Introduction to the Family Medicine Emergency Medicine Rotation at the Hand & Upper Limb Centre

Introduction to the Family Medicine-Emergency Medicine Rotation at the Hand & Upper Limb Centre

St Joseph’s Health Centre London, Ontario 2

Background:

Residents who are enrolled in the Family Medicine Emergency Medicine year rotate through the Hand & Upper Limb Centre (HULC) on a routine and nearly constant basis. The rotation procides an opportunity to increase your knowledge and acquire technical skills to deal with problems related to several aspects of upper extremity surgery. In addition, learning objectives of this rotation include assessment of other soft tissue injuries, facial trauma, as well as casting and splinting. This is a rotation that is multi- disciplinary including orthopedic surgery and plastic surgery as well as physio and occupational therapy.

Staff of the Hand & Upper Limb Centre:

Dr Graham King is a Professor and the Director of HULC and site chief for orthopedics at St Joseph’s Health Centre. He completed his residency in orthopedics in Toronto and fellowship training in Calgary and the Mayo Clinic. His clinical interests are in hand, wrist and elbow surgery. He co-directs the Bioengineering Laboratory at the Hand & Upper Limb Centre.

Dr Doug Ross is a Professor. He completed his plastic surgery residency in Toronto and then completed fellowships in Toronto and Louisville, Kentucky. His clinical interests include hand, wrist, peripheral nerve and reconstructive microsurgery. He is also interested in surgical education and completed his Masters degree in Education at the Ontario Institute for Studies in Education at the University of Toronto. He is the Chair of the Division of Plastic Surgery and Director of Surgical Education for the Department of Surgery.

Dr David Chess is an Associate Professor. He completed his orthopedics residency at Dalhousie and subsequently completed an arthroplasty fellowship in London. He currently treats non-operative upper extremity problems.

Dr Bob Richards is an Associate Professor. He completed his plastic surgery residency in Edmonton followed by fellowships in Toronto, California and London. His clinical interests are in hand, wrist and aesthetic surgery as well as clinical outcomes.

Dr Ken Faber is an Associate Professor. He completed his orthopedic residency in London followed by fellowship training in London and Vail, Colorado. His clinical interests include hand, wrist, elbow and shoulder surgery. He also is interested in surgical education and completed his Masters degree in Education in Springfield, Illinois. He is the Program Director for the HULC Fellowship.

Dr Bing Siang Gan is a Professor. He completed his plastic surgery residency in London followed by fellowship training in Toronto and Boston. His clinical interests are in hand, wrist and reconstructive microsurgery as well as wound healing. Dr Gan co-directs the Cell Biology Research Laboratory at the Hand & Upper Limb Centre.

Dr. Darren Drosdowech is an Associate Professor. He completed his residency in Winnipeg followed by a should and sport medicine fellowship in London. His clinical interests are in shoulder surgery. 3

Dr George Athwal is an Associate Professor. HeDarren Drosdowech completed his orthopedic residency at Queens and fellowships in sports Medicine and shoulder surgery in New York and the Mayo Clinic. His clinical interests are in sports medicine and shoulder surgery.

Dr Ruby Grewal is an Associate Professor. She completed her orthopedic surgery residency in Vancouver followed by fellowships in London and Australia. She completed her Masters in Clinical Epidemiology while in London and has a research interest in clinical outcomes. Her clinical interests include hand, wrist and other upper extremity surgery.

Dr. Marie-Eve Lebel is an Assistant Professor. She completed her orthopaedic residency at Laval University followed by a sports medicine fellowship in London. Her clinical interests are in shoulder surgery.

Organization of the Rotation:

It has been our experience that virtually all Family Medicine residents that rotate with us want to minimize their time in the operating room and concentrate on the various ambulatory clinics. We are happy to support this.

There are a large number of orthopedic, plastic, and off-service residents rotating through our service. In addition, there are clinical fellows and medical students. Each of these groups has differing educational needs and objectives but some areas will overlap. We endeavour to keep any “conflicts” to a minimum but if you perceive there to be problems, please let us know.

During the day (8 am to 5 pm), you will carry a pager which will be first call for emergency referrals. These will be both from the Urgent Care Centre at St Joseph’s as well as around London and Southwestern Ontario. If there are two Family Practice Emergency Medicine residents at the HULC simultaneously, the pager usually alternates between the two residents on a daily basis. At times, the number of calls coming to this pager can be significant.

Particularly at the start of your rotation, you should discuss with the senior resident/consultant on call as to how he/she wishes these referrals to be handled. The call schedule is posted throughout the Hand & Upper Limb Centre (You will find that at times the listed resident on call is actually sited at another hospital and in this case, you should review the case with the on-site senior resident assigned to the consultant on call). For instance, many referrals can be faxed to the Hand & Upper Limb Centre [(519) 646-6049] and scheduled for the next available clinic with the consultant. However, referrals may be seen the same day for reasons related to the injury, OR scheduling, consultant away times etc.

Because the Hand & Upper Limb Centre is an integrated, multi-disciplinary unit, you will find that orthopedic and plastic surgeons care for problems which are outside the traditional “boundaries” of the specialties. For instance, all wrist fractures, hand injuries, tendon injuries etc are handled by the HULC consultant on call no matter which specialty 4 certification they hold. In case of confusion, the senior resident or consultant are always available to guide appropriate decision making.

If a decision is made to accept a referral and have the patient transferred to SJHC, you should discuss where to refer the patient with the nurse who is in charge of the HULC clinic that day (typically Lorna or Cathy). For instance, it is often easier to see a patient with a wrist fracture requiring reduction in the clinic but there may be no clinic staff, X-ray technicians etc present when the patient finally arrives and thus the patient is better directed to the Urgent Care Centre which is open until 10 pm. Generally, if the patient cannot arrive at the HULC clinic by 4 pm, they are best directed to the Urgent Care Centre. After 10 pm, arrangements can be made to bring patients via the on-call resource nurse. This should be discussed with the senior resident/attending staff before arrangements are made. You should note that we do not manage acute, poly- traumatized patients and because there is no ICU on site, we need to be cautious in accepting patients with significant co-morbidities or life-threatening infections such as necrotizing fasciitis etc.

If in doubt, patients should be directed to the Urgent Care. Please notify emergency triage at 67070 if a patient has been accepted to be seen in Urgent Care. Triage will require patient name, a brief description of the injury, and a contact physician for when the patient arrives. If a patient can be expected to require admission then please ensure that a bed is available by calling admitting at 66015 to hold a bed for that patient. You should recall that patient transfers always take much longer than you would expect on the basis of driving times alone.

When seeing a referral, you should carry out an appropriate history and physical examination and formulate a treatment plan before discussing the patient with the resident or consultant. You will have at all times appropriate senior residents/fellows/consultants available for guidance.

If you accept a referral, the expectation generally is that you would remain at the hospital until at least 5 pm to assess the patient. Obviously, if the patient is anticipated to arrive later in the evening and you are not on-call, you should discuss the referral with the on- call resident who will be called to see the patient.

If you accept and assess a patient, you should continue to follow that patient during their hospital stay in order to appreciate how various clinical problems are expected to be treated and recover. This includes attending some portion of their OR to observe the relevant pathology and treatment. You should follow-up their progress on the floor as well. This is particularly true for patients with non-operative problems such as cellulitis etc. When writing admission orders, please write clearly state and write whom the patient is admitted under.

You will also receive pages from the floor about patient problems during the day as well as when on-call. If necessary, you should go and assess the patient and if you are unsure about how to handle these, you should contact the resident on the particular service for guidance. For complex, highly specialized patients such as free flap patients or replantations, it is probably best to have a senior resident assess the patient if the question is of adequate perfusion. However, problems such as low urine output, medical issues etc may be reasonably treated by yourself with backup if necessary. 5

On alternate Thursday mornings from September to June, during your academic half day, you should sign your pager over to the St Joseph’s resident on the service on call for that day (ie plastic surgery resident if Drs Richards/Gan/Ross on call, orthopedics resident if Drs King/Faber/Drosdowech/Grewal/Athwal/Lebel on call). This should be done via a call to the appropriate resident each Thursday at the time of sign over. When your academic day is over, you should check in with the team to review any ongoing or pending issues/referrals.

HULC Clinics:

The schedule of consultants’ clinics is appended. You should plan to spend each day in the clinic. Attending a variety of clinics will expose you to the assessment and physical examination of various problems in the upper extremity. In order to avoid excessive numbers of residents/students in particular clinics, you should check with the senior residents in orthopedic and plastic surgery at SJHC to see how many housestaff are expected to attend particular clinics. Typically, schedules are available for the entire month.

On Call Duties:

You will be incorporated in the call schedule. The frequency is not onerous. If you have specific requests for time not on-call, you should contact the administrative chief residents in Plastic Surgery and Orthopedic Surgery at least one month in advance of the 1st day of the call month in question. The scheduling is complex given the need to coordinate multiple housestaff in different specialties. Vacation is granted on a first- come, first-served basis.

Call for the rotation can be confusing. Each day there are two consultants on-call; one for plastic surgery and one for orthopedic surgery. One of the two consultants will also be covering HULC. This includes all calls from the periphery or Urgent Care Centre. Plastic surgery call is also city-wide coverage, and thus covers both LHSC campuses after 6 pm.

As per the PAIRO guidelines, you are permitted to go home at noon the day following call if you have been up a significant portion of the night (defined by the PAIRO agreement as: “a resident who commences work in the hospital after midnight but before 6 a.m.; OR ii) a resident who works for at least four (4) consecutive hours at least one hour of which extends beyond midnight”). Therefore, if the night has been quiet or if you have answered a few calls by telephone during the night, you should expect to complete a normal day’s work post-call. You will find your time here very short and much of what you see will have direct relevance to your practice. Generally speaking, the educational value of the rotation will be directly proportional to the enthusiasm and effort you bring to the service.

Rotation Specific Objectives:

Your program director, has provided problem-based educational objectives for your rotation under the following headings. A more comprehensive list is available on your evaluation form. 6

 Knowledge: . Management of soft tissue injuries . Assessment and diagnosis of the injured hand and wrist . Assessment and diagnosis of shoulder injuries (dislocation, cuff tear etc) . Assessment and diagnosis of elbow injuries . Wound and bite injuries . Soft tissue infections . Burns . Hand & wrist injuries . Facial injuries . Relevant imaging

 Technical skills: . Reduction of hand & wrist fractures and dislocations . Wound closure . Splinting and casting . Revision amputations . Extensor tendon repair

You should recognize that while many of these objectives will be met by direct observation and “doing” (ie reduction of wrist fractures), others will require independent reading and study.

There is a comprehensive program of seminars which occur each morning at 7:00 am in the Roney Auditorium “A”. These are broken down into general topics:

 Monday: Shoulder and Elbow  Tuesday: Hand & Wrist  Wednesday: Separate orthopedics and plastics city-wide rounds, locations vary  Thursday: Hand & Wrist  Friday: Shoulder and Elbow

Some of these subjects will be very specifically surgery related and may not be of interest to you. However, many will have direct relevance to your future practice and educational objectives (eg physical examination, metacarpal fractures, fingertip injuries, radius fractures) and you should plan to attend. The schedule is available several months in advance.

One technical skill that is useful to improve upon during your month is the application of casts. A particularly useful way to do this is to “follow” a patient that you see in clinic to the cast room to apply the cast under the supervision of our cast technician.

Evaluation:

You should try to review your evaluation form and any specific learning objectives you might have with either Drs Ross or Faber early in your rotation. Frequently evaluation forms do not come to our attention until after the resident has left the service. Daily 7 evaluations may be completed in conjunction with the consultant that you spent the majority of a day with. You should remind him/her (at the start of the day) that this will be occurring as it is not a commonly used evaluation tool amongst the surgical training programs

Conclusion:

We expect that your rotation at the Hand & Upper Limb Centre will be a valuable part of your emergency medicine year. The nurses in the clinic, residents, and fellows are a valuable resource, and are available to provide orientation at the start of your rotation and advice as your rotation progresses. We are open to any suggestions you might have to improve your experience. If you have concerns or questions, please feel free to approach us.

Staff of the Hand & Upper Limb Centre

Revised January, 2011.