Intern Responsibilities for the Trauma Surgery

You are to arrive at 6:00am to round on your service prior to attending morning report/academic conferences. The ONE exception to this arrival time is the intern assigned to the Trauma Day rotation. You will arrive to round with the post call team at 6:30am, after morning report you will assume responsibility for tasks remaining to be completed for the post call team’s patients. This DOES NOT mean that the post call team leaves progress notes unwritten for the Trauma Day intern to write. The post call team is responsible for progress notes on their patients. The Trauma Day intern IS, however, responsible for swing team progress notes on the swing team intern’s day off.

Tiger Connect: Upon arrival to work, you MUST opt-in to your assigned role in Tiger Connect. For the Trauma Day intern, you will opt-in to the role of the team you are covering for the day AFTER completing sign out with that team. You are to opt-out of your role at the conclusion of your assigned duty hours AFTER you have signed out to the covering intern, who will opt-in to that role.

Our trauma service uses Ryder Practice Guidelines (RPGs) to help standardize care for common clinical situations. These RPGs are available online at miamirpg.org or as a link from the Ryder Trauma Center website (https://rydertraumacenter.jacksonhealth.org/trauma-critical-care-guidelines/ or miamirpg.org). As an intern on the trauma service, the RPG site should be saved as a favorite on your phone. You are expected to be familiar with the RPGs as they relate to the patients you are caring for. These are guidelines, not protocols, and should not be adhered to blindly. You as a physician (as well as your supervising attending) are ultimately responsible for the orders that you place. If you think that one of your patients needs care that deviates from an RPG, notify your senior resident/fellow/attending and discuss in detail. There are two RPGs (Tertiary Surveys for Trauma Patients and Discharge Medications for Trauma Patients) of special interest to interns. These are included as Addendum 1 and Addendum 2 at the bottom of this document for your reference.

• Be prepared for rounds with the resident and/or fellow by the specified time with current vital signs, lab results and all imaging results.
• You are expected to know all current medications your patients are receiving, their indication and duration.
• Documentation must be completed for each patient on your service every day.
  • In order for the daily progress note to be compliant, the following data must be entered for all patients:
    • Entered Upon Admission:
      • 1. History of Present Illness (HPI)
      • 2. Chief Complaint
      • 3. Family history
      • 4. Past Medical History
      • 5. Past Surgical History
      • 6. Review of Systems
      • 7. Physical Exam – fill out all 12 selections (do not leave any blank)
    • Updated Daily:
      • 1. Events of the last 24 hours
      • 2. Daily Plan – this should include what is planned and WHY, reflect the reasoning behind the plan
      • 3. Vital Signs
      • 4. Fluid Balance
    • Updated As Needed:
      • 1. Drains (type and daily output)
      • 2. Antibiotics (name and indication of each)
      • 3. Respiratory
      • 4. Nutrition
      • 5. Medications
      • 6. IV Access
      • 7. GI and DVT Prophylaxis
• The house staff team is responsible for writing a note every day to include weekends and holidays. This includes all patients in the, TICU and the IMCU as well as on satellite floors, pediatrics, PICU, NSICU, and MICU.
• The daily progress note should NOT be a bulleted list of every event throughout the entire hospital course. It should reflect the events of the last 24 hours and the thought process behind interventions.
• Be prepared to present floor patients on your service to the rounding Attending surgeon when notified. The presentation of the floor patients is the intern’s responsibility. You should know your patients better than anyone.

Complete an accurate, comprehensive history and physical exam and admission orders on each patient admitted to your service. Additionally, the “Problem List” MUST be filled out in Miracle/Cerner for each patient when they are admitted.

Consults: A consult note/history & physical must be completed by the respective service for all consults seen.

• When seeing a consult ensure that a consult order has been placed in Cerner by the requesting physician (in the case of Burn consults in Resus, the order should be from Trauma to Burns). If no consult order has been placed, POLITELY inform them that the consult cannot be completed until that is done.

Perform a Post Operative Check on all floor patients on your service when they undergo surgery.

Perform all other patient care related tasks as assigned by your resident and/or fellow.

Provide an accurate sign out prior to leaving at the conclusion of your shift. Under NO circumstances is it acceptable to leave prior to signing out your service, ensuring uninterrupted care. After you have completed sign out, make sure you opt-out of your assigned role in Tiger Connect and that the coverage intern has opted-in.

Attend Morning Report with your team. Barring patient care emergencies, you will be expected to attend academic conferences.

You will be on a q3 day call schedule as follows:

Call: 24hour trauma call along with your team, arriving to work no earlier than the time specified.

Post Call: begin rounding in time to be prepared to round with your team prior to morning report, typically by 0645. Either prior to morning report or immediately after, the team will conduct attending rounds. After attending rounds, review patient care tasks with the Trauma Day intern, after which you will leave no later than 10am.

Swing (Pre-Call) Day: Arrive to the hospital at the specified time. Conduct patient care tasks as needed. Be prepared to sign out to the Trauma Day intern in time to leave the hospital no later than 2pm.

You will be off one day in six. Your day off will be every other swing day (pre-call day) as decided in discussion with your resident/fellow. The Trauma Day intern will be off one weekend day per week. These are your only approved days off. If you require another day off for some reason, this must be approved by Dr. Garcia (Dr. Namias can approve a change if Dr. Garcia is unavailable) and will only be considered on a case-by-case basis and ONLY for extraordinary circumstances.

Your assigned duty hours are as described above. These hours must be observed and adhered to. Neither arriving to the hospital prior to the assigned time, nor remaining at the hospital after the designated time will be tolerated. Violation of these work hours will result in disciplinary action. The first violation will result in a one-day suspension from the rotation. A second violation will result in a three-day suspension from the rotation. A third offense will result in a failing evaluation for the rotation. Only the most extreme circumstance will be excused (ie, you are active performing chest compressions during a code) and will be considered on a case-by-case basis.

Ryder Practice Guideline – Tertiary Surveys for Trauma Patients

Purpose
The purpose of the tertiary survey is to avoid missed injuries in trauma patients. All trauma patients should undergo tertiary surveys ideally within 24 hours of admission. Since patients who remain sedated, altered, or critically ill are at increased risk for missed injury, these patients should have their tertiary survey repeated once their ability to report focal tenderness becomes reliable.

Personnel
The trauma day intern is responsible for ensuring that tertiary surveys have been completed for all recently admitted patients. When the trauma day intern has a day off, tertiaries are the responsibility of the intern covering swing. Medical students may assist with tertiary surveys and may write tertiary notes based on the template below but the physical survey and other findings must be confirmed by the intern and the intern must co-sign the tertiary survey note. The geriatric trauma nurse practitioner rounding with the team will assist with orienting interns to the tertiary survey process.

In the TICU or SICU, the ICU fellow is responsible for ensuring that tertiary surveys are completed. When a patient is transferred from ICU level of care to IMCU or med-surg, tertiary surveys should be repeated and documented by the intern covering the patient’s primary service.

Tertiary surveys should also be performed prior to discharging patients to home from the trauma resuscitation unit (TRU). The resuscitation resident is responsible for performing and documenting tertiary surveys for patients discharged from the TRU. Any new findings should be reviewed with the attending on call.

Key Elements of Tertiary Surveys

• Review of prior imaging and final interpretations
• Review of recent labs
• Head to toe physical survey with attention to new areas of concern (the template below can be used as a checklist for physical survey as well as for documentation)
• Plan: New imaging ordered, new consults placed

Documentation
Tertiary surveys should be documented in a separate note (not as part of an H and P or progress note). The note type should be “Surgical Progress Note”, select the template “Free Text Note”, and change the title to “Tertiary Survey.” Once the note is open, use the template below. This template can also be used to create a dot phrase for ease of use. Tertiary notes do not need to be forwarded to an attending for co-signature.

Sample Template of Tertiary Survey Note (must be edited to reflect any positive findings):

Subjective complaints:
No pain or other complaints aside from appropriate level of discomfort associated with previous known injuries.
Physical Exam:
Neurologic: GCS 15 (E4 V5 M6), no focal motor or sensory deficits
Head and Neck
Scalp: no lacerations, bruising, or swelling
Facial bones: no instability, bruising, or swelling
Eyes: PERRLA, EOMI
Ears/Nose: no bleeding or clear drainage
Oral cavity: Intact dentition, no malocclusion, intact oral mucosa
Trachea: Midline, no subcutaneous emphysema
Soft tissue of neck: No ecchymosis, laceration, or swelling
Chest: No bruising, or crepitus; ribs and sternum stable with no focal tenderness or deformity
Abdomen: Soft, non-tender, non-distended, no ecchymosis or seatbelt sign
Pelvis: Intact with no crepitus or deformity, no tenderness at pubic symphysis
Extremities: No deformity or tenderness, normal range of motion, sensation and motor function grossly intact
Vascular: 2+ radial, femoral, DP/PT pulses
Back: No ecchymosis, lacerations, or abrasions
Spine: No cervical, thoracic, or lumbar tenderness

Studies:
Admission imaging with final interpretations and recent labs reviewed.
Additional imaging ordered: none
New consults placed: none

Ryder Practice Guideline – Discharge Medications for Trauma Patients

Outpatient Venous Thromboembolism Chemoprophylaxis:
Patients with orthopedic injuries including fractures of pelvis/hip/femur/tibia/fibula should be discharged with a prescription for 4 weeks of outpatient VTE chemoprophylaxis unless specifically excluded by a trauma attending.
Orthopedic injuries listed above WITHOUT traumatic brain injury: ASA 81mg BID x 4 weeks
Orthopedic injuries listed above WITH traumatic brain injury: Enoxaparin 30mg BID x 4 weeks

Outpatient Antibiotics:
In general, patients should not be discharged with oral antibiotics for fractures or soft tissue injuries due to limited benefit, risk of clostridium difficile infection, and development of resistance. Any recommendation for outpatient antibiotics must be discussed with the trauma attending prior to prescribing.

Outpatient Levetiracetam (Keppra)
Please prescribe oral levetiracetam at discharge to complete the intended duration of therapy.

• Patients with traumatic brain injury without seizures should usually complete a total course of 7 days of levetiracetam. The typical dose is 1000mg BID for adults and 500mg BID for geriatric patients.
• For patients with TBI who experience seizures, please ensure that outpatient anti-epileptic prescriptions match consulting service recommendations for outpatient agent and duration.