Surgical Oncology Resident Surgical Oncology Resident Handbook . Division of Surgical Oncology

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    Surgical Oncology Resident Handbook

    Division of Surgical Oncology Department of Surgery

    East Carolina University, Brody School of Medicine

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    Table of Contents: Weekly Schedule Page 3

    NC Tissue Consortium Page 4

    Communication Page 5

    Admissions Page 6

    Deportment Page 6

    Pain Management Page 8

    Operating Room Conduct Page 8

    Education Page 8

    Rounding Page 9

    Consultations Page 11

    Clinic Page 12

    Tumor Board Page 12

    Chain of Command Page 12

    Reading Schedule Page 14

    Surgery Oncology Investigations Page 15

    Breast Issues Page 21

    Clinical Pathways Page 23

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    8am-9am Breast Conf. LJCC 248 MANDATORY

    M&M Grand Rounds (please see attachment for schedule) PCMH Audit.

    7am-8am GI Tumor Board LJCC 248 MANDATORY

    7am-9am Teaching Conf. Surgical Library

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    9am-9:30am Case Conf. Location TBD (led by Chief Residents)

    9am-12pm Dr. Bellin Brst. Clinic MANDATORY 1pm-5pm Dr. Bellin Brst. Clinic MANDATORY

    9am- Service Rounds

    9am-12pm Dr. Zervos GI Clinic MANDATORY

    9am-12pm Dr. Bellin Brst. Clinic MANDATORY

    9am-12pm Dr. Fitzgerald GI Clinic MANDATORY

    9:15am-12pm Dr. Fitzgerald Brst. Clinic MANDATORY

    12pm-1pm Tumor Board Oncology Conf. PCMH Audit.

    12pm-1pm Teaching Conf. BSOM 4S20 MANDATORY

    1pm-5pm Dr. Bellin Brst. Clinic MANDATORY

    1pm-5pm Dr. Fitzgerald GI Clinic MANDATORY

    1:30pm-5pm Dr. Fitzgerald Brst. Clinic MANDATORY

    1pm-5pm Dr. Zervos GI Clinic MANDATORY

    Surgical Oncology Rotation Schedule for Residents

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    North Carolina Tissue Bank:

    The Division of Surgical Oncology supports the North Carolina Tissue Consortium, a tissue bank sponsored by the UNC Lineberger Comprehensive Cancer Center. The objective of the NCTC is to promote cancer- related and basic science research by providing a facility for procurement, processing, and storage of normal and malignant human specimens. Patients are approached for consent to participate in research during their clinic visit prior to surgery. No specimen is procured unless the patient has been appropriately informed and signed a consent form for procurement. On the day of surgery, tissue bank staff is paged by a circulating nurse to retrieve the specimen and transport it to the pathology department for assessment. Tissue is only procured after the pathologist has obtained the appropriate specimen information for patient care (e.g. diagnosis, inking of margins, etc.). All samples are frozen and stored at the Brody School of Medicine until requested for use by an investigator.

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    COMMUNICATION Communication is first in this manual for a reason. COMMUNICATION is always first. When in doubt, call. When not in doubt, call. You will receive a call schedule at the beginning of the rotation – attending call coverage begins during the week when that attending leaves the hospital and from that time Friday evening until 7 am Monday. You are only responsible to communicate with the on-call attending during off hours – they will decide whether to contact the patient specific off call attending. During business hours, communicate directly with the attending of record.

    Text messaging: Texting is here to stay but until a text message is acknowledged it is only a ONE WAY form of communication. This is due to different attending preferences about carrying cell phones and sporadic cellular coverage at PCMH. Please, do not communicate or report your intention to carry out a test or procedure by text message unless that text is acknowledged as received by the intended recipient. Absence of this acknowledgement can be regarded as the message not being received or communicated. Pagers: Since we all carry pagers and pager coverage is universal, this form of communication does not require acknowledgement of receipt. Remember, when in doubt, communicate. You will NEVER be discouraged from doing so. Paging is the preferred method by which to contact the attending. Cell Phones: Cell phone calls are the easiest method of communication provided the phone is answered or within range. Again, don’t assume that any voice message left on a cell phone has been received or appropriately communicated for the reasons stated above. Paging is the only foolproof method of one-way communication.

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    PATIENT ADMISSIONS If you are not notified of a patient transfer after hours, discuss this with the on call attending. Ideally, any patient accepted from an outside hospital or asked to go to the ER will be discussed with the on call resident before that patient arrives. Regardless of time of day, after you have had a chance to meet the patient and go over their records, contact the responsible attending to discuss the plan of care. This can save hours, if not days from the ensuing hospitalization as the accepting attending may be privy to information or details of the patient’s illness that are not apparent in the patient’s record and may have a specific plan of care in mind. If an attending is out of town, you can not admit a patient under their name regardless of whether or not there is an established relationship with that patient. Admit those patients to the responsible covering physician. DEPORTMENT Cancer is a serious illness. On this service it is commonly a terminal diagnosis. Many of you have been touched by cancer either personally or though family. Please keep in mind the following general guidelines: When a patient is informed of a cancer diagnosis, they will remember the exact words in which it is imparted to them for the rest of their life. It is important to keep this in mind in patients who do not yet know their diagnosis or pathology. Unless you are asked directly by a patient, and you feel comfortable, do not discuss pathology or new diagnoses of cancer until the attending has a chance to do so. Simply state that “The pathology is complete and Dr. _____ will discuss it with you when he or she rounds.” Discussion of intraoperative findings “his belly was ate up with cancer” with patients or family members may be taken out of context and create insurmountable obstacles in subsequent care and treatment planning. As with anything else in life, presentation is everything, learn from your attending in this regard so that you can add this skill to your armamentarium. This is the art of medicine, and is not easily taught. Complete understanding of the implications of a diagnosis or pathology report is crucial in having a meaningful discussion about pathology. Similarly, present yourselves with the necessary countenance to impart your seriousness about the task at hand. Do not laugh, joke or carry on in patient care areas, that is anywhere on 1 south, the ASU, the recovery room.

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    Anywhere that a patient or patient’s family might have opportunity to observe or overhear. Keep this in mind regardless of the patient’s state of consciousness or even their own frame of mind. You would be surprised what a patient is capable of comprehending despite being seemingly oblivious. You are our eyes and ears, our representatives when we cannot be there, please act accordingly and, whenever in doubt, just treat the patient or patient’s family the way that you or your family member would wish to be treated under like circumstances. PAIN MANAGEMENT All laparotomy patients should receive postop pain management in the form of a PCA without basal rate. Do not institute a basal rate without the permission of the attending. A standard PCA dose is 1mg morphine every 6 minutes with a 10 mg lockout. Dilaudid is 0.2-0.4 mg every 6 minutes. Again, basal rates are forbidden unless explicitly requested by the attending. Oncology nurses are acutely aware of pain issues and oftentimes may request that you increase pain medications beyond doses that you feel comfortable with or feel are appropriate. Remember, you are ultimately responsible for the orders that you write. Use discretion and sound medical judgment in deciding how much pain medicine beyond standard doses is appropriate for a given situation. Patients with epidural catheters should not have PCA pumps. Similarly, unexplained hypotension in a patient with an epidural should be managed initially with cessation of the epidural dose. If this does not correct the problem, contact the attending. Epidurals are generally removed between postoperative days 3-5. Beyond that they generally hinder the progress of the patient. Anticipate removal of epidural catheters in patients tolerating liquids and hold Lovenox or other blood thinners accordingly.

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    OPERATING ROOM CONDUCT The operating room is your classroom – treat it accordingly: show up on time and prepare for your case lesson. Your attending will apply t