ACS

HOME BASE:

​8200 tele floor, 8300 basic floor, 8100 SICU

TEAMS (A/B):

1 attending (changes weekly), 1 senior on during days (6:30a-6:30p), another during nights (6:30p-6:30a), two or three “juniors” (intern or pgy2), varied students. Two nurse practitioners, Lauren and Cherry Ann, help out M-F 7am to 3pm, mostly with SICU patients.

CALL:

You will alternate day call with the other team - one junior usually handles floor consults, while the other handles ED consults. The PGY-2 will help with floor and ED consults/traumas. At 6:30pm, you will sign out to the night float juniors.

PATIENT LISTS:

ACS and other surgery lists are on the network (S: drive) which you can access from any computer. You need a surgery resident to log onto the computer because they have access to the surgery drive (just like we have access to the emergency folder/drive). It’s a pain if you can’t access the list. You can usually access the lists from the call room because it is likely that a surgery resident has already logged into that computer.

SCHEDULE:

All traumas come to the on-call ACS team all day and night (so each morning, there will likely be new pts from trauma activations overnight). On weekdays (6:30a to 6:30p): you cover all traumas (with the help of the PGY-2). One intern on the call team carries the pager and goes down to traumas while the others finish rounds, floor work etc and carries the floor consult pager. You must see level C activations within one hour. The senior must be present for level B activations. The attending and senior must be present for level A activations. One intern may go home when rounds and floor work is finished. One intern has to stay until 7 pm and sign out to the night “floor” intern. The gen surgery teams cover all gen surg consults and vascular team covers all vascular consults during the week. There is a lot of overlap in what is considered gen sure versus ACS.

At night (6:30p to 6:30a): Unless you are scheduled for night float, you don’t have to worry about this: The on-call intern for “ER” takes all traumas, ER general surgery and ER vascular consults/admissions. The on-call intern for “floor” takes all floor calls and floor work.

On weekends: You will get sign out from general surgery, vascular, surg onc, and transplant surg during the day. The on call intern for “ER” takes all traumas, ER gen surg and ER vascular consults/admissions. The on call intern for “floor” takes all floor calls and floor consults until you sign out to the night float residents. Chief all consults with the senior on for the weekend. There is a separate senior or fellow on for vascular - for vascular consults, page them ASAP to staff your consults, as those patients may need an urgent intervention (OR) and the fellow is often not in house at the time. Have a very low threshold for calling the attending for transplant.

CALL ROOM:

Room #8002. On 8th floor just outside elevators. Intern rooms are at the end of hall on right and labeled. Typically, the “trauma/ER” call intern takes the room with bunk beds with the students, and the “floor call” intern takes the single bed room. You need to call x88131 to have your badge activated (though for many it just worked on the first day, so check)

DAYS OFF:

Minimum 4 days off. You will only come in the weekends that you are scheduled to be on "ER" or "Floor" consults. The other weekend days are off. That typically works out to four weekend days off and four on.

TYPICAL DAY:

You need to get the hospital in time to round on all your patients before running the list with your senior or by 6:30 am for sign out from night float - typically whichever is later! Rounds might take all day (attendings may need to come and go for traumas, or if they have clinic, lectures, or outpatient cases scheduled) so you only round once each day. The size of service usually gets smaller during week and balloons over weekend. Census varies from 8-45 patients (usually between 10 and 30).

6-7am: (depending on list): Get sign out from intern on-call about any traumas admitted overnight. Update the list, and divide and conquer

8-9:30am start time: Rounds (depending on when attending wants to do it). Get floor work done DURING rounds, as it is decided, otherwise there will be no time to do it. Occasionally attendings will ask you to come help with an elective case or clinic. Try to do some trachs and stuff with Catalano, he’s really cool. When rounds and floor work is done, one intern needs to stay until 7 pm to cover trauma pager and sign out to the night intern. Other intern(s) should be able to go home. In reality don't expect to go home before the night team comes.

6:30pm: Sign out to on call person. If rounds are still going, you may be able to get the night float team to take over for you.

PAPERWORK:

• Trauma H&P: Type trauma in the smart box. Adult trauma H&P.
• Trauma progress notes: found on 8100 or 8200. Usually can find some in the call room
• The list: There are a few things that are helpful to do for polytrauma patients because it is very hard to keep track of all their different injuries, what imaging they’ve had etc. If you do these things on admission, rounds will go a lot quicker and easier. Make a “Problem List” on the trauma list of all of the patient’s injuries organized by systems. BHT (blunt head trauma), BCT (blunt chest trauma), PCT (penetrating chest trauma), BAT(blunt ab trauma), spine, ortho, and incidentals.
• Discharges: Do NOT need to fill out the final progress like MICU and CCU. Brief discharge summary. Fill out prescriptions, usually write them under your senior resident's name. Have this ready as early as possible. Need to order d/c all lines, d/c home. Write this early so nursing can prepare. It's sad to write an extra note for a failed discharge because you were too busy after rounds to write the orders. You need to write diet, activity level, weight bearing status, meds, return to ER if…, incidental findings on CT, and follow up appointments with phone numbers for clinics so the nurses will know what to tell the patients.

​STUFF TO REVIEW:

ATLS, general surg info, Procedures (central lines, chest tubes, how to pull a chest tube)

PEARLS:

• Typically, during the weekday, the NP’s take the ICU patients. However, know about them because you cover over the weekend and if they have a ton of patients and the floor is not so bad it's good form to even out the load with them.
• The bad traumas are complex, with multiple injuries, and this can be very hard to keep track of. Being organized from the start with the problem list organized by systems will make rounds go faster.
• Go down to the trauma activations. It is more fun than rounds and you may get good procedures.
• Weekends are the busiest time for the on call team because half of the residents are off and the workload is the same. Be prepared for that. Most of the attendings of this service are very nice and friendly. Know your ATLS algorithms in your sleep.
• The culture is for the teams you cover to leave a patient list with the intern's phone number on it for any questions. This is obviously dangerous as you may never see that list if it's busy. Try to make them actually sign out to you in person.
• Carry trauma shears
• Be aggressive about getting procedures. It's competitive, especially chest tubes. Push to do them and you will.
• Substance abuse: ensure UDS is ordered on all traumas and don't forget the BAITS consults on patients who test positive for etoh/drugs(brief intervention by SW). It will holdup your discharge.