Goals and Objectives - Curtis National Hand Center



Children’s Hospital of Philadelphia

Curriculum and Goals and Objectives

For the

MedStar Union Memorial Hospital Hand Fellow

2017-2018

The MedStar Union Memorial Hospital Hand Fellow will spend one month at the Children’s Hospital of Philadelphia (CHOP). This rotation provides a focused and intensive experience with hand and upper extremity problems in children and adolescents. The fellow will work in the clinic and operating room with Dr. Benjamin Chang, Dr. Robert Carrigan, Dr. Apurva Shah and Dr. Bong Lee.

In order to facilitate learning, a furnished apartment is maintained within walking distance of the hospital and the fellow does not have on-call responsibilities on this rotation.

The focus of the CHOP rotation is to provide experience in both developmental and traumatic problems. This rotation will provide knowledge in diagnosis and treatment of hypoplastic thumb/radial club hand, syndactyly and polydactyly, various anatomic deficiencies, disorders of blood vessels and nerves, including brachial plexus pathologies.

The goals and objectives of this rotation are to enable the fellow to develop the skills to incorporate the care of congenital and pediatric hand surgery into their careers after fellowship.

Core Competency Areas

Upon completion of this rotation, the hand surgery fellow should:

• Understand the embryological development of the hand and upper extremity.

o Medical knowledge

• Understand the classification systems of congenital hand anomalies.

o Medical knowledge

• Become familiar with the etiology, natural history and treatment options for congenital brachial plexus palsy injuries.

o Patient care

o Medical knowledge

o Practice-based learning and improvement

• Understand surgical techniques and procedures for specific congenital deformities including: longitudinal and transverse deficiencies, duplications, syndactyly, hypoplasia, macrodactyly/gigantism, etc.

o Patient care

o Medical knowledge

o Practice-based learning and improvement

• Understand treatment considerations for traumatic injuries in the pediatric population.

o Patient care

o Medical knowledge

o Practice-based learning and improvement

• Understand the complexities and techniques utilized for hand rehabilitation, prostheses, radiographic evaluation and splinting in the pediatric population.

o Patient care

o Medical knowledge

o Practice-based learning and improvement

o Interpersonal and communication skills

o Systems-based practice

Didactics

• Shriner’s Hospital Thursday conference at 630 am – if you schedule allows

o Medical knowledge, interpersonal and communication skills

Weekly Schedule

Patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice

• Monday 8 am RC ortho clinic – 2 Wood

• Tuesday 8 am BC plastic hand clinic – 1 Wood

AS all day OR

1 pm BC ortho clinic – 2 Wood

530 pm Plastic surgery conference - 10 Penn Tower

• Wednesday 645 am Student Lecture – CHOP

715 am BC/RC OR all day

AS all day OR

• Thursday 8 am BC adult clinic (1st , 3rd , 4th , 5th) – Cam, 1st floor

7 am BC Exton OR (2nd)

1 pm BL ortho clinic – 2 Wood

• Friday 7 am BL/RC OR

Noon BC OR

DAY BEFORE OPERATIVE PROCEDURES

Patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, systems-based practice

• Review office notes (Epic)

• Review x-rays, retrieve from PACS

• Review and print pathology for tumors Medview or Epic

• Make sure any special equipment or implants are available

• Check OR schedule for missing or add-on cases, scheduling conflicts

• Read about cases

OR DAY

Patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, systems-based practice

• Mark operative site in holding

• Pull up x-rays on PACS in OR

• Put path reports in chart (send to path)

• Make sure circulator has equipment or implants

• Antibiotics only for:

o Implants or grafts

o Contaminated or infected wounds

o Case length over 2 hours

o Cardiac prophylaxis

o Open fracture or joint

EQUIPMENT

Interpersonal and communication skills, systems-based practice

• All Hand Cases

o Hand table, tourniquet

o Hand instrument tray

o Bipolar cautery (hand)

o Monopolar cautery (forearm)

• Fractures

o Suction

o Fluoroscopy, lead

o Synthes drill (CHOP)

o Cast cart

o Forearm shaft

▪ Small fragment set

o Distal radius

▪ Medartis distal radius plate set

▪ 0.062 k-wires & driver

o Metacarpal/phalangeal

▪ Medartis hand plate set OR

▪ Synthes hand modular set

▪ 0.045, 0.035 double-ended k-wires

• Nerve repair

o Micro instruments

o Possible neurogen nerve conduit

o Cast cart

TYPICAL HAND OR SET-UP

• Rotate OR table 45-90 degrees

• Attach hand table

• Wrap Webril around upper arm

• Apply tourniquet (18” adult, 12” child)

• Cover tourniquet/Webril with plastic 1000 drape, keep prep off Webril

• Attach inflation cable to tourniquet

• Chlorhexidine prep hand, forearm

• Scrub tech covers hand table with sheet and puts down a blue towel folded in half lengthwise under arm tourniquet

• Wrap blue towel around tourniquet, clip

• Put arm through extremity drape

• Cover legs with down sheet

• Suction for trauma or facture cases

• Bipolar pedal under table

• Fluoro on operative side

• Fluoro screen on opposite side

POST-OP INSTRUCTIONS

Patient care, medical knowledge, interpersonal and communication skills

Pain meds unless skin only case

Antibiotics for implants or infection

Follow-up (dressing off, return visit)

Trigger 5 day 2 wks

Lesion 2 day 2 wks

Extensor cast 4 wks exam OOC

Flexor cast 4 wks exam OOC

Syndact cast 2 wks exam OOC

CTR 2 day 2 wks sut. Out

K-wire case 1 wk x-ray in cast

Plate splint 1wk x-ray OOC

Skin graft no 1 wk bolter off

Nerve cast 1 month exam OOC

ARRANGING FOLLOW-UP

Patient care, Interpersonal and communication skills

CHOP Plastic 215-590-2208 Rosa

Ortho 215-590-1527 Crystal

Email all OR cases at end of day to:

Attending and

CHOP Rosa Casasanto

Houn Lim

Crystal Brown

Meg Maguire

Email should contain:

Name

MRN

Procedure

F/U When

?X-ray, in or out of cast

HAND CLINIC

Patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, systems-based practice

• Activate EPIC account day l of rotation

• Get .BC EPIC Smartphrases

• Review these sections

o Chief complaint .RFV

o Enter DOI, DOS, procedure

o Pain score

o Medications – reviewed

o Allergies – reviewed

o Medical problems

• Complete these sections:

o EPIC progress note

o Select appropriate Smartphrase

o If no Smartpharase, SOAP note with

▪ .BCNAD (CHOP)

• Edit template as needed

• F2 through entire note

• Return patients: import last note & edit

• Pay attention to detail

• Minimize abbreviations

• Name fingers: index, long, ring, small

• Note goes into letter to PMD

• Do not refer to “Dr. Chang” in note

• IMP: “Healing well after” not S/O

• Spend time on the PLAN

o Explain what we plan and why

o Treatment: OT, meds, surgery

o Tests: x-ray EKG, labs

o Follow-up when?

o ?X-ray, in or out of case

• Diagnosis

o Look for coding cheat sheets in each room

o Useful site for hand codes:

▪

o Type search term into EPIC or

o Type EXACT ICD-10 code: xxx.xx

o Be specific: MC shaft or neck fx?

o Add to problem list

• Orders

o Enter CPT codes with .999 suffix

o “Case Consult” to have cast or splint placed or removed in cast room

o Med Rex print out on special paper

o “Occupational therapy” (CHOP)

o Bill for fracture care in office

▪ If we initiate definitive fracture care

▪ Subsequent visits ................
................

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