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Surgical oncology


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Surgical oncology

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Surgical oncology

  1. 1. MSKCC Surgical Oncology Resident Orientation Sung (Steve) Kwon, MD, MPH Pager 3712 John C. McAuliffe, MD, PHD Pager 3727
  2. 2. Resident Orientation Orientation Topics • Places to know – “where to go” • Team structure – “how you fit in” • Expectations – “how to act” • Communication – “who to talk to”
  3. 3. Resident Orientation Where to go Rockefeller Building RRL Conferences Zuckerman Building ZRC Grand Rounds Main Hospital Memorial 1275 York Ave
  4. 4. Resident Orientation Hospital floors Floor Services M19 Private Patient Rooms-Surgery and Medicine M18 Thoracic, SACU M17 Telemetry, H&N, and Melanoma/Sarcoma M16 HPB and GI Oncology M15 Colorectal and GMT M14 Telemetry, Thoracic and Thoracic Medicine M12 Leukemia and Lymphoma M11 ICU, Private Bathroom, MRI, Shortcut to H11/H12 M10 Gyn, Gyn Oncology, Breast, Breast Oncology, and PRS M9 Pediatrics M8 BMT M7 Neurology, NUS, Ortho 6 PSC, Main OR, and PACU, Shortcut to H11/H12 M5 Urology C5 Pathology 3 Echo Lab, Main Lab, and M-312 = PST (7 am – 6 pm) 2 SDH OR, SDH PACU, and GI Suite C2/H2 X-ray, US, IR, CT H1 Urgent Care Center (UCC) MAIN OR 6 fl SDH OR 2 fl Urgent Care Center UCC Patient floors M YorkAve 67th Street 68th Street 1stAve
  5. 5. Resident Orientation Department Leadership Peter Scardino, MD Chairman Ronald DeMatteo, MD Vice Chairman William Jarnagin, MD HPB Chief Sam Singer, MD GMT Chief Julio Garcia-Aguilar, MD Colorectal Chief Rich Wong, MD H&N Chief Monica Morrow, MD Breast Chief Nadeem Abu-Rustum, MD Gyn Chief David Jones, MD Thoracic Chief John Healy, MD Orthopedics Chief Peter Cordeiro, MD PRS Chief Emily Renkin Education Training Specialist ** Resident contact
  6. 6. Resident Orientation Who to talk to If you have questions about… 1. Where you should be – ask your fellow 2. What you should be doing – ask your fellow 3. When you should be somewhere – ask your fellow 4. What to prepare for – ask your fellow 5. What weekends you are working – see master schedule, ask fellow to clarify 6. Questions about the daily call schedule, computer access, security badges – call or email Emily Renkin at x7537
  7. 7. Resident Orientation Fellow’s Schedule by Team Service Monday Tuesday Wednesday Thursday Friday GMT Ariyan/Yoon Clinic-A, OR-Y OR-A GMT DMT OR-A Clinic-Y Brady/Crago OR-B, OR-C Clinic-S GMT DMT OR-S, Clinic-B OR-B Coit Clinic OR Clinic/DMT OR Admin Singer OR OR GMT DMT Clinic Admin Strong/Untch OR Clinic GMT DMT OR OR-U HPB Allen OR OR Clinic D'Angelica Clinic OR OR DeMatteo Admin OR Clinic OR Admin Kingham Clinic OR OR Jarnagin OR Clinic OR CR Guillem Clinic/DMT OR Endoscopy OR Clinic Nash/Temple Clinic-N/DMT OR-N / Clinic- T OR-T Clinic-N Clinic-N Paty Admin/DMT OR OR Clinic OR/Admin Garcia-Aguilar Clinic qowk OR Clinic Admin OR Weiser Clinic OR OR
  8. 8. Resident Orientation Team Structure • HPB, GMT, CR services = General Surgery – 1 or 2 attendings – 1 Fellow (or Cornell PGY4-5) – on call for their patients 24/7 – ± Resident / intern / medical student – 2 or 3 ward NPs/PAs (shared among services/teams) – Help with floor management during the day – Not responsible for notes – Not responsible for hand off – Help them with orders, admission, discharges…your friend
  9. 9. Resident Orientation Expectations The same expectations as any other surgical residency in the country.
  10. 10. Resident Orientation Dress Code Dress professionally.
  11. 11. Resident Orientation Expectations Ward Rounds • Contact overnight cover for check out/events • Print team list, gather vitals, labs • Daily notes • Order entry • Maintain the “hand-off” list daily • Afternoon/Evening rounds • Communication with RNs & NPs is essential – In between cases, before p.m. rounds • Sign-out at 6pm (M15) • Copy list, face to face • Certain situations phone call on-call resident with important info • Use dedicated patient list in HIS • Weekends – arranged at beginning of month. On average, work 6 days out of 7. don’t ask to change unless significant personal issues arise. • Weekend is same as week day (6-6)!
  12. 12. Resident Orientation Expectations Discharges – Don’t need a discharge summary – Plan for discharge needs in advance • Discuss with NPs/case management/SW – Medication reconciliation • Home Medication List – Completed by pharmacist • Discharge meds include home meds (Dispense zero if patient has at home) – Sign all scripts and place in front of patient’s chart • Done in advance for planned discharges: think ahead regarding those to be d/c over weekend. Help a brother out! Find it under CIS tab TOOLS  Go to HIS  E-medical record
  13. 13. Resident Orientation Helpful Hints • Team lists can be created in HIS • Use order sets for many common procedures • “Pathway” order sets; PACU order sets, etc. • Labs need to be ordered purposefully (up to three days) • TPN service (GI service) will order daily TPN (not you) • Need approval for most Abx by ID, telemetry by Cardiology • You need to order oral contrast separately for CTs • “Treatment room” = wound care nurses • Case managers very helpful for discharge & home care • NP’s on GMT and Colorectal cover many teams and patients • They don’t work for you, they work with you • NP’s on HPB cover fewer teams, but more complex patients and can be quite helpful. They know more than you.
  14. 14. Resident Orientation Intensive Care • SACU – Surgical Acute Care Unit • Similar to “progressive care” or “step-down” unit • For patients that need q2h vitals or telemetry • No pressors/inotropes, no art lines; can do Amio drips • Open unit with dedicated NP support 24 hrs/day • ICU – Intensive Care Unit – Closed unit – Need to follow patients closely for surgical issues – Must communicate daily with ICU team – Coordinate with ICU staff for family meetings, medical issues
  15. 15. Resident Orientation Communication • EVERY patient needs to have the hand off tab updated after the OR and daily BY YOU! – Direct communication with on-call person is always preferred if there are important items to be signed out • The covering physician tab should also be updated to reflect the person who will receive the initial calls on patients (usually resident or NP during the day and resident/PA at night)
  16. 16. Resident Orientation Communication • Check your MSKCC email
  17. 17. Resident Orientation Expectations in the OR • Before OR: • Review the patient history and relevant imaging a day or two before • This is what you’ll have to do for the rest of your life, so start now. • In OR: • Introduce yourself to nurses/scrub techs (duh) • Complete pathology requisition • Open relevant radiology images • Open gloves • Offer to go get patient • Place venodynes/foley if appropriate • Start post-op orders (it saves time)
  18. 18. Resident Orientation Post-op Routine PACU • Sign out to nurse and NP • Orders – pathway PACU and floor/discharge orders • Same day discharges • Drop off prescriptions at the pharmacy • Brief op note completed before out of OR Short Stay (rare for HPB, CR, GMT) – More likely: Gyn, Urology, Breast, H&N – Stay < 23 hr, template-driven pathway order sets – Stay on M19
  19. 19. Resident Orientation Night & Weekend Call • Standard pager number - 7874 (SURG) • 6pm to 6am on weekdays – 12 hour shifts on weekends (6am-6pm & 6pm-6am) • Coverage of HPB, GMT, CR, Breast, Opthalmic oncology (new) and H&N • Usually divided amongst resident, PA, nocturnalist • OpthalmicOncology – usually 1-3 inpatients, receive signout from Opthalmology PA @6PM. No fellow this academic year, any significant issues directed to attending • Ward calls • Most patients should be seen and assessed • Especially confused or agitated patients • Call fellow directly for urgent matters; we want to know • Backup person is the on-call surgery fellow for help • You can email fellow with non-urgent overnight updates such as • “I increased metoprolol from 5 to 7.5”, or “I re-anchored a foley after failed in-and-out cath”
  20. 20. Resident Orientation SCOD (Consult) Responsibilities • This applies only to PGY 2-5 (not interns*) • Pager 7263 • Residents on the HB, GMT, and CR – New inpatient & UCC surgical consults from 6 a – 6 p – SCOD assigned on a rotational basis (schedule posted on web) • Determine if the patient has been seen by an MSKCC surgeon before • Review all pertinent clinical, laboratory, and radiographic data • Write note and formulate an assessment and plan; write admit orders • Contact the fellow (i.e. page, find in O.R. and DO NOT EMAIL!!!) • New patients are assigned to the on-call attending/fellow • Communicate plan to the primary team • Follow-up on any labs or studies that you and the fellow have requested • DO NOT “collect” consults throughout the day. • Not allowed in OR on days that you are SCOD
  21. 21. Resident Orientation SCOD = General Surgery Consults If the patient has never been seen by an appropriate surgical attending Example : bowel obstruction, followed by a H&N surgeon still needs a gen surg attending Contact fellow for the on call attending
  22. 22. Resident Orientation Find the Fellow How to find correct service fellow: • See master schedule • Posted in nursing station by attending • During the weekends, pager is forwarded to correct fellow (usually) • See weekend rounding • On the MSK intranet Search “surgery” Select Call schedules – surgery housestaff Under staff assignments , select the correct month
  23. 23. Resident Orientation Surgery Team & Call Schedules
  24. 24. Resident Orientation On-call Scenarios • Just remember that all of these patients have cancer and bad things can happen • Low urine output in postoperative patient – Bleeding until proven otherwise • Altered mental status – Do not give sedatives until serious medical conditions are excluded • Tachycardia – R/O bleeding, PE, & MI
  25. 25. Resident Orientation Resident Teaching Conference Fridays, 6:30-7:15 am in H1207 Topics pertaining to General Sugery by surgical oncology fellows *See email reminders Monday and Thursday. Required but remind your fellow on Thursday evening Mandatory for GMT, CR, HPB residents Come prepared to interact!
  26. 26. Resident Orientation Mandatory Conferences • Surgical Core Curriculum – Fellows/Residents Mondays,7:00-8:00 am location varies • Surgery Grand Rounds – All surgical services Mondays, 8:00-9:00 am in ZRC Auditorium • Surgical Oncology Conference – Fellows/Residents Wednesdays, 7:00-8:00 am location varies **There are also Service specific conferences -- discuss with your fellow
  27. 27. Resident Orientation “Admin Day” ≠ Day off • Colorectal • Mondays 3pm – Journal Club, M&M • Mondays 4pm – Research conference • Mondays 5pm – DMT (disease management team) • GMT • Wednesdays 8AM –Teaching/M&M/SarcomaConf • Wednesdays 9AM– Imaging conference/DMT • HPB • Thursdays 7:00am – Journal Club, M&M • Thursdays 1pm – BlumgartTeachingConference • Thursdays 3pm – Research Conference • Thursdays 4pm – DMT
  28. 28. Resident Orientation Computer Systems Demonstrations 1. Call schedules 2. Fellows web site http://ssurpapp1:8080/surfellows/Fellows_Website/Welcome.html 3. OR schedule 4. Grease board 5. Handoff list 6. Brief op note 7. Paging
  29. 29. Resident Orientation Summary • Opportunity to interact with surgeons and physicians who are the top of their field • Cases and Operations that you may not have seen before Please remember… • Resident colleagues support each other – talk to each other and exchange numbers • If you feel lost, have a question, or need some help… – Reach out to your fellow – Get help from a co-resident – Call or email one of us
  30. 30. Resident Orientation MSKCC 1275 York Breast Clinic 53rd Clinic