HOUSESTAFF MANUAL

JACKSON MEMORIAL TRAINING PROGRAM IN GENERAL SURGERY AT THE UNIVERSITY OF MIAMI/JACKSON MEMORIAL MEDICAL CENTER

TA B L E O F C O N T E N T S Administrative Faculty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Medical Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Program Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Resident Function by Year Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Description of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technical Lab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Examinations & Required Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Promotions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evaluations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Service Rotations and Vacation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General Administrative Functions and Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Procedure for Occupational Exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dictations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Licensure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Supervision – Lines and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Grievance and Arbitration Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix A – Instructions for Lanier Dictation Stations, Operating Room, Labor and Delivery Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix B – Operative Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix C – Discharge Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix D – Department of Surgery Faculty Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix E – Housestaff Telephone Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix F – General Surgery Training Program - Typical Categorical Rotation . . . . . . . . . . . . . . . .

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THE MEDICAL CENTER The University of Miami/Jackson Memorial Medical Center is one of the largest teaching general health care facilities in the Southeastern United States. It occupies a unique position in South Florida caring for the most seriously ill and injured patients in the region. This high level of care requires up to date technology and a highly competent staff. With over 8000 employees, including 1600 nurses and 1500 physicians, the medical center includes the University of Miami Leonard M. Miller School of Medicine, Jackson Memorial Hospital, the Miami Veterans Administration Medical Center, Bascom Palmer Eye Institute, Sylvester Comprehensive Cancer Center, Highland Park (Psychiatric) Pavilion, Mailman Center for Child Development, UM Hospital and Clinics, Louis Calder Memorial Library and other medical libraries, affiliated research institutions and community outreach programs. The keystone of the medical center, and the major teaching hospital for the University of Miami Leonard M. Miller School of Medicine, is the 1567-bed Jackson Memorial Hospital which was founded in 1917 as The Miami City Hospital. It is governed by the Public Health Trust, which is a citizen’s board responsible to the Board of County Commissioners of Dade County. Other facilities include the 27 million dollar trauma center (RYDER TRAUMA CENTER) and a 27 million dollar comprehensive cancer center (SYLVESTER COMPREHENSIVE CANCER CENTER). In addition to its mission of providing the best possible patient care, the medical center is also involved in research and education. It contributes to the goal of ensuring future health care excellence through training physicians (jointly with the VA Medical Center) and other health care professionals. 2

PROGRAM DESCRIPTION This is an ACGME approved, five-year straight surgical, non-pyramidal program, which graduates six residents annually. Four hospitals are utilized: Jackson Memorial (JMH); The Veterans Administration Medical Center (VA); Mount Sinai; Hollywood Memorial; and Miami Children’s. Jackson Memorial is the sponsor and the primary teaching hospital. The VA is an integrated institution while all others are affiliated. The teaching faculty at Jackson Memorial and the VA all have clinical appointments at those institutions and most have appointments in the Department of Surgery at the University of Miami Leonard M. Miller School of Medicine. A director of surgical education is appointed at each affiliated institution. The teaching faculty at all affiliated institutions have teaching appointments at those institutions and most have clinical appointments in the Department of Surgery at the University of Miami Leonard M. Miller School of Medicine. The goal of this program is to provide training in the field of general surgery for those entering that specialty and in the basic surgical skills for those residents diverting into the various specialties. For the purpose of instruction, the program has been divided into educational units (services). Each unit must provide experience in pre and post operative care which includes the development and staffing of appropriate clinics. A senior resident is assigned to each service and is responsible for all patient care and administrative activities. At JMH and the VA his/her activities are supervised by a group of full time JMH or VA faculty members, one of whom is appointed chief of service. At these institutions, each service has developed areas of specific interest and 4

expertise and patients with these specific problems are admitted to the appropriate service on the basis of the disease process. A curriculum has been developed that covers those problems presently considered a part of general surgery as outlined by the ACGME’s six competencies, and for the purpose of instruction, each subject is assigned to a service where the topic coincides with the expertise of the service. Methods which assure adequate instruction in the various topics. One day a week is reserved for clinic care. Research is formally incorporated into the program and presently two residents rotate through various research facilities, both local and remote, for varying periods following their second year. Each resident will perform approximately 1200 major operations of a variety consistent with the requirements of the American Board of Surgery and the Residency Review committee for General Surgery. A systematic method for evaluation of each resident, using those methods suggested by the ACGME, is in place, as are methods for evaluation and improvement of the educational program. This includes input (participation) by the teaching faculty and residents. Complimenting this service instruction is a group of conferences and technical labs. Included is a weekly mortality and morbidity conference and a series of basic science conferences.

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COMPETENCIES PATIENT CARE Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to: • • • • • • • • •

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communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families gather essential and accurate information about their patients make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment develop and carry out patient management plans counsel and educate patients and their families use information technology to support patient care decisions and patient education perform competently all medical and invasive procedures considered essential for the area of practice provide health care services aimed at preventing health problems or maintaining health work with health care professionals, including those from other disciplines, to provide patient-focused care

MEDICAL KNOWLEDGE Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to: • demonstrate an investigatory and analytic thinking approach to clinical situations • know and apply the basic and clinically supportive sciences which are appropriate to their discipline PRACTICE-BASED LEARNING AND IMPROVEMENT Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to: • analyze practice experience and perform practice-based improvement activities using a systematic methodology • locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems • obtain and use information about their own population of patients and the larger population from which their patients are drawn • apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness • use information technology to manage information, access on-line medical information; and support their own education • facilitate the learning of students and other health care professionals 7

INTERPERSONAL AND COMMUNICATION SKILLS Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to: • create and sustain a therapeutic and ethically sound relationship with patients • use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills • work effectively with others as a member or leader of a health care team or other professional group PROFESSIONALISM Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: • demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development • demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices • demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities 8

SYSTEMS-BASED PRACTICE Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to: • • • • •

understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources practice cost-effective health care and resource allocation that does not compromise quality of care advocate for quality patient care and assist patients in dealing with system complexities know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

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R E S I D E N T F U N C T I O N BY Y E A R L E V E L The program is based on the concept of progressive responsibility. The first year rotations are chosen so as to provide a broad introduction to surgery and surgical care. At this level, the resident takes an active part in patient evaluation and management. He/she will be responsible for the initial history and physical, pre-operative preparation and often participates in the operative procedure. He/she will also have an active, and to some extent, independent role in the overall management of most patients. He/she will act as the operating surgeon on appropriate cases. The senior resident and/or attendings carefully supervise these activities. The second year is similar to the first but with the opportunity for more independent activity. On pediatric surgery, his/her responsibility increases in the neonatal unit and in the trauma resuscitation unit, he/she will assume more independent responsibility and become involved in resuscitation of the critically injured patient. This experience is enhanced by rotations through the Surgical Intensive Care Unit. Other rotations include colorectal surgery, general and vascular surgery at the VA. In the third year, he/she is the senior resident on selected services and, thus, the opportunity for independent responsibility increases considerably. His/her operative experience is increased by rotations through Transplantation, Burns, and nearby Mount Sinai Hospital on Miami Beach. In the fourth year, he/she is responsible for the overall management of the service. This function is associated with considerable independent responsibility, both clinical and administrative. Most major diagnostic or therapeutic procedures, however, must be discussed 10

with the chief resident or attending. He/she may supervise a junior resident on appropriate cases. The volume of complex cases on most services allows for the performance of these procedures at this level under the direct supervision of an attending or chief resident. There are rotations which concentrate on Surgical Oncology, Hepatobiliary Diseases, Pediatric Surgery, Trauma, Thoracic, Vascular and Head and Neck Surgery. In the fifth year, he/she is primarily responsible for the overall operation of the service. He/she participates in the pre-operative and post-operative evaluation of all patients and performs those procedures required to complete his/her training in General Surgery. He/she may independently order major diagnostic procedures. All operative procedures, however, must be presented to an attending surgeon. He/she will supervise a junior on appropriate procedures. On most low volume major cases, such as Whipples, direct attending supervision is provided.

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BRIEF DESCRIPTION OF SERVICES BURN CENTER Nicholas Namias, M.D., Chief C. Gillon Ward, M.D. Louis Pizano, M.D. Carl Schulman, M.D. Each year the Burn Center admits 300 patients to the hospital and has 1,600 clinic visits. The core resident complement includes a third year General Surgery Resident assisted by two General Surgery Interns. At various times there is also a rotating fellow from Plastic Surgery or Trauma/Critical Care. The Burn Team approach is the foundation of care of the burn patient. The team is responsible for all admissions coming through trauma resuscitation, the emergency room, and the outpatient burn clinic. The full time non-physician members of the team include nurses and nurse practitioners, wound care technicians, occupational and physical therapists, and a social worker. Psychological, child protection, and pediatric intensive care services are available on an as needed basis. The majority of the burn patients are from South Florida, but include patients from all of Florida, the Caribbean, Central America, and South America.

CELLULAR TRANSPLANTATION Camillo Ricordi, M.D., Chief Norma Kenyon, M.D. The main activities within the Service of Cellular Transplantation comprise processing of tissues and organs for cell harvest and purification. The cells retrieved are used both for experimental sudies and for clinical applications. The two major areas of cell transplantation are 12

BRIEF DESCRIPTION OF SERVICES pancreatic islet preparation and purification for transplantation in patients with Type I and Type II diabetes mellitus and bone marrow harvest and processing for donor bone marrow infusions in patients receiving organ and/or cellular grafts. This latter approach is to develop donor specific unresponsiveness in the recipient. Surgical residents at any year of their training can learn and actively participate in cell separation, purification and transplantation performed at the Cell Transplant Center. They will acquire knowledge in transplantation immunobiology and participate in the design of research protocols in both basic and clinical science.

COLON & RECTAL SURGERY Michael Hellinger, M.D., Chief Laurence R. Sands, M.D. Foriano Marchetti, M.D. The Colon and Rectal Service is staffed by two full time faculty members committed to patient care, clinical research, and resident, and medical student teaching. In addition, the Service has one two-year fellowship position available. Along with the treatment of routine anorectal disorders, (such as hemorrhoids, fissures and fistula), more complex problems are managed. With the use of the anorectal physiology lab, (which includes anorectal EMG, anal manometry, pudendal nerve studies and rectal ultrasound), complex disorder of defecation and incontinence can be more scientifically investigated. The service also participates extensively in the multidisciplinary approach to patients with colorectal neoplasm and inflammatory bowel disease; thus, offering the resident the opportunity to be involved in the state-of-the-art surgical techniques including laparoscopic techniques. 13

BRIEF DESCRIPTION OF SERVICES GENERAL SURGERY Joe Levi, M.D., Chief Duane G. Hutson, M.D. Danny Sleeman, M.D. John L. Lew, M.D. The General Surgery Service provides the basic structure for care of private referrals as well as indigent care utilizing a thirty-bed unit at Jackson Memorial Hospital. In addition, with the aid of various didactic conferences, instruction is given on the operative and non-operative skills of a wide spectrum of general surgical problems with the emphasis on complex fore gut problems including esophageal, gastric, duodenal, hepatobiliary, and pancreatic problems. The service provides intensive exposure to a variety of pathology ranging from laparoscopic (minimally invasive procedures) to radical resections and reconstructions.

KIDNEY & PANCREAS TRANSPLANTATION George W. Burke III, M.D., Co-Director Gaetano Ciancio, M.D. The Service of Kidney and Kidney/Pancreas Transplantation is quite active. The referral area consists of 5.1 million people as part of the most active transplant program in South Florida. The rate of transplantation is at about 150 per year with between 25 and 50 kidney/pancreas transplants being performed. The rates of patient and graft survival are among the highest in the nation. There are two conferences weekly with the adult and pediatric nephrologists respectively as well as a teaching conference on Saturday morning on 15

BRIEF DESCRIPTION OF SERVICES Patient rounds are twice a day with the first and second year Fellows and the first-year resident rotating in the service. Other regular activities of the Liver/GI service include Pediatric Transplant, Adult Transplant and Biopsy Conferences. Adults and children undergoing liver and gastrointestinal transplant are operated on in the main operating room area (West Wing 3rd floor). The Adult Surgical Intensive Care Unit and Pediatric Intensive Care Unit are located in Central Building 3rd floor and East Tower 4th floor, respectively. From the ICUs, the patients are transferred to the Adult Transplant Unit (West Wing 15th floor) or Pediatric Referral Unit (East Tower 6th floor). With an exponential growth rate, the Liver Transplant Program ranks among the most active in the country. The patient survival rates have been excellent, around 90%. With Dr. Adnreas Tzakis’ pioneering expertise, 10 patients have received small bowel transplants and multivisceral abdominal transplants have been done in three other patients. Only a few transplant centers in the world have developed such a clinical experience with these types of transplants. State of the art clinical and basic research includes study on concomitant bone marrow transplantation, immunomonitoring, new immunosuppressive and antiviral agents. The transplant recipient is an extremely complex patient, and offers the surgical resident an excellent opportunity to learn how to care for patients with multi-system involvement, as well as a basic understanding of transplant medicine.

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BRIEF DESCRIPTION OF SERVICES in three. At the end of their rotation they will be expected to present a short presentation dealing with plastic surgery to the group.

SURGICAL ER The emergency room is an extremely active facility providing experience in the management of a broad spectrum of surgical emergencies. It is supervised by a group of board certified emergency medical attendings. The resident is totally integrated into the service actively participating in the management of assigned patients. The service also provides experience in the use of consultants and the administrative problems associated with emergency care.

SURGICAL ONCOLOGY Alan S. Livingstone, M.D., Chief Frederick L. Moffat, M.D. Dido Franceschi, M.D. Seth Spector, M.D. Eli Avisar, M.D. Leonidas Koniaris, M.D. The Surgical Oncology Service has a faculty of six attending surgeons, two Surgical Oncology fellows, one 5th year resident, one 4th year resident and two 1st year residents. This service is active at JMH, the JMH Breast Health Center (an outpatient clinic facility with radiological and minor surgical capabilities), and the University of Miami Hospital and Clinics/Sylvester Comprehensive Cancer Center (UMHC/SCCC). 20

BRIEF DESCRIPTION OF SERVICES The scope of practice of the service includes the diagnosis and surgical treatment of breast cancer and breast diseases, head and neck neoplasms (including salivary and thyroid tumors), gastrointestinal cancers (esophagus, stomach, small bowel, pancreas, liver, biliary tree, colon, rectum and anus), soft tissue neoplasms of all sites, neuroendocrine tumors, nonmelanoma skin cancer, cutaneous and mucosal malignant melanoma, and complicated recurrent and metastatic neoplasia. In addition, house staff assigned to this service are exposed to and receive training in upper aerodigestive endoscopy, colonoscopy/endoscopic polypectomy, endoscopic and intraoperative ultrasound techniques, cryoablative surgery for hepatic neoplasia, operative gamma detection probe scintimetry for abdominal cancer surgery and sentinel lymph node biopsy. The residents are educated and trained in the multidisciplinary management of cancer patients and the importance of participation in Service, Institutional and multicenter clinical trials and protocols. The service has six operating rooms per week at JMH for major surgery, and performs approximately 50 major and minor surgical procedures per month at UMHC/SCCC. In addition, the attendings and fellows assist the first year residents in four to ten excisional and radiological localization breast biopsies per week at the Breast Health Center. Residents also staff the JMH Elective I Service clinic on Tuesdays and Fridays under the supervision of the fellows and attending surgeons. A weekly service conference is held on Tuesday morning for teaching and review of the scheduled surgical procedures for the coming week. The residents are also required to attend the weekly Breast Health Center conference on Monday afternoons and the multidisciplinary Tumor Board on Friday mornings. In addition, there is a Sylvester Breast Tumor Board on Tuesday afternoons, the Head and Neck Tumor board on Thursday afternoons, and the weekly Sylvester Cancer Center Grand Rounds on Fridays at noon. Formal teaching rounds on service inpatients at JMH and UMHC/SCCC are held on Saturday mornings. 21

BRIEF DESCRIPTION OF SERVICES Service of Cardiothoracic Surgery and the Department of Pediatrics and Anesthesia. Clinical projects, many in cooperation with the Department of Anesthesia, are ongoing.

TRAUMA/CRITICAL CARE Mark G. McKenney, M.D., Chief Jeffrey Augenstein, M.D. Co-Chief Patricia M. Byers, M.D. Enrique Ginzburg, M.D. Mauricio Lynn, MD Nicholas Namias, M.D. Louis Pizano, MD David V. Shatz, M.D. Danny Sleeman, M.D. Kenneth G. Proctor, PhD Carl Schulman, M.D. Fahim Habib, M.D. Rafael Sanchez, M.D. The Trauma Service is responsible for all trauma patients transported to Jackson Memorial Hospital and the Ryder Trauma Center. Further coordination with all Dade County Fire Rescue systems and with the Office of Trauma Services for Dade County is part of the responsibility of the Trauma Service. Also, the Service is responsible for most surgical emergencies seen in the Emergency Department and admitted patients throughout Jackson. The service evaluates approximately 3,500 trauma patients per year of which 2,300 are 23

BRIEF DESCRIPTION OF SERVICES admitted to the Trauma Service. The Trauma Service performs approximately 1,800 surgical cases per year including both trauma and general surgery. The Service is made up of 3 teams, Red, Blue and Green, which are on call every third day. Trauma Red consists of a chief resident, 4th year resident, and a 2nd year resident, a 1st year resident and a mid-level practitioner. Trauma Blue and Green substitutes a trauma fellow for the chief resident. Also, a 2nd year resident who is also on call every third day covers the Trauma Resuscitation Unit. There is a Trauma Journal Club each week in which a particular topic is discussed relating to the type of patients seen by the Service. This is specifically designed for the senior level residents but is attended by all year levels and medical students. Also, there is a Trauma Morbidity and Mortality Conference held monthly where all complication, deaths and interesting cases are discussed. All members of the Trauma Service participate actively in clinical research and are well represented at most of the national trauma meetings including the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma, Association. Specific topics of interest include use of ultrasonography and laparoscopy in evaluation of abdominal trauma, current nonoperative management of blunt hepatic trauma, management of peripheral vascular trauma, the nutritional assessment of the trauma patient. A Clinical Research Conference is held weekly. This conference is designed for the fellows but is attended by all levels and medical students. At the Clinical Research Conference all proposed clinical research studies are presented prior to submission to UM IRB and implementation The Crash Study is funded by the Department of Transportation and managed by the 24

BRIEF DESCRIPTION OF SERVICES William Lehman Injury Research Center that is investigating injury patterns with seat belt and air bag auto crashes. The Surgical Intensive Care Service shares responsibility for the care of operated patients in the Surgical Intensive Care Unit and the Trauma surgical critical care/trauma attendings and two anesthesiology - critical care attendings that provide coverage in the two units. The 20 bed Surgical Intensive Care Unit admits approximately 1,200 patients per year; the Trauma Unit admits an additional 900 patients. There are both surgical critical care and anesthesia critical care fellowships and the fellows share responsibility for bedside care with the operating team. General Surgery resident experience in surgical critical care is provided at the first year level in the SICU. Residents learn to collect information, organize and present the daily report on morning rounds and perform procedures under the supervision of the fellows and 3rd year surgical residents and the mid-level practitioners. The 3rd year resident functions on the level with the critical care fellows. In this role, the resident is the central repository of all information and communicates both with the ICU critical care attending and the general surgery chief residents. The educational program includes a weekly conference of interesting cases from both units, a resident/fellow discussion of controversial critical care topics, didactic conferences delivered by fellows and attendings, a videotape library and extensive handouts including the “Handbook of Critical Care.” Recently, the U.S. Army selected Ryder Trauma Center as its primary training site for forward surgical teams. Under the direction of Thomas E. Knuth, MD (LTC MC), these soldiers receive intensive exposure to the large clinical caseload, and unique training with simulators, mass casualty drills, and the opportunity for designing and conducting investigations related to the 25

BRIEF DESCRIPTION OF SERVICES disease and its management. Because there is, by design, no fellowship program in General Vascular Surgery, the PGY5s and PGY3s are either the surgeons or first assistants in all vascular reconstructive cases, providing them with significant operative experience in most routine vascular operations. Diseases treated include: thoracic, thoracoabdominal and infrarenal aortic surgery, upper and lower extremity revascularization for ischemia, visceral vessel reconstructive, renal artery reconstruction and cerebrovascular reconstruction surgical and Endovascular technique are used in our new fully equipped interventional operating room. Additionally, we treat patients with complex vascular trauma; the thoracic outlet syndrome, and renal failure requiring dialysis grafts and fistulas.

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TECHNICAL LAB Location:

McKnight Building--8th floor.

Administrator: Susan Mazzola Phone: (305) 326-6480 Veterinarian Technician:

Ray Gonzalez Phone: (305) 547-3700

Access:

Card required.

Availability of resident area: 24hrs-7days wk. Conference (audiovisual) room: Schedule with administrator.

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E X A M I N AT I O N S & R E Q U I R E D R E A D I N G S • ABSITE, this is a standard examination developed by the American Board of Surgery and is designed to evaluate both basic science and clinical knowledge. Fifty percent of the questions are clinical and fifty percent basic science. This will be given annually to all year levels. It is mandatory for all categorical residents and optional for preliminaries. • Chart Stimulated Recall: these are given at the 4th & 5th year levels and specifically relate to a procedure performed, or a patient managed. • Required Reading: Go to the Virtual Mentor Website at www.virtualmentor.org every month for the current issue of this online publication. This is the AMA’s online ethics journal for medical students and physicians. • Standardized Patient: these are given annually to the 4th years.

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PROMOTIONS All resident appointments are for one year only with re-appointment depending on an overall satisfactory performance. There are four major factors, which enter into decisions for reappointment (promotion). A) ABSITE Residents obtaining below the thirtieth percentile on the in-service exam will 1) be placed on academic probation and assigned to a tutor. 2) have a mid-term evaluation with the tutor and the Program Director. If the individual on probation obtains above the thirtieth percentile on the follow-up exam, probation will be withdrawn. If the individual on probation obtains less than the thirtieth percentile on the follow-up exam, the Residency Review Committee will review the resident’s file with special emphasis on the following: a. the tutor evaluation b. the mid-term evaluation c. performance in the clinical tract (outstanding vs. average) d. preparation for conferences

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After careful review of these factors, the Residency Review Committee will: I. II. III.

Promote with continued academic probation Require that the year be repeated Dismiss

B) Clinical Performance An overall satisfactory performance is required for re-appointment. This factor may be used as the sole determinate in making decision related to re-appointment. C) Administrative Performance This should not be taken lightly. An inadequate performance may not only jeopardize reappointment but may be the sole determinant for suspension or termination.

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E VA LUAT I O N S • Service evaluation: Each service will provide to the program director a written evaluation of all resident performances following each rotation. This will reflect both clinical performance and basic knowledge. These evaluations will be reviewed by the program director who will initiate proper counseling where appropriate. • All residents will be asked to evaluate the following anonymously: ■

The training program

■

Each service

■

Faculty

Note: All evaluations are available in the Housestaff office for review by the individual resident.

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S E R V I C E R O TAT I O N S A N D VA C AT I O N These rotations have been designed to meet the requirements of the Residency Committee for Surgery and to provide those rotations requested by the various specialties. Because of the complexity of the first year schedule, it is generated in the Housestaff Office. All other year levels are produced by the residents at each level. In the first year, vacations are built into the schedule. In all other years, vacations are taken off of service (please see below). Every attempt is made to provide vacation time requested in the first year; however, the likelihood is that all will not be honored. A yearly schedule will be provided.

Vacations cannot be taken on the following services: PGY PGY PGY PGY

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II: III: IV: V:

EIV, VA-Alpha, and ICU Burns. EIV or pediatrics, unless there is a fellow on the service. VA

GENERAL ADMINISTRATIVE FUNCTIONS AND RULES ABSENCE FROM WORK AND MOONLIGHTING • Absence from work: All absences from work must be reported to and/or approve by the Housestaff office and the chief of the service on which you are rotating. • Moonlighting: Forbidden. RECORDING AND SUBMISSION OF CLINICAL EXPERIENCE OPERATIVE I. The first rule is simply to collect your personal data on every procedure on which you are involved. You should record the details of your participation. Were you the surgeon, teaching assistant, 1st assistant, etc.? This includes cases done in all areas (ER, clinics, etc…). Of particular importance is endoscopy of any type. II. Enter all operative procedures where you are the surgeon of record in the ACGME Data Collection System by following below instructions: • • • • •

Obtain a username and password from the Housestaff Office Log on to the ACGME website at www.acgme.org On the left hand side of the screen, click on Resident Case Log System Click on Login Type in your username and password. Please note that you are not to change this password; if you do so, you are to notify the Housestaff office immediately. 35

• Click on Procedures • Click on Add to enter your cases NON-OPERATIVE: Anesthetics (General and local). Orthopedic problems. General Rules: Special Rules are as follows: • First year – you must pay careful attention to the recording of suturing lacerations. You must record this definitively. Specifically, you must review the list of CPT codes in the ACGME Resident Date Collection System and choose the appropriate code. This should be recorded even if done in the E.R. or any other area. • Chief year – All ICU patients on whom you operated or actively participated in their care, should be recorded. • All patients with multiple organ trauma who did not require operation but were managed in the ICU must be entered in the ACGME Resident Date Collection System. DEA NUMBER A DEA # to be used in Jackson Memorial Hospital will be provided by the Physician Services Office at your request, but is not mandatory. A Florida DEA number can be obtained by contacting the DEA Department directly at 305-590-4870 for the Miami DEA division. Please note that a DEA number is not required for residency. 36

PROCEDURE FOR OCCUPATIONAL EXPOSURES Employment in a healthcare setting places you at risk for exposure to bloodborne pathogens (BBPs) such as Hepatitis B and C and HIV infection. Although the risk of contracting HIV is much lower (0.3%) as compared to Hepatitis B (6-30%) or Hepatitis C (4-12%), it is important to treat all occupational injuries as serious events. In your current role, you are more likely to experience an occupational injury from a suture needle. Although this carries less risk to you than a hollow-bore needle injury, an injury from a suture needle should be viewed as a serious injury. In the event of an occupational injury, certain actions need to be followed to decrease your risk:. 1) The first is to immediately wash the injured area with soap and water. Vigorous scrubbing, squeezing, cutting, or application of chemicals to the injured area is NOT recommended. 2) If the injury involves a splash to the eyes or skin, the area needs to be irrigated with copious amounts of solution from the eye irrigation station or water. 3) Deep lacerations that may require sutures or stitches require that the staff member report immediately to the Urgent Care Center. All other injuries should NOT go to the Urgent Care Center. 4) After the area is washed or irrigated, the injured employee needs to notify his/her supervisor that an injury has occurred. The supervisor can help the employee contact the Employee Health Service (EHS). The EHS is available by pager 24 hours a day, 365 days a year at 1-866-7NEEDLE or 1-866-763-3353. Please contact the EHS immediately after any occupational exposure. EHS will arrange for emergency treatment, source 37

PROCEDURE FOR OCCUPATIONAL EXPOSURES blood testing and provide follow-up testing for the injured employee. 5) Obtain the name and medical record number of the source patient. Ask the charge nurse on the unit where the patient resides to assist you in obtaining additional information about the source patient. If you do not work on the floor where the patient resides, call EHS at 1-866-7NEEDLE for instructions. 6) Do not approach the patient or the patient’s chart without permission from the charge nurse of the unit where the patient resides. The charge nurse where the patient resides is responsible for obtaining information from the patient’s record and arranging for source blood to be obtained following an occupational exposure. Drawing blood for any reason without the patient’s consent is illegal. A doctor’s order is not necessary to test a patient following an occupational exposure. HIV counseling for an occupational exposure does not have to be provided by the doctor unless the patient is actually suspected of having HIV infection or the patient asks for additional information from the doctor. EHS will test source blood for HIV, Hepatitis B and Hepatitis C. 7) For injuries that occur in the operating room or during diagnostic procedures source blood can not be tested or drawn until the source has been given an opportunity to consent 24 hours post anesthesia. Call EHS for assistance in this situation. 8) It is important to report all occupational injuries to EHS. If you believe that work practices or equipment has contributed to your occupational injury, please contact the OSHA BBP Exposure Control Coordinator at 305-585-7996 to discuss your injury. All calls and information communicated to the Exposure Control Coordinator are confidential. 38

C O M M U N I C AT I O N • All evaluations and examination results are discussed with each resident by the Program Director semi-annually or as deemed appropriate. • All residents, as a group, will meet with the program director every 4 months by year level. • Communication from the Housestaff Office will utilize the university e-mail address assigned to you, and which can be obtained through the Housestaff office. This requires that you check your e-mail daily and respond appropriately. If effectively utilized, it should significantly decrease the necessity for paging.

39

MEDICAL RECORDS JMH At JMH, each of you is assigned a day on which you are to report to the medical records office on the 1st floor central building for the purpose of completing your medical records. Missing a day will result in a courtesy call from the Housestaff office reminding you of this deficiency. Should this occur a second time, you will be directed to meet the Program Director or Dr. Shatz, however, if this occurs a third time you will be directed to meet with the medical records committee, which will be chaired by the chief of surgery. You will be asked to explain this deficiency. The committee will outline an appropriate course of action.

40

D I C TAT I O N S •

•

Operative Notes: Must be dictated the day of the operation and by the person taking credit for the case. The instructions for dictating an operative note at Jackson are found in appendix A and an example of an operative note is in appendix B. Discharge Summaries: Must be completed prior to discharge. Please note the example and the fact that the discharge summary should be of reasonable length, and outline the follow-up suggestions for management. Instructions for dictating a discharge summary at Jackson are found in appendix A and an example of a discharge summary is in appendix C. The 1st year resident assigned to the service is responsible for these dictations on all patients who are discharged from the service during his/her rotation. He/she is not responsible for patients discharged during other time periods.

41

SUPERVISION LINES OF RESPONSIBILITIES Providing the appropriate supervision of all resident activities, both administrative and clinical, is essential to training at all year levels and is based on the concept of progressive responsibility. Providing guidelines for resident supervision and a mechanism for obtaining consultation on a service is the responsibility of the chief of service. However, the ultimate responsibility of the care of an individual patient is the responsibility of the attending assigned to that patient. Should the assigned attending wish to impose restrictions on the management of an individual patient, which are more stringent than the service’s guidelines, it is his/her duty to inform the residents involved. It is the services’ responsibility to establish a mechanism whereby appropriate attending consultation is available in a timely manner, at all times. Further, it is recognized that the clinical and administrative experience of residents, even at the same year level, is not uniform and that his/her activities must be adjusted accordingly. Thus, it is the responsibility of the individual resident to recognize that a particular function is beyond his/her expertise and that senior consultation is required. Guidelines: A) Requires Attending approval: a. Major invasive procedures b. Admissions 43

SUPERVISION LINES OF RESPONSIBILITIES c. Patient transfers or discharge d. Scheduling and performance of major operative procedures e. Unscheduled absence from the service B) Requires attending notification: a. Major clinical status changes b. Consults C) Coordinated patient care: The ultimate authority in the management of a patient is the service to which the patient is officially assigned. In the case of multiple physician providers, (i.e., consultants, ICU staff, etc.) the assigned service remains “in charge” and must be aware of and coordinate all administrative and clinical activities. D) Monitoring: The appropriateness of supervision on all services will be evaluated by the periodic use of resident and fellow surveys processed anonymously. 44

GRIEVANCE AND ARBITRATION PROCEDURES Section 1: In a mutual effort to provide harmonious working relationships between the parties to this Agreement, it is agreed to and understood by both parties that the following shall be the sole procedure for the resolution of grievances arising between the parties as to the interpretation of and application of the provisions of this Agreement. The parties further agree that other disputes shall be reviewable and appealable as set forth in other parts of this Agreement and that the union-management committee may address concerns not falling under the grievance/arbitration or other appeal procedures. Section 2: Except as otherwise provided in this Agreement, the term "grievance" shall mean: A. A dispute concerning the application or interpretation of the terms of this collective bargaining agreement; B. A claimed violation, misinterpretation, or misapplication of the rules, regulations, authorized existing policy, practice, or orders of the Trust affecting housestaff. The following shall not be considered grievances: a formal or informal counseling, disputes over progress in the educational program, discharge of clinical responsibilities, the timely decision to renew the appointment of a housestaff officer, advancement decisions, a program termination, and any matters for which other appeal procedures are provided for in this Agreement (or otherwise specifically made available to this bargaining unit). 45

GRIEVANCE AND ARBITRATION PROCEDURES Section 3: A class grievance (general grievance) shall be defined as any dispute which concerns two or more employees within the bargaining unit. Class grievances should attempt to name all employees or classifications covered in a grievance; however, the absence of a housestaff officer’s name shall not exclude him/her from any final decision or award. Class grievances, at the option of the union, may be submitted at Step 2. Section 4: Each written grievance, when filed, shall contain a brief statement of the facts of the violation claimed (including the date, or approximate date, upon which the violation occurred), together with the article(s) of the contract violated, and the remedy sought. Section 5: Grievances shall be processed in accordance with the following procedure: A grievance may be brought no later than fourteen (14) calendar days after the date on which the grievance arose (or was reasonably likely to have become known) by an individual housestaff officer and CIR, or by CIR alone, and shall be undertaken pursuant to a two (2) step grievance procedure as follows: Step 1. The aggrieved employee, and/or the union, shall discuss the grievance with the concerned Chief of Service or designee. The Chief of Service or designee shall 46

GRIEVANCE AND ARBITRATION PROCEDURES respond to the grievance within (14)_fourteen calendar days. Grievances of an administrative nature not directly under the control of the Program Director may be filed with the Director of Physician Services. Step 2. If the grievance has not been satisfactorily resolved in Step 1 thereof, the aggrieved employee and/or the union may appeal to the Senior Vice-President for Medical Affairs within (14)_fourteen calendar days. The Senior Vice-President for Medical Affairs may conduct a meeting and shall respond to the employee with a copy to the union within (14) fourteen calendar days of the appeal. Section 6: Failure by the employee or the union to observe the time limits for submission of a grievance at any step will automatically result in the grievance being considered abandoned. Failure by the Public Health Trust to respond to a grievance within the prescribed time limits will automatically move the grievance to the next step. Section 7: Each party shall be allowed one (1) extension of time, not to exceed seven (7) calendar days. This extension can be used only once during the grievance. The other party must be notified of the requested extension. Additional extensions may be granted in good faith settlement discussions or by mutual agreement. 47

GRIEVANCE AND ARBITRATION PROCEDURES Section 8: The parties acknowledge that as principle of interpretation, employees are obligated to work as directed while grievances are pending. This does not limit the rights an employee may have under federal, state, or local laws where the employee is faced with an immediate physical danger at work. Section 9: Individual grievants and a representative of the grievant class will be permitted to attend any grievance meeting scheduled by the Trust. Meetings will be scheduled at times mutually convenient to the persons involved. Section 10: Employer Responses All responses required in Step 1 and Step 2 above shall be directed to the aggrieved employee with a copy furnished to the union. In class grievances, copies will be directed to the union only. A rejection of a grievance at any step of the procedure must contain a statement of the reasons for the rejection. Section 11: Arbitration A. If the union is not satisfied with the reply in Step 2 of the grievance procedure, the union shall have thirty (30) days to file a request for arbitration to Federal Mediation 48

GRIEVANCE AND ARBITRATION PROCEDURES and Conciliation Service (FMCS) or American Arbitration Association (AAA) and provide a copy to the Trust. B. The union shall request a list of seven (7) arbitrators from Federal Mediation and Conciliation Service (FMCS) or American Arbitration Association (AAA). The parties shall each strike from said list, alternately, three (3) names, after determining the first strike by lot, and the remaining name shall be the arbitrator. Nothing herein shall prohibit the parties from agreeing on an impartial arbitrator outside the above procedure. C. The arbitrator shall promptly conduct the hearing on the grievance at which both parties shall be permitted to present their evidence and arguments pursuant to the Voluntary Labor Arbitration Rules of the American Arbitration Association. The decision of the arbitrator shall be rendered in writing with copies of the award promptly furnished to both parties, no later than thirty (30) calendar days after the conclusion of the hearing, and such decision shall be final and binding. D. Each party will pay its own expenses and will share equally in expenses incurred mutually in arbitration. Employees required to testify will be made available without loss of pay; however, whenever possible, they shall be placed on call to minimize time lost from work and, unless directly required to assist the principal union representative in the presentation of the case, they shall return to work upon completion of their testimony. The intent of the parties is to minimize time lost from work and disruption of patient care. 49

GRIEVANCE AND ARBITRATION PROCEDURES E. The arbitrator shall limit his/her opinion to the interpretation or application of this Agreement and shall have no power to amend, modify, nullify, ignore, or add to the provisions of this Agreement. F. Grievances, as defined, may be submitted regarding the matters contained in the Agreement or arising from conditions of employment. Matters excluded from the grievance procedure are not arbitrable.

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APPENDIX A

INSTRUCTIONS FOR LANIER DICTATION STATIONS, OPERATING ROOM, LABOR AND DELIVERY ROOM STEP STEP STEP STEP STEP

1: 2: 3: 4: 5:

STEP 6:

Lift handset Enter your 5 digit physician number Enter the 1 digit report type (NEW) Enter the 7 digit patient medical record number Enter the 8 digit service date (MM/DD/XXXX) For Discharge Summaries enter date of admission For Operative Report enter date of procedure After or during the prompt “BEGIN YOUR DICTATION”, you may commence dictating. Hold down the “D” button to dictate, the “R” button to rewind, and the “L” button to listen.

MULTIPLE DICTATION: After completing your first report, press the next button, you will then hear a Voice Prompt instructing you to enter the new report type and patient medical record number. (See Step 4). INTERCOM TO MEDICAL RECORDS: To speak to someone in the Health Information Management (HIM) Department during your dictation, touch the button marked “intercom” to HIM and wait for someone to answer. To resume your dictation simply hold down the “D” button. 51

FAST FORWARD TO LAST DICTATED WORD: If you have rewound to an earlier part of your report and do not want to listen to the rest of the report, but do want to continue dictating, hold down the “F” button until you hear the soft tone, then you can resume your dictation. SPECIAL NOTE: The new system does not have an audible rewind and fast forward. DICTATION ON STANDARD TELEPHONE (JACKSON ONLY): STEP 1: STEP 2: STEP 3:

STEP 5:

STEP 6: 52

Dial 2-2110 Enter your 5 digit physician number Enter the 1 digit report type (NEW) Report types: 1. Operative Report 2. Discharge Summary 3. Consultation 4. Diagnostic Procedure (Cardiac Catheterization Report and Gastroenterology Procedure) Enter 8 digit service date (MM/DD/XXXX) For Discharge Summaries enter date of admission For Operative Report, Diagnostic Procedure (Cardiac Catheterization Report and Gastroenterology Procedure) enter date of procedure, enter date of service for consultation. After the prompt “Begin your Dictation” you many commence with your dictation.

This system is equipped with Voice Operated Relay (VOR) thus when you stop dictating after several seconds a soft tone will come on the line, when you resume dictating the tone will end. Any standard touch tone telephone may be used for dictating in the hospital. Dictation must be completed according to these instructions in order to properly access the dictation system and enable the dictation to be verified. DICTATION CONTROLS: 1 2 3

-

4 6 8 9 #+0

-

to listen after touching either 4 or 8 to resume dictating after touching 4 for short rewind, then playback, then automatic dictate at tone to pause to end of dictation to beginning of dictation to disconnect Intercom to HIM, to resume dictation touch 3 for short rewind and playback, when tone comes on, resume dictation

MULTIPLE REPORTS: After completing your first report touch “5”. You will hear a voice prompt to enter the new report type and patient medical record number. SPECIAL NOTE: The new System does not have an audible rewind and fast forward. 53

GASTROENTEROLOGY PROCEDURES: A. B. C. D. E. F. G. H. I. J. K. L.

Date of Procedure Patient’s Name and Medical Record Number Referring Physician Name (if known) Procedure Physician Name (resident and attending Procedure (Upper Endoscopy, Colonoscopy, etc.) Instrument (Type of Endoscope) Indication for Procedure (History and Justification for Procedure) Physical Examination (including chest, heart, abdomen) Sedation Description of Procedure (History and Justification for Procedure) Diagnosis Plan (follow-up Recommendations, etc.)

INSTRUCTIONS TO REVIEW A REPORT STEP 1: STEP 2: STEP 3: STEP 4:

Dial 2-2110 Touch # + 1 to enter review mode Enter your user name (physician 5 digit number) Select 1 of the 4 options to review by: Press “1” to review by medical record number: • Enter the patient’s 7 digit medical record number. Press “2” to review by report type and medical record number:

54

• Enter report type: 1. Operative Report 2. Discharge Summary 3. Consultation 4. Diagnostic Procedure (Cardiac Catheterization Report and Gastroenterology Procedure) • Enter patient’s 7 digt medical record number Press “3” to review by medical record number and date of service. • Enter patient’s 7 digit medical record number. • Enter 8 digit date of admission for a Discharge Summary and date of procedure for Operative Report and Gastroenterology Procedure. Press “4” to review by dictating physician. • Enter physician 5 digit number. Once you have accessed the report, the following system controls are available to you: 1 Listen, use after pause 4 and 8 3 short rewind then play back use 8 4 pause, touch 3 or 1 to listen 5 previous report on same patient 6 to end report, then touch 3 to hear last few words 8 to beginning of report, then touch 1 to listen 9 to disconnect #+0 Intercom NOTE: THESE REPORTS CANNOT BE EDITED OR CHANCED IN ANY WAY. 55

TO REVIEW ANOTHER REPORT: Touch “#” + 5, then select 1 of the 4 review options DICTATION INSTRUCTIONS, REPORT OUTLINE, AND REPORT REVIEW INSTRUCTIONS DISCHARGE SUMMARY OUTLINE: A. Patient’s name B. Medical record number C. Admission and discharge date D. Attending physician, 5 digit physician number E. Your name and 5 digit physician number F. Admission diagnosis G. Discharge diagnosis H. Brief history I. Pertinent physical findings J. Significant lab data or evaluation studies and/or mental status K. Hospital course (including adverse drug reactions) L. Disposition/follow-up M. Medications N. Patient/family instructions (including dietary and physical activity limitations) O. Physician responsible for signing discharge summary and his/her 5 digit physician number. 56

OPERATIVE REPORT OUTLINE: A. Patient’s name, medical record number, and date of procedure B. Your name and 5 digit physician number C. Preoperative diagnosis D. Postoperative diagnosis E. Operation F. Attending surgeon 5 digit physician number G. Resident surgeon 5 digit physician number H. First assistant surgeon 5 digit physician number I. Anesthesia J. Justification K. Procedure L. Physician responsible for signing report and his/her 5 digit physician number

SPECIAL NOTE: CORRECT MEDICAL RECORD NUMBER, PHYSICIAN NUMBER AND NUMBER, ADM. DATE (D/C SUMMARY), PROCEDURE DATE (OP), AND PHYSICIAN RESPONSIBLE FOR SIGNING REPORT, ARE OF EXTREME IMPORTANCE SINCE THEY ARE THE IDENTIFIERS FOR THE INTERFACE WITH THE HOSPITAL COMPUTER. 57

CONSULTATION REPORT OUTLINE: A. B. C. D. E. F. G. H.

Patient’s name Medical record number Your name and 5 digit physician number Consultation date Referring services Referring attending physician Reason for consultation History: 1. Present illness 2. Review of systems 3. Medical history 4. Surgical history 5. Medication 6. Allergies 7. Social history 8. Family history I. Exam findings J. Lab data/diagnostic studies K. Assessment L. Recommendation M. Physician’s name and number responsible for signing report 58

APPENDIX B EXAMPLE

O P E R AT I V E N O T E PRE OP DX:

Mass right groin

POST OP DX: Right indirect inguinal hernia OPERATION:

Repair right indirect inguinal hernia

SURGEON:

Dr. X

ASST. SURG:

DR. Y

ATTENDING:

Dr. Z

ANESTHESIA: Local with sedation ------------------------------------------------------------------JUSTIFICATION:

42 yr. Old Caucasian male with mass in right groin present one year, increases in size with cough & strain, occasional pain & discomfort. No GI or GU symptoms. Risks, options and complications explained. Consent signed

------------------------------------------------------------------59

O P E R AT I V E N O T E PROCEDURE: The patient was prepped & draped in the supine position. Local anesthesia was established by the 7 steps of Ponka using 1/2% Xylocaine. The pubic tubercle & iliac crest was identified. An oblique incision parallel to the inguinal ligament was carried down through the skin & subcutaneous tissue to expose the external oblique aponeurosis. The external oblique was opened in line with its fibers through the external inguinal ring. The ilioinguinal nerve was identified, retracted, and avoided. The cord was freed from the floor of the inguinal canal. The cremasteric muscle on the anterior medial aspect of the cord was incised & an indirect sac was identified. By sharp & blunt dissection the sac was separated from the cord down to its neck. The sac was transfixed at its neck with a non-absorbable suture. The sac was amputated distal to the suture & sent to the pathologist. The base of the sac was allowed to retract and the spacc was filled with “X” plug. The edge of the plug was sutured to the transverse abdominal muscle & inguinal ligament at the internal ring with 3 non-absorbable sutures. No direct hernia was present in the floor of the inguinal canal. A “X” type onlay was placed to cover the pubic tubercle & surround the cord at the internal inguinal ring. Several non-absorbable sutures fixed the onlay to the underlying internal oblique muscle and inguinal ligament. The cord and ilioinguinal nerve were replaced in its normal anatomic position. The external oblique was closed with a running non-absorbable suture and created a new external inguinal ring. The subcutaneous tissue was approximated. The skin was closed with a running 40 mattress nylon. Dry sterile dressing was applied. Estimated blood loss 10 cc. Dictated by: HAROLD S. GOLDSTEIN, M.D.

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APPENDIX C EXAMPLE DISCHARGE SUMMARY DATE OF ADMISSION:

12/24/2002

ATTENDING PHYSICIAN:

JACQUES BOURGOIGNIE, M.D.

RESIDENT PHYSICIAN:

SOHEL MOMIN, M.D.

ADMISSION DIAGNOSIS:

1. 2. 3.

DISCHARGE DIAGNOSIS:

1. 2. 3.

PAGE 01 OF 07

DATE OF DISCHARGE: 12/27/2002

END STAGE RENAL DISEASE WITH VOLUME OVERLOAD. DIABETES. CORONARY ARTERY DISEASE; STATUS POST MYOCARDIAL INFARCTION. END STAGE RENAL DISEASE. URINARY TRACT INFECTION. ALLERGIC REACTION TO DIALYSATE REQUIRING PRE-MEDICATION WITH BENADRYL AND ZANTAC PRIOR TO HEMODIALYSIS. 61

PAGE 02 OF 07

4. 5.

DIABETES. CORONARY ARTERY DISEASE, STATUS POST MYOCARDIAL INFARCTION.

HISTORY OF PRESENT ILLNESS: THE PATIENT IS A FIFTY-FIVE-YEAR-OLD FEMALE WITH A PAST MEDICAL HISTORY OF DIABETES, END STAGE RENAL DISEASE ON DIALYSIS TIMES TWO YEARS. ALSO HISTORY OF CORONARY ARTERY DISEASE, STATUS POST ONE YEAR PRIOR TO ADMISSION. STATUS POST STENT TIMES TWO TO THE RIGHT CORONARY ARTERY WHO PRESENTED TO THE MEDICAL EMERGENCY ROOM AFTER BEING SEEN AT GAMBRO. THE PATIENT HAS BEEN ON TUESDAYS, THURSDAYS AND SATURDAYS DIALYSIS TIMES THREE WEEKS AS SHE WAS PREVIOUSLY ON PERITONEAL DIALYSIS AND WAS RECEIVING HEMODIALYSIS SECONDARY TO HAVING PERIOTONITIS TWO WEEKS PRIOR TO ADMISSION. SHE WAS LAST DIALYZED ON DECEMBER 21ST 2002 AND WAS SUPPOSED TO BE DIALYZED ON THE MONDAY PRIOR TO ADMISSION, HOWEVER, THE LINE WAS CLOGGED AT THAT TIME AND THE PATIENT WILL RETURN ON TUESDAY TO GAMBRO AND WAS TOLD TO COME TO JACKSON MEMORIAL HOSPITAL SECONDARY TO POOR FLOW THROUGH HER PERMA CATHETER LINE. SHE ALSO REPORTED HAVING A COUGH WHAT PRODUCED CLEAR SPUTUM AND DENIES HAVING ANY FEVERS OR CHEST PAIN BUT SHE DOES REPORT NAUSEA AND VOMITING. SHE FURTHER STATES THAT SHE TAKES 62

PAGE 03 OF 07

ANTIBIOTICS FOR HER PERITONITIS PRIOR TO HEMODIALYSIS AND ALSO RELATEDS THAT EVERY TIME SHE IS PLACED ON HEMODIALYSIS, SHE GETS SHORT OF BREATH REQUIRING ALBUTEROL INHALERS. PAST MEDICAL HISTORY:

AS ABOVE.

PAST SURGICAL HISTORY:

CESAREAN SECTION AND A PERMA CATHETER PLACEMENT

ALLERGIES:

NO KNOWN DRUG ALLERGIES.

CURRENT MEDICATIONS: THE PATIENT IS ON PROTONIX, PLAVIX, SYNTHROID, RENAGEL AND A SLIDING SCALE INSULIN FOR DIABETES. SOCIAL HISTORY: ONE-THIRD OF A PACK PER DAY TIMES FOUR YEARS TO TOBACCO USE. DENIES ANY INTRAVENOUS DRUG USE OR ALCOHOL USE OR ABUSE. FAMILY HISTORY: SIGNIFICANT FOR CORONARY ARTERY DISEASE, HYPERTENSION AND DIABETES. 63

PAGE 04 OF 07

PHYSICAL EXAMINATION: THE PATIENT’S BLOOD PRESSURE IS 130’S OVER 80’S HEART RATE WAS IN THE 80’S. TEMPERATURE WAS AFEBRILE. RESPIRATORY RATES WERE 22. THE PATIENT WAS 99 PERCENT ON TWO LITERS OF NASAL CANNULA. IN GENERAL: THE PATIENT WAS IN NO APPARENT DISTRESS. HEAD, EARS, EYES, NOSE AND THROAT: PROPTOSIS. NECK: SUPPLE, NO JUGULAR VENOUS DISTENTION. NO LYMPHADENOPATHY AND NO CAROTID BRUITS DETECTED. THYROID WAS NON PALPABLE. HEART EXAMINATION: REGULAR RATE AND RHYTHM WITH OCCASIONAL PREMATURE ATRIOVENTRICULAR CONTRACTIONS. NO MURMURS, RUBS OR GALLOPS. LUNGS: DECREASES BREATH SOUNDS ON THE RIGHT BASE WITH DULLNESS TO PERCUSSION. ABDOMEN: WAS OBESE, SOFT, NONTENDER, NONDISTENDED. EXTREMITIES: NO CLUBBING, NO CYANOSIS, NO EDEMA. PLUS TWO PULSES. SIGNIFICANT LABORATORY DATA: ON ADMISSION ARTERIAL BLOOD GAS ON ROOM HAD A PH OF 7.36, PC02 OF 39, PAO2 OF 77 WITH O2 SATURATION OF 95 PERCENT COMPLETE BLOOD COUNT ON ADMISSION HAD A WHITE BLOOD CELL COUNT OF 26.8, HEMOGLOBIN AND HEMATOCRIT OF 8.7 AND HEMATOCRIT OF 28, PLATELET COUNT OF 260. GLUCOSE WAS 162, SODIUM WAS 141, POTASSIUM OF 4.8, CHLORIDE OF 104, BICARBONATE OF 24, BUN OF 39, CREATININE OF 7.9. ALBUMIN WAS 3.2, LIVER FUNCTION TESTS WERE NORMAL. PT WAS 13.5. CHEST X-RAY SHOWED A DOUBLE 64

PAGE 05 OF 07

LUMEN CATHETER IN THE RIGHT IJ LINE WITH ONE TYPE IN THE SUPERIOR VENA CAVA AND THE OTHER IN THE RIGHT ATRIUM. HILAR AND MEDIASTINAL STRUCTURES ARE UNREMARKABLE. CARDIAC SILHOUETTE WAS ENLARGED. BOTH COSTOPHRENIC ANGLES WERE SHARP. THERE WAS NO EVIDENCE OF EDEMA OR CONSOLIDATION. AN EKG SHOWED FLIPPED T-WAVES IN THE INFERIOR LEADS. CARDIAC ENZYMES TIMES THREE WERE NEGATIVE. A URINALYSIS SHOWED MODERATE LEUKOCYTES AND TOO NUMEROUS TO COUNT WHITE BLOOD CELLS WHITE BLOOD CELLS. HOSPITAL COURSE: THE PATIENT WAS TREATED WITH PO ANTIBIOTICS USING TEQUIN FOR HER URINARY TRACT INFECTION. SHE WAS AGAIN SENT TO DIALYSIS IN HOUSE, HOWEVER, SHE AGAIN WAS SHORT OF BREATH. ON HEMODIALYSIS FURTHER HAD LOW AND HEMODIALYSIS WAS SUBSEQUENTLY STOPPED SECONDARY TO THE SHORTNESS OF BREATH. AT THAT TIME IT WAS FELT THAT THE PATIENT WAS HAVING AN ALLERGIC REACTION TO THE DIALYSATE, THEREFORE, DIALYSATE WAS CHANGED. THIS, HOWEVER, DID NOT RESULT IN ANY CHANGE OF SYMPTOMS NEXT TIME THE DIALYSIS WAS ATTEMPTED AGAIN. THE PATIENT AGAIN BECAME WITH SHORTNESS OF BREATH WITH HEMODIALYSIS REQUIRING OXYGEN AND ALBUTEROL INHALERS. THEREFORE, THE PATIENT WAS STARTED ON ZANTAC AND BENADRYL PRIOR TO DIALYSIS. THE PATIENT SUBSEQUENTLY HAD LESSENING OF HER SYMPTOMS AND SHORTNESS OF BREATH AND

65

PAGE 06 OF 07

WAS ABLE TO COMPLETE A FULL COURSE OF DIALYSIS. FURTHERMORE, ADEQUATE FLOW OF THE PERMA CATHETER WAS GAINED WHEN THE PATIENT WAS LYING MORE RECUMBENT IN THE STRETCHER, THEREFORE, THE PERMA CATHETER WAS NOT CHANGED. THE PATIENT WAS DISCHARGED ON DECEMBER 27TH 2002 WITHOUT ANY COMPLICATIONS. SHE WAS INSTRUCTED TO TAKE BENADRYL AND ZANTAC PRIOR TO DIALYSIS. DISPOSITION: THE PATIENT WAS DISCHARGED TO HOME. FOLLOW-UP: WITH GAMBRO FOR HER NORMAL TUESDAYS, THURSDAYS AND SATURDAYS DIALYSIS. DISCHARGE MEDICATIONS: AT HOME – THE PATIENT IS TO RESUME MEDICATIONS. SHE WAS FURTHER GIVEN TEQUIN 200 MGS PO QD TIMES FIVE DAYS FOR THE URINARY TRACT INFECTION. METOPROLOL WAS ADDED 25 MGS PO BID. BENADRYL 25 MGS ONE TABLET PRIOR TO DIALYSIS. THE PATIENT WAS ALSO PLACED ON ZANTACT 150 MGS PO BID. ALBUTEROL METER DOSE INHALERS TWO PUFFS Q FOUR TO SIX HOURS PRN FOR SHORTNESS OF BREATH DURING THE DIALYSIS. DIET: WAS RENAL DIET AND LOW-CHOLESTEROL DIET. ACTIVITIES: AD-LIB.

66

PAGE 07 OF 07

JACQUES BOURGOIGNIE, M.D.

328/

JOB#: 26728

DD:

2/21/2003

DT:

2/23/2003

AMERICAN MEDICAL TRANSCRIPTION CORR 3/10/2003

67

HOUSESTAFF TELEPHONE DIRECTORY JMH ORs continued MISCELLANEOUS AMERICAN BOARD OF MED. SPECIALTIES ACGME AMERICAN BOARD OF SURGERY AMERICAN COLLEGE OF SURGEONS ECFMG

847-491-9091 312-464-4012 215-568-4000 312-202-5000 215-386-6900

6-2476 6-2478 6-2480 6-2483 6-2484 VA ORs 305-575-4455 x6211

CLINICS (JMH) BREAST CLINIC BURNS COLON AND RECTAL SURG. (EIII) CT SURGERY HEPATOBILIARY PANCREATIC SURG. (EII) KIDNEY TRANSPLANT (POST-OP) KIDNEY TRANSPLANT (PRE-OP) LIVER TRANSPLANT (POST-OP) LIVER TRANSPLANT (PRE-OP) PEDIATRIC SURGERY PLASTIC SURGERY SURGICAL ONCOLOGY (EI) TRAUMA/CRITICAL CARE UROLOGY VASCULAR SURGERY LAPAROENDOSCOPIC/BARIATRIC SURG. (EIV)

74 75 76 77 78

305-585-7410 305-585-1269 305-585-5468 305-585-5468 305-585-5468 305-355-5276 305-355-5241 305-355-6092 305-355-5160 305-585-7096 305-585-5285 305-585-5468 305-585-1249 305-585-5468 305-585-5468 305-585-5468 73

APPENDIX F General Surgery Training Program University of Miami/Jackson Memorial Medical Center Typical Categorical Service Rotations

74

PGY 1

PGY 2

PGY 3

General Surgery Cardiothoracic Colorectal ER Intensive Care Neurosurgery Pediatric Surgery Plastics Surgical Oncology Trauma Technical Lab Vacation

General Surgery General Surgery Colon & Rectum Laparoscopy & Endoscopy General Surgery Pediatric Surgery Intensive Care Trauma Trauma Vascular

Burns Cardiothoracic Gynecology Surgical Oncology Transplant Trauma Vascular

PGY 4

PGY 5

Vascular and Thoracic Surgery General Surgery Hepatobiliary Pancreatic Surg. Pediatric Surgery Surgical Oncology Trauma/Emergency Surgery

Colorectal General Surgery Hepatobiliary Pancreatic Surg. Surgical Oncology Trauma/Emergency Surgery Vascular