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: ***
2
3	Service:				Hepatibiliary					Skin/Soft Tissue/Breast
4	Residents:				Astrid					***
5	Vacations:				Spencer					***
6	Attending on call:				MacGillivray
7
8	MONDAY	Attending	OR	Time	Case	Coverage	Attending	OR	Time	Case	Coverage
9					CONFERENCE 7AM
10		Mac	Clinic			Laura
11	APPs: Laura
12
13		Royal	16	730	Subtotal gastrectomy	Astrid
14		Royal	16	140	Thigh melanoma w/SLNB	Astrid
15		Fitzy	8	730	Whipple	Pletch
16		Fitzy	8	1250	Lap liver resection	Pletch
17
18
19	TUESDAY
20	7AM Tumor Board: Liver/ Rectal (4th Tues. of the month)
21
22		Fitz	12	740	Liposarcoma	Astrid
23	APPs: Laura	MacG	SSC	730	Total thyroid	Jordan
24		MacG	SSC	940	Right thyroid	Jordan
25		MacG	SSC	12	Total thyroid	Jordan
26		MacG	SSC	220	Left neck dissection	Jordan
27
28
29
30
31	WEDNESDAY
32	7AM Tumor Board: Liver (2nd Wed. of the month) Melanoma/Cutaneous (3rd Wed. of month)	Mac	Clinic		AM + PM Clinic	Liz
33
34	APPs: Liz
35
36
37
38
39
40
41
42
43	THURSDAY
44	7AM Tumor Board: Upper GI (1st Thurs. of the month) Rectal / Lower GI (2nd Thurs. of the month) Surg Onc Leadership Mtg (3rd Thurs.)				CONFERENCE 7-11AM
45		Fitzy	Clinic		AM + PM Clinic	APP
46	APPs: Liz Amy
47		MacG	12	830	Para, left thyroid	APP
48		MacG	12	1040	Para	APP/Astrid
49		MacG	12	110	Right neck dissection	APP/Astrid
50		MacG	12	320	Para	APP/Astrid
51
52
53
54
55	FRIDAY
56	715AM Green Team Mtg (every 3rd Friday)	Fitz	Clinic		AM + PM Clinic	APP
57
58	APPs: Liz Amy
59		MacG	3	730	Para	APP/Astrid
60		MacG	3	925	Total thy	APP/Astrid
61		MacG	3	1130	Whipple vs enucleation	Astrid
62
63
64
65
66
67
68	SATURDAY/SUNDAY
69
70	Attending on call:
71	Saturday / Sunday APP:
72	Green Resident Days:
73	Green Resident Night:


1	Week of: ***
2
3	Service:				Hepatibiliary					Skin/Soft Tissue/Breast
4	Residents:				Spencer, Astrid					***
5	Vacations:				***					***
6	Attending on call:				***
7
8	MONDAY	Attending	OR	Time	Case	Coverage	Attending	OR	Time	Case	Coverage
9					CONFERENCE 7AM
10					Patriot's Day
11	APPs: Amy
12
13
14
15
16
17
18
19	TUESDAY
20	7AM Tumor Board: Liver/ Rectal (4th Tues. of the month)	Royal	Clinic		AM Clinic	Spencer
21
22		MacG	SSC9	730	Thyroid	Donna
23	APPs: Amy, Donna	MacG	SSC9	940	Thyroid	Donna
24		MacG	SSC9	1200	Thyroid	Donna
25		MacG	SSC9	220	Thyroid	Donna
26		Royal	12	730	Biopsy axillary mass	Astrid
27
28
29
30
31	WEDNESDAY
32	7AM Tumor Board: Liver (2nd Wed. of the month) Melanoma/Cutaneous (3rd Wed. of month)	Mac	Clinic		AM + PM Clinic	APP
33		Royal	12	730	Subscap mass	Astrid
34	APPs: Donna, Amy	Royal	12	1010	melanoma	Astrid
35		Royal	12	1240	forearm excision	Astrid
36		Royal	12	300	arm, elbow, cheek excision	Astrid
37
38
39
40
41
42
43	THURSDAY
44	7AM Tumor Board: Upper GI (1st Thurs. of the month) Rectal / Lower GI (2nd Thurs. of the month) Surg Onc Leadership Mtg (3rd Thurs.)				CONFERENCE 7-11AM
45		Royal	Clinic		AM + PM Clinic	Astrid
46	APPs: Amy, Laura	MacG	19	840	Para	Spencer
47		MacG	19	1020	Thyroid	Spencer
48		MacG	19	1240	Lap chole	Spencer
49
50
51
52
53
54
55	FRIDAY
56	715AM Green Team Mtg (every 3rd Friday)	Royal	Clinic		AM + PM Clinic	Spencer
57
58	APPs: Laura				none?
59
60
61
62
63
64
65
66
67
68	SATURDAY/SUNDAY
69
70	Attending on call:
71	Saturday / Sunday APP:
72	Green Resident Days:
73	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			Residents on-service	Resident vacations	APP vacations	Other events/anticipated coverage gaps

2	Block 1	July 1-9	Misercola, Heidt	-	Jamie
3		July 10-17	Misercola, Heidt	-	Jamie
4	Block 2	July 18-30	Misercola, Heidt	-		July 20 - Britt out for Boards
5		July 23-30	Misercola, Heidt	-	Chris
6	Block 3	July 31-Aug 6	Misercola, MacDowell	-	Chris
7		Aug 7-13	Misercola, MacDowell	-
8	Block 4	Aug 14-20	Misercola, MacDowell	-	Angela	Premium per diem offered
9		Aug 21-27	Misercola, MacDowell	-		Lobster bake Aug 25
10	Block 5	Aug 28 - Sept 3	Misercola, Gleaton	-
11		Sept 4-10	Misercola, Gleaton	-
12	Block 6	Sept 11-17	Misercola, Gleaton	-
13		Sept 18-24	Misercola, Gleaton	-		Britt out for ATLS instructor course
14	Block 7	Sept 25 - Oct 1	Douglas	-
15		Oct 2-8	Douglas	-
16	Block 8	Oct 9-15	Douglas, Zhang	-
17		Oct 16-22	Douglas, Zhang	-
18	Block 9	Oct 23-29	Douglas, Vernamonit	-
19		Oct 30 - Nov 5	Douglas, Vernamonit	-
20	Block 10	Nov 6-12	Douglas, Vernamonit	-
21		Nov 13-19	Douglas, Vernamonit	-
22	Block 11	Nov 20-26	Douglas, Meader	-
23		Nov 27 - Dec 3	Douglas, Meader	-
24	Block 12	Dec 4-10	Douglas, Meader, Moccia	Douglas
25		Dec 11-17	Douglas, Meader, Moccia	-
26	Block 13	Dec 18-24	Siciliano, Dowli	Dowli
27		Dec 25-31	Siciliano, Dowli	Siciliano
28	Block 14	Jan 1-7	Siciliano, Dowli	-
29		Jan 8-14	Siciliano, Dowli	-
30	Block 15	Jan 15-21	Siciliano, Murphy	-
31		Jan 22-28	Siciliano, Murphy	-
32	Block 16	Jan 29 - Feb 4	Siciliano, Murphy	-
33		Feb 5-11	Siciliano, Murphy	-
34	Block 17	Feb 12-18	Siciliano, Devan	-
35		Feb 19-25	Siciliano, Devan	Devan
36	Block 18	Feb 26 - March 4	Siciliano, Devan	-
37		March 5-11	Siciliano, Devan	-
38	Block 19	March 12-18	Lipinska, Dowli	-
39		March 19-25	Lipinska, Dowli	-
40	Block 20	March 26 - April 1	Lipinska, Dowli	-
41		April 2-8	Lipinska, Dowli	-
42	Block 21	April 9-15	Tung, Bernal	Tung
43		April 16-22	Tung, Bernal	-
44	Block 22	April 23-29	Tung, Bernal	-
45		April 30 - May 6	Tung, Bernal	-
46	Block 23	May 7-13	Wilkes, Mack	Mack
47		May 14-20	Wilkes, Mack	-
48	Block 24	May 21-27	Wilkes, Mack	-
49		May 28 - June 3	Wilkes, Mack	-
50	Block 25	June 4-10	Ackerman, Pletch	-
51		June 11-17	Ackerman, Pletch	-
52	Block 26	June 18-24	Ackerman, Murphy	Murphy
53		June 25 - July 1	Ackerman, Murphy	-


1	Week of: 5/2
2
3	Service:				Hepatibiliary					Skin/Soft Tissue/Breast
4	Residents:									***
5	Vacations:									***
6	Attending on call:
7
8	MONDAY	Attending	OR	Time	Case	Coverage	Attending	OR	Time	Case	Coverage
9					CONFERENCE 7AM
10
11	APPs:
12
13
14
15
16
17
18
19	TUESDAY
20	7AM Tumor Board: Liver/ Rectal (4th Tues. of the month)
21
22
23	APPs:
24
25
26
27
28
29
30
31	WEDNESDAY
32	7AM Tumor Board: Liver (2nd Wed. of the month) Melanoma/Cutaneous (3rd Wed. of month)	Mac	Clinic		AM + PM Clinic
33
34	APPs:
35
36
37
38
39
40
41
42
43	THURSDAY
44	7AM Tumor Board: Upper GI (1st Thurs. of the month) Rectal / Lower GI (2nd Thurs. of the month) Surg Onc Leadership Mtg (3rd Thurs.)				CONFERENCE 7-11AM
45
46	APPs:
47
48
49
50
51
52
53
54
55	FRIDAY
56	715AM Green Team Mtg (every 3rd Friday)
57
58	APPs:
59
60
61
62
63
64
65
66
67
68	SATURDAY/SUNDAY
69
70	Attending on call:
71	Saturday / Sunday APP:
72	Green Resident Days:
73	Green Resident Night: