Logistics - Peds surg

Phone numbers

  • Floor pager: 13806
  • Consult pager: 28087
  • TPN pharmacist: 78287, press 3 for TPN. Ask them to set up a log-in for 'Infusion Studio' if you want to put in the orders yourself, or can just ask pharmacy to do it for you (renewing order is pretty self explanatory).
  • ARC phone #: 19705, anesthesia scheduler - need to call when adding on OR cases to make anesthesia aware
  • OR front desk: 6507212820 (or x12820) for add-ons 
  • Fax for consents - 650-725-5577
  • 24 hr outpatient line - 650-723-6439
  • Spanish interpreter over the phone - 650-724-8222

General flow:

  • Workroom - located in PCU 300, closest to the double doors
  • 2 interns: alternate between floor and OR
    • OR: help make the list in AM if no med student, break off during rounds to check in patients ~ 6:45 AM (needs to be done before 7 AM), post op orders, etc. Leave after last case is done if floor is quiet
    • Floor: Hold pager, take and give signout (6AM, 6PM to either R2 on nights or PD resident), make lists, see consults, round - with chief in the AM, RTL w fellow in PACU prior to OR, then round with attending. 
  • 3 NPs, they are great resources
  • try, try to get all your floor work done by 9am, so you can handle floor consults 11-1pm, then wrap those up by 3pm so you can handle ED consults that come in 4:30-6pm
  • 6 PM: sign out, usually sign out floor + consult pagers to adult consult PGY2 resident
  • Wednesdays -  no OR
    • +/- path conference in the AM?
    • Division meeting in the AM - run the list w all the attendings, so make a bajillion copies of the cover page. 
    • Clinic at 12:30 PM (Epic context is Surgery Welch). Raji (another senior NP) is usually around to hold the pagers so you can go to clinic!
  • Weekends - 24 hr call, with post-call day
    • Call room: walking from workroom to the PICU, go past the stairs, and then badge in to the hallway on the right. Most rooms are reserved for PICU but there are 1-2 unreserved rooms that you can use.

Enrico's two rules:

  • bilious emesis in neonate --> bowel obstruction until proven otherwise --> call chief and fellow and see patient ASAP
  • don't wake kids up unless someone tells you
Consults:
  • I think the easiest way to do consults is if it's nonurgent, see the patient first, then group text everyone. Sick, emergent consults I try to let everyone know ASAP then immediately head over. Always write a consult note when you see the patient, it will make everyone's lives easier. The NPs will help out
  • See below for frequent consults

OR:

  • Checking in patient: update interval H&P (click on patient from the OR board or schedule, it'll bring you to the day of surgery navigator, click on "add interval") if H&P is < 30d, make sure there's a consent, go mark the pt if surgery has a side, sometimes pt doesn't have preop orders (it's an order set) so uh, just throw them in. Inpatients only need consent/marking, but doesn't hurt to do an interval anyways *shrug emoji*
  • Postop:
    • If same day discharge: go to postop tab, complete med rec, go to DC instructions, use additional instructions only, and fill out the general surgery tab. Then go to DC orders, and hit general DC.
    • If going back to the floor: postop tab, med/orders rec, throw in a bunch of floor orders (will send photos of order sets you should have), then hit OK to transfer.
  • Adding on cases:
    • Elective cases > 1-2 days out: email marisanchez@stanfordchildrens.org AND atrujillo@stanford.childrens.org with case request info: name, MRN, DOB, operating surgeon, diagnosis, operation, case duration, date. Also include things like: do they need cardiac anesthesia, any implanted hardware, etc.
    • Immediately add-on for same day/next day: go down to OR front desk (in old hospital by OR 2-7) and fill out a scheduling request form (in red folder on wall) (need same info as above), hand to front desk person, and notify anesthesia scheduling/ARC (phone #: 19705)
Discharges:
  • ADT Navigator --> Discharge --> med/order rec --> do that, here you can add discharge meds
  • DC instructions --> use additional instructions --> gen surg
  • DC orders --> dc patient
  • Call PCP to let them know their kid was inpatient/discharged
  • Email Urania to schedule follow up appointment if necessary
    • If only phone follow up needed, those are done automatically so you don't have to email anyone
  • Discharge summary

Admits:

  • Not too different from adult admits; use the order sets
  • Transfer: uploading outside imaging - take CD to film library (go down to train station on 1st floor, head towards the bear/cafeteria - green door/sign on right that says Radiology/Xray/Ultrasound. Give CD to person at front desk and fill out their form; can ask them to upload Stat
  • ED admit: ask the resident to tell their clerk to make a peds hospital encounter (they need the admitting attending name) so that you can put in orders/do an H&P

Traumas:

  • Adult ACS generally runs traumas in ED, if it's an isolated head injury they get admitted to NSGY, otherwise it's to us or PICU (cannot go to gen peds due to protocol, has to be ICU or a 'surgical' team)
  • Peds trauma 99 everyone shows up: let chief and/or fellow know immediately, as they have to be there for the trauma
    • No need to ask for trauma activation, you will get a page
  • Copy/paste the trauma H&P from Stanford side onto peds
    • The two disparate Epics are really annoying and sometimes you can't write a note for the peds side bc an encounter hasn't been created. Just write the note SOMEWHERE so you can copy it over later.
  • Do tertiary survey < 24h later

 

Frequent consults/cases

Appendicitis

  • See appendicitis order sets
  • Acute non-perf'd
    • pre-op abx (ceftriaxone/flagyl once daily dosing)
    • Go to the OR and then if the case is done early enough in the day usually go home from PACU. If the case is later in the day they'll get admitted for the night and go home in the morning. Pain meds if they get admitted is usually tylenol/morphine. When they go home they get tylenol/motrin; roxi if needed.
    • No abx needed after procedure if not perforated. If they ended up being perforated, they get abx for home (augmentin BID)
  • Perforated
    • Pre-op abx typically Zosyn
    • If it's early enough and there's no abscess they may operate, vs IR drainage.
    • If they don't operate they admit them for IV, NPO, and mIVF and then you just take it day by day on whether they can eat. 

G-Tube placement:

  • Parameters: French (diameter/thickness, e.g. 14 Fr), length (length of tract, e.g. 1.2 cm), profile (high vs low (Mickey)). For example '14 Fr 1.2 cm high-profile'.
  • Pre-op questions:
    • Weight (ideally > ~ 2kg for GTube, > 10 kg for GJ tube)
    • Any hx reflux (may need to do Nissen at same time)
    • Do they have cardiac or other congenital anomalies (cardiac anomalies more likely to have malrotation etc.) -> request an upper GI beforehand to rule out anatomic issues
    • What feeds are they currently on and why; what happens with oral feeds; why do they want the G tube
  • Post-op care:
    • See smartphrases: GTDCINSTRUCTIONS, NICUGTUBE
    • OK to start meds immediately through G-tube
    • Non-cardiac babies
      • OK to restart feeds 6hrs after surgery at 25% of previous volume, then advance by 25% q6h to goal
      • If baby was receiving bolus feeds, should receive: 25% for first feed, 50% for second feed, 75% for third feed, etc
    • Cardiac babies (more sensitive to fluid status?)
      • Hold all feeds for the first 24hrs
      • Then can restart as above (25% q6hrs)
    • Can sign off POD 1-2 if tolerating goal rate
    • If there are external sutures, need to remove POD #5 (by us, or if discharging soon can teach parent or tell them to go to PCP/our clinic)
  • Outpatient instructions:
    • Pt will need first g-tube change in 3 months at the Pediatric General Surgery Clinic 
    • If the g-tube were to come out before 3 months: please place new G-tube into hole, do not inflate the balloon and call the surgery office. Do not feed through the g-tube until okayed by the doctor. You may need to come to the ER for a g-tube study, especially if it is within 6 weeks of the g-tube being placed.
    • If G tube comes out after 3 months is less of an emergency as tract is more mature, but should still get something in there (even if just 8 Fr Foley).
  • G tube fell out
    • See above - if tract < 3 months old, will close up more quickly so should put something in there fairly quickly
    • G tubes are located in OR storage room (near ORs 2-7). Also grab lube, sterile water for wetting tube/balloon, and +/- red rubber catheter/dilators if need to dilate to put in.
  • G tube leaking
    • If high-profile tube, make sure bumper is cinched down/secured
    • If low-profile (MicKey), can exchange for a high-profile which usually has a better seal
    • In general putting a larger Fr tube not a great solution as it will just end up dilating the tract

Intussusception

  • Usually after viral infection (concentration of Peyer's patches/lymph nodes near ileocolic junction predisposes to intussusception)
  • Sudden onset, colicky pain, usually child is drawing knees up
  • 50% before 1 year old; if older usually 2/2 lead point (appendix, malignancy/polyp/lymphoma, etc)
  • If has progressed to red current jelly stool, may be indication that air enema will not be as successful
  • 'bullseye' on ultrasound; pretty sensitive
  • Reduce with air enema

Pyloric stenosis

  • 2-8 weeks of age; acquired disease, M > F, unclear etiology
  • Thickening of mucosa and muscle
  • Nonbilious projectile vomiting
  • Correct dehydration/metabolic alkalosis (hypochloremic, hypokalemic) first (need to correct the respiratory depression from alkalosis prior to surgery/intubation)
    • NS bolus followed by D5 1/2 NS + 20 KCl
  • Diagnose with ultrasound; elongated and thickened pylorus > 16 mm in channel length and > 4 mm in diameter
  • Treatment - Pyloromyotomy

Port/Hickman removal/placement 

  • Do the parents/patient know why they're getting it??? Make sure primary team has talked to them/we are not breaking the news that they have cancer and need chemo
    • Basics - Hickman/Broviac = tunneled line (can get pulled on but easy to access); port-a-cath = completely internalized, but needs needle poke to access (however can leave accessed for up to 7 days at a time)
  • What is the port/Hickman for (e.g. chemo)
  • Which do they want; how many lumens, etc.
  • Which side (usually do right side, but sometimes will need to do left if they have a VP shunt on the right for example)
    • If no preference, they do not need to marked before surgery
  • Ask referring provider to put in 'line placement peds surgery' order for billing purposes (that order will ask them for most of the above info)

Cholecystectomy/Splenectomy:

  • Usually admitted overnight for observation and pain management. Go home POD1 with just alternating tylenol and motrin

Umbilicus disorders

  • Umbilical hernia - elective repair if still persistent after age 4 years, spontaneously resolve frequently in early age. Operate if incarcerated
  • Gastroschisis - to the right of the umbilicus, 2/2 involution of the R umbilical vein. No sac; bowel is more unhealthy than in omphalocele
    • Left umbilical vein -> round/falciform ligament -> left portal vein
  • Omphalocele - through umbilicus, with sac. More a/w chromosomal abnormalities
  • Omphalomesenteric duct/vitelline duct - connection with ileum (can turn into Meckels)
  • Urachus - connection with bladder
    • Should excise due to risk of infection, malignancy
  • Granuloma - make sure no drainage/opening, then cauterize with silver nitrate
  • Omphalitis (red belly button) in newborn is medical emergency; needs IV abx and NICU - can become nec fasc easily

Inguinal hernia

  • Difficult to examine in babies. Will have thickened spermatic cord. Higher risk of incarceration so those are operated on soon after diagnosis. Repair in premies before discharge. If non-thickened cord and kid is fairly comfortable, is likely hydrocele (which will not reduce)

ECMO

  • Every now and then will get a blast page about someone about to go on ECMO
  • Contact chief and/or fellow immediately
  • We do cannulation/decannulation for ECMO
  • Exception: we do NOT do cannulation for CV-ICU patients. however, always double check with the chief no matter what if you get this page

Epic access: first initial + last name (usually), pw same as SHC epic

Haiku access: http://haiku.stanfordchildrens.org (takes 2-3 days to process)

Radiology images: 'Web Resources' on left-hand side, then Radiology PACS

Epic context: general surgery ip svc. Use Surgery Welch to have the clinic schedule pop up

Lists:

  • Shared lists; need to be shared with you by NP or someone who has access
    • Pediatric surgery inpatient - main list
    • Dugout - all the patients we've been consulted for in the past and signed off but sometimes they pop back up
    • Discharges - self explanatory.
  • Updating one-liners: ADT navigator --> brief ID. Always have surgery, DoS, and primary surgeon's initials
  • Making the list physically: organize rooms top down,
    1. Print patient handoff
      • Numbers: On the right/empty space, write dosing weight x 24 gives you a rough estimate the minimum amount of UOP the patient should have over 24h (1 cc/kg/hr). Write out I/Os in table format. Include diet at bottom. Point out notable labs, meds, events etc.
    2. Print patient list in the upper right hand corner. Put HD/POD for each patient
      • Top right corner 'Print' - Patient List 'Portrait'
      • Columns: Custom
      • Uncheck 'new results' 
      • No blank column, Portrait, X-Small
    3. Print surgical cases of the day (pics how to format it).
      1. Top right corner 'Print' - Print from Screen, Portrait, Fit width to page
    4. Copy #2 and #3 onto the same page to make the cover sheet
  • Make like...7 copies on the first day just in case. Attending only needs cover sheet. Carry all of them with you bc you never know when rounds will be.

Set up print cases of day

  • Top bar - Surgical Cases (by Service)
  • Status - scheduled, arrived, completed
  • Search options - case date: T, T (I also make a separate one with T, T+7 to see all cases for upcoming week)
  • Search options - Providers:
    • Bruzoni, Matias
    • hartman, gary edwin
    • fuchs, julie robin
    • wall, james kennedy
    • chao, stephanie D
    • Shew, Stephen Brian
    • Chiu, Bill
    • Mueller, Claudia Mera
    • Sylvester, Karl Gerad
    • Powell, David Mann
    • Dunn, James Chung Yu
    • Pratt, Janey Sue Andrews
  

Orders - order sets to favorite

  • Appendectomy (appendicitis, Non-perforated) post-op
  • Appendectomy (appendicitis, Perforated) post-op
  • Appendicitis admission
  • Bariatric surgery post-op
  • Cholecystectomy post-op
  • Gastrostomy (PEG) placement post-op
  • General pre-op (inpatient)
  • General pre-op or APU (outpatient)
  • General surgical admission
  • General surgical post-op
  • Intussusception (Non-op reduction) admission
  • Pull-through procedures post-op
  • Pyloric stenosis admission
  • Pyloric stenosis repair post-op
  • Same-day surgery post-op
  • TPN monitoring (established)
  • Trauma admission

Notes - SmartTexts to Favorite

  • IP Transfer/accept note
  • LPCH amb gen surg avs
  • pediatric trauma tertiary survey
  • Peds surg admission H&P
  • Peds surg consult note IP
  • Peds surg Discharge summary
  • Peds surg minor procedure note
  • Peds surg pectus excavatum prog
  • Peds surg progress note
  • Peds surg trauma progress note
  

 

 

 

 

 

author: last edited: May 14, 2019, 11:01 a.m. | pk: 152

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