THere is a lot of good info in this post but this is extremely important. Go through the case in your head. Start with the cannulated k wire and make sure its in the set. Make sure the drill bit is in the set. Make sure the screws are in the set. Make sure the screw driver is in the set. Make sure the plates are there. Make sure the sutures are on the table. The gauze, 4x4, kerlix, ace whatever the attending wants. Make sure the cast cart is in the room. Anything and everything you can think of make sure its present.
I remember a time I was scrubbing with one of our ortho foot/ankle attendings. I was doing the case and called for a screw driver. The tech said there was no driver. The attending lost it on my for not checking prior to starting the case. To this day I wont allow the patient to be brought back to the room until I've gone through the case in my head and verified all hardware is present. Cant rely on reps to make sure its all there. Sets come incomplete more ofen than they should.
Amen. It is infinitely preferable to dump a Synthes set on the table before a case than during a case. Drill bits love to hide.
This is even more relevant if the rep isn't present. They can sometimes solve these problems if they are present.
If you know that your attending prefers to just use 1 size screw ie. they use locking screws and just use 14s or something like that. The kit might not contain 8+ of just that size.
Know what a locking screw and a non-lock screwing look like so when the nurse hands you one and not the other you can just hand it back.
If you find yourself watching a case that you aren't scrubbed into - obviously varies by program - and you aren't familiar with the hardware, scrub in just to handle the tray in the back. Obviously don't screw it up or slow people down. But feel all the different screws and see what drills go with each of them.
We used to use a Biomet ankle plating set that was definitely more complicated. Just throwing that out as an example.
Are you doing a soft tissue mass where it is either hard to locate (flat) OR a day before someone drained it in the clinic. Before the case in the presence of the patient - mark/draw/delineate etc the entirety of the mass and where it hurts. There is nothing worse than starting the case and realizing no one knows where the mass or lesion is. Do not let the patient be sedated if there is ANY doubt about where the lesion is.
Before you book a posterior heel screw removal on a morbidly obese person - ask yourself who is going to be holding the leg.
The time to figure out how the patient will be non-weight bearing is when the case is booked or during a pre-planned PT appointment. Not after the surgery.
Working people and blue collar people will often want to return to work sooner than you want them to. Often at their 1st post-op visit. I'm still trying to sort out how to address this myself, but I recommend the following.
(a) Do not book a major fusion for a patient on a first visit. The patient has no understanding or appreciation of what is going to happen to them.
(b) Bring a family member to the scheduling visit. Hell, if things start to fall apart - bring a family member to post-op visits. Get someone else in the room who can try to be your voice of reason.
If a patient presents to a follow-up where they are being transitioned from a cast/splint to a boot and they didn't bring a boot with them - they cannot leave the appointment until they buy a boot from your office or hospital. They will not buy it otherwise.
In general, knee rollers are amazing/superior to crutches.
Really ask yourself if a patient should be on a blood thinner after surgery. I saw a patient placed on blood thinners for a 1st MPJ fusion. He was allowed to walk at 3-5 days. He was never immobilized in a cast or even a CAM boot. He had no history of DVT or family history of DVT. He was brought in for observation to a hospital for an issue with heart palpations/faintness at 4 weeks. The podiatrist was called and asked by hospital medicine if he really needed to still be on blood thinners. The podiatrist said yes. He fainted a few days after discharge, hit his head, and died from a brain bleed. He shouldn't have been on a blood thinner to begin with.
Try to understand the mentality of the doctor you refer patients to for BKA. An EHR referral for "needs BKA" was always far less successful than a phonecall or bedside consultation together where you spell out the patients 2 year history of a failed battle with Charcot.
Cultures taken at bedside need to be placed into the hands of a nurse who already has the labels, tags, orders, whatever set-up. I've literally had a nurse throw away cultures I gave them in the patients room.. I didn't have orders for those. I didn't know who they belonged to. It seems absurd, stupid, whatever now - but close the entire loop. Cultures left on a table? Good luck with that.
Is the case starting in 5 minutes? Is the patient still in their inpatient room. You could go get them. You can wait for them... the case will probably be an hour late.
Sometimes you have to fight to make a case happen. That may mean running around a hospital talking to the ED doc, the anesthesiologist, the hospitalist, etc.
If you've never spoken to a hospitalist before you should SBAR/write down what you intend to say before hand especially if you are asking them to admit and take primary. My experience is that the medical side of things is not difficult for them. What they hate is the social/side/discharge related stuff.
Your hospital may have social coordinators who can help resolve things like placing patients in skilled facilities and arranging wound care, IVs, medications, etc. These are people to be "friendly" with and have in your phone. They can solve problems for you.
You see an inpatient. You take care of them. You sign off on them. The medical director of my hospital walked up to me one time. She was very ...sassy. "Hi, I see you signed off on this patient. Courteous doctors place saved discharge orders ahead of time to help their inpatient counterparts."
If you order an MRI and there's a question of whether the problem is in the ankle or the foot - order both. Sometimes the MRI people will say something to the affect of - oh, we'll just do 1 and expand the field. It always looked like crap to me when they did this.
If a patient is admitted to the hospital on 5 different oral anti-diabetes medications, is still uncontrolled, and you are doing medication reconciliation - they are probably going to be on insulin. This isn't rocket science but it will still be funny to you the first time you see it.
We talked about this for the OR, but you should have a very good idea of where supplies are in your hospital's inpatient floor closets. Your attending very likely will be pissed if you steal things from their office to bring them to the hospital floor.
