Green OR Schedule - Google Drive


1
2	Cases	Plan to cover all of the breast & melanoma cases, plus occasional other skin lesion cases.	If there are multilpe cases going at once, check in with Green chief to determine who can provide additional coverage. All attendings are independent and do not need cases covered, but want to know if they will be without a resident.
3
4	Rounds	Round on any inpatients you have in the hospital. It is usually not many.	Do round on all overnight breast patient's in scarborough or bramhall Anybody that Plastics operates on, Plastics becomes primary. They will handle all dispo stuff.
5
6	Clinic	Location	Scarborough breast center - right-most entrance as you face the building. Go in, take first big right, then double doors to the waiting room are on your left. Go to the right of the desk then straight back.
7		Overview	The breast center is a very well-organized operation, staffed almost exclusively by women. Appointments for benign conditions and surgical follow-ups look pretty much like you would expect. However, appointments for cancer diagnoses are a bit different - the patient will be roomed with their faimily members in one of the 4 "Consult Rooms" - these have carpet and soft chairs, and a separate exam area in the back. Patient's with new cancer gnereally see a slew of people - one of the APPs initially, a surgeon (often at a later visit), their APP again, and Cindy the breast cancer navigator who gives the patient a tote bag (this is called "toteing" the patient) full of resouce pamphlets and funny-shaped pillow. (Breast cancer is very well funded.)	The center has mammography and ultrasound in the same suite. Medical oncology is in an adjacent suite. Everyone works pretty closely together.
8		Where to sit	If you go straight back from the desk and turn right and go past the photocopiers, there is a small room with 2 computers labeled "Provider Dictation." The room has no permanent inhabitants - Dr. Rutstein will sit there when the are in clinic - and it is usually fair game to put your bag in there and use one of the computers as a home base.
9		Charting	The clinic is on Epic for records. There is a new patient info sheet, either completed at the visit, or sometimes prior and in "media" tab. This is very helpful for history, risk factors, etc. when doing notest. There are dot phrases for Dr. Teller/Desjardin, just ask which they want you to use. Rutstein still usually dictates all her H&P's, but was ok with resident's writing follow-up visit notes.	Beware, there is (as of July 2015) currently no way to designate a co-signer on outpatient notes. You have to tell the attending you wrote the note, and then they can add their addendum. Yes, it's stupid. They're "working on it."	After the note, you have to asign a level of service to the encounter and put follow-up requirments in the "wrap up" screen. Talk to the attending before signing the encounter.
10
11		People in Clinic	APP's are starting to cross cover everyone but have some Drs they work with more
12		Lynn Ried -	APP that works with Dr. Rutstein, and Dr. Teller/Desjardin as well - SHE IS THE PERSON TO TALK TO if you are going to a Rutstein clinic. When Rutsteins sees new patients, Lynn has generally seen them all first and dictated a full H&P at a prior appointment and ordered all the appropriate studies and work-up - by the time they see Rut there is basically a plan already made and they "meet with the surgeon" as more of a fomrality. Check in with Lynn about the day before clinic starts; she can direct you who is good to see.	Currently, the APPs don't feel they are equipped to have residents shadow or work with them for their clinic days. This may change
13		Karen Gronberg	APP that works with Dr.Desjardin and Teller. Also does the full work-up before patients meet with their surgeons. Also a great reasource; maybe a bit less itnerested in teaching than Lynn.
14		Dr. Liz Pietras	One of the breast radiologists. Willing to discuss imaging wity you and allow you to watch biopsies
15		Mary Tard & Alicia ...	MA's at the fron desk - check patients in and if you let them know who you are going to see, will give you the chart and let you know when they are in a room
16		Andrea	Is some form of radiology coordinator. Her office is to the left past the breakroom. Check in with her if you want to arrange shadowing the mammo or ultrasound techs or watching biopsies (it seems good to attach yourself to a tech for biopsies, so you get to see the process of positioning prior to the radiologist coming in).
17
18	Breast tumor board	Where/when	Thursday at 12:00-1:00 in the conference room off the little "library" area which is on the right as you come in the buidling and head towards the breast center. Just ask one of the attendings to show you on your first clinic day. It's very close.	However, this is subject to frequent change. Update this sheet if time or location of breast conference changes!
19		Who	Attended by surgery including APPs, med onc, radiology, pathology, social work, genetics. Having all these people at the table is part of requiremnets for accreditation as a breast center.
20		What	There are several types of questions generally trying to be answered by the group at tumor board - For a new cancer diagnosis, does the pt need surgery or medical therapy first? - If surgery is done, does pathology etc indicate need for any MORE surgery, or do they go on to med onc? (ie "path review") - Given receptor status and risk profile including age, does a patient need chemo or just endocrine therapy, or both? - For patients with incompelte work-up, is any special imaging needed, like MRI? - How agggressive should we really be with this octegenarian? (or nonagenarian?) - Is the patient a candidate for genetic testing based on family history? Of course there are more, but those are the common ones
21		Expectations	You are expected to attend tumor board. You are expected to present a few patient's per week. KEY: You won't be on the email chain, so talk to Cindy on Monday or Tuesday and she can give you the schedule with full names - make a copy so you can figure out who to present. Dr. Desjardin volunteered to send my the tumor board sheet by email, I just had to remind her. Talk with Lynn and Karen about who you will present, and they will let you do the talking. If the surgical attending is actually going to conference (hopefully this will happen more in future) you should talk to the attending too.	When presenting patients, the appropriate format is: "This is a 46 y/o woman with right infiltrating ductal carcinoma, clinical stage IIB (T2N1), ER-/PR-/H+, s/p neoadjuvang chemo (AC x4, Taxol x12), now s/p right RSL lumpectomy/ALND on 12/31/2013 needing a post-op path review." Adjust the content as necessary.
22
23	Specifics by Case	Lumpectomy	Unless this is for a palpble mass, most will be an RSL (radio-seed localized) lumpecotmy - patients have a radioactive I-99 seed placed up to 5 days before OR and you find it using the radiation probe in the OR. Take note of the in-vivo and ex-vivo counts (in-vivo should be higher than ex-vivo).	Almost all will go home the same day.	Can't use suction in the wound with the seed due to fear of loosing seed (apparently this creates havoc) - so only dab until seed confirmed in specimen by xray.
24		Mastectomy	Without reconstruction	Routinely stay overnight. Will have received pre-op teaching including some info about drains. See in AM and discharge; usually attending will want to see them too before they go home.
25			With reconstruction	Routinely stay overnight. PLASTICS will handle all their d/c stuff including instructions and scripts. They get extensive pre-op teaching. They get antibiotics until the drains come out.
26		Breast sentinel node biopsies	Radiology tech will come in Pre-op and inject technetium-99 in 4 areas around nipple. They carry special little box. Dr. Rutstein routinely uses methylene blue injected while patient asleep under nipple. Dr. Teller/Desjardin, only if no radio tracer signal is present in the axilla.	Use probe and blue color to locate sentinel nodes. After first (usually highest) count node is removed, remove any additional nodes with counts >=10% of highest count - up to 3 nodes.
27		Melanoma with sentinel node biopsies	Especially for turnk melanomas, need to have sentinel lymph node localized before operation. Will be booked for appt with radioloy ~2 hrs before surgery and get techentium-99 injected at melanoma site and then imaged -- nodal basin will light up and rads will mark the skin overlying the hot node	May drain to more than one basin (ie bilateral axilla) Also inject blue dye in OR once pt asleep.	Same rules as breast for finding and removing nodes.
28		Scarborough Cases	FYI if they stay overnight - 1st call is the attending
29
30	Spedifics by attending
31		Dressings	All attendings use mastasol/steris/tega
32		Dr. Desjardin	does the running sub q monocryl with knots, the other two are without knots.
33			She does her mastectomies with tumesence and sharply, and routinely takes extra margins from lumpectomy sites
34		Dr. Teller/Rutstein	Do their cases in similar techniques. Mast/lump with cautery, selective margin takers.
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1	Week of 9/18
2
3	Service:	Surgical Oncology
4	Residents:	Ben/Audria
5	Resident covering Breast:	None
6	Vacations:	None
7	Attending on call:
8
9	MONDAY	Attending	OR	Time	Case	Coverage
10		7:00 AM - Monday Morning Educational Conference
11	APPs: Liz
12		Fitz	Bram 8	730	Lap SB resection	Ben after conf
13			Bram 8	1010	Diag Lap	Ben
14			Bram 8	1140	Inguinal lymphadenectomy	Audria
15			Bram 8	1320	R neck melanoma, SLNB	Audria
16			Bram 8	1530	Inguinal lymphadenectomy	Audria
17
18		Mac	Bram 12	730	Para, ?total thyroid	Audria
19			Bram 12	910	Para, ?total thyroid	Liz
20			Bram 12	1130	Para	Liz
21			Bram 12	1320	Open distal panc/spleen	Ben
22
23		Royal			clinic	uncov
24
25	TUESDAY
26		7:00 AM - Tumor Board Liver/Rectal (4th Tuesday of the month)
27	APPs: Donna
28
29		Fitz	Bram 15	730	Robot Gastrectomy	Ben
30			Bram 15	1310	Robot Liver Resection	Ben
31
32		Mac	SSC 9	730	R Thyroid	Donna
33			SSC 9	940	Total Thyroid	Donna
34			SSC 9	1200	Diag Lap and Mediport	Donna
35			SSC 9	1420	Thyroglossal duct cyst	Donna
36
37		Royal			clinic	uncov
38
39
40
41	WEDNESDAY
42		7:00 AM - Tumor Board Liver (2nd Wednesday of the month), Melanoma/Cutaneous (3rd Wednesday)
43	APPs: Liz/Donna
44
45		Royal	Bram 12	730	R upper back melanoma	Audria
46			Bram 12	940	RLQ ab wall mass resection	Ben
47			Bram 12	1210	R shoulder mass resection	Ben
48
49		Mac			clinic	Liz or Donna
50
51
52
53	THURSDAY
54		7:00 AM Tumor Board Upper GI (1st Thursday of the month), Rectal/Lower GI (2nd Thurs.), Surg Onc Leadership (3rd Thurs.)
55		7:00 - 11:00 AM - Morning education, M&M, Grand Rounds, Chair Conference
56	APPs: Liz/Donna
57					Melnick until 2pm
58		Mac	Bram 12	830	Para	Liz or Donna
59			Bram 12	1040	Para	Liz or Donna
60			Bram 12	1230	Total Thyroid	Liz or Donna
61			Bram 12	1450	Para, ?Total Thyroid	Audria
62
63		Fitz			clinic	uncov
64
65					Ben has a chief case at 1100, and procedure in PM
66
67	FRIDAY
68		7:15 AM - Green Team Meeting (Every 3rd Friday of the month)
69	APPs: Beth
70
71		Mac	Bram 14	730	Whipple	Chris
72					Para	Donna
73
74
75
76					Ben at procedure in AM
77
78
79
80
81
82
83
84
85	SATURDAY/SUNDAY
86	Attending on call:	***
87	Saturday / Sunday APP:	***
88	Green Resident Days:	***
89	Green Resident Night:	***


1	Week of 9/11
2
3	Service:	Surgical Oncology
4	Residents:	Ben/Audria
5	Resident covering Breast:	None
6	Vacations:	None
7	Attending on call:
8
9	MONDAY	Attending	OR	Time	Case	Coverage
10		7:00 AM - Monday Morning Educational Conference
11	APPs: Donna
12		Fitz	Bram 15	730	Robot Splenectomy	Ben after conf
13			Bram 15	1150	Robot Gastrectomy	Ben
14
15		Royal	Bram 9	815	Basal Cell on face	Audria after conf
16			Bram 9	1145	Melanoma on back	Audria
17			Bram 9	1415	Dermatofibrosarcoma	Audria
18
19		Mac			clinic
20
21
22	TUESDAY
23		7:00 AM - Tumor Board Liver/Rectal (4th Tuesday of the month)
24	APPs: Liz
25
26		Fitz	Bram 16	730	Bile Duct Resection	Ben
27			Bram 16	1310	Diag Lap	Audria
28			Bram 16	1510	R inguinal lymph node	Audria
29
30		Mac	SSC 9	730	R Thyroid	Liz
31			SSC 9	950	L Thyroid	Liz
32			SSC 9	1210	R Thyroid	Liz
33			SSC 9	1430	Total Thyroid	Liz
34
35		Royal	SSC 1	740	LLE melanoma	uncov
36			SSC 1	1010	Lap appy	uncov
37
38	WEDNESDAY
39		7:00 AM - Tumor Board Liver (2nd Wednesday of the month), Melanoma/Cutaneous (3rd Wednesday)
40	APPs: Liz/Val
41
42		Royal	Bram 12	730	L calf melanoma	Audria
43			Bram 12	1100	SCC scalp	Audria
44			Bram 12	1400	R forearm sarcoma	Audria
45
46		Fitz	Bram 8	900	Whipple	Ben
47			Bram 8	1540	L groin exc biopsy	Ben
48
49		Mac			clinic	APP
50	THURSDAY
51		7:00 AM Tumor Board Upper GI (1st Thursday of the month), Rectal/Lower GI (2nd Thurs.), Surg Onc Leadership (3rd Thurs.)
52		7:00 - 11:00 AM - Morning education, M&M, Grand Rounds, Chair Conference
53	APPs: Amy
54
55		Mac	Bram 12	830	Para	Amy
56			Bram 12	1050	Total Thyroid	Amy
57			Bram 12	1310	R Thyroid	Audria
58			Bram 12	1530	Total Thyroid	Audria
59
60		Fitz			clinic	Ben
61
62
63
64	FRIDAY
65		7:15 AM - Green Team Meeting (Every 3rd Friday of the month)
66	APPs: Amy
67
68		Mac	Bram 14	730	Total Thyroid	Audria
69			Bram 14	950	L Thyroid	Audria
70			Bram 14	1210	Total Thyroid	Amy
71			Bram 14	1430	Para, ?Thyroid	Ben
72
73		Royal			SMHC x2	Uncov
74
75
76					Audria wellness half-day in PM
77
78
79
80
81
82	SATURDAY/SUNDAY
83	Attending on call:	***
84	Saturday / Sunday APP:	***
85	Green Resident Days:	***
86	Green Resident Night:	***


1	Week of 9/4
2
3	Service:	Surgical Oncology
4	Residents:	Ben/Audria
5	Resident covering Breast:	None
6	Vacations:	None
7	Attending on call:
8
9	MONDAY	Attending	OR	Time	Case	Coverage
10		7:00 AM - Monday Morning Educational Conference
11	APPs: Liz
12					LABOR DAY
13
14
15
16
17
18
19
20
21
22	TUESDAY
23		7:00 AM - Tumor Board Liver/Rectal (4th Tuesday of the month)
24	APPs: Donna
25
26		Fitz	Bram 16	730	Rectal Cancer Excision	Ben
27			Bram 16	1310	Lap R Colectomy	Ben
28
29		Mac	SSC 9	730	L Thyroid	Donna
30			SSC 9	940	L Thyroid	Donna
31			SSC 9	1200	Staging Laparoscopy	Donna
32			SSC 9	1420	Diag Lap	Donna
33
34		Royal			Clinic
35
36
37
38	WEDNESDAY
39		7:00 AM - Tumor Board Liver (2nd Wednesday of the month), Melanoma/Cutaneous (3rd Wednesday)
40	APPs: Amy/Donna
41
42		Royal	Bram 12	730	R ear SCC	Audria
43			Bram 12	910	L axillary lymph node bx	Audria
44			Bram 12	1110	LLE melanoma	Ben
45			Bram 12	1340	R arm melanom	Ben
46
47		Mac			Clinic	Donna
48
49
50	THURSDAY
51		7:00 AM Tumor Board Upper GI (1st Thursday of the month), Rectal/Lower GI (2nd Thurs.), Surg Onc Leadership (3rd Thurs.)
52		7:00 - 11:00 AM - Morning education, M&M, Grand Rounds, Chair Conference
53	APPs: Donna/Amy
54
55		Mac	Bram 12	830	Para, ?thyroid	APP
56			Bram 12	1010	Para	APP
57			Bram 12	1200	Para	Audria
58			Bram 12	1350	R Thyroid	Audria
59			Bram 12	1610	Lap takedown of PEG site	Ben
60
61		Royal	Bram 8	830	R axillary lymph node dissection	APP
62
63
64	FRIDAY
65		7:15 AM - Green Team Meeting (Every 3rd Friday of the month)
66	APPs: Donna
67
68		Fitz			clinic	Audria in PM
69
70
71
72
73
74
75
76
77
78
79
80
81
82	SATURDAY/SUNDAY
83	Attending on call:	***
84	Saturday / Sunday APP:	***
85	Green Resident Days:	***
86	Green Resident Night:	***


1	Week of 8/28
2
3	Service:	Surgical Oncology
4	Residents:	Ben/Audria
5	Resident covering Breast:	None
6	Vacations:	None
7	Attending on call:
8
9	MONDAY	Attending	OR	Time	Case	Coverage
10		7:00 AM - Monday Morning Educational Conference
11	APPs: Donna
12		Fitz	Bram 8	0730	Open Liver Resection (w/ Audett)	Ben
13			Bram 8	1450	Right Inguinal Lymph Node	Ben/Audria
14
15		Mac			Clinic
16
17
18
19
20
21
22	TUESDAY
23		7:00 AM - Tumor Board Liver/Rectal (4th Tuesday of the month)
24	APPs: Amy/Donna
25
26		Royal	SSC 7	730	Scalp Melanoma	uncov vs Audria
27			SSC 7	1020	L cheek Basal Cell	uncov vs Audria
28
29		Fitz	Bram 15	730	Robot Liver Cyst Marsupialization	Ben
30			Bram 15	1000	Robot Distal Panc	Ben
31			Bram 15	1430	Lap SB resection	Ben
32
33		Mac	SSC 9	730	Thyroid Lobectomy	APP
34			SSC 9	950	L thyroid	APP
35			SSC 9	1210	L thyroid	APP
36			SSC 9	1430	Total Thyroid	APP
37
38	WEDNESDAY
39		7:00 AM - Tumor Board Liver (2nd Wednesday of the month), Melanoma/Cutaneous (3rd Wednesday)
40	APPs: Amy/Beth
41
42		Fitz	Bram 12	730	Whipple	Ben + Audria
43			Bram 12	1410	Open Right Liver Resection	Ben + Audria
44
45		Mac			Clinic
46
47
48
49
50	THURSDAY
51		7:00 AM Tumor Board Upper GI (1st Thursday of the month), Rectal/Lower GI (2nd Thurs.), Surg Onc Leadership (3rd Thurs.)
52		7:00 - 11:00 AM - Morning education, M&M, Grand Rounds, Chair Conference
53	APPs: Donna/Liz
54
55		Mac	Bram 12	830	Para	APP
56			Bram 12	1050	L Neck Dissection	Ben after conf
57			Bram 12	1310	Para	Audria
58
59		Fitz			Clinic	Ben after Mac Case
60
61
62
63
64	FRIDAY
65		7:15 AM - Green Team Meeting (Every 3rd Friday of the month)
66	APPs: Liz
67
68		Mac	Bram 14	730	Para	APP
69			Bram 14	950	Total Thyroid	Audria
70			Bram 14	1210	Right Thyroid	Audria
71			Bram 14	1430	Redo L Neck Dissection	Ben
72
73		Fitz			Clinic	uncov
74
75
76
77
78
79
80
81
82	SATURDAY/SUNDAY
83	Attending on call:	***
84	Saturday / Sunday APP:	***
85	Green Resident Days:	***
86	Green Resident Night:	***


1
2	2015 American Thyroid Assocaition Guidlines:	https://www.thyroidcancercanada.org/userfiles/files/ATA_Guidelines_Thyroid_Nodules_2016.pdf	AKA, everything you ever watned to know about thyroid nodules
3
4	Mac Clinic:	Arrival:
5		Where to sit:
6		People to know:
7		Lunch?	No break. Do bring food and munch as you go.
8		Outpatient Epic:	Notes:
9			Plan section:
10			Wrap up:
11
12
13	OR	Positioning for thyroid cases	Supine, both arms tucked, shoulder roll, head on a shay	You should set up the nerve monitor by placing the electrodes (green above, white below) over the upper sternum and plugging everyting into the color-codes spots on the little connector box
14
15		Thyroidectomy operative steps (MacGillivary):	Incision using knife (not bovie) to get all the way through dermis	Open platysma with bovie, make flaps under plattysma up to thyroid cartilage and down to sternal notch (avoid the EJ veins)	Open mildine cervical fascia, use bovie to get the straps off the thyroid	Kitner time. Peel soft tissues away from thyroid. Usually middle thyroid vein first then go to upper pole. Tie AND clip and harmonic most upper pole vessls	Work around the middle and lower pole, detaching from trachea when easy to do so	On underside of thyroid, will have to find nerve and use stimulator to ensure preservation of nerve
16			Once thyroid out and parathyroids look ok:	Fibrillar in space	Close midline fascia with 3-0 vicryl	4-0 vicryl w knots to close platysma, then do more local	close skin with 4-0 monocryl, no knots, and dermabond
17
18
19
20		Espohagectomy	4x ports, supraumbilical 12 port
21		Post-op esophagctomy


1	Week of: ***
2
3	Service:	Surgical Oncology
4	Residents:	***
5	Resident covering Breast:	***
6	Vacations:	***
7	Attending on call:	***
8
9	MONDAY	Attending	OR	Time	Case	Coverage
10		7:00 AM - Monday Morning Educational Conference
11	APPs:	Mac	Clinic		AM Clinic	APP
12		Royal	Clinic		PM Clinic	APP
13
14
15
16
17
18
19
20	TUESDAY
21		7:00 AM - Tumor Board Liver/Rectal (4th Tuesday of the month)
22	APPs:	Fitz	Clinic		AM Clinic	APP
23
24
25
26
27
28
29
30
31
32
33	WEDNESDAY
34		7:00 AM - Tumor Board Liver (2nd Wednesday of the month), Melanoma/Cutaneous (3rd Wednesday)
35	APPs:	Mac	Clinic		AM + PM Clinic	APP
36
37
38
39
40
41
42
43
44
45
46	THURSDAY
47		7:00 AM Tumor Board Upper GI (1st Thursday of the month), Rectal/Lower GI (2nd Thurs.), Surg Onc Leadership (3rd Thurs.)
48		7:00 - 11:00 AM - Morning education, M&M, Grand Rounds, Chair Conference
49	APPs:	Royal	Clinic		AM + PM Clinic	APP
50
51
52
53
54
55
56
57
58
59	FRIDAY
60		7:15 AM - Green Team Meeting (Every 3rd Friday of the month)
61	APPs:	Fitz	Clinic		AM + PM Clinic	APP
62
63
64
65
66
67
68
69
70
71
72
73	SATURDAY/SUNDAY
74	Attending on call:	***
75	Saturday / Sunday APP:	***
76	Green Resident Days:	***
77	Green Resident Night:	***