Geography
| Task | Location |
|---|---|
| Home ward | JK Level 6 – Childrens Ward – Paediatric Patients 1A/ 1B – Adult Surgical Patients |
| Morning meeting point | 0730 at Room G.24 in the Paediatric Outpatient Clinics in JK ground floor. This is primarily used as the Orthopaedic Office. Enter either through the main waiting area (walk past reception and follow signs) or through the door marked “volunteers and staff lounge” in the corridor near the Joan Kirner main entrance which is opposite the pharmacy. |
| Your pager | Ortho intern pager: #467 Ortho HMO pager: #227. HMO also holds the GP Liaison Phone 0402 968 483. Remember to forward calls to your mobile at the start of the rotation Weekend cover pagers: #166 / 5027 (PRS HMO) / #541 (PRS + ENT + ophthal HMO) / #471 (PRS intern) |
| Patient list | ~2-5 paediatric patients (elective & trauma) Consults from medical teams |
| Handover | 0730 |
| RMO Quarters | Sunshine – Level 1, opposite birth suite, corridor between ICU and theatre (code written on door) |
| Clinics | Monday – AM JK Paediatric Fracture Clinic (Harris) Tuesday – AM FH wound clinic (HMO/intern)/ Phone PAC (HMO/intern) – AM JK Paediatric Orthopaedic Elective Clinic (Harris – every 4 weeks but fortnightly with the Wed Harris clinic) – PM FH Fracture Clinic Wednesday – PM JK Paediatric Orthopaedic Elective Clinic (Harris – every 4 weeks but fortnightly with the Tues Harris clinic) Thursday – AM JK Paediatric Fracture Clinic (Johnson) Friday – JK Paediatric Orthopaedic Elective Clinic (Johnson) – AM week 1/2/4, All Day week 3 |
About the Role
- The SH orthopaedic team primarily takes care of paediatric ortho (inpatients, trauma, and a significant outpatient clinic). We also see adult trauma and provide consults to other units.
- The job is unique because there are many different systems to navigate and keep track of, you are not only looking after the Sunshine inpatients – this document should hopefully provide a guide to help this make a bit more sense!
- This rotation is very heavy on admin and very light on inpatient jobs, so any free time should be spent working on clinic preparation.
- Make sure the Sunshine trauma excel sheet (front sheet) is printed once it has been updated (by the morning reg) and stapled to the audit sheet (which should have a list of current inpatients).
- Please familiarise yourself with adding patients to the audit
- Ward round notes are taken on paper (we traditionally do not take a WOW on the round), and then transcribe notes onto EMR later.
- When seeing a new patient, bring a consent form and a marking pen and an ARP form (for adult patients) – super handy!
- You will also be expected to do discharge summaries for patients coming out of theatre in JK (especially elective cases and paed surgery cases!) – the recovery nurses will page you or call you on the office phone – do not ignore office phone calls.
Responsibilities
- Joan Kirner Paediatric fracture clinic preparation (formerly XR triage) (Friday and Wednesday for Monday and Thursday clinic)
- Footscray consultant clinic preparation (formerly XR triage) (throughout the week for Friday clinic)
- Ensure Sunray Audit up to date in the morning (with new patients, referrals, postops)
- HMO to do jobs on the Sunshine Trauma sheet
- Print lists/ward round notes/do ward jobs
- Discharge summaries and booking pt follow up
- Admission notes, consent forms, ARP forms as requested
- Xray meeting (alternates between all ortho HMOs (Footscray, Sunshine, Williamstown) – this is a HMO only job
- GP phone (not for clinical referrals/advice, but for expediting clinic appts, clarifying outpatient plans etc). Password is 57575. Remember to forward the number to your mobile at the start of the rotation.
Weekly Schedule
Monday | Ward round + jobs Paeds fracture clinic (ensure HMO completes phone clinic list too) Complete outstanding jobs from clinic (FTAs etc.) Consultant clinic preparation Go over discharges from weekend and ensure each pt has a clinic booked and DC summary completed |
| Tuesday | Ward round + jobs PAC Harris OPC (once every four weeks – please check on EMR/rosters in advance) Footscray wound and fracture clinic (one person to go but NOT during Harris clinic weeks) |
| Wednesday | Ward round + jobs Harris OPC (once every four weeks every fortnightly with the Tuesday clinic) Paeds fracture clinic preparation Consultant clinic preparation |
| Thursday | Ward round + jobs Paeds fracture clinic (ensure HMO completes phone clinic list too) Complete outstanding jobs from clinic (FTAs etc.) Consultant clinic preparation |
| Friday | Half day person goes to Footscray to attend Xray meeting and assist in consultant clinic Ward round + jobs Johnson OPC (3 out of 4 Fridays) Tulloch OPC (once every 3 months or so) Paeds fracture clinic preparation Consultant clinic preparation |
Consultant clinic preparation (formerly known as xray triage)
This job entails ordering xrays, plaster technician referrals, chasing correspondence and hubbing and spoking relevant imaging for patients who will be seen in the Friday consultant clinics.
Key steps include:
- Generating the list of patients from “Ambulatory Organiser” on EMR
- Change the date to the upcoming Friday
- Ensure that “ASC Orthopaedic” is ticked in the “Patients for: … ” text
- Go through the list and check their Bossnet clinic notes/EMR notes/Bossnet GP referrals and ensure their imaging is up to date (pointers and protocols below)
- “Tick off” every patient by writing a sticky note next to the patient in Ambulatory Organiser
Acquiring imaging
– Generally the only imaging you can “order ” for an upcoming patient will be xrays. This is because they can be done on the day of clinic
– Any advanced imaging such as ultrasound, CT, MRI, SPECT (bone scan), PET will usually be organised by the consultant or the referring GP/specialist and should be ordered/performed well in advance of the clinic
– Your job will be to acquire all the relevant imaging, either by ordering new xrays or chasing and collating all the other imaging (by hub-and-spoking them or calling and asking the patient to bring in CDs/reports of their imaging)
– The registrar triaging the patient will often have written what they would like done (can access on Bossnet)
Ordering xrays
These are some general guidelines for ordering xrays
For NEW patients with
1. Knee pathology
AP, Lateral, Skyline, WB PA 20 degrees flexion (Rosenberg), bilateral long leg views WB (leg lengths) with template markings for calibration
2. Hip pathology
AP, Lateral, Charnley with template markings for calibration
3. Foot and ankle pathology
Weight bearing bilateral foot and ankle XRs (AP, Lat, mortise)
4. Shoulder pathology
AP, lateral and Grashey views (can consider Velpeau/Westpoint views if instability or dislocations)
5. Wrist pathology
AP and lateral view
6. Elbow pathology
AP and lateral views (can consider internal and external rotation views to better assess radial head/humeral condyles
For FOLLOW UP/REVIEW patients, check documentation to see whether any specific imaging has been requested. Otherwise, some general pointers to remember would be:
1. Patients who have not had imaging for over 3 months after a joint replacement (hip, knee, shoulder)
2. Post TKR patients: AP, lateral, skyline of the knee (3, 6 months), long leg views (6 months)
3. Post THR patients: AP pelvis and hip lateral (3, 6 months)
4. Post foot and ankle surgery patients: Consultant specific, however in general, order weightbearing FOOT xrays (e.g. for DMMOs, Weils, Scarf Akins, IPJ fusions, Lisfrancs) NOT toes. For ankle replacements, order weightbearing ANKLE xrays.
5. Post scaphoid surgery patients: scaphoid view
6. Always order the joint xray for fractures/surgical fixations close to the joint (i.e. distal radius = wrist, proximal humerus = shoulder, tibial plateau = knee)
7. For long nails/plates, order a “stitched full length xray” (e.g. full length stitched AP, lateral xray of the femur for long plates)
When not to order x-rays:
1. Post op knee/shoulder/hip arthroscopy patients DO NOT need x-rays unless specified
2. Post op ACL reconstructions DO NOT need further x-rays after day 1 post op unless specified
3. Post op removal of metal patients DO NOT need further x-rays unless specified
In addition:
Please DO NOT order X-rays for any of Mr Harris’s patients unless instructed to by Mr Harris
Please DO NOT order X-rays for any of Mr Hussaini’s patients unless instructed to by Mr Hussaini
Paediatric fracture clinic preparation (formerly known as xray triage)
Again, this follows the same principles as the consultant clinic prep. Acquire/order xrays if needed. Contact patient/chase scans if pre-injury xrays or advance imaging obtained elsewhere.
The only difference here is you will quite often also be making plaster technician referrals as well. They are extremely helpful. They can apply/take off/adjust backslabs, casts, splints and braces, slings, CAMboots.
Some things to keep in mind:
1. For all query fractures that are <= 1 week old, get out of plaster and xray
2. For most distal radius/ulna buckle fractures
– change from current slab to a moulded BEFG cast and xray in the new cast
3. For most Gartland 1 or 2 supracondylar fractures
– xray in current backslab at initial clinic review
– clinical review +/- xray at subsequent reviews at discretion of consultant
4. Important to rule out non accidental injury (NAI) for concerning mechanisms/fractures/carer-child interactions
– multiple/bilateral fractures especially including: clavicle fractures, long bone fractures
– delay in seeking medical care
– changing explanation for injury over time/between carers
– neglect
– ALWAYS discuss this with a consultant/paediatrics team
5. For all postop patients
– follow postop plan, however keep in mind this may be adjusted by the consultants Mr Johnson or Mr Harris who are paediatric specialists
6. For all new referrals
– see notes for consultant clinic prep
– hub and spoke relevant imaging (may be impossible to do if they have it done at a small centre, in which case you will have to call them, get a login and down the DICOM images onto a USB and pass onto medical imaging/radiographers)
– follow registrar triage notes or above suggestions
7. When ordering xrays, follow the advice above as for consultant clinic and request the joint it is closest to or the long bone if it is midshaft
e.g. for distal radius: order “wrist xray” or proximal humerus order “shoulder xray”
8. For plaster technician referrals, make sure to put in the correct date on the EMR referral so it pops up on their worklist for the day
9. Make sure that you hand in a printed sheet with the prepared clinic to the admin staff in advance, stating which order patients should be seen in e.g. plaster techs -> xray -> Dr
GP Liaison Phone
Phone Number: 0402 968 483
Password: 57575
Person responsible:
– Sunshine Orthopaedic Registrar (Toan Phu)
– Sunshine Orthopaedic Resident
Role:
– To liaise with GPs to communicate and coordinate management of Orthopaedic Outpatients known to the unit
Examples of patients:
– post-operative patients
– patients known to Orthopaedic Fracture or Elective Clinic
Examples of tasks:
– Clarifying post-operative plans
– Checking patients have clinic appointments
– Booking and expediting appointments
– Checking that patients are on the waitlist for surgery
Not suitable referrals:
– All new referrals must be directed to the Sunshine Orthopaedic Registrar On Call via switchboard on 8345 6666
– Triaging – this is a registrar decision making process
– Upgrading waitlist category for clinic appointment or surgery
– GP to send updated referral to Orthopaedic Clinic & specify change in clinical situation requiring expedited review
– Call Orthopaedic Registrar On Call if needing to discuss expediting surgery
Logistics:
– Divert phone number to your personal mobile at the start of the rotation
– Otherwise, need to carry the phone at all times
– GP Log Book needs to be filled out for every phone call. Please email Orthopaedic Registrar Toan Phu at the end of every week an update quoctoan.phu@wh.org.au
– If unsure how to manage call, escalate to Orthopaedic Registrar at the operation or Orthopaedic Registrar On Call
Log Book:
– Every phone call needs to be logged on the logbook for audit and patient care|
– Patient’s details, GPs details including return phone number must be recorded so that GP can be contacted if management plans change
– Put registrar’s name in action if discussed with one
GP Logbook
| Patient | Date/Time | GP | Query | Time of call back to GP | Action |
Other job specifics
Organising an MRI under GA
Sometimes this is an isolated GA MRI. Sometimes this might follow a procedure in theatre e.g. EUA, arthrogram.
1. Order the MRI on EMR (make sure to include the consultant name/provider on the request)
2. Protocol the MRI with the MRI consultant (usually a HMO/registrar job but the intern can do this too)
3. Call Jennifer Roberts 8345 6639 (Anaes office) to ask for Anaes assistance. She will tell you when she will have an Anaes (who can do paeds) available for the MRI
4. Call MRI techs 83450788 and inform them of Anaes availabilities. Find a mutual time between MRI and Anaes that will work (may require back and forth)
5. Call OT NIC if required if this is following a theatre case. Call anaesthetist in charge so they can inform the anaesthetist involved in the case.
6. Morning of the MRI – ensure to check with all parties (NIC of theatre, if the Anaes is coming from the emergency theatre, Anaes in Charge and MRI techs to ensure all is going ahead)
7. The patient may need presciption of sucrose or coral for sedation
Paediatric HITH
Paeds HITH is managed through the Royal Children’s Hospital.
1. Once BC negative for minimum 48hrs, can consider a long line or mid line (discuss w paeds and/or anaes to organise this
2. Pt will need to be accepted under a bedcard at the RCH (either ortho or ID. ID is easier to get in touch with, ortho rarely answer their pages. So if nil preference, best to speak to ID and ask for them to place the pt under their bedcard)
3. The accepting RCH team will need to do the HITH referral for you
4. Call HITH at RCH (through RCH switch, it’s the wallaby ward usually) and speak to the NUM – currently Megan. Ensure that all paperwork is filled and ensure pt’s first home visit appt is scheduled prior to discharging the patient.
5. Ensure clear documentation re who is following the patient up and ensure to book all of their follow up
Authors and Contributors
- Mike Millar / Toan Phu 10/2023
- Matthew Sun 24/1/2024