Specific Procedures

Admissions

The fellow will complete physicals and histories for new patient admissions in detail, particularly in terms of evaluating the general medical condition, neurologic status, and previous treatment. If the patient arrives with a complete history and physical that has been performed by the family practitioner, then a summary note should be dictated which should include more specific information about the spine and neurologic examination. The fellow should particularly write or dictate a note indicating that the patient has been informed of the surgical procedure, the post-operative course, and the complications of surgery. Specifically, this should include statements concerning infection, phlebitis, pneumonia, neurologic injury causing weakness, numbness or paralysis, hardware failure, non-union, and pain. Do not dwell on this subject if the patient indicates the attending physician has already covered this. The fellow should review relevant aspects particularly of the history and physical and surgical indications of the junior resident.

Surgery

The fellows should work closely with the nurse practitioners and secretaries ensuring that patients are appropriately scheduled for surgery and that appropriate x-rays and the other investigations have been collected prior to the date of surgery. The summary folders on pre-operative patients are to be reviewed by the fellow prior to surgery. This should be done not only to complete the file, but also for pre-operative surgical planning, and to give the fellow an opportunity to discuss with the attending surgeon, the different indications and alternatives to the surgical approach.

The fellow is expected to arrive in the operating room promptly (15 minutes before scheduled surgery) and assist the anesthesiologist as necessary to facilitate moving the patient into the operating room and positioning the patient. In addition, the x-rays should be hung, and interaction made with the operating room nurse to ensure that the appropriate instruments are available.

At the time of surgery, fellows will be taught techniques of exposure, fusion and instrumentation both anteriorly and posteriorly, as well as techniques of decompression. As fellows develop greater experience and demonstrate greater competence, the level of involvement in cases will increase.

Weekly surgical schedules will be prepared by the administrative office staff and distributed, and it will be the responsibility of the fellows to familiarize himself/herself with the patient history and proposed procedure.

Daily Rounds and Post-operative Care

All patients admitted to the hospital should be seen by the fellow on a daily basis. It is the responsibility of the fellow to review the post-operative films and perform the post-operative check on the evening of surgery. This includes a detailed neurologic check and review of post-operative films. Any significant problems should be brought to the attention of the attending physician immediately.

Wound care routine will include changes at 48 hours following which a light bandage or no bandage is applied as per attending preference. Wounds are checked on a daily basis for erythema, hematoma, drainage, dehiscence, etc. Foley catheters are usually discontinued when the patient’s ileus clears and/or when the patient is medically stable and mobile enough to use the facilities. If it is removed too soon, multiple straight catheterizations result, and if it is removed too late, there is an increased risk of urinary tract infections. Chest tubes are generally pulled when the drainage is less than 100-150cc per day or when persistent drainage is serous (reactive pleuritis caused by the chest tube itself). Watch for chyle.

Post-operative chest x-rays should be taken and checked by the fellow after removal of chest tubes. Pain medication is somewhat variable and generally includes PCA in the early post-operative period. Patient activity and bracing should be discussed on an individual basis with the attending. Use of Toradol (Ketorolac) or other NSAID’s may interfere with fusion and should be checked with the attending on a case-by-case basis.

Bracing

Brace prescriptions should be discussed with the attending and the patient should be viewed standing prior to brace fitting to better define brace needs. The patient also needs to be examined in the brace to check fit, decompensation, etc., and x-rays in braces checked. In general, TLSO #6 is prescribed for long fusions; Cybertec 1000 or a similar corset is used for short lumbar fusions/decompressions.

Evening and Weekend Coverage

All hospital patients should be seen every day including weekends. Evening coverage at the University is by the residents who should consult with the fellow or attending physician as needed. Weekend coverage may be arranged so that the chief resident and fellow can alternate Saturday and Sunday rounds or full weekends as desired. Fellows will take general orthopedic trauma call at UC-Moffitt hospital on a rotating basis with other attending staff. This averages one week per 3-4 months.

Discharges

Patients should be given an idea of when their discharge is to take place so that they can make preparations. This should be done at least two days in advance of discharge. The planning should, in fact, begin shortly after surgery, and if there is going to be any problem at home with the patient caring for themselves, social workers should be involved. Patients should be given appropriate medication. They should be given a return appointment and all final x-rays should be checked prior to discharge. If the patient has sutures that have to be removed by the family doctor, a short letter should be written indicating the nature of the treatment and a polite request for removal of the sutures or wound care.

Patients that live out of the state are generally seen approximately 4 months after the surgery. They will need interim checkups and visits with their referring physician or family doctor; therefore, a brief letter should accompany the patient. Generally, x-rays are taken at 1 month following discharge and the referring physician is requested to have these x-rays taken and have copies sent to the attending physician.

Clinics

Fellows have first priority with the attending physicians in the clinics. They will be expected to assist the attending physician in the evaluation and work-up of new patients. They will also be responsible for the dictation of clinic notes. Dictation from the clinics is to be submitted for transcription on the day of the clinic to the secretary of the attending physician.

Medical Records

Discharge summaries shall be done promptly following discharge. (University policy is that discharge summaries be dictated within 24 hours of discharge.) In particular, attention should be paid to describing the condition of the patient at the time of discharge as well as the state of the final x-rays and their measurements. A detailed follow-up plan should also be documented.

Summary X-ray Folders

Summary x-ray folders are to be prepared by either the fellow or resident (at the direction of the fellow). Pre-operative, post-operative, and follow-up x-rays shall be kept in the summary folder and arranged in chronological order.

Education and Interaction with House Staff

The fellow is responsible for helping the residents have a good learning experience, and balanced participation at all levels of patient care including surgery, clinics, conference, and patient records. It is obligatory that the resident attend all education conferences held at the hospital.

At UCSF, the prime responsibility of running the spine service will fall to the fellow. The fellow will function as a junior consultant, ensuring appropriate patient management. The staff should, however, be apprised of developments at all times.

Phone Messages from Patients

Phone messages from patients or persons calling regarding necessary patient information will be placed in the respective fellow’s office. Charts will be pulled and placed with the message when necessary. The fellow is expected to respond to these on a daily basis. If there is any difficulty in providing patient satisfaction of appropriate care, the attending physician should be contacted. If the attending physician is out of town and the patient needs to be seen immediately, the fellow should arrange to see the patient himself/herself in the clinic. It is not acceptable to simply tell the patient to go and see his family doctor or to go to the emergency department if there is a problem related to his spine or previous spine surgery. It is important to document what is done regarding a patient message, particularly with medication refills, so that duplication and over-prescription is avoided.

Projects

At the commencement of the fellowship, the fellows will be presented with a list of suggested subjects. One or more of them should be selected, or areas of interest to the fellow may be proposed. There is a protocol sheet, which should be submitted for each project for approval by the attending spine surgeons. This protocol consists of:

1. The subject of the project.
2. The plan of evaluation
3. The attending physician assigned to lend assistance to the fellow throughout the preparation of the project.
4. Authors to be involved.
5. Sequence of the authors.

Fellows are encouraged to submit abstracts to appropriate major meetings. Deadlines and abstract forms are available in the departmental offices. Plans for submission of abstracts should be discussed with the attendings involved so their patient coverage and travel reimbursement policy can be clarified if the abstract is accepted. At the very least, a draft form of the papers should be completed by the second week of June.

Charts and X-rays for Studies

Requests for charts and/or x-rays for studies must be supplied preferably in writing to the records clerk. These will be pulled and appropriate documentation will be made. However, no more than 10 charts and x-rays may be pulled at any one time. Upon the return of these to the records room, further charts and x-rays will be supplied.

Under no circumstances are charts to be removed from the premises at any time. X-rays may be sent to the university; otherwise they are not to be removed from the premises. No charts and/or x-rays may be taken home.

Holidays and conference time

Two weeks of holiday time and one week of conference time will be allotted each year. This includes time for interviews, visits, and other miscellaneous days off. If additional time away from the service is required, it must be approved by all of the staff through the Department Chair’s assistant. Arrangements for conference and holiday time away should be approved by all spine attendings well in advance to ensure that the appropriate coverage of spine patients will be available. The fellow and UCSF chief resident may not have time off simultaneously.

Emergencies and extenuating circumstances do arise and we will always be pleased to discuss these and find a reasonable solution.

Travel

Attendance of fellows at academic meetings and conferences is encouraged, and requests to attend such meetings are to be submitted well in advance. If travel for presentation at additional meetings is desired, requests for time away and travel reimbursement has to be approved by the staff office through the Department Chair’s assistant. These arrangements need to be made well in advance of the requested dates otherwise expenses will not be paid. Upon approval, the fellow shall be responsible for making his/her arrangements using the following guidelines:

1. Transportation shall be reimbursed at a rate for air travel based upon economy class or super-saver rate, if possible.
2. Meals and room accommodations have specific limitations based on the location. Guidelines are available from the University office in advance of the trip.
3. Registration and course fees at cost.
4. Transportation, e.g. taxi, parking, etc.
5. Reimbursement for conference travel is limited to one meeting per year.

Only travel expenses actually incurred will be reimbursed. Receipts are required for all expenses. Receipts should be detailed vendor receipts rather than the more general charge card transaction slips. Expenses will not be reimbursed without receipts for airline tickets, hotel bill, registration, and course receipts. In addition, a list of meal expenses is needed. Receipts are needed for car rental and the maximum allowable for bus or taxi transport during a single trip is $30.00.

Photography

There is support available for preparation of slides for presentations, however, slides taken for the fellow’s personal archives should be taken by the fellow himself/herself.

Benefits and Insurance Coverage

Fellows are eligible for health insurance benefits and should receive and complete the application within three days of your first day of work. Malpractice insurance is arranged through the Department of Orthopaedic Surgery.