- There is always 1 hand consultant on call, and usually a fellow or registrar
- There is always 1 general consultant on call
- There are 3 orthopaedic trainees on site 0700-1530 Monday to Friday.
- There is 1 orthopaedic trainee on site 1530-2400 Monday to Friday (usually in JHH OT9)
- There is 1 orthopaedic trainee on site 0730-2400 Saturday and Sunday (usually in JHH OT9)
- There is an SRMO who has a ‘tag along’ role with you for 3 shifts per week, who should be supervised during procedures and taking referrals. They are allocated to learn about the responsibilities of the registrar and are not expected to be doing your work independently or unsupervised.
This roster has 2 shift times: 0700-1700 and 1400-2400
The General Orthopaedic consultant roster is 1800-1800 in usual hours, and 0800-0800 in the Christmas shut down period.
The Hands consultant roster hours is 0800-0800.
Consultants on for Friday usually do the weekend aswell.
Carry a folder. It means you can do things on the run (important for boss ward rounds, where you don’t want to come back to the ward twice, and where you may not have a resident).
- The folder should contain: pathology forms, x-ray forms, theatre booking slips, consent forms (kid, adult, substitute), a couple of admission booklets (incredibly hard to find at times), letter heads and envelopes, script pads, and know your provider number for referring to private rooms
Use a proforma sheet to document important details on with a box large enough to put a sticker on the sheet which can be photocopied for handover.
Keep all consults, every patient you make clinical decisions, and of course admit, notated. If you are junior, run it all by the orthopaedic trainee (always one around) or the boss at some time (the sooner the better).
Due to the shift-work nature of the job, this is one of the most crucial components.
Write down all the relevant details AT THE TIME the referral is first made. This will not only ensure the patient is not missed in ED/ward rounds, but also means the important information is already there when it comes to doing the handover sheet.
Every handover MUST contain details of all referrals and include:
- Patient details including name, age, MRN (patient sticker preferable)
- A brief history of injury, mechanism etc.
- Relevant co-morbidities (including anticoagulants)
- If coming from a peripheral centre, then which one
- Outcome e.g. admitted, discharged, fracture clinic, GP etc
- If the patient is admitted then:
- Which boss?
- Is the boss aware?
- If the patient is for theatre then:
- Is the case booked?
- Has the patient been consented?
- Also include any info relevant to the case e.g. blood/aspirate results, other specialty reviews etc
Any outstanding jobs – highlight them so that it’s obvious to the next person (This is particularly helpful for the morning team. A courtesy phone call between 7-7:30am will also be greatly appreciated by them for the more complex cases)
Tick off the completed jobs – that way things will not be forgotten
Make time for a handover at 2pm when the evening person starts their shift and give them a handover sheet of the admissions from that day. This is handy when the boss wants to do a late afternoon round. It is also crucial for the evening runner to update the training registrar in Theatre 9 about the patients admitted during the day before going home. Giving them a photocopy of the handover sheet is helpful. It is also equally important to leave a copy of the handover sheet in “The Cave” on F1 for the morning team.
If referrals are written down clearly and logically at the beginning, it can then be used as the handover sheet (ie proforma sheet). This will save you a lot of time at the end of a busy day!
JHH Emergency Department
Hanging out in ED and keeping your ear to the ground is the best way of approaching the job. You can scan peripheral hospitals on CAP to see what is in their departments. Knowing what is coming is the key to organising things. Also hanging out in ED will allow you to intercept trauma calls that we are not alerted about.
All referrals must be seen and documented in the notes, and recorded in the handover log. This includes phone consults and gives you the opportunity to track patient care and to have all imaging reviewed by a senior registrar or consultant. Furthermore, it is often the only document available to correlate the phone advice given to off-site hospitals.
The role requires you to triage all referrals with regards to:
- Clinical urgency
- Time of referral
- Optimise flow of theatres
The most important aspect is clear verbal and written communication with staff and patients. Legible written documentation will help you out in this regards, and potentially save many more phone calls.
All notes must clearly delineate basic admission clerking, which includes:
- Date/ Time
- Name/ Team
- Medications/ Allergies
- Imaging and lab results
Always take clinical photos of soft tissue injury and share them with the person giving the meeting. Take a couple if you need to in order to get the wound, and put it into perspective. A limb shot and a close up is the best way.
THE TEAM PLAN needs to clearly list ALL steps pending:
- Admission status and under which surgeon this has been discussed, or to follow up
- If they are returning for admission the next day they require a consent form/ RFA. The bed manager needs to be contacted, and a slip into theatre, otherwise the patient is not booked.
- Further Investigations
- Imaging/ CT or USS investigations etc
- Bloods/ MSU/ Micro result pending
- Fasting status and planned theatre time
- Cannulas/ catheters
- Neurovascular obs, Elevation of limb, Weight bearing status
- Medications should be charted
- Usual medications
- Analgesia/ Anti-emetics/ Aperients
- DVT prophylaxis
- Consent (If you know the patient will need OT, fill the consent form and booking slip before talking to the patient – you can always rip it up. Not having consent can cause delays for the patient at the front desk before going through to bay).
- Document risks and benefits discussed with patient
- If not consented why not and who to contact for consent
- NFR status (if appropriate)
- And reasons why discussion, and if for review
- You must liaise with these teams it is not ED’s responsibility
- Document referral made, and with what team responsible
- This includes those with likely ASA>3, who will need anaesthetic review pre-op
When admitting a patient the people that need to be informed are:
- Admitting Consultant (contact by phone, catch them in theatre or clinic)
- Training Registrar
- Often in Theatre 9
- Run admissions by the Orthopaedic trainees as they are great for advice about how to approach the cases, what further management is needed, equipment to be booked etc – They can help you sift through the information before talking to the boss
- Consultant/ Duty Officer/ ED In Charge (red shirt)
- Nurse caring for patient
- Theatre Staff (see further detail below)
- Patient and family members
Getting a CT/ USS/ MRI
The CT registrar is usually in the CT reporting room, same goes for the USS Reg, and if you’re lucky the MRI boss is around. Talking face to face with the imaging team is much more likely to get you the test you need when you need it.
Procedures in ED
Closed reductions, open fracture/ dislocations, plasters/slabs are for you to organise and do in the ED. You need to liaise with the in charge and ED senior for appropriate sedation and to facilitate timeliness of the reductions.
Aspirates are almost always your responsibility and you need to chase the results.
Outside Imaging – a lot of peripheral hospitals have imaging that we cannot immediately access. Speak to radiology (at the other hospital) about uploading the images prior to accepting patients.
Any transfer that is from anywhere other than the Mater or Belmont should be discussed with the on call consultant prior to accepting them.
Spine transfers – An important component for referral is the neurological examination in addition to the imaging, so it is important that the referring doctor liaise directly with Dr Kuru. ANY decline in neurology is a surgical emergency, as is Cauda Equina or an epidural abscess. Unstable spines can be managed in traction, flat on back. Liaise early with the orthoapedic trainee and Dr Kuru about any spinal emergencies.
No case should be taken to theatre without the consultant being aware.
Booking patients is the only way that the theatres know how much work we have, and what resources we need.
Don’t stock-pile slips.
When discussing it with the anaesthetist always know about the patient’s exercise tolerance (flights of stairs), past GAs, and if you think they’ll need a consult, fill out a consult form (best done in ED), suggest it to the anaesthetist (shows you understand the issues and that you’re safe) and pin it on the board in the anaesthetic office or the pigeon hole for overnight reviews.
When discussing the patients with the boss, always ask for what equipment is needed. This saves the red hat or the orthoapedic trainee making a repeat phone call.
All booking slips must include:
- Patient sticker
- Date for operation
- Procedure planned
- Equipment –
- Position i.e. prone?
- Usual equipment, anything extra? Does it need ordering in?
- II needed
- Major Co-morbidities
- Fasting status/ time
- Surgeon –
- Consultant vs Operating surgeon
- Time available
- Triage Category
- All cases discussed with Nurse in Charge (55483) and Duty Anaesthetist (55051)
- Slips for surgery that day are left with the In-Charge nurse
- Slips for any other day go to Jayne’s desk in the office (not on weekends)
- All acute cases need a slip in theatre in addition to RFA form if you are bringing them back for surgery a following day
Liaise directly with theatre 9 anaesthetist for all cases for theatre that day
As Ortho often run a number of theatres, it is best to liaise directly with the anaesthetist responsible for that list ie. Theatre 4 hands list should be told about the disarticulated hand etc.
Decide early if a pre-op anaesthetic review is required, and refer.
Anaesthetic Consult Forms (55051)
- Planned operation and date
- Blood results & X-match status, Imaging results, ECG/ Echo etc.
Attendance on the daily ward round is ideal if there are no urgent cases in the ED awaiting review, as you will often be the point of contact for JMOs and other teams.
Weekend ward rounds at the JHH including general ortho trauma, paediatric, and any Dr Kuru spine patients are run by the unaccredited trainee and best attended early in the morning to minimise conflicting interests during the day. The previous night’s trainee is able to hold the phone for 4 hours while you complete the ward round.
If part of the ward round cannot be completed it is best dealt with when the evening unaccredited trainee arrives at 2pm.
Suspected orthopaedic emergencies (most commonly “?compartment syndrome?”) in the JHH wards will often be referred to you and should always be treated as an emergency until proven otherwise.
The day unaccredited trainee is responsible for the Thursday X-Ray Meeting @ 5pm and the evening person is responsible for the Monday Trauma Handover Meeting @ 7am.
Both meetings should be attended by each unaccredited registrar working in the lead-up week. You are now rostered Monday 7-11am to attend the meeting and handover ward round if you worked the week leading up to it. It is very important to attend because the usual training registrars often don’t know the patients who were admitted over the weekend.
A good way of doing the meetings is updating at the end of every day.
Get the list off CAP. Search by the day of all orthopaedic cases at the JHH and RNC (trauma patients are shifted there occasionally) in both Orthopaedics and Paediatric Orthopaedics (it depends on how the red hat books them).
For the Thursday meeting, you can usually belt it out during work (start on Wednesday, finish on Thursday before 5pm).
For the Monday meeting, it may be best to come into work early, ie. 12pm, to spend two hours belting it out, trying to get some done Saturday night, then come in early on Sunday to finish some. This is a much better idea than starting it at 2am on Monday morning, and finishing it at 5am and presenting it 2 hours later.
The format of the meeting slides should be:
- Theatre availability
- (E.g. “OT9 all day; OT5 half day….15 cases outstanding: 10 general, 5 hands” etc. in a clear bullet point form)
- Pending cases (present before the day trainees leave the meeting for OT at 0730)
- Cases completed since last meeting (all relevant imaging, slices, clinical photos etc.)
- Discussion cases / anything a consultant has asked you to present to the department for opinion or interest. This will often be led by the person who knows the patient most.
Save meeting to the orthopaedic fileshare / cave computer. You can view previous meetings there. It is best to label them by the date. This means that the person following you can also pull the ‘pending’ x-rays for the next meeting to save time.
When formatting, it is best to keep the x-rays as big as possible on the screen, and show standard views in correct orientation unless they weren’t taken.
Other Bits and Pieces:
- If you’re not in scrubs you’re doing it wrong.
- There is nothing to eat that does not come out of vending machines after 9pm
- The coffee shop does not open until 9 on a weekend – smash the ward round and then grab a quick cup on the way to ED
- You catch more flies with honey
If you don’t know… Ask…