRN, put stickers on once account opened

ER Admissions
TRAUMATIC injuries go to ortho DRY GANGRENE goes to vascular CRITICAL LIMB ISCHEMIA goes to vascular SACRAL WOUNDS go to general surgery or medicine

Post-Op Admissions
All patients except SDS patients must be re-admitted after surgery Op Note Admission Orders
Insulin orders, PCA, etc.

Print off Post-op Medication order and think about each med when checking continue / discontinue DVT ppx start on . Call ID, Call Hospitalist, Call GIM consult (If not following) Add to list / Update list

Post-op SAME DAY SURG

FILL OUT A CLINIC WHITE SHEET Bring to Katherine Prescriptions Op-Note part of short SDS H&P Orders:
DSG instructions Shower instructions Follow-up info DC IV and DC home when PACU criteria met

FILL OUT A CLINIC WHITE SHEET Bring to Katherine

Dont
Give renal patients potassium, or any electrolytes without talking with Medicine, R2 or R3 Dont remove a drain unless an attending or R3 told you to do so. Dont remove dressing from closed incisions on POD #1, they come down on POD #2 and are changed QOD Dont forget to give Lasix chasers with blood transfusions, unless the patient is hypoVOLEMIC Dont stop Asprin and/or Plavix unless asked to do so Dont forget to fill out WHITE SHEETS

Academic Stuff
Tuesday mornings we have our LIMB conference in the LIMB conference room. 730-830AM LIMB chief organizes 1st Tues of the month is vascular conference 4th Tues is Journal Club The rest is resident & attending presentations per the schedule hanging up in the conference room The conference schedule will be emailed to you by the Limb Chief If you give a presentation, please add it to the *Limb Conference Folder on the L:Limbshare drive Feel free to access this folder to review previous presentations Friday evenings we have 3rd year medical student presentations.

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