Arrowhead Burn/SICU

Please contact the Rotation Director and Rotation Coordinator at least 4-5 weeks prior to the start of the rotation. Points of contact may be found under Rotation Information.

Rotation Paperwork

Complete paperwork below and submit NLT 8 weeks in advance of rotation start date. 

Trauma

**We are not currently rotating with the Trauma team. Info kept in case we start it up again. See below for SICU info***

Team Layout

The trauma team/system is set up differently at ARMC than at Scripps Mercy.  There is a PGY-5 Chief who oversees the Surgery service (Trauma, General Surgery, and Vascular Surgery teams.)  There are senior (Pgy-3/4) residents assigned to each respective team and ~3-4 interns assigned to the surgery service, although, not tied directly to a specific team for the month.  You will take the junior/intern “call” phone (x4149) on most days of this rotation and carry the trauma pager.  There will be a senior resident who will also be on call and therefore carry the senior (x4168) call phone.  There are also many third-year medical students assigned to the surgery service that write the daily progress notes and will also write H&P’s on the consults and trauma patients.   They use WhatsApp to communicate between the teams because the hospital has good WiFi but terrible cell reception.

First Day

DTS will likely not cover the night before the rotation therefore plan to drive up the morning of.  Turnover is at 0630 in the Oak Room. This is easy to find, in the main lobby of the hospital after walking into the main entrance.  Park in lot across from the main entrance, tell the security guard it is your first day and that you are a resident.  Upon walking into the hospital day 1, you will have to go through the metal detector and get a student wristband for the day.  At some point on day 1, you can get your badge from HR on the first floor.  

Schedule

0630 – 1800ish 

Plan to work 5 - 6 days each week.  Will likely work 1-2/4 weekend days during these two weeks.  

Daily Routine

They have two levels of traumas – Trauma Activation is worse than Trauma Alert.  On Monday-Thursday, you will respond to all traumas.  Friday-Sunday, ED runs the Trauma Alerts, you will only respond to the Activations.  See “Running a Trauma” below for more information on this.  Once the disposition is determined, you will help place paper 

Most days, you will also carry the consult phone.  You will take calls mostly from the ED and medicine team with consults.  Upon receiving a consult, you can text the medicine students on WhatsApp to go start a paper/written H&P on the patient.  Depending on how busy I was, I would usually try to look up the patient quick then see the patient within 15-20 minutes.  Some consults, I would see independently if the students don’t respond or I knew I could knock it out quick.  Once seeing the patient, labs, imaging, and developing a plan, call the senior resident to discuss plan and assist with disposition planning, admission orders, or OR consent.  I received anywhere from 5 – 10 consults daily plus the traumas on top of that.

Following turnover at 0630, you will round of the Trauma patients (10-25?) with an intern and senior resident assigned to the trauma service.  The attending will rarely round with you on the floors.  The students write the paper notes and the senior needs to sign them, leaving us no role in the documentation.  You may be asked to help with notes on the weekends.  That being said, rounds are informal and you can assist the intern with placing orders but try to take some ownership of the patients and being part of the team.  On the floor, vitals, labs, imaging, and consultant notes tend to be in computer system – Meditech, however the trauma notes are hand written.  

Try to update the lists throughout the day with the admits.  This will make it easier at the end of the day to leave on time.  The night intern comes in at 1800 and this is when you can hand off the phone, pager, and turnover.  

Running a Trauma

This is also a bit different than at Scripps Mercy.  ED senior resident takes the airway, surgery senior resident serves at “Trauma Captain” at the foot of the bed.  There will also be a resident performing Primary Assessment and assigned to Procedures.  You will likely rotate through the roles doing primary assessment, procedures or later in the rotation – Trauma Captain.  All team members don sterile gown, cap, mask, and either sterile or standard gloves.  Oddly enough, even the folks with sterile gloves on don’t seem to ever remain sterile prior to procedures.  *Every trauma patient gets a Mepilex over the sacrum and a DRE when you turn the patient.   The trauma surgeon may or may not be in the trauma bay during traumas – most often NOT.  

SICU

Schedule

0600 – 1700ish (some days earlier, some later)

Plan to take overnight call 5-7 times throughout the month rotation. 

Daily Routine

You will get turnover from the overnight resident at 0600 in the Burn ICU workroom 2 North.  If this is your first day, take the main elevator to the second floor, buzz in to the clerk on 2 North and they will point you in the right direction. The team will then divide up the patients and then start gathering information from the paper charts as well as the computer through MediTech. All vitals and I/O's are on paper. Labs and imaging can be found electronically. If you have a medical or PA student usually you will have them arrive about an hour earlier and gather vitals and I/O's on all patients prior to you getting there.  This can be extremely helpful as it is time consuming to go through the paper charts.  The size of the team varies and the number of patients will also vary. Usually there are 2-3 surgical residents (2nd years), 1-2 EM residents (arrowhead 2nd years rotate through as well) and 1-2 medical or PA students. They have also started rotating critical care fellows through as well. NMCSD 3rd year ICU fellows will rotate through for a month so you may see a familiar face.  The surgical ICU is a closed unit so you are the only team allowed to write orders on surgical patients. Rounds using start at 0800 usually however can certainly vary if the attending is in the OR or busy. They make an effort to start with the overnight resident's patient's first however depending on how sick or unstable a patient is they may see those patient's first. Currently only two of the surgeons round in the ICU – Dr. Wong and Dr. Woodward.  Rounds will usually last 1.5 - 2 hours or so but really depends on other distractions. Rounds are working round so one resident will be putting in orders and another will pull up imaging.  The pharmacist will round with you and they can put in all medication orders. This will make your life a lot better so use the pharmacist when available. They are also very knowledgeable about how the unit works, so often times they can help you with process questions as well. Presentations for rounds should be systems based, starting with any overnight events. Get every patient without a tube in their trachea to us an incentive spirometer and write in on your note.  Make note of chest tubes and whether they are on water seal or suction and if there is an air leak or not. For all patients that have been operated on state what post-op day it is as well as antibiotic day and what you are treating. After rounds, the team will run the lists, update orders, take new admissions, work on transfer summaries and eventually get either breakfast burritos or lunch. The surgery residents may get pulled into the OR depending on what the schedule for the OR looks like. Depending on how busy it is you may be able to go to trauma activations during this time as well. You should plan to carry the trauma pager on you so you don't miss them. You will turnover to the night resident when everything has wrapped up during the day usually around 1700, but plan to stay later as this is a very busy service. Weekends are run the same as week days and everyone is assigned days off throughout the block. 

 There are academics 3 times a week. Mondays are M&M’s  at 0700 in the Oak room where they present any death or poor outcome. If you have a death or adverse event on a patient you were seeing you may be asked to write an M&M and present it. There is a template in the resident tools folder, just ask one of the arrowhead residents to help you find it. Wednesdays are trauma conference at 0700. They usually go over a topic in trauma and talk through some cases or pertinent points in management. Thursdays at 0730 is mock oral boards for the surgery residents.  You will meet in the conference room on 2 Center and they will go over a topic by reading through a review that has been created by one of the arrowhead interns. They include 8-10 questions and will make you answer the questions, but don't worry they don't expect you to know surgery specifics. If you have a fellow on with you I encourage you to ask them for mini lessons on key ICU topics like vent management, CRRT, etc.     

On call, you will cover the SICU patients in addition to the Burn unit patients.  The burn resident will give you turnover at night before they leave. You may also get consults on burn patients in the ED that you can do basic burn care for an admit vs. follow-up in clinic.  The Burn charge nurse will be your best resource when you get consults. Ask them to come see the patient with you and then take pictures to send to the attending who is on call for Burn. Usually the charge nurse will be able to tell you if a patient needs to be admitted or not, and then will help you with wound care if you are sending the patient home.  Both Dr. Wong and Dr. Woodward are accessible by cell phone.  New admits need an electronic H&P in Meditech and to be added to the list. They do not need wound care as they will do that in the unit once admitted.