DEPARTMENT OF

ORTHOPAEDIC SURGERY
RESIDENCY PROGRAM MANUAL
2015-16

TABLE OF CONTENTS

FacultyandResidentContactInformation
PoliciesandProcedures
MedicalRecords
PatientCare
StanfordMondayMorningConference
GrandRounds
MorbidityandMortalityConference
Travel
OnCallScheduling
Vacations
AAOSOrthopaedicInTrainingExam(OITE)
AdvancedCardiacLifeSupport(ACLS)Certification
ResidentDisputations
OrthopaedicSubspecialtyFellows
RotationsataGlance
Arthritis
Foot&Ankle
Hand
Pediatrics
SCVMC
Spine
SportsMedicine
Trauma
Tumor
VAPAHCS

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RESIDENCYPROGRAMPOLICIESANDPROCEDURES

MEDICALRECORDS
CURRENTMEDICALRECORDSMUSTBEAVAILABLEFORPATIENTCAREATALLTIMES.CLINICALFINDINGS
MUSTBERECORDEDINDETAIL,PROMPTLYANDLEGIBLY.PATIENTS'MEDICALRECORDSMUSTNOTBE
REMOVEDFROMTHEHOSPITALORMEDICALCENTERFORANYREASON.

A.Failuretocompletemedicalrecordsappropriatelywillresultinsuspensionofhospitalprivilegesand
withholdingofpaychecks,denialofrequeststoattendprofessionalmeetings,and/ordenialof
certificationuponcompletionofrotationatagiveninstitution.

B.Dictationandtranscriptionproceduresdifferwitheachinstitution.Theadministrativestaffateach
institutionwillbeavailabletoassistyouwiththeseprocedures.

C.Alltelephonecallsfrompatientsshouldbedocumentedandprescriptionsshouldalsobenotedinthe
documentation.Theseshouldbeccedtotheattendingofrecord.

D.BesuretodocumentallfindingsandphysicalexamdetailselectronicallyintheEpicsystem,butdo
notcutandpasteallofthepreviousdataintothedailynotes.InitialH&Pnotesmustbecosignedby
theattendingofrecord.

PATIENTCARE
A. Residentsareresponsibleforinpatientcareforpatientsontheirservice.Thiscareincludesperiodic
rounds,preoperativeexaminationforsurgicalcases,andsurgeryinconjunctionwithattending
facultyandclinicalfacultyphysicians.Nopatientistobetakentotheoperatingroomwithout
consultationofanattendingphysician.Chiefresidentsperformorthopaedicconsultationswithinthe
hospital.

B. Documentedsignouttotheoncalljuniorresidentismandatoryeveryweekdayeveningat6pmor
laterfortheArthritis,Foot&Ankle,Trauma,andTumorservices.

C. Onweekends,theresidentsontheArthritis,Foot&Ankle,Trauma,andTumorservicesshould
preparetheirpatientsfordischargewithappropriatedocumentationandorders.Relianceonthe
oncallresidentunfamiliarwiththepatientstoperformtheentiredischargeisinappropriate.

D.Outpatientcareresponsibilitiesincludeclinicwithattendingfaculty,andworkupofassignedtopics
withchartreviewforpatientcarereviewmeetings.Whensurgeryandhospitaladmissionare
needed,theresidentswillconsultwiththechiefresidentforguidanceandconfirmationof
treatmentplanforpatientsseenwhileoncall.

E.Residentsmustmaintainapresentableappearanceforpatientcare.Thisincludescleanclothes,
propergrooming,cleanlabcoats,cleanshoes,etc.

F.Residentsshouldknowtheirpatientshistory,pastmedicalhistoryandmedicationsthoroughly.

G.ResidentsshoulddocumentallcomplicationsandpresentthematthemonthlyMorbidityand
Mortalityconferences.Seetheattachedsheetforthestandardformat.

H.ResidentsshouldbeawareofthecurrentpagingsystematStanford.Theoperatorsmaynotknow
theappropriateresident/fellowtocontact.Ifinappropriatelypaged,trytodirectthecallandbe
familiarwiththecallcoverageforeachservice,whichisestablishedwellinadvance.

I.Residentsareexpectedtomakeroundstwiceperdayandatleastoncewithaseniorresident,fellow
orattending.

J.Duringthefirst3monthsoftheacademicyear,thesenior/chiefresidentoncallmustseeallpatients
andfilmspriortoadmission.Allsplintingandreductionsmustalsobesupervisedbythesenior/chief
residentduringthefirst3monthsoftheyear,andpostsplinting/reductionxraysmustbeobtained
priortodischargeortransfertothefloor.

K.IntheEmergencyRoom,allopeninjuriesshouldreceiveproperacutecare,i.e.reductionofgross
deformities,woundirrigation,coveragewithsteriledressings,andimmobilizationwithasplint.

STANFORDMONDAYMORNINGCONFERENCE
A. Presentationsstartpromptlyat7:15amintheRadiologyMusculoskeletalReadingRoom.

B. Thepresentationsaretobelimitedto10minutesinlength.Thiswillallowfor5minutesof
discussionforeachtalk.

C. TheChiefResidentonTraumaisinchargeofdeterminingthethreeservicespresentingeach
Monday.ThescheduleshouldbeevenlydistributedbetweenTrauma,Tumor,FootandAnkle,
ArthritisandSpine.TheTraumaChiefisalsoresponsibleforeachconferencerunningontime.This
includesendingpresentationswhichextendbeyond10minutes.

D. Ifamedicalstudentispresenting,theChief/Senioroftheirrespectiveserviceisresponsiblefor
reviewingthestudentpresentationaheadoftimeandensuringcompliancewiththeaboverules.

GRANDROUNDS
WednesdaymorningEducationalConferencewillconsistofthefollowing:

EachWednesday,ClinicalCoreLecturesbeginat6:30amandrunfrom6:307:55am.Thefirst90minutes
ofeachconferenceconsistsoftwolecturesencompassingallaspectsofgeneralandsubspecialty
orthopaedics,rheumatology,rehabilitationmedicine,etc.,basedonatwoyearrevolvingcore
curriculum.Dr.RaffiAvediancoordinatesourcliniclectureseries.Thethirdhourfrom8:009:00amis
ourGrandRoundslecturegivenbyfacultymembersandguestlecturers.EachChiefandSeniorResident
(PGY4andPGY5)givesoneGrandRoundslectureduringtheyear.

OncepermonthwehaveaMorbidityandMortalityConferenceinwhichallaffiliatedinstitutionshave
theircomplicationspresentedanddiscussedindetailbytheresidentsandattendingstaff.Thissession

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willrunfrom6:307:55am.Thistakestheplaceoftheclinicallectureandcasepresentationsonthat
particularWednesday.

Duringthesummerquartereachyear,wehaveanatomylecturesanddissectionforthreehoursper
weekonWednesdaymornings.Thisdidacticandpracticalconferenceissupervisedbytheattending
staffthathaveaparticularinterestinthatanatomicallocation.Allresidentsattend.

WehaveaPathologycourseonthethirdWednesdayofthemonthinplaceoftheclinicallecture.This
PathologycourseisgivenbyStanfordfulltimepathologists,radiologists,andorthopaedicstaff.

ATTENDANCEATALLWEDNESDAYMORNINGCONFERENCESISMANDATORY.NOEXCEPTIONS!

MORBIDITYANDMORTALITYCONFERENCE
1. ResidentsreportingatM&MforStanfordservicesmustcompleteQAformstobereturnedtothe
QAChairman,Dr.MichaelBellino,bythe5thofeachmonth.Formswillbeputintoyourmailbox;if
youneedadditionalformsorhavenotreceivedany,pleasecontacttheQAadministrativeassistant.
2. Allservicesmustreportregardlessofwhetherornottherearecomplicationstoreport.
3. Ifnocomplicationsaretobereported,bepreparedtosubmitaninterestingcase.
4. M&MReportingResponsibility:

StanfordServices:
Arthritis

PGY4
Spine

PGY4
Sports

PGY5
Hand/Shoulder&Elbow
PGY4
Trauma

PGY5
Peds

PGY4
Tumor

PGY4
Foot&Ankle

PGY3

SCVMC:
Blue

PGY5
Red

PGY5

TRAVEL
Thedepartmentprovidesthefollowing:

1.TravelandexpensesfortheChiefResidentstoattendtheAmericanAcademyofOrthopaedic
Surgeons(AAOS)AnnualMeeting.ThepurposeofthisistointroducetheChiefResidentstoalarger
fieldoforthopaedicsandtogivethemtheopportunitytoseethelatestinequipmentandscientific
endeavorsoftheorthopaediccommunity.

2.Travelandexpensesupto$1200,assumingtheavailabilityoffunds,foranyresidentwho,with
facultysponsorship,readsapaperatanational,international,ormajorregionalmeeting.Leavewill
begrantedforresidentswhoarepresentingatameeting(thisdoesnotincludeposter

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presentations).Leavemustberequestedsix(6)weekspriortothemeeting.Thereisamaximum
fundingof$2400peryear,nottoexceed$1200permeeting.ExamplesofmeetingsincludeAAOS,
ORS,andspecialtysocietymeetings(example:NASSforSpine).Residentsarerequiredtomake
arrangementsforcoverageoftheirserviceandcallwhileattendingthemeeting.

3. TravelandexpensesforanAOBasicorAdvancedCourseduringthePGY2orPGY4year.

4. TravelandexpensesforoneBoardReviewCourseduringthePGY5year.

5. Travelandexpensesupto$2500foreachChiefResidenttoundertakeamedicalmissiontoan
underservedregionoftheworld.

ONCALLSCHEDULING
InternsandresidentsmustbeavailabletothepatientcareunitsandtotheEmergencyDepartment.The
firstcallresidentwillbeeitherinthebuildingorwithin20minutesofthefacility.Itistheresponsibility
oftheresidenttobesurethatthebeeperfortakingcallsoutsideofthebuildingisingoodworkingorder
andthatatelephoneisimmediatelyavailableattheoutsidelocation.(Pleasenote:Certainbuildings
madeofreinforcedconcretemaynotpasstheradiosignalsnecessarytoactivatethebeeper.)

Anoncallscheduleispreparedmonthlybythedepartmentoffice.TheCoordinatorforResidentAffairs
mustbenotifiedatleastsixweeksinadvanceofanyplannedabsences.
1. Theobjectiveofoncallactivitiesistoprovideresidentswithcontinuityofpatientcareexperiences
throughouta24hourperiod.Inhousecallisdefinedasthosedutyhoursbeyondthenormal
workdaywhenresidentsarerequiredtobeimmediatelyavailableintheassignedinstitution.
2. MaximumHoursofWorkPerWeek:Dutyhoursmustbelimitedto80hoursperweek,averaged
overafourweekperiod,inclusiveofallinhousecallactivitiesandallmoonlighting.
3. Moonlighting
Residentsarenotrequiredtoengageinmoonlighting.Allresidentsengagedinmoonlightingmust
belicensedforunsupervisedmedicalpracticeinthestatewherethemoonlightingoccurs.Itisthe
responsibilityoftheinstitutionhiringtheresidenttomoonlighttodeterminewhethersuch
licensureisinplace,adequateliabilitycoverageisprovided,andwhethertheresidenthasthe
appropriatetrainingandskillstocarryoutassignedduties.Stanforddoesnotprovidemalpractice
coverageformoonlighting.Theprogramdirectormustbenotifiedinwritingthattheresidentis
moonlighting,andthisinformationismadepartoftheresidentsfolder.

a. Moonlightingmustnotinterferewiththeabilityoftheresidenttoachievethegoalsand
objectivesoftheeducationalprogram.
b. Timespentbyresidentsinmoonlightingmustbecountedtowardsthe80hourmaximum
weeklydutyhourlimit.
c. PGY1residentsarenotpermittedtomoonlight.
d. MoonlightingisnotpermittedwhileoncallatanyStanfordaffiliatedinstitution.

4. MandatoryTimeFreeofDuty:Residentsmustbescheduledforaminimumofonedayfreeofduty
everyweek(whenaveragedoverfourweeks).Athomecallcannotbeassignedonthesefreedays.

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5. MaximumDutyPeriodLength

a. DutyperiodsofPGY1residentsmustnotexceed16hoursinduration.
b. DutyperiodsofPGY2residentsandabovemaybescheduledtoamaximumof24hoursof
continuousdutyinthehospital.
c. Residentsmustnotbeassignedadditionalclinicalresponsibilitiesafter24hoursof
continuousinhouseduty.
d. Inunusualcircumstances,residents,ontheirowninitiative,mayremainbeyondtheir
scheduledperiodofdutytocontinuetoprovidecaretoasinglepatient.Justificationsfor
suchextensionsofdutyarelimitedtoreasonsofrequiredcontinuityforaseverelyillor
unstablepatient,academicimportanceoftheeventstranspiring,orhumanisticattentionto
theneedsofapatientorfamily.Underthosecircumstances,theresidentmust:(i)
appropriatelyhandoverthecareofallotherpatientstotheteamresponsiblefortheir
continuingcare;and,(ii)documentthereasonsforremainingtocareforthepatientin
questionandsubmitthatdocumentationineverycircumstancetotheprogramdirector.

6. MinimumTimeOffbetweenScheduledDutyPeriods

a. PGY1residentsshouldhave10hours,andmusthaveeighthours,freeofdutybetween
scheduleddutyperiods.
b. PGY24residentsshouldhave10hoursfreeofduty,andmusthaveeighthoursbetween
scheduleddutyperiods.Theymusthaveatleast14hoursfreeofdutyafter24hoursofin
houseduty.
c. PGY5residentsmustbepreparedtoentertheunsupervisedpracticeofmedicineandcare
forpatientsoverirregularorextendedperiods.Theremaybecircumstanceswhenthese
residentsmuststayondutytocarefortheirpatientsorreturntothehospitalwithfewer
thaneighthoursfreeofduty.

7. AtHomeCall

a. Timespentinthehospitalbyresidentsonathomecallmustcounttowardsthe80hour
maximumweeklyhourlimit.Thefrequencyofathomecallisnotsubjecttotheeverythird
nightlimitation,butmustsatisfytherequirementforonedayinsevenfreeofduty,when
averagedoverfourweeks.
b. Athomecallmustnotbesofrequentortaxingastoprecluderestorreasonablepersonal
timeforeachresident.

VACATIONS
Eachresidentisallocated15workingdaysofvacationperyear,inincrementsoffiveconsecutive
workingdaysduringanyrotationperiod(weekendsbeforeorafter,tomakeatheoreticaltotalofnine
daysofvacation,maybearrangedbyprioragreementwiththeResidencyProgramDirectorandthe
Chiefoftheirrespectiveservice).VACATIONTIMEMAYNOTBETAKENDURINGTHELASTWEEKOF
JUNE,THEFIRSTWEEKOFJULY,DURINGTHEORTHOPAEDICINTRAININGEXAMINNOVEMBER,DURING
DISPUTATIONWEEK,ORDURINGTHEAAOS.Inaddition,sixweeksofadvancenoticeisrequiredforany
meeting,courses,etc.thattheresidentexpectstoattendoutsideofvacationtime.Thisisnecessaryso

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thatappropriateadjustmentstoclinicschedulingandotherresponsibilitiescanbemade.TheChief
AttendingoftheService,ChiefResidentoftheService,andResidencyDirectormustallbenotifiedof
proposedvacationtimeinwritingandmustbeapprovedbyallthree.

Oneweekperyearisalsoallowedforacademictimesuchaseducationalconferencesormeetings,etc.
Academictimeoffmustbeapprovedatleast6weeksinadvance.Awrittenplanfortheuseofthistime
mustbeapprovedbytheServiceChiefandDr.Avedian.

SickLeaveandFamily/MedicalLeavepolicy:ResidentsaretofollowthecurrentHouseStaffPoliciesand
ProceduresasspecifiedbytheGMEOffice.

FellowshipInterviews:ResidentsareallowedfiveworkingdaysoffduringthePGY4yeartointerviewfor
fellowships.Anyadditionaldayswillcounttowardseducationalleave.

AAOSORTHOPAEDICINTRAININGEXAM(OITE)
The2015OITEisscheduledforSaturday,November14,andismandatoryforallresidents.

ADVANCEDCARDIACLIFESUPPORT(ACLS)CERTIFICATION
TheFacultyoftheDepartmentofOrthopaedicSurgeryrecommendsthatallresidentstaketheACLS
Course.

RESIDENTDISPUTATIONS
EachresidentisrequiredtocompleteastudythatculminatesinaDisputationpresentationinthespring
ofthePGY5year.TheDisputationisanintegralpartoftheresidencyinorthopaedics,andtheproject
maybeintheareaofclinicalscienceorbasicscience.

ThefollowingtimetableisrecommendedinthepreparationoftheDisputationPaper:

1. PGY2ThePGY2residentwillfilloutaformalResidentResearchProposalFormnolaterthan
March1oftheirPGY2yearandmeetwiththeResearchCommitteeconsistingofDrs.Goodman,
Smith,andGiori.Theformwouldlistthefollowing:
nameofresident
projecttitle
nameoffacultymentor
abstractofwhatistobedoneincludingbriefreviewofpertinentliterature,hypothesis,
experimentaldesign(materialsandmethods),proposedstatisticalanalysisand
anticipatedresults
resourcesneeded
signaturesoftheresidentandfacultymentor

Theproposalwouldconstituteamaximumofthreepages,includingamaximumof10
references.Amoredetailedliteraturereviewwouldbecarriedoutbytheresidentwhenthe
proposalhasbeenreviewedandapprovedbytheresearchcommittee.

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Adecision(yes/modifyandresubmit/no)wouldbecommunicatedbytheResearchCommittee
tothePGY2andmentorbyMay1ofthePGY2year.Thisaffordssufficienttimefortheresident
toincorporatecomments,revise,revamporselectanewtopic.Ifthelatterdecisionismade,
theresearchcommitteewillmeetwiththeresidentdirectlyandtrytohelphim/herselecta
relatedornewtopicandwriteanewproposalwithintwomonths.

DuringthePGY2year,theresearchmaybeginonceapprovalisobtained.Theresidentshould
completeacomprehensiveliteraturesearchonthesubjectandbeginwritingtheIntroduction
andMaterialsandMethodssections.Thesemustbesubmittedtotheresearchcommitteeby
DecemberofthePGY3year.

ThePGY2residentandresearchmentorshouldmeetatleastevery36months.

2. PGY3ThePGY3residentshouldhavehis/herprojectinprogress.ThePGY3residentandresearch
mentorshouldmeetatleastevery36months.

ThePGY3residentwillprovidetheResearchCommitteewiththeIntroductionandMaterialsand
MethodssectionsbyDecemberofthePGYIIIyear.TheresidentwillpresenttheIntroductionand
MaterialsandMethodsPreliminaryResultssectionsinoralformatonResearchDay.

3. PGY4Theresearchprojectisprobablystillinprogress.ThePGY4residentandresearchmentor
shouldcontinuetomeetatleastevery36months.Atthemiddleendoftheyear,theproject
shouldbenearingcompletion.TheResultsandDiscussionsectionsshouldbewrittenanda
manuscriptproducedinthestyleoftheJournalofBoneandJointSurgeryorothertargeted
subspecialtyjournal.

4. PGY5Theresearchprojectshouldbecomplete.Themanuscriptmayhavetoberevisedduringthe
PGY5year.Theaimistogetfinalacceptanceofthemanuscriptforpublication.

Residentsoftenperformmorethanoneresearchprojectduringthecourseoftheirtraining.TheChief
ResidentswillpresenttheirresearchprojectatDisputations.Successfulcompletionoftheprojectand
presentation,aswellasdefenseoftheproject,arerequiredforgraduation.

ORTHOPAEDICSUBSPECIALTYFELLOWS
Postresidencyfellowsmaybepresentonsomeservices.Theseindividualsareenrolledinanadvanced,
concentrated,postresidencylearningexperiencewithoneormoreexpertsinanorthopaedic
subspecialtyarea.Thefellowshipusuallylasts12months.Therolesofthefellowwillbeto:

1)Activelyassistthesurgeonand/orresidentinoperativecases
2)Participateinorthopaedicclinicsandonthewardinthecareofpatients
3)Engageintheteachingofresidents,medicalstudents,nursesandothermedicalpersonnel
4)Performcollaborativeresearchstudies

Thefellowandresidentontheorthopaedicservicehavedistinctroles.Whereastheresidentusuallyhas
thedaytodaywardresponsibilitiesandperformsorassistsinmanysurgicalcases,thefellow
participatesinthemorechallenging,advancedcasesthatrequirespecializedpostresidencytraining.

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Thefellow'seducationshouldnotinterferewiththatoftheresident,especiallyintheoperatingroom.
Onthecontrary,thefellowshouldbeaneducationalresourcefortheresidentandtheorthopaedic
subspecialtyservice.

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ROTATIONSATAGLANCE

ARTHRITIS:OVERVIEW

Thearthritissurgeryrotationincludesthepreoperative,operative,andpostoperativemanagementof
patientswithjointproblemsordinarilyofaseverenature.Theresidentsassignedtothisservicecan
expecttooperatethreedaysormoreaweekandatleastonefulldayofclinic.

Theorganizationoftherotationisratherstrictinitsobservanceofavarietyofprotocols,mostofwhich
arepartofongoingstudies.Allpatientsofthearthritissurgeryclinicareonpreprintedpatient
informationcollectionformsadministeredtothepatientbytheclinicwithyourhelp.Physical
examinationsareoftenperformedbythephysicaltherapistwhofillsformsout.Thepatientfillsoutthe
patientselfadministeredforms.ALLPHYSICIANSASSIGNEDTOTHEARTHRITISSURGERYSERVICEARE
RESPONSIBLEFORREVIEWINGTHEARTHRITISSURGERYRECORDOFEACHPATIENT.THEYSHOULDBE
FAMILIARWITHTHECONTENTSOFTHISRECORDINMANAGEMENTANDTREATMENTFOREACH
PATIENTTHEYEXAMINE.Inadditiontoreadingtherecord,theyareresponsibleforimprovingits
contentswherethepatienthasfailedtofillouttheanswertosomethingorwherethephysicaltherapist
hasincorrectlymeasuredsomethingaboutthepatientandrefertothesearthritisrecords.

AllofthetotalkneeandhipoperationsinthehistoryoftheStanfordUniversityOrthopaedicServiceare
availableonacomputerizedrecord.Indeed,anyinterestedresidentcanusethisrecordforeither
educationalorresearchpurposes.

Therotationonthearthritisservicerequirespotentialavailabilityeverydayoftheweekfor
emergencies,preoperative,andpostoperativecareofapatient.

Duringperiodswherethereisnoclinicandnooperation,theresidentsareencouragedtospendtheir
timedoingresearch.Whileitishopedthattheresidentwillbeusingthetimetodoresearchrelativeto
arthritis,itissatisfactoryiftheyareworkingonanyresearchprogram.Thisresearchshouldbe
supervisedbyoneofthefacultymembersofthedepartment.

Residentswhoareinterestedineitherclinicalorbasicscienceprogramsandresearchareencouragedto
contactafacultymemberatanytimeduringtheirresidencyaswellasduringthetimetheyareonthe
service.

Vacationandabsencesfromresponsibilitiesfallundertheguidelinesofthosefortheresidencyin
general.Becauseofthepatientloadandtheresponsibilitiesofthisservice,itisimperativethatall
vacationsorabsencesfromtheArthritisSurgeryservicebeconfirmedbythefacultyatleastsixweeksin
advance.Vacationswillalwaysbeapprovediftheymeetthedepartmentalcriteria.Thefaculty,
however,mustberenotifiedofanyvacationatthetimearesidentcomesonservicewhetherornot
previousnotificationhasbeengiven.

ThefollowingarerequirementsorguidelinesforresidentsontheArthritisService:

A.Adailyprogressnotemustbewrittenbyaresidentorfellow.

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B.Theresidentmustwriteapreoperativenotethatincludesasummaryofthemostsalientproblemat
hand,includingdiagnosis,theproceduretobeperformed,andastatementofalternativeprocedures,
andpotentialrisksandcomplications.Youareexpectedtoknowandfollowtheprogressofthepatient
onadailybasis,sevendaysaweek.EachcasewillbereviewedinpreopconferenceonThursdays.

C.Thereshouldbeadischargenoteonthedayofdischarge.Thisnotemustmentionthediagnosis,
procedure,andtheprovisionsforfollowup,withthefollowupappointment.

D.Pleasebedressedandintheappropriateoperatingroom15minutespriortothefirstcaseofthe
morning.Recurrenttardinessmayresultinlostsurgicalprivileges.

ARTHRITIS:RESIDENTGOALS&OBJECTIVES

DESCRIPTION
Theteachingaimoftheserviceasitpertainstotheresidentistoeducatehim/herinthediagnosis,
surgicalandnonsurgicaltreatmentandoutcomeofarthritisandadultreconstructivecases.Thiswill
includeresidentparticipationintheorthopaedicclinic,intheoperatingroom,andintheemergency
roomaswellasinnumerousteachingconferencesandrounds.Theserviceisalsoactiveinbasicand
clinicalresearchprojectsinwhichtheresidentcanparticipate.

RESIDENTROLEANDEXPECTATIONS
ThePGY2residentwillbeinvolvedwiththeassistanceofoperativeproceduresandtheworkupof
arthroplastypatients.ThePGY4residentwilltakeamoreleadroleintheoperativeproceduresand
clinicaldecisionmaking,allundertheguidanceoftheattendingstaff.

READINGS
RecommendedreadingincludestheOKU,theOKUHipandKneeReconstructionBook,theAdultHipand
AdultKneetextbooks,relevantpartsofCampbell'sOrthopaedics,andnumerousjournalarticlesand
portionsoftextssuggestedbythefaculty.

CONTACT
JamesHuddleston,MDjhuddleston@stanford.edu
WilliamMaloney,MDwmaloney@stanford.edu
StuartGoodman,MDgoodbone@stanford.edu

GOALSANDOBJECTIVES
Bytheendoftherotation,theresidentwill:

PatientCare:Obtainacumenindiagnosingandproposingtreatmentintheclinicalsetting,andanalyze
availableinformationtomakediagnosticandtherapeuticdecisionsbaseduponsoundclinicaljudgment,
bestavailableevidence,andpatientpreferences.

MedicalKnowledge:Knowthebasicandclinicalscienceonwhichadultreconstructivesurgeryis
grounded.Obtainknowledgefortheworkup,classification,andtreatmentoptionsfor
reconstruction/totaljointsurgery.Obtainknowledgeandcomprehensionofsurgicalapproachesfor
reconstructivesurgery.

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Theresidentshouldbeproficientinbasicsurgicalskillsincludingprimarytotalkneeandhipplacement,
andshouldhaveexposuretorevisionhipandkneeprocedures.Thefellowmayalsobeexposedto
synovectomyandosteotomyofvariousjointsandspecificarthroscopicproceduresastheyrelateto
arthritissurgery.

PracticeBasedLearningandImprovement:Demonstrateselfimprovementthroughacritiqueoftheir
performanceduringpresentationofM&Mcases.

InterpersonalandCommunicationSkills:Demonstrateinterpersonalskillsandprofessionalismnecessary
toadequatelyeducateapatientontheirdiagnosisandconveytherisks,benefits,andcomplicationsof
availabletreatmentoptions.Demonstratecourtesyandtimelinesswithcolleagues,patients,and
ancillarystaff.

Professionalism:Demonstrateinitiativeintheneedsofpatientsandprofessionalstaff,showinghonesty,
compassion,andrespectforthepatientissuesbothintermsofthemedicaldiagnosisandthe
psychosocialramifications.Demonstrateprofessionalismandcommunicationskillstocounselpatients
regardingarthroplastyandtherisksandbenefits.

SystemsBasedPractice:Abilitytoindependentlyaccessandutilizeoutsideresourcessuchashome
healthcareandanticoagulationservicesinthecareandmanagementofthispatientpopulation.

COGNITIVEKNOWLEDGE
Theresidentwillbeabletoperformtheclinicalskillslistedaboveandbeabletodemonstratetothe
satisfactionofhis/hersupervisor(s)afundamentalknowledgeandunderstandingofthegeneralareas
andprovideadetailedknowledgeoftheincidence,etiology,pathophysiology,naturalhistory,clinical
diagnosis,investigations,management,prognosisandcomplicationsofeachofthespecificdisease
processeslistedbelow:

GeneralAreaofKnowledge:
1.AdultosteoarthritisYoung/elderlypatients
2.Adultandjuvenileinflammatoryarthritis
3.Intra/extraarticularsofttissueproblems
4.MusculoskeletalPathology
5.OrthopaedicTrauma(Periprostheticfractures)&complications

SpecificDisease:
1.Hip/knee/shoulder/elbowosteoarthritis/rheumatoidarthritis/neuropathicjoint/septicjoint
2.Softtissueinjuries/conditionspertainingtotheupperandlowerextremities
3.Limbischemia,infection&vascularinjuryrelatedtotrauma
4.Diseasesspecifictopathologicalfracturesandtheirmanagementi.e.)tumors,OI

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FOOTANDANKLE:OVERVIEW

WelcometotheOrthopaedicFootandAnkleSurgeryService.Youwillspend10weeksontheservice
andthiswillbeyourmostconcentratedexposuretofootandankledisordersduringyourresidency.
Thereisalargeamountofinformationtolearnandskillstoacquireinthisrotation.

Theattendingphysiciansconductacomprehensiveeducationprograminwhichconferencesareheld
MondaymorningsfollowingtheStanfordOrthopaedicSurgery7:00amconference.Therewillbeapre
opconferencethatreviewscasesandassignmentsfortheweek.Wewillhavepresentationsonvarious
subjectspertinenttofootandanklesurgery.Eachresidentwillbeexpectedtogiveatleastone
presentationduringtherotation,coveringatopicoftheresident'schoice(alistoftopicswillbe
provided).

Theresidentwillparticipateinthecareoffractures,sprains,tendondisorders,arthritis,congenital
deformities,sportsinjuries,complexreconstructions,andtotalanklearthroplasty.

Pleasefollowtheguidelinestolearnthemostfromthisrotation.Theprimaryskillsacquiredduringthis
rotationare:
Diagnosisofcommonfootandankledisorders
Outpatientmanagementofcommonfootandankledisorders
Inpatientmanagementofpreandpostoperativefootandanklesurgerypatients

Residentsmustlearnthebasicsurgicalanatomy,primaryexposures,andwoundclosures.

Yourdutiesarespecifiedbelow:
1)
AMRoundsmustbeperformedandnoteswritteninfullbeforethefirstscheduleddailydutyof
clinic,xrays/grandroundsand/orOR.
2)
AllpatientsreturningfromthePACUshouldbeseenpostoperativelywhenbackontheward.A
clearnotewithtimeseenmustbeinchartdocumentingexaminationwhenthepatientleavesthe
PACU.Notepainstatus,orientation,neurologicstatusdescription(i.e.NVIisinadequate),
dressing,drainageandmobilizationplan.
3)
Weekenddutiesarecoveredbytheresidentorroundingresident.Theroundingresidentmust
communicatewiththeattendingoneachinpatient.Iftheresidentisnotroundingonaparticular
weekend,itishis/herresponsibilitytoidentifytheroundingresidentandcommunicatewiththat
personregardingpatientsummary,issues,anddisposition.
4)
Timeliness:Reporttimes,inscrubsandinappropriateORforsurgerydays,are0700ifcasesare
scheduled.Reporttimeforclinicis5minutesbeforefirstscheduledpatient.Onceagainthat
meansatRedwoodCityorASCandreadytoseepatients.
5)
Holiday:Vacationweekwillbepickedbythe1stFridayontherotationandclearedwithDr.Chou
(ordesignate)ortwomonthsbeforevacationstarts,whicheverisearlier.Theresidentmaynot
takeoffthefirstorlastweekoftheservice,oraweekwheneitherthefelloworPAwillbegone,
orwhentheStanfordservicewillnothaveadequatecoverageperDr.Maloneysdirections.
6)
ClinicNotes:Onclinicdays,theresidentwillseepatientsinclinic.Forthenewpatientsthe
residentmustdoacomprehensivehistoryandphysicalexamination.Handnotesshouldbetaken.
7)
HospitalDictations:ORandDischargeSummariesmustbedoneonthedateofservice.Keepthe
lognumberstoverifycompletion.Theattendingwilldeterminewhoshoulddictatethesurgical
report.Theattendingmayelecttodothedictation.Ifthereisanyquestion,confirmwiththe

20

8)

attendingthatthedictationhasbeendone.Thedictationdateisannotatedonalltranscriptions
andwillbechecked.Samedaydictationsaretheminimumacceptablestandard.
Narcotics:Telephonerenewalsshouldbedoneduringtheday.Ifthereisaquestion,callthe
attending.Ifstillunresolved,tellthepatientyouneedtocheckwiththeattendingintheAM.Ifthe
painissobaditcannotbetolerated,seethepatientintheERatnightorintheclinicduring
businesshours.

TheFootandAnkleSurgeryrotationreadinglistisinMedHub.

FOOTANDANKLE:RESIDENTGOALSANDOBJECTIVES

DESCRIPTION
Residentswillobserveandparticipateinthediagnosisandmanagementoffootandankledisorders
duringan8weekrotationintheirPGY3year.ClinicpatientsareevaluatedattheStanfordMedicine
OutpatientCenterofficeinRedwoodCity.Thisprogramstressesthephysicalexaminationofthefoot
andankle,theworkupandtreatmentoforthopaedictumors,andoperativeapproachestofootand
anklesurgeryinboththeelectiveandtraumasetting.

RESIDENTROLEANDEXPECTATIONS
Residentsonthefoot&ankle/tumorservicewillfunctionasanimportantmemberofthecareteam,
assistinginclinicalpatientevaluationandsurgicalmanagementunderthedirectsupervisionand
guidanceoftheattendingstaff.
Thefoot&ankleserviceiscomposedofonePGY3resident.

READINGS(availableintheresidentlibrary)
CoughlinMJ,MannRA,SaltzmanCL.(2007).SurgeryoftheFootandAnkle,8thEdition.Mosby.
KelikianAS,SarrafianSK.(2011).SarrafiansAnatomyoftheFootandAnkle.LippincottWilliams&
Wilkins.
PinzurMS.(2008).OrthopaedicKnowledgeUpdate:FootandAnkle4.AAOS.
BulloughPG.(2009).OrthopaedicPathology.Mosby.

CONTACT
LorettaChou,MDlchou@stanford.edu

GOALSANDOBJECTIVES
Bytheendofthisrotation,theresidentwill:

PatientCare:Obtainacumenindiagnosingandproposingtreatmentintheclinicalsetting,andthe
surgicaltreatmentoffracturesoftheankle,pilon,talus,calcaneusandlisfrancjointandreconstructive
footandankleproceduresaswellasreconstructivefootandankleprocedures.

MedicalKnowledge:Obtainknowledgeandcomprehensionofcommonsurgicalapproaches,
nonoperativeandoperativetreatmentoptionsforcommonfootproblemssuchasbunions,neuromas,
hammertoes,heelpainsyndrome,tarsaltunnelsyndrome,ankleinstability,arthritis,andpesplanus.
Obtainknowledgefortheworkup,classification,andtreatmentoptionsforavarietyofboneandsoft
tissuetumorsofthespine,pelvis,andextremities.

21


PracticeBasedLearningandImprovement:Demonstrateselfimprovementthroughacritiqueoftheir
performanceduringpresentationofM&Mcases.

InterpersonalandCommunicationSkills:Demonstratetheinterpersonalskillsandprofessionalism
necessarytoadequatelydiagnoseandtreatavarietyoftraumaticandelectivefootandanklesurgeries.
Demonstratecourtesyandtimelinesswithcolleagues,patients,andancillarystaff.

Professionalism:Demonstrateinitiativeintheneedsofpatientsandprofessionalstaff,showing
honesty,compassion,andrespectforthepatientissuesbothintermsofthemedicaldiagnosisandthe
psychosocialramifications.

SystemsBasedPractice:Demonstrateunderstandingofhowtoworkeffectivelyinvarioushealthcare
deliverysettingsandsystemsforpatientswithfootandankledisorders,includingtheTransferCenter
atStanfordforlowerlimbtraumaticinjuries.Demonstratecollaborationwiththeprosthetistinthe
planningandfittingofvariousorthosesandprostheticdevicesforthelowerlimb.

22

HAND:OVERVIEW

ResidentsinthePGY3yearspendatotaloffourmonthsonthehandservice,whichisan
interdisciplinaryteamcollectivelyknownastheChaseHandandUpperLimbCenter.Therearetwo
residentsontheservice:PGY3inorthopaedics,andPGY4inplasticsurgery.Dr.Hentz,Dr.Ladd,Dr.
Chang,Dr.Yao,andDr.Curtinrepresentthefulltimeacademicfaculty.Theresidentsexperiencehasa
balanceofoperativeandclinicexperienceoftheupperlimb,includingbrachialplexusdisorders.The
twoStanfordhandfellows,boardeligiblesurgeons(PGY6)trainedeitherinorthopaedicorplastic
surgery,serveasliaisonsbetweentheattendingandresidents.Theresidentexperienceiscentraltothe
handrotation.

Theattendingphysiciansconductacomprehensiveeducationprograminwhichconferencesareheld
twiceweekly,coveringvarioussubjectspertinenttohandandupperextremitysurgery.Theseinclude
Mondaymorningchalktalkswiththefellowat7:00amandpreopconferenceat7:30am,and
Wednesday4:30pmdidacticconference.Eachresidentwillbeexpectedtogiveapresentationduring
therotation,coveringasubjectoftheresident'schoice.

Injuriesandconditionsaffectingthenewborntotheelderlyrepresentthebreadthofthepatient
populationseenonthisservice.Theresidentwillparticipateinthecareofcongenitalhandanomalies,
obstetricalpalsies,sportsinjuries,complexreconstructions,andjointreplacementsforarthritic
conditions.

Thetworesidents,alongwiththePGY4onShoulderandElbow,dividetheemergencyroomcallintoa
scheduleofevery1/3night,withbackupeitherwiththehandfelloworthemicrosurgeryfellow,in
conjunctionwiththehandattending.Infectionsandinjuriesinvolvingthehandandcarpusarewithin
theexclusiverealmofthehandsurgeryservice,aswellascomplexinjuriesinvolvingtheupper
extremity,suchasvascularandcomplexnervousinjuries.Treatmentofhandanddistalradiusfractures,
andsofttissueinjuriesoftheentireupperextremity,complementyourgeneralorthopaedicexperience.

TheMondaymorningsessionisheldatSMOCat450BroadwayStinRedwoodCity,andbeginswitha
7:00aminformalchalktalkwiththefellowsandapreopconferencethatreviewscasesandassignments
fortheweek.Theresidentsrotateweeklytopresentpreopcases.Didacticconferencesareheld
Wednesdayafternoonat4:30pm,usuallyinourconferenceroomat770WelchRoad.Lectures,
introductiontohandandupperextremitytherapy,JournalClub,Anatomydissection,andmicrovascular
trainingrepresentthescopeofformaldidacticsessions.Inaddition,athematicrevieworpresentation
ofresearchinprogressisrequired,onatopicofyourchoice.

HAND:RESIDENTGOALSANDOBJECTIVES

DESCRIPTION
Thegoalofthehandrotationistoprovideabreadthofexperienceandexposuretodisordersaffecting
thehand.TheStanfordHandandUpperLimbCenterrepresentthemostcomprehensive
interdisciplinaryprograminthecountryofitskind.Clinicpatientswillbeseenat450BroadwayStreet,
RedwoodCityandLPCHcongenitalhandclinic.OperativeprocedureswillbedoneatStanfordMedicine
OutpatientCenter,450BroadwayStreet,RedwoodCity.

23

RESIDENTROLEANDEXPECTATIONS
Residentsonthehandandupperlimbservice(PGY3)willbeaprimarymemberofthecareteamunder
thesupervisionofattendingstaff.TheresidentwillworkcloselywiththePGY4PlasticSurgeryresident
whowillalsobeonservice,aswellasthefellow.Theresidentwillgainproficiencyinsofttissuehandling
andmicrosurgeryaswellasthetreatmentofabroadvarietyofhandandupperlimbdisorders.

READINGS
AcorecurriculumisusedbasedonthehandtextbookprovidedtoyoufromtheEdwardKimMemorial
BookFund,TrumblesPrinciplesofHandSurgeryandTherapy.Thisisaugmentedbyselectedreadings
andconferencetopicsaschosenbythefacultyandfellow.

GOALSANDOBJECTIVES
Bytheendoftherotation,theresidentwill:

PatientCare:Obtainacumenindiagnosingandproposingtreatmentintheclinicalsetting,and
analyzeavailableinformationtomakediagnosticandtherapeuticdecisionsbaseduponsoundclinical
judgment,bestavailableevidence,andpatientpreferences.Performatanupperresidentlevelin
surgicaltechniquespertainingtosofttissue,nerve,skeletalstructures,andmicrosurgicalprocedures.
Theresidentwillparticipateinselfevaluationandimprovementinthemicrosurgerylabforsurgical
skills.

MedicalKnowledge:Obtainknowledgeandcomprehensionofthebasicdisordersthatafflictthe
upperlimb,andgaininsightintothemethodologyandproceduresincorporatingitstreatment.
Particularemphasisisplacedontheimportanceofinterdisciplinaryapproach.Interpretinginformation
obtainedfromahistoryandphysicalexamination,incorporatingdatafromradiologyandlaboratory
studies,understandinganatomy,andincorporatingthisknowledgeintosurgicalskillsforhandand
microsurgeryisfundamentaltotherequiredknowledge.Softtissuehandling,microvascular
environmentofthelimb,andpathologyofsystemicdiseaseprocessesareasessentialaslearningthe
indicationsforsurgeryandthetypeoffixationchosen.

PracticeBasedLearningandImprovement:Demonstrateselfimprovementthroughacritiqueoftheir
performanceduringpresentationofM&Mcases.

InterpersonalandCommunicationSkills:Demonstratetheinterpersonalskillsandprofessionalism
necessarytoadequatelydiagnoseandtreatavarietyoftraumaticandelectivehandinjuriesand
disorders.Thisreflectsthebehaviorofarolemodeltopeers,juniorresidents,andmedicalstudents.
Demonstratecourtesyandtimelinesswithpatient,family,andprofessionalinteractions.

Professionalism:Demonstratesrespect,compassion,integrity,andhonestyasitrelatestopatient
interaction.Takesinitiativeinaddressingtheneedsofpatientsandpeers;acknowledgesandaddresses
errors,andpursuesselfimprovement.

SystemsBasedPractice:Demonstratecompetenceandabilitytointeractwithoutsideinstitutionsinthe
timelytransferanddecisionmakingprocessfortraumatichandinjuries,andutilizesresourcessuchas
theTransferCenterintheemergentcareofamputateddigitsatoutsidehospitals.Interpretandapply
techniquesandprotocolsinconjunctionwithhand,physical,andoccupationaltherapyasitrelatesto
patientcareandmanagement.UtilizeandsynthesizeoutsideresourcesrangingfromLaneLibraryand
itswealthofolderprimarysources,Lanesonlineresources,professionalonlineresources(American

24

AcademyofOrthopaedicSurgeons,AmericanSocietyofSurgeryoftheHand,AmericanAssociationof
HandSurgeons),PubMed,andothereducationalopportunitieswhichenrichtheclinicalandacademic
educationoftheresident.

25

PEDIATRICS:OVERVIEW

STANFORDCHILDRENSHEALTHSERVICES
PACKARDCHILDRENSHOSPITAL
ORTHOPAEDICSERVICE

Faculty:

LawrenceRinsky,M.D.

JamesGamble,M.D.,Ph.D.

ScottHoffinger,M.D

MeghanImrie,M.D.

JeffYoung,M.D.

JamesPolicy,M.D

CharlesChan,M.D

StephaniePun,M.D

KaliTileston,M.D(FellowJuly2014Aug2015)

Secretary:

PattySiordia

7235243

ClinicNurse:

TerriPena,R.N.

4978263

SurgeryScheduler:

JuanRodriguez

7216831

Clinicworkroom:

4978891

RESIDENTONCALLSCHEDULE
ResidentswillbeoncallforourpatientsatPackardHospitalandanyolderpatientsadmittedtoStanford
UniversityHospital.Theoncallschedulewillbeworkedoutbytheresidentsinamonthlybasiswiththe
assistanceoftheFellowbeginningJuly2014.Ifaresidentisgoingtobeabsentbecauseofvacations,
courses,etc.,he/sheshouldnotifyPattySiordia,AdministrativeAssistant,inadvance,TerriPena,R.N.,
andtheotherresidentsontheChildren'sService.Acopyoftheresident'scallscheduleshouldbegiven
toMrs.Siordia,whowilldistributetotheswitchboard,nursingunits,etc.Whennooutpatientclinicis
scheduled,theresidentoncallmustbeavailabletotheclinicstaff.ThePediatricOrthopaedicresident
willalsobethetriageforanyPediatricOrthopaedicoperative(emergency)cases.

WORKROUNDS
Residentsareexpectedtomakeroundsontheirpatientstwicedaily.Allpatientsaretobeseenonthe
wardthesamedayaftertheirsurgeryasapostopcheck,andanoteshouldbewrittenintheEpic.

SURGICALSCHEDULING
Electivesurgicalschedulingisusuallydonethroughthesurgeryscheduler,JuanRodriguez.DONOT
SCHEDULEELECTIVESURGERYYOURSELFUNLESSASKEDTODOSO.Youwillbeexpectedtoschedule
emergencycasesandsomeaddoncases.

26

ADMISSIONS
ChildrenadmittedastraumapatientsbytheSUMCattendingswillbetransferredtothePackard
Childrensserviceonthenextregularworkingday.

Asacourtesy,residentsmaybeaskedtofollowanoccasionalpatientadmittedbyoneofthecourtesy
faculty.Thisisarareevent.Patientcaremustalwaystakepriority.

RECORDKEEPING
A.Forpreopcases:dictateonLSPCHlineforchildren,SUHlineforadultswhowillbeadmittedtoSUH.

B.Foranypatientadmitted,evenifnotgoingtosurgery,dictatetheH&P.

C.Dischargesummaries:dictateonLSPCHdictationsystemforchildrenandSUMCforadults.Discharge
summariesaredueoneverypatientadmittedanddischargedfromLSPCH.KEEPUPTODATE.Deficiency
noticesaresentweeklyfromMedicalRecords.

D.OperativeNotes:dictatefindingsseparatelybeforeyougointotheoperativetechnique.

OUTPATIENTCLINIC
SURGERY
Dr.Rinsky
MONDAY
Dr.GambleAM
Dr.Imrie
Dr.YoungPM
Dr.HoffingerAMCPMC/PMLPCH
Dr.ChanAMEmeryville/PMWalnutCreek
Dr.PunAM/PMCPMC
Dr.Gamble
TUESDAY
Dr.RinskyAM&PM
Dr.Pun
Dr.ImriePM
Dr.YoungAM&PM
Dr.HoffingerAMEmeryville
Dr.ChanAM/PMEmeryville

WEDNESDAY
Dr.RinskyPMonly
Dr.GamblePMonly
Dr.ImriePMCPMC
Dr.YoungPMMenloClinic
Dr.HoffingerPMEmeryville
Dr.ChanPMLPCH
Dr.Rinsky
THURSDAY
Dr.GambleAM&PM
Dr.HoffingerJohnMuir,
Dr.ImrieAM&PM
CHO.LPCH(4th)
Dr.YoungAM
Dr.ChanPMWalnutCreek
Dr.PunAMCPMC/PMLPCH
Dr.Young
FRIDAY
Dr.RinskyAM
Dr.Chan
Dr.GambleAM
Dr.ImrieAM
Dr.HoffingerAM/PMWalnutCreek
Dr.PunAMRedwoodCity/PMCPMC

Allpatientsmustbepresentedtotheattendingphysician.PLEASEBEINTHECLINICONTIME.

27


TEACHING
A.Medicalstudents,pediatricresidents,andPhysicalMedicine&Rehabilitationresidentsmaybe
assignedtotheoutpatientclinicsandwillshareinpatientcare.

1.Ingeneral,castsmaybeappliedbytheorthopaedicresident,butnotstudentsorPM&R
residents.

2.Medicalstudentsonclerkshipsmakeroundswiththeresidents,seepatientsinOPCand
participateinsurgery.Theorthopaedicresidents,inadditiontoattendingstaff,shouldwelcome
theopportunitytoteachmedicalstudents.

B.ResidentTeachingConference
GeneralPediatricPreoperativeroundsareeveryWednesdayAMbeginningat10am.
EveryotherWednesday:10:45amMotionAnalysisconferencefollowsResidentTeachingconference.
AllTeachingroundsareintheParkerConferenceroomatPackard.

RESEARCH
Residentsareencouragedtoworkwiththeattendingsonresearchprojects.

MORTALITYANDMORBIDITYCONFERENCE
ObtainnumberofoperationsandadmissionsfromPattySiordia.Dictateashortnoteonthe
complicationsofdeathsandgivetoToniWrotenintheDepartmentOffice.

INPATIENTCONSULTATIONS
Residentswillpromptlyseeallinpatientconsultations.Alwayspresenttheconsultationtoanattending
physician.WriteanoteintheEpicanddictateanotetogointoEpicrecord.

LEAVINGTHEHOSPITAL
Ifyouleavethehospitalduringtheweek,lettheorthopaedicnurseknowwhereyouwillbeandhow
youcanbereached.Afterhours,alwaysletthetelephoneoperatorattheLSPCHswitchboardknow
whereyouwillbeandyourbeepernumber.Itisimportanttomakecontactssoallresidentsare
accountedfor,andmaybecontacted,from8:306:30duringtheworkingday.Atnightandon
weekends,theoncallresidentmustbeavailableatalltimes.

PEDIATRICS:RESIDENTGOALSANDOBJECTIVES

DESCRIPTION
Residentswillobserveandparticipateinevaluationandtreatmentplanningforalloutpatientsunderthe
directsupervisionoftheattendingstaffatLucilePackardChildren'sHospital.Theresidentswillassistin
thesurgicaltreatmentofallchildrenundergoingoperativeproceduresatPackardChildren'sand
StanfordHospitals.

Residentswillparticipateinthepostoperativemanagementofallpatientsunderthedirectionofthe
attendingstaff,andevaluateinpatientconsultswithattendingoversight.TherewillbeonePGY3and
onePGY4resident,andoccasionallyaPGY1,ontheservice.

28


RESIDENTROLEANDEXPECTATIONS
Understandtheetiology,pathogenesis,treatmentoptions,andoutcomesinthecareofpediatric
patientswithorthopaedicproblems.Understandtheinherentdifferencesinthecareofthepediatric
populationascomparedtoadultorthopaedics.Becomefluentincurrentareasofpediatricorthopaedic
research.ThePGY4residentwillbegivenmoreresponsibilitiesintheclinicandoperatingroomafter
completionoftheirPGY3rotation.

READINGS
OrthopaedicKnowledgeUpdate:Pediatrics

CONTACT
LarryRinsky,MD(lrinsky@stanford.edu)
ProfessorandChief,PediatricOrthopaedics

GOALSANDOBJECTIVES
Bytheendoftherotation,theresidentwillparticipateinand/orachieve:

PatientCareandSystemsBasedPractice:Competenceinclinicalskillsnecessaryforthepediatricpatient
aswellastheirfamiliesinthehistoryandphysicalexamination.Workeffectivelyinthepediatrichealth
caredeliverysettingandsystemsspecifictothecareofthepediatricpatient.Advocateforquality
patientcareandoptimalpatientcaresystemsandworkingwithdifferentorganizationssuchasChild
ProtectiveServices.

MedicalKnowledge:Informalclinicalteachingduringoutpatientclinicsandintheoperatingsuiteand
participationinthePreoperativePlanningConferenceeachWednesdayatPackardChildren'sHospital,
includingapediatricTeachingConferenceeveryotherWednesdaywillformabasisforanunderstanding
ofpediatricOrthopaedics.ResidentswillalsoreviewoneortwosectionsfromPOSNAwebsiteCore
Curriculum.AmonthlyjournalclubreviewingcurrentissueoftheJournalofPediatricOrthopaedicswill
bedone.

PracticebasedLearningandImprovement:Demonstrationofselfimprovementthroughacritiqueof
theirperformanceduringpresentationofM&Mcases.

InterpersonalandCommunicationSkills:Competenceinthecommunicationwithpediatricpatientsand
theirfamiliesinprofessionalismthroughademonstrationofrespectandcompassionforthevarious
pediatricpatients.

Professionalism:Demonstrationofinitiativeintheneedsofpatientsandprofessionalstaff,showing
honesty,compassion,andrespectforthepatientissuesbothintermsofthemedicaldiagnosisandthe
psychosocialramifications.

SystemsBasedPractice:Abilitytoindependentlyaccessandutilizeoutsideresourcessuchashome
healthcareandanticoagulationservicesinthecareandmanagementofthispatientpopulation.

29

SCVMC:OVERVIEW

SANTACLARAVALLEYMEDICALCENTER
DEPARTMENTOFORTHOPAEDICSURGERY
MONTHLYCALENDAROFTEACHINGEVENTS

A.DAILYAttendingWardRoundsand:

MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
OrthoConference BlueClinic
StanfordGrand
BlueSurgery
BlueClinic
Rounds

PediatricLecture

BlueSurgery
RedSurgery
XRayConference RedClinic
RedSurgery
RedClinic

B.WEEKLY

GrandRounds:Mondaymorning7:309:00AM.FirstMondayofthemonthisPediOrthocases.
XRayConference:Wednesdaymorning(followingGrandRoundsatStanford)at11:30AM.

C.SPECIALTYCLINICS

Thursday:SportsMedicine
Friday:PediatricOrthopaedics

SCVMCORTHOPAEDICRESIDENCYTRAININGPROGRAM
1.TheOrthopaedicSurgeryatSCVMCisatwoservicesystemwithaPGY3,orseniorresident,
responsibleforeachteam.Withthetwoteamconcept,alternatedaysoncallandalternateweekends
oncall,beginningSaturdayandSunday,willbefollowed.TheChiefResidentsdutiesaretotheOR
unlessaresidentisonvacation.

2.Exceptforemergencyabsences,residentsareexpectedtoadvisetheOutpatientOrthopaedicClinic
personnel,his/herteamattending,andtheChairoftheDepartmentofhis/herplannedabsence1.5
monthspriortothedeparturesothattheloadofpatientsassignedcanbedeleted.Failuretodosocan
resultincancellationofthatabsence.

3.Theprimaryfunctionoftheorthopaedicresidentoncallistobeavailableforemergencyconsultation
forthat24hourperiodoftime.IftheOrthopaedicClinicpersonnelandtheattendingarenotified
enoughinadvance,clinicalandoperatingroomresponsibilitieswillbereduced.Theemergencyroom,
thepageoperator,andtheDepartmentOfficearenotifiedofhis/herwhereaboutsforimmediate
response.Pleaseseeregulationsregardinguseofoncallbeepers.

4.Theoncallschedulewillbemadeoutinadvanceattheonsetofthethreemonthrotation.

5.Thechiefresidentsareonafourmonthrotationbasisandthejuniorresidentsareonathreeor2.5
monthrotation.

30

6.UrgentpatientsreferredfromoutsidephysicianswillbeseenintheEmergencyRoomafterclearance
frombedcontrolormaybeadmitteddirectlyorwalkinclinic.

7.Apreoperativenoteshouldbemadebythechiefresidentsoneachpatientonhisserviceandunder
his/hercare.Ahistoryandphysicalnoteshallbedoneoneverypatientadmittedtothehospitalbythe
residentresponsiblefortheadmission.Adischargesummaryshallbedictatedatthetimeofdischarge
oneachpatientbytheresidentresponsibleforthepatient.Anoperativenotewillbedictatedonevery
patient,attheendofthesurgery,bytheresidentresponsibleforthatpatient.

8.Nopatientwillbetakentotheoperatingroomatanytimewithoutconsultationfromtheattending
staff.

9.Thejuniorresidentoncallshouldreviewwithhis/herchiefresidentorattendingbothpreandpost
treatmentxraysonallpatientstreatedduringhisoncallperiod.Thisshouldbedoneattheconclusion
ofhisoncallperiod.Thispermitsafeedbackteachingmechanismfortreatmentrenderedtothepatient
andalsopermitsanalterationoftreatmentplan,ifnecessary.

10.AnOrthopaedicCastTechnicianwillbeavailablefrom3:00PMuntil9:00PMeachdaytoaidinthe
castandtractiontechniques.Anattemptwillbemadetoprovide,priortothe9:00PMdepartureofthe
casttechnician,anorthopaedicbedwithskeletalapparatustobeusedfrom9:00PMuntil8:00AMthe
followingmorning.Thistraumabedislocatedbysterileprocessing.

11.InpatientcastworkwillnotbedoneduringtheOrthopaedicClinichoursintheOutpatientCast
Room.ThistiesuptheOrthopaedicClinicpersonnel,theclinicphysiciansandmaycauseverylengthy
waitsforpatients.

12.AfacultymemberwillbeavailableintheClinicforjuniorresidents,studentsandchiefresident
consultation.

13.TheMondaymorningGrandRoundsConferenceisoneoftheinterestingcasepresentationsto
communityorthopedists.Themosteffectiveformatiscasepresentationpriortotreatmentwithout
revealingtreatment.Theconferencewillstartpromptlyat7:30AM.EachResidentisresponsiblefor
presentationbyhis/herteamofatleasttwocases.Thepresentingresidentwillprepareafiveminute
reviewofcurrentliteratureregardingthecase.

14.AllelectivesurgeriesaretobescheduledbytheChiefResidentthroughthedepartmentsecretary.
Allcasesmustbepresentedtotheattendingpriortoscheduling(theresponsibleattending'snamewill
benotedonthesurgeryboard).Electivesurgeriesmustbescheduledpriorto10:00AMthedaybefore
surgery.

EachOrthopaedicresidentshouldcheckwiththesecretaryatleastonceperdayformessagesasthe
operatorshavebeeninstructedtotransferasmanycallsaspossibletotheOrthopaedicofficefor
messages.Thisisdoneinanefforttorelievetheresidentfromansweringtrivialcallsthatcouldbe
handledelsewhere.
Residentvacationsareassignedwithinasixweekwindow.AllRedteamresidentswilltakevacationin
thefirstsixweeks.AllBlueteamresidentswilltakevacationinthesecondsixweeks.Thisisforeach
threemonthrotation.

31

SCVMC:RESIDENTGOALSANDOBJECTIVES

DESCRIPTION
ResidentrotationatSantaClaraValleyMedicalCenterincludestworotationsperyearinthePGY2,
PGY3,andPGY5years.RotationsaredividedbetweentheRedteamandtheBlueteamwith23
monthsineachyearrespectivelyspentoneachteam.

RESIDENTROLEANDEXPECTATIONS
Thisvariesgreatlydependingtheresidentyear:

PGY2
Rotationsareessentiallythesameonlywithadifferentsetoffacultymembers.Therotationforthe
PGY2yearisageneralrotationwithprimaryorientationtotraumaanditsramifications.ThePGY2
residentisresponsibleforthehistoryandphysical,operativeanddischargesummaryreports,aswellas
daytodayroundsonpatientsassignedtohim/her.Inaddition,therearetwoclinicsperweekandthe
residentisexpectedtopresenthis/hercasesattheWednesdayinpatientconference.ThePGY2
residentmayalsoberequiredtopresentcasesattheMondaymorningGrandRoundsonassignment
fromeithertheChiefResidentorattendingonthatservice.

PGY3
ThePGY3residentisalsoinvolvedwithtrauma,butgainsexposuretosportsmedicineandpediatric
orthopaedicsaswell.

PGY5
TheChiefResidentisresponsibleforthedaytodayrunningofhis/herteam.S/heisresponsibleforthe
assignmentofcasesintheoperatingroomtotheappropriatejuniorresident.S/heisexpectedto
functionasajuniorfacultymemberwithregardstoinstructionintheartoforthopaedicsurgerytothe
juniorresident.TheChiefResidentisresponsibleforallinpatientconsultationsonhis/herdayofcall.
InpatientconsultationswillremainwiththeChiefResident.TheChiefResidentisresponsibleforthe
operatingroomscheduling.

READINGS
OrthopaedicKnowledgeUpdate:Trauma
RockwoodandGreen:FracturesinAdultsandChildren

GOALSANDOBJECTIVES
Bytheendofthisrotation,theresidentwill:

PatientCare:Obtainacumenindiagnosingandproposingtreatmentintheclinicalsetting,andanalyze
availableinformationtomakediagnosticandtherapeuticdecisionsbaseduponsoundclinicaljudgment,
bestavailableevidence,andpatientpreferences.

MedicalKnowledge:Obtainknowledgeoftrauma,sportsmedicine,andpediatricorthopaedicinjuries
anddisordersincludingpatientmanagementskillstodiagnoseandtreatthesedisorders.

32

PracticeBasedLearningandImprovement:Demonstrateselfimprovementthroughacritiqueoftheir
performanceduringpresentationofM&Mcases.

InterpersonalandCommunicationSkills:Competenceintheinterpersonalskillsandprofessionalism
necessarytotreatpatientsattheSantaClaraValleyMedicalCenter,withspecialfocusoncareofthe
indigentpatientandabilitytoaccessoutsideresourcesforassistancetothesepatientsoncedischarged
fromthehospitalorclinic.

Professionalism:Demonstrateinitiativeintheneedsofpatientsandprofessionalstaff,showinghonesty,
compassion,andrespectforthepatientissuesbothintermsofthemedicaldiagnosisandthe
psychosocialramifications.

SystemsBasedPractice:TheabilitytoutilizeandaccessthetechnologyavailableattheSantaClara
ValleyMedicalCentertoevaluateimagingstudiesandaccessadditionalinformationtoassistinthecare
oftheirpatients.

33

SPINE:OVERVIEW

WelcometotheOrthopaedicSpineService.Youwillspendseveralmonthsontheserviceandthiswillbe
yourmostconcentratedandspecificexposuretospinaldisordersduringyourresidency.Youmustbe
motivatedanddedicatedtomakingthemostofthistimeandexperience.Thereisatremendous
amounttolearnandarelativelyshortperiodoftimetodoso.Bycloselyfollowingtheguidelinesbelow
youwillgetthemostoutoftherotationandbestcontributetotheserviceatalevelappropriatetoyour
training.

Theprimaryskillsacquiredduringthisrotationare:1)diagnosisofcommonspinaldisorders;2)
outpatientmanagementofcommonspinaldisorders;3)inpatientmanagementofpreandpost
operativespinalsurgerypatients;4)patientcarecoordinationwithassociatepractitioners(Fellow,PA
andRNs)alsocaringforpatientsontheservice;5)fundamentalsofworkerscompensationandcivil
litigationdocumentationandstrategiesinpatientcare.

Eachofyouwillbeassignedtooneoftheattendingstobetheprimaryhousestaffforthatperiod(going
tothatfacultysclinicandsurgery).Thethreeattendingservicesare:1)Hu,2)Alamin,3)Cheng.We
havethreePAsfortheservice,twoofwhomwillberelativelynew;theywillhaverotationsalsoand
coverasneeded.Itistheresponsibilityofbothresidentstoknowtheentirewardserviceforallthe
attendingsandcommunicateamongtheteam.

Ofequalimportanceistheacquisitionofsurgicalskillstoperformspinalsurgery.Residentsmustlearn
thebasicsurgicalanatomy,safeandexpeditiouspositioningofsurgicalpatientsandprimaryexposures,
bonegraftharvestingandpreparation,andwoundclosures.Residentsmasteringtheseskillsinthefirst
halfoftherotationwillbeadvancedtosimpledecompressionandinstrumentationtechniques.

Yourdutiesarespecifiedbelow.Failuretoperformtominimumstandardwillresultinanunsatisfactory
performanceratingfortherotation.AsatisfactoryratingisrequiredforBoardCertification.

SPECIFICRESPONSIBILITIES
AMRoundsmustbeperformedandnoteswritteninfullbeforethefirstscheduleddailydutyofclinic,x
rays/grandroundsand/orOR.Thisisperformedasateamtogetherwiththefellowsinordertobe
familiarwithallofthespinepatientsinhouse.Adequatetimemustbegiventoaccomplishthis.Tothat
endroundsshouldbeginNLT06000615inordertobeintheORandmarkthepatientsby0710.This
mayneedtobeearlieriftheservicehasmanypatientsorseveralverysickpatients.Timemanagement
isaclinicalskillandfailingtocompleteroundsontimereflectspoorclinicaljudgment.Youmustexpect
thateverythingwillnotbefineonroundsandgivetimetotroubleshootbeforeyournextobligation
arrives.

Rounds:Allpatientsmustbeseeneachdayeveryweekdaybytheresident.Itisnotacceptablefor
patientstobeseenexceptonweekends.Whenpossible,youshouldcommunicateanychangesinstatus
notedonroundstotherelevantattendingearlyinthemorningbefores/hemakesrounds,and
significantchangescommunicatedasneeded.ICUpatientsandothersthosewhoneedfollowup
evaluationshouldbeseenintheearlyeveningaswell.

AllpatientsreturningfromthePARshouldbeseenwhenbackontheward.Aclearnotewithtimeseen
mustbeinchartdocumentingexaminationwhenthepatientleavesthePAR.Notepainstatus,radicular

34

pain,orientation,neurologicstatusdescription(i.e.NVIisinadequate),dressing,drainageand
mobilizationplan.

Weekenddutiesaredividedbetweentheserviceresidentsandoncallresidents.Oneortheothermust
roundifthereareinpatientsorconsultsinhouse.Youwillbeexpectedtoupdatetheattendingsas
requested.

Timeliness:Reporttimes,inscrubsandinappropriateORforsurgerydaysare0710ifcasesare
scheduled.OnWEDreporttimeis1000afterGrandRoundsforpreopcaseconferenceinRedwoodCity.
Residentsmustknowthecasestatusandcheckeacheveningifunsure.Reporttimeforclinicis5
minutesbeforefirstscheduledpatient.OnceagainthatmeansatRedwoodCityandreadytosee
patients.Iftheresidentislatefordutytwiceduringtherotation,theywillbewarnedandthereafter
recommendationmadetheybeplacedonprobation.Repeatedtardyperformancewillbeconsideredto
constituteunsatisfactoryperformancefortherotation.Cleanandprofessionalappearanceisexpected
inclinic;scrubsarenotpermittedexceptunderunusualcircumstances.

Atleastoneafternoonperweek(thedaydependsinthefacultymembersclinic/ORschedule)PMis
researchtimedesignatedforresidentprojects.

Holiday:Vacationweekwillbepickedbythe1stFridayontherotationandclearedregardingconflicts
withSueGokeyGonzalez,thespineserviceadministrativeassistant,andthenapprovedbyDr.Huor
designateortwomonthsbeforevacationstarts,whicheverisearlier.Ifaweekhasnotbeenpickedone
willbeassigned.Theresidentmaynottakeoffthefirstorlastweekoftheservice,orwhenaPAwillbe
gone,orwhentheStanfordservicewillnothaveadequatecoverageperDr.Maloneysdirections.

ClinicNotes:Onclinicdays,theresidentwillseepatientsinclinic.Ataminimum,theresidentwillsee
mostofthenewpatientsandfollowupsasableandpresentthesetotheattendinginaclear,focused
andrelevantfashion.Forthenewpatients,theresidentmustdoacomprehensivehistoryandphysical
examinationanddictatethesefortranscription.Writtennotesshouldbetakenanddictations
completedaftertheclinictooptimizepatientflow.Theresidentwillproofreadthesenotesandmake
necessarycorrections.Theresidentsevaluationwillbestronglydeterminedbythedepthofclinical
understandingdemonstratedinthesereports.

HospitalDictations:ORandDischargeSummariesmustbedoneonthedateofservice.Keepthelog
numberstoverifycompletion.Theattendingwilldeterminewhoshoulddictatethesurgicalreport.The
attendingmayelecttodothedictationbuttheresidentmustbeabsolutelyclearthishasbeendone
sinceitishisorherresponsibility.Ifthereisanyquestion,confirmwiththefelloworattendingthatthe
dictationhasbeendone.Thedictationdateisannotatedonalltranscriptionsandwillbechecked.Same
daydictationsaretheminimumacceptablestandard.

Nightcall:seeseparatepolicysheet.

NeurosurgeryandOrthopaedicSurgeryalternatecalleachweekforinpatientspineconsults,EDspine
consults,transferofspinepatientsandcodedtraumaspinepatientconsults.Fornationalholidayson
Mondays,thepreviousweekofcallextendsthroughthatMondayandendsonTuesdaymorning.

35

CoverageforEDandconsultspinepatientsistakenonarotatingweeklybasisunlessthereferring
doctor(orpatient)specificallyrequestsaspecificattending;inthatcasetheconsult/referralgoestothe
specificattending.

Allconsult,admissionnotesneedtobedesignatedasrequiringanattendingcosign.

Theattendingoncallshouldbeinformedofallnewconsultswithunstablethoracolumbarfractures,
cervicalfractures,tumors,infectionsorneurologicdeficitsassoonascalledfortheconsult.

Duringthedayfrom7amto6pm,thespinejuniorresidentwilltakeallcallsforspineconsults.The
backupforthespinejunioristhespineseniorresidentorgeneralorthoseniorresidentoncall.

TheSpineattendingoncallistobepresentforanyspinefracturereductionsandforanyoperative
cases.

Forpatientswithpolytrauma,themostsevereinjurydictatestheservicetowhichthepatientgoesand
shouldbedeterminedattheattendinglevelonacasebycasebasis.Forexample,apatientwithadistal
radiusfractureandathoracolumbarburstfractureshouldbemanagedbytheSpineteam.Ontheother
hand,apatientwithanopenbookpelvicinjuryandlumbarspinousprocessfracturesshouldbe
managedbytheTraumateam.

AnyrequeststoclearthecervicalspinearetobeobligedbytheOrthopaedicdepartment.

BesuretoevaluateentirespinefromC1tosacrum.

Afterevaluatingthepatient,writeaninitialshortnoteinchartwithdateandtime.Noteshouldcontain
consultingteam/physician,initialdiagnosis,spineattending,planandnotetofollow.Forexample,
CalledbyDr.XinGeneralSurgerytoseepatient.Diagnosis:bilateralC56jumpedfacetsina
neurologicallyintactpatient.DiscussedwithDr.Spine.Plan:MRICspine,closedversusopenreduction
inOR.Fullnotetofollow.Remember:
a.tomarktheEPICnoteasaConsultation;
b.associatethenotewiththeORDERforCONSULTATION(ifdone);
c.markforCOSIGNbyattending.

Ifthespineattendingoncalldoesnotreturnapage/text/callwithin10minutes,firstcallSueinthe
spineofficetolocatetheattending.Ifthatattendingisunavailable,callanyofthethreeother
attendingsforassistance.TheSpineServicecoverageschedulesenteachmonthbySuedelineates1st
and2ndcallsaswellasbackupcallsforattendings.

Callsforhospitaltransfersshouldbetriageddirectlytotheattendingoncall.

Narcotics:Spinepatientsoftenhavetroublewithnarcoticdependency,addictionandabuse.Patients
canbeexpectedtotakenarcoticsforseveralweeksafterdecompressivesurgeryandperhapsseveral
monthsafterfusionsurgery.Atdischargebeabsolutelyclearwiththepatienthowmuchtheyshould
take.Giveatleasttwoweeksworthofmedicationunlesspatientdefers.Telephonerenewalsshouldbe
doneduringtheday.Ifthereisaquestion,callthePAorattending.Ifthepainissobaditcannotbe
tolerated,seethepatientintheERatnightorintheclinicduringbusinesshours.Thegeneralguideline
isthatnoprescriptionsshouldbegivenafterofficehours.

36

Eachresidentwillreceiveaninformalevaluationbyanattendingatthemidpointoftheirrotationanda
formalevaluationattheend.Theresidentshouldscheduletheirmidrotationevaluationwiththe
attendingwithwhomtheyhaveworkedmost.

IFANYTHINGISNOTCLEARTOYOUABOUTTHESEDIRECTIONSFORAPPROPRIATESERVICEDUTY,YOU
MUSTSPEAKWITHDR.HUANDHAVETHISCLARIFIEDBEFORETHESTARTOFTHESERVICECALLDR.
HU,OFFICEAT7217616,ORONCELLPHONEAT4153507209.

SPINEREADINGLIST(ArticlesinboldaremarkedforthePGY2level)

AdolescentIdiopathicScoliosis
BernhardtM,BridwellKH.Segmentalanalysisofthesagittalplanealignmentofthenormalthoracic
andlumbarspinesandthoracolumbarjunction.Spine14(7):71721.

BetzRRetal.Anteriorversusposteriorinstrumentationforthecorrectionofthoracicidiopathic
scoliosis.Spine26(9):10951100,2001.

DavidsJR,ChamberlinE,BlackhurstDW.Indicationsformagneticresonanceimaginginpresumed
adolescentidiopathicscoliosis.JBoneJointSurgAm.86:21872195,2004.

KingHAetal.Theselectionoffusionlevelsinthoracicidiopathicscoliosis.JBoneJointSurg65(9):1302
13,1983.

LenkeLG,BetzRR,HarmsJ,BridwellKH,ClementsDH,LoweTG,BlankeK.Adolescentidiopathic
scoliosis:Anewclassificationtodetermineextentofspinalarthrodesis.JBoneJointSurg.Am.
83:11661181,2001.

WeinsteinSL.Naturalhistory.Spine1999,24(24):25922600.

AdultDeformity
BaronEM,AlbertTJ:Medicalcomplicationsofsurgicaltreatmentofadultspinaldeformityandhowto
avoidthem.Spine,31(19Suppl):S10618,2006.

BridwellKH.DecisionmakingregardingSmithPetersenvs.pediclesubtractionosteotomyvs.
vertebralcolumnresectionforspinaldeformity.Spine31(19S)Suppl:S17178,2006.

BridwellKHetal.TheprosandconstosavingtheL5S1motionsegmentinalongscoliosisfusion
construct.Spine28(20S)Suppl.S23442,2003.

EckKR,BridwellKH,UngactaFF,RiewKD,LappMA,LenkeLG,BaldusCandBlankeK.:Complications
andresultsoflongadultdeformityfusionsdowntoL4,L5,andthesacrum.Spine,26(9):E18292,
2001.

EdwardsCC,BridwellKH,PatelA,RinellaAS,BerraA,andLenkeLG:LongadultdeformityfusionstoL5
andthesacrum.Amatchedcohortanalysis.Spine,29(18):19962005,2004.

GlassmanSD,BridwellK,DimarJR,HortonW,BervenS,andSchwabF:Theimpactofpositivesagittal
balanceinadultspinaldeformity.Spine,30(18):20249,2005.

37


KimYJ,BridwellKH,LenkeLG,RhimS,ChehG:Pseudarthrosisinlongadultspinaldeformity
instrumentationandfusiontothesacrum:Prevalenceandriskfactoranalysisof144cases.Spine,
31(20):23292336,2006.

KukloTR:Principlesforselectingfusionlevelsinadultspinaldeformitywithparticularattentionto
lumbarcurvesanddoublemajorcurves.Spine,31(19Suppl):S1328,2006.

LoweT,BervenSH,SchwabFJ,BridwellKH:TheSRSclassificationforadultspinaldeformity:buildingon
theKing/MoeandLenkeclassificationsystems.Spine,31(19Suppl):S11925,2006.

PotterBKetal.Preventionandmanagementoftheiatrogenicflatbackdeformity.CurrentConcepts
Review.JBoneJointSurg,86A(8):17931808,2004.

Cervical
EdwardsCCetal.Corpectomyversuslaminoplastyformultilevelcervicalmyelopathy:Anindependent
matchedcohortanalysis.Spine2002;27(11):116875.

HellerJG,SassoRC,PapadopoulousSM,etal.ComparisonofBRYANcervicaldiscarthroplastywith
anteriorcervicaldecompressionandfusion:clinicalandradiographicresultsofarandomized,
controlled,clinicaltrial.Spine2009;34(2):101107.

HilibrandAS,CarlsonGD,PalumboMA,JonesPK,BohlmanHH.Radiculopathyandmyelopathyat
segmentsadjacenttothesiteofapreviousanteriorcervicalarthrodesis.JBoneJointSurgAm81:519
28,1999.

MummaneniPV,BurkusJK,HaidRW,etal.Clinicalandradiographicanalysisofcervicaldiscarthroplasty
comparedwithallograftfusion:arandomizedcontrolledclinicaltrial.JNeurosurgSpine2007;6(3):198
209.

PatelCK,FischgrundJ.Complicationsofanteriorcervicalspinesurgery.InstrCourseLect2003;52:465
469.

RaoRD,CurrierBL,AlbertTJ,BonoCM,MarawarSV,PoelstraKA,EckJC.Degenerativecervical
spondylosis:clinicalsyndromes,pathogenesisandmanagement.JBoneJointSurgAm.2007
Jun;89(6):136078.

RaoRD,GourabK,DavidKS.Operativetreatmentofcervicalspondyloticmyelopathy.JBoneJoint
SurgAm.2006Jul;88(7):161940.

Degenerative
AtlasSJ,DelittoA.Spinalstenosis:surgicalversusnonsurgicaltreatment.ClinOrthopRelatRes
2006;443198207.

AtlasSJ,KellerRB,WuYA,DeyoRA,SingerDE.Longtermoutcomesofsurgicalandnonsurgical
managementofsciaticasecondarytoalumbardischerniation:10yearresultsfromthemainelumbar
spinestudy.Spine2005;30:92735.

38


BassewitzH,HerkowitzH.Lumbarstenosiswithspondylolisthesis:currentconceptsofsurgical
treatment.ClinOrthopRelatRes2001;(384):5460.

CarreonLY,GlassmanSD,HowardJ.Fusionandnonsurgicaltreatmentforsymptomaticlumbar
degenerativedisease:asystematicreviewofOswestryDisabilityIndexandMOSShortForm36
outcomes.SpineJ.2008SepOct;8(5):74755.

Fusionandnonsurgicaltreatmentforsymptomaticlumbardegenerativediseaseasystematicreviewof
OswestryDisabilityIndexandMOSShortForm36outcomes.pdf

HerkowitzHN,KurzLT.Degenerativelumbarspondylolisthesiswithspinalstenosis:aprospectivestudy
comparingdecompressionwithdecompressionandintertransverseprocessarthrodesis.

HilibrandAS,RandN.Degenerativelumbarstenosis:diagnosisandmanagement.JAmAcadOrthop
Surg1999;7:239249.

SpivakJM.Degenerativelumbarspinalstenosis.JBoneJointSurgAm1998;80:10531066.

WeberH.Lumbardischerniation:acontrolled,prospectivestudywithtenyearsofobservation.Spine
1983;8:131140.

WeinsteinJN,LurieJD,TostesonTD,HanscomB,TostesonAN,BloodEA,BirkmeyerNJ,HilibrandAS,
HerkowitzH,CammisaFP,AlbertTJ,EmerySE,LenkeLG,AbduWA,LongleyM,ErricoTJ,HuSS.Surgical
versusnonsurgicaltreatmentforlumbardegenerativespondylolisthesis.NEnglJMed.2007May
31;356(22):225770.

WeinsteinJN,LurieJD,TostesonTD,SkinnerJS,HanscomB,TostesonANA,HerkowitzH,FischgrundJ,
CammisaFP,AlbertT,DeyoRA.SurgicalvsNonoperativeTreatmentforLumbarDiskHerniation:The
SpinePatientOutcomesResearchTrial(SPORT)ObservationalCohortJAMA.2006;296:24512459.

WeinsteinJN,TostesonTD,LurieJD,TostesonAN,HanscomB,SkinnerJS,AbduWA,HilibrandAS,Boden
SD,DeyoRA.SurgicalvsNonoperativeTreatmentforLumbarDiskHerniation:TheSpinePatient
OutcomesResearchTrial(SPORT):ARandomizedTrialJAMA.2006;296:24412450.

WeinsteinJN,TostesonTD,LurieJD,TostesonAN,BloodE,HanscomB,HerkowitzH,CammisaF,
BodenSD,HilibrandA,GoldbergH,BervenS,AnH;SPORTInvestigators.Surgicalversusnonsurgical
therapyforlumbarspinalstenosis.NEnglJMed.2008Feb21;358(8):794810.

Infection
FangA,HuSS,EndresN,etal.Riskfactorsforinfectionafterspinalsurgery.Spine2005;30(12):1460
5.

KleinJD,HeyLA,YuCS,etal.Perioperativenutritionandpostoperativecomplicationsinpatients
undergoingspinalsurgery.Spine1996;21(22):267682.

OlsenMA,MayfieldJ,LauryssenC,etal.Riskfactorsforsurgicalsiteinfectioninspinalsurgery.J
Neurosurg(Spine2)2003;98(20):14955.

39


OlsenMA,NeppleJJ,RiewKD,LenkeLG,BridwellKH,MayfieldJ,FraserVJ.Riskfactorsforsurgicalsite
infectionfollowingorthopaedicspinaloperations.JBoneJointSurgAm.2008Jan;90(1):629

SassoRC,GarridoBJ.Postoperativespinalwoundinfections.JAmAcadOrthopSurg.2008
Jun;16(6):3307.

Trauma
BrackenMB,ShepardMJ,HolfordTR,etal.Administrationofmethylprednisolonefor24or48hoursor
tirilazadmesylatefor48hoursinthetreatmentofacutespinalcordinjury:resultsofthethirdnational
acutespinalcordinjuryrandomizedcontrolledtrial:Nationalacutespinalcordinjurystudy.JAMA
1997;277:15971604

DenisF.Spinalinstabilityasdefinedbythethreecolumnspineconceptinacutespinaltrauma.Clin
Orthop1984;189:6576.

JacksonRS,BanitDM,RhyneALIII,DardenBV.Uppercervicalspineinjuries.JAmAcadOrthoSurg
2002;10:271280.

KwonBK,VaccaroAR,GrauerJN,etal.Subaxialcervicalspinetrauma.JAmAcadOrthoSurg
2006;14:7889

PanjabiMM,ThibodeauLC,CriscoJJ,WhiteAA.Whatconstitutesspinalinstability?ClinNeurosurg
1988;34:313339.

SpivakJM,VaccaroAR,CotlerJM.Thoracolumbarspinetrauma:I.Evaluationandclassification.JAm
AcadOrthoSurg1995;3:345352.

SpivakJM,VaccaroAR,CotlerJM.Thoracolumbarspinetrauma:II.Principlesofmanagement.JAm
AcadOrthoSurg1995;3:353360.

VaccaroAR,DaughertyRJ,SheehanTP,etal.Neurologicoutcomeofearlyversuslatesurgeryforcervical
spinalcordinjury.Spine1997;22:26092613.

VaccaroAR,LehmanRAJr.,HurlbertRJ,etal.Anewclassificationofthoracolumbarinjuries:the
importanceofinjurymorphology,theintegrityoftheposteriorligamentouscomplex,andneurologic
status.Spine2005;30:232533.

Tumor
AmesCP,WangVY,DevirenV,VrionisFD.Posteriortranspedicularcorpectomyandreconstructionof
theaxialvertebraformetastatictumor.JNeurosurgSpine.2009Feb;10(2):1116.

BorianiS,WeinsteinJN,BiaginiR.Primarybonetumorsofthespine:terminologyandsurgicalstaging.
Spine1997;22:10361044.

ChiJH,GokaslanZL.Vertebroplastyandkyphoplastyforspinalmetastases.CurrOpinSupportPalliat
Care.2008Mar;2(1):913.

40

GalaskoCS,NorrisHE,CrankS.Spinalinstabilitysecondarytometastaticcancer.JBoneJointSurgAm
2000;82(4):57094.

PatchellRA,TibbsPA,RegineWF,etal.Directdecompressivesurgicalresectioninthetreatmentof
spinalcordcompressioncausedbymetastaticcancer:arandomizedtrial.Lancet2005;366:6438.

TokuhashiY,MatsuzakiH,ToriyamaS,etal.Scoringsystemforthepreoperativeevaluationof
metastaticspinetumorprognosis.Spine1990;15:11101113.

WhiteAP,KwonBK,LindskogDM,FriedlaenderGE,GrauerJN.Metastaticdiseaseofthespine.JAm
AcadOrthopSurg2006;14(11):58798.

SPINE:RESIDENTGOALS&OBJECTIVES

DESCRIPTION
Residentswillobserveandparticipateinthediagnosisandmanagementofspineinjuriesanddisorders
duringan810weekrotation.

RESIDENTROLEANDEXPECTATIONS
Theresidentwilltakeresponsibilityinthediagnosisandmanagementofspineinjuriesanddisorders
underthedirectsupervisionoftheattendingstaff.

READINGS
OrthopaedicKnowledgeUpdate:Spine

CONTACT
SerenaS.Hu,MD

GOALSANDOBJECTIVES
Bytheendofthisrotation,theresidentwill:

Patientcare:Attainprimaryskillsin:
a.diagnosisofcommonspinaldisorders
b.competencyinspinalandneurologicalexamination
c.basicreadingofspinalimagingstudies
d.interpretationofspecialtests:discography,diagnosticblocks,EMG
e.herniatedcervicalandlumbardiscs
f.spinalstenosis
g.commonbackache
h.spondylolisthesis
i.spinaldeformity
j.metastaticdisease

MedicalKnowledge:Obtainknowledgeandcomprehensionofcommonsurgicalapproaches,
nonoperativeandoperativetreatmentoptionsforspinaldisorders/conditions.Obtainknowledgefor
theworkup,classification,andtreatmentoptionsfortheseproblems.

41


PracticeBasedLearningandImprovement:Demonstrateselfimprovementthroughacritiqueoftheir
performanceduringpresentationofM&Mcases.

InterpersonalandCommunicationSkills:Demonstrateinterpersonalskillsandprofessionalismnecessary
toadequatelyeducateapatientontheirdiagnosisandconveytherisks,benefits,andcomplicationsof
availabletreatmentoptions.Demonstratecourtesyandtimelinesswithcolleagues,patients,and
ancillarystaff.

Professionalism:Demonstrateprofessionalismandinterpersonalskillsnecessaryforinpatient
managementofpreandpostoperativespinalsurgerypatients.

SystemsBasedPractice:Achievecompetenceinpatientcarecoordinationwithassociatepractitioners
(Fellow,PAandRNs)alsocaringforpatientsontheservice.Abilitytoworkwithoutsideservices
includingworkerscompensationandcivillitigationdocumentationandstrategiesinpatientcare.

42

SPORTSMEDICINE:OVERVIEW

Thecurriculumofthesportsmedicinerotationwillconsistofevaluatingpatientsinaclinicsetting,
assistinginsurgery,participatingindidacticsportsmedicineconferences(everyTuesdayincludinggiving
1presentation),participatinginaSocraticmultidisciplinarysportsmedicineconference(threeMondays
amonth),participatinginbimonthlyjournalclub,practicinginaquarterlycadavericarthroscopiclab,
workingwithaphysicaltherapist,andinsomesituations,participatinginaresearchproject.

OUTPATIENTCLINIC
Theresidentwillbetaughtphysicalexamtechniquesrelatedtosportsmedicinedisorders,particularly
oftheshoulder,elbow,kneehipandwristandhand.
Theresidentwillbeeducatedaboutbothnonoperativeandoperativetreatmentmethods.

SURGERYASSISTANCE
Theresidentwillbetaughtthebasicsofkneeandshoulderarthroscopy.
Theresidentshouldattheendoftherotationbeabletodemonstrateproficiencyinthesetwo
procedures.
Theresidentmayalsobeexposedtothebasicsofarthroscopyofthehip,elbow,wristandankle.
TheresidentwillbetaughthowtoassistinmorecomplicatedproceduressuchasACLreconstruction
andarthroscopicrotatorcuffrepair.

Thecontentofthesportsmedicinerotationwillincludebutnotbelimitedtothefollowingtopics:

OveruseSyndromes
StressFractures,Tendonitis,ExertionalCompartmentSyndrome

InjuriesintheImmatureAthlete
TibialSpineAvulsioninjuries,OsteochrondritisDissecans,DiscoidMeniscus,Apophysitis,etc.

CervicalandLumbarSpineInjuries
Incidence,treatmentandpreventiontechniques

ShoulderDisordersandInjuries
RotatorCuffTears,ShoulderInstability,SLAPLesions,ACJointDysfunction

ElbowDisordersandInjuries
Tendonitis,LigamentInjuries,OCD,BicepsTendonInjuries

HandandWristDisordersandInjuries
Uniqueaspectsofthesedisordersastheyrelatedtosportsmedicine

KneeDisordersandInjuries
Ligamentinjuries,Meniscalinjuries,ChondralInjuries,Arthritisinayoungathlete,KneeBracing

HipDisordersandInjuries
LabralInjuries,FemoroacetabularImpingement,ChondralInjuries,SportsHernia,OsteitisPubis,etc

43

FootandAnkleDisorders
AnkleInstability,AchillesTendonitis/Tears,AnkleArthroscopy

Rehabilitation,ExercisePhysiologyandStrengthTraining

SportsRelatedTumors
Introductiontobenignandmalignanttumorsthatmimicsportsinjuries

OtherContent
Concussions,SportsRelatedMedicalProblems(dermatology,nutrition,cardiology,pulmonary)
NutritionalSupplements,SteroidUseandAbuse

WEEKLYSCHEDULE

Safran
Fanton
McAdams
Dragoo

Monam

Clinic

49ers(occclinic)

OR

Monpm

Arrillaga

Clinic

OR

Tuesam

OR

Clinic7:302

OR2Rooms

Clinic

Tuespm

OR

Clinic7:302

OR2Rooms

Clinic

Wedam

Academic OR2Rooms

Clinic(afterGR)

Arrillaga(afterGR)

Wedpm

Academic

OR2Rooms

Academic

Clinic

Thursam

Clinic

Clinic

Clinic

OR2Rooms

Thurspm

Clinic

Clinic

OR2Rooms

Friam

OR

OReveryotherweek OR

PTClinicuntil9:30am

Fripm

OR

Academic

OR

SPORTSMEDICINE:RESIDENTGOALSANDOBJECTIVES

DESCRIPTION
Residentswillobserveandparticipateinthecareofthesportsmedicinepatient.

RESIDENTROLEANDEXPECTATIONS
Asaprimaryfunction,theroleoftheresidentwillbetoperformmajorandminoroperationsinthe
capacityofprimaryorassistantsurgeon.Theresidentandfellowwillalsoparticipateininitial
evaluation,perioperativecare,andnonoperativetreatmentoforthopaedicinjuriesanddiseases,
includingthoseoftheknee,shoulder,elbowandhip,inadditiontogeneralorthopaedicsandsports
medicine.TherewillbeincreasedclinicalandoperativeresponsibilitiesofthePGY3rotationasfollows:

44


PGY3
Bytheendofthesportsrotation,thejuniorresidentshouldbecompetentinperformingacompleteand
thoroughexaminationoftheshoulder,elbow,hipandknee.Theresidentshouldlearntheskillsto
examineanathletebothonandoffthefield.Skillsneedtobedevelopedtoobtainhistoryandphysical
examinationwiththeinjuredathlete.Theresidentshouldalsobecompetentinidentifyingvarious
sportspathologyandinitiatingtheappropriateworkup.Theresidentshouldbeawareofthenatural
historyandrecommendtreatmentforcommonoverusesyndrome,ligamentdeficienciesandfractures.
TheyshouldbecomfortableindiagnosingcommonsportsinjuriessuchasACLruptures,meniscaltear,
rotatorcuffrupture,impingementsyndromeandelbowligamentinjuries.Theyshouldbefamiliarwith
variousworkupforsuchpathology,suchasinjections,provocativetests,classicsymptomsandmagnetic
resonanceimaging.Withthisrotation,theresidentshouldbecompetentininterpretingvariousspecific
radiographicviewsforspecificpathology,e.g.RosenbergViewformildkneeDJDandAxillaryviewto
lookforOsAcromiale,etc.SincealotofdiagnosesarealsomadewiththeassistanceofMRI,residents
shouldbecomfortableininterpretingMRIoftheshoulderandknee.

Theresidentshouldconcentrateonthedevelopmentofsurgicalskillsinthevariousexposuresforthe
shoulder,elbow,hipandknee.Duringthisrotation,theyshoulddevelopcompetencyinarthroscopy.
Thisrotationshouldprovideampleopportunitytoimprovetheirarthroscopytechnique.Juniorresidents
shouldbeabletoperformsimplediagnosticarthroscopyofthekneeandshoulderbeforetheendofthe
rotation.IfworkingwithDr.Safran,theyshouldalsobeabletoperformsimplediagnostichip
arthroscopy.Besidesmasteringsimplesurgicalprocedures,theresidentshouldunderstandthepossible
complicationsoftheseoperationsandbeabletoidentifysignsandsymptomsofpatientswith
complicationsfollowingtheseoperations.

READINGS
1.ManualofSportsMedicineSafran,McKeag,VanCamp
2.OrthopaedicKnowledgeUpdateSportsMedicine2
3.OrthopaedicKnowledgeUpdateShoulderandElbow
4.OrthopaedicKnowledgeUpdate6
5.KneeSurgeryFu,Harner
6.ReviewofSportsMedicineandArthroscopyMiller
7.TheHughstonClinicSportsMedicineBookBaker
8.SurgicalExposuresinOrthopaedicsHoppenfeld

CONTACT
MarcSafran,MDmsafran@stanford.edu

GOALSANDOBJECTIVES
Bytheendoftherotation,theresidentwill:

PatientCare:Attainthesurgicalskillsnecessaryfortriangulationinshoulderandkneearthroscopy.The
residentshouldbecompetentinbasicshoulderandkneearthroscopicproceduresbytheendofthe
rotation.Theresidentwillalsobeexposedtowrist,elbow,andhiparthroscopyduringtherotation.

MedicalKnowledge:Gainknowledgeofthefollowingtopics:
1.Biomechanicsofligaments
2.Shoulder,elbowandkneebiomechanics

45

3.Commonelbowpathology,includingligamentinsufficiency,overusesyndrome
4.Kneeligamentreconstruction,ACLMCL,PCL,PLCandmultiligamentinjuredknees
5.Meniscalpathology
6.Osteochondraldefect
7.Patellofemoraldisordersandtreatment
8.Stressfractures
9.Overusesyndromeandvarioustendonitises
10.Rotatorcuffpathology
11.Acromioclavicularjointpathology
12.Impingementsyndrome
13.Shoulderstiffness
14.Shoulderinstabilityandtreatment
15.Managementofathletesbothonandoffthefield
16.Sportsinjuriesinthepediatricpopulation
17.Femoroacetabularimpingement
18.Hiplabraltears
19.Hipbiomechanics
20.Elbowinjuries
21.Epicondylitis
22.Ligamentinjuriesoftheelbowulnarcollateralandlateralulnarcollateralligaments

PracticeBasedLearningandImprovement:Demonstratecompetenceintheabilitytoevaluatetheir
ownperformanceandutilizeattendingfeedbacktoimprovetheirperformance,bothinclinic/ORand
thesurgicalskillslab.

InterpersonalandCommunicationSkills:Demonstrateinterpersonalskillsandprofessionalismnecessary
toadequatelyeducateapatientontheirdiagnosisandconveytherisks,benefits,andcomplicationsof
availabletreatmentoptions.Demonstratecourtesyandtimelinesswithcolleagues,patients,and
ancillarystaff.

Professionalism:Demonstrateinitiativeintheneedsofpatientsandprofessionalstaff,showinghonesty,
compassion,andrespectforthepatientissuesbothintermsofthemedicaldiagnosisandthe
psychosocialramifications.

SystemsBasedPractice:Learntoappropriatelydelegateresourcemanagementanduseofoutside
servicessuchasphysicaltherapy,MRIandinterventionalradiology,andteamtrainers.Theresidentwill
alsobecomefamiliarwithreturntoplayguidelinesandonfieldtreatmentconsiderationsforthe
athlete.

46

TRAUMA:OVERVIEW

DavidW.Lowenberg,M.D.,RotationDirector

WelcometotheOrthopaedicTraumaService.Yourtimeonthisservicewillbespentinlearningthe
surgicalandnonsurgicalmanagementoftheskeletallyinjuredpatient.Thiswillincludethepoly
traumatizedpatient,andthemultidisciplinarycoordinationofcarewithothersurgicalsubspecialties.
Youmustbemotivatedanddedicatedtomakingthemostofthistimeandexperience.Thereisalarge
volumeofmaterialtoabsorb,andthiswillserveasabasisformuchofyourfutureknowledgeinthe
careoftheinjuredpatient,whichisoneoftheprimarypillarsinthefieldoforthopaedicsurgery.The
serviceisruninatopdownfashion,withtheChiefResidentcoordinatingcare.BeginningonAugust1a
TraumaFellowshallalsobeontheservice,andwillassisttheChiefResidentincoordinatingtheservice
andpatientcare.

ROTATIONGUIDELINES
Morningreportsignoutroundswilloccureverydayoftheweek.Itisheldintheradiologyreadingroom
at6:45AMonMonday,7:00AMonTuesday,ThursdayandFriday,and6:00AMonWednesday.

FracturecaseconferenceoccurseveryFridaymorningattheradiologyreadingroombeginningat7:15
AMrightaftermorningreport.

Vacationandabsencesfromresponsibilitiesfallundertheguidelinesofthosefortheresidencyin
general.Becauseofthepatientloadandtheresponsibilitiesofthisservice,itisimperativethatall
vacationsorabsencesfromtheorthopaedictraumaservicebeapprovedbytheservicechiefatleastsix
weeksinadvance.Vacationswillbeapprovediftheymeetthedepartmentalcriteria.Thefaculty,
however,mustberenotifiedofanyvacationatthetimearesidentcomesonservicewhetherornot
previousnotificationhasbeengiven.

OTHERREQUIREMENTS
A. Adailyprogressnotemustbewrittenbyanintern,residentorfellowoneverypatientonthe
service,aswellasconsultpatientsthathaveundergonesurgicalinterventionbyourservice.These
canbeassignedtotheP.A.orNursePractitionerontheservice,butitistheresponsibilityofthe
residentsandinternstomakesurethatthisisdoneonadailybasis.

B. Theresidentteamisexpectedtoknowandfollowtheprogressofeachpatientonadailybasis,
sevendaysaweek.Anyissuesregardingapatientaretobebroughtupthechainofcommandto
theChiefResidentandtotheAttendingSurgeonofrecord.Thisshouldoccurregardlessoftheday
oftheweek.Anynonurgentissuesshouldbebroughtupatmorningreportsignoutrounds.

C. Thereshouldbeadischargenoteonthedayofdischarge.Thisnotemustmentionthediagnosis,
procedure,andtheprovisionsforfollowupwiththefollowupappointmentdocumentedinthe
dischargeplan.Careshouldbetakenthatthefollowupappointmentiswiththesurgeonofrecord.
Itisalsoimperativethatalldischargedpatientsbegivenenoughoftherequiredmedications,
includingpainmedications,tomakeittotheirfollowupappointment.

D. Pleasetryandbepunctualtotheoperatingroomsoastokeeptheflowofcasesmoving.

47

CONSULTS
A. Allconsultandadmissionnotesmustbedesignatedforattendingcosignature.

B. Duringdaytimehours,theChiefResidentthentheattendingstaffingtheTraumaRoomshouldbe
informedofallnewconsultsassoonastheconsultiscomplete.After6:00PMtheSeniorResident
followedbytheattendingoncallshouldbenotified.

C. Duringthedayfrom7amto6pm,thetraumajuniorresidentwilltakeallcallsforinpatientandER
consults.ThebackupforthejuniorresidentistheChiefResident.TheChiefResidentmaydesignate
theinternstoperformapreliminaryevaluationandstarttheconsultwhennecessary.

D. Attemptsshouldbemadetoseeallinpatientconsultsasrapidlyaspossible,andseeallERconsults
onaveryrapidbasis,withnodelayover30minutes.

E. UponcompletionoftheinpatientorERconsult,afullnoteinEPICisrequired.Mentionshouldbe
madeifthecasewasreviewedwithanattendingortheChiefResident.Ifthecasewasnotreviewed
withtheattending,thenmentionshouldbemadethatthecasewillbereviewedwiththeattending,
andthenthisactionistobecarriedout.

Duringthe201314Academicyear,theprimaryresponsibilitiesoftheChiefResidentaretoserveas
manageroftheTraumaServiceandstafftheoperatingroomsforcases.TheroleoftheR2istohandle
allinpatientandERconsultsfrom7:00AMto6:00PMMondaythroughFridayaswellascovercasesas
perthedirectionoftheChiefResidentintheOR.Theinterns,serviceNP(Miki),andPA(Meena)will
coverfloordutiesandinpatientmanagementduties.

Ifanyissuesofurgencydevelopduringthecourseofyourduties,pleasecontactanavailableattending
orcallServiceChiefDavidLowenberg,M.D.directlyonhiscellat(415)5315537.

ForanyquestionsregardingtheStanfordUniversityResidentRotations,contactthechiefresident.

RESIDENTCOVERAGEOFTHEEMERGENCYDEPARTMENT
ThechiefresidentisresponsibleforprovidingresidentcoveragetotheStanfordUniversityEmergency
Room.AtStanfordUniversityHospitalonweekdays,allemergencyroomcallsshouldbedirectedtothe
juniorresidentontraumacall.Thejuniorwillanswerthecallandtakecareofanyorthopaedic
emergencyintheemergencyroom.Ifapatientistobeadmittedforanyreasonfromtheemergency
room,thechiefresidentwhoisadmittingthepatientwilldiscussthecasewiththeTraumaattending
whoiscoveringemergenciesonweekdaysfrom8:00AMto6:00PM.After6:00PMalltheemergency
caseswillbeaddressedtotheOrthopaedicAttendingcoveringemergenciesaccordingtotheday'scall
schedule.Onlythenwillthepatientbeadmittedunderthatparticularattending,unlessother
arrangementsaremade.Thejuniorresidentshoulddiscussallcaseswithhisseniororchiefresident.

After6:00PM,theemergencyroomcallwillbecoveredbythechiefresidentandtheappropriatejunior
residents.Thechiefresidentmaydelegatetheauthorityfortheoncallscheduletotheemergencyroom
toanotherresident.Thetourofdutywillbefrom6:00PMto6:00AMonweekdaysandfrom8:00AM
to8:00AMonweekends.Appropriateadjustmentstotheoncallscheduleshouldbemadeifconflicts
occur.Theresidentsoncallareexpectedtoabidebythetime/distancerulesmentionedintheGeneral
Outline.

48

Itshouldbestressedthatthejuniorresidentsshoulddiscussallbutthemostroutineemergencyroom
caseswiththechiefresident,ifthereisanyquestionaboutdiagnosisortreatment.Anypatientwhois
admittedtothehospitalmusthaveanorthopaedicattending.Thisincludespatientsadmittedtothe
orthopaedicservice,aswellasanyconsultationsperformedonemergencyortraumapatientswhoare
subsequentlyadmittedtoanotherservice.

NONUNIVERSITYEMERGENCYADMISSIONS
Theresidentonthefirstcalltotheemergencyroommay,butisnotexpectedto,assistinsurgeryonany
nonuniversitypatientgoingtosurgeryduringthenighttimeorweekendhours.Theattending
physicianisexpectedtoplaceabriefhistoryandphysicalinthechart.Weprovidecoveragefortrauma
consultsforPaloAltoMedicalFoundationpatientsbutdonotcoverPAMFpatientswithpostoperative
complications.

UNIVERSITYEMERGENCYADMISSIONS
TheresidentonfirstcalltotheemergencyroomisexpectedtoworkupandassistonanyUniversity
admissionduringthenighttimeorweekenddays.AllconsultsperformedbyaPGY2fromJune
Decembermustbediscussedwiththechiefresidentoncall.Allotherconsultsmaybediscussed
dependingontheexperienceofthejuniorresidentandthejudgmentofthechiefresidentoncall.All
admissionsmustbediscussedwiththechiefresidentoncall,anditistheresponsibilityoftheChiefto
communicatewiththeattendingofrecord.

TRAUMA:RESIDENTGOALSANDOBJECTIVES

DESCRIPTION
ThegoalofthisrotationistogivetheR2athoroughoverviewinthemanagementoftraumaticailments
thatafflictthemusculoskeletalsystem.TheR2shouldalsogainexperienceinproperlyperforminga
musculoskeletalconsultandcommunicatingeffectivelywithotherservices.TheR2willberequiredto
makedecisionsrequiringmusculoskeletalcarewhilehavingthesupportandresourceoftheChief
Residentandattendingsurgeons.TheR2shouldgainexperienceintheclosedreductionofcommon
fracturesaswellaspropersplintingandcastingtechniques.ThegoalfortheR4istolearntotakea
leadershiproleinrunningabusyservicebyservinginasupportroletotheChiefResident.Atthesame
timehe/sheshouldworkonperfectingsurgicalskillssothattheybecomeproficientatgoingthrough
thesurgicalrepairofmostcommonfractureswithconfidence.

ThegoalfortheChiefResidentistofurtherdevelophis/hersurgicalskillsinadvancedintramedullary
roddingandplatingtechniques.TheChiefResidentwillalsolearnnewtechniquesinexternalfixation
includingcircularfixation,aswellasthetreatmentofnonunionsandmalunions.Attheendofthe
rotationtheChiefResidentshouldbecomfortablewiththemanagementofalllongbonefractures,their
management,andevaluation.He/sheshouldalsohaveabasicunderstandingofthetreatmentofpelvic
andacetabularfractures,andunderstandthebasicstepsininitialmanagement.TheChiefResident
shouldunderstandtheprinciplesofDamageControlOrthopaedicsandthecareofthepoly
traumatizedpatient.He/sheshouldalsobecomfortableinthemanagementandinitialstabilizationof
openfractures.

READINGS
OKUTrauma

49


CONTACT
DavidLowenberg,MDdavid_lowenberg@stanford.edu

TheTraumaSurgeryrotationreadinglistisinMedHub.

GOALSANDOBJECTIVES
Bytheendoftherotation,theresidentwill:

PatientCare:Obtainacumenindiagnosingandproposingtreatmentintheclinicalsettingandanalyze
availableinformationtomakediagnosticandtherapeuticdecisionsbaseduponsoundclinicaljudgment,
bestavailableevidence,andpatientpreferences.

MedicalKnowledge:demonstrateproficiencyinthedecisionmakingandplanningoftraumatic
orthopaedicinjury,thebiomechanicalandbiologicalbasisoffracturehealingandsurgicalknowledgeof
reductionandfixationtechniques.Inaddition,theresidentshouldunderstandtheprincipleofpost
traumaticreconstructionandthemanagementofcomplicationsassociatedwithmusculoskeletal
injuries.

PracticeBasedLearningandImprovement:Theresidentwilldemonstratecompetenceintheabilityto
evaluatetheirownperformanceandutilizeattendingfeedbacktoimprovetheirperformance,bothin
clinic/ORandthesurgicalskillslab.

InterpersonalandCommunicationSkills:Demonstrateinterpersonalskillsandprofessionalismnecessary
toadequatelyeducateapatientontheirdiagnosisandconveytherisks,benefits,andcomplicationsof
availabletreatmentoptions.Demonstratecourtesyandtimelinesswithcolleagues,patients,and
ancillarystaff.

Professionalism:Theresidentwilldemonstratetheinterpersonalskillsandprofessionalismnecessaryto
treatthetraumapatientwhichincludesinteractionswithpatientfamilymembersinoftenstressful
situations.

Systemsbasedpractice:Theresidentwilldevelopanunderstandingandabilitytoutilizeoutside
resourcessuchasthetransfercenter,inordertoassistoutsidehospitalsfortraumareferrals.The
residentwillalsobecompetentinworkingwiththeemergencyroomandtraumateamsinthecareof
themultipleinjuredpatientandtheutilizationofadditionalresourcestooptimizecareinthetrauma
setting.

50

TUMOR:OVERVIEW

MUSCULOSKELETALTUMORSERVICERESIDENT
DavidG.Mohler,M.D.,RotationDirector
RaffiS.Avedian,M.D.AssistantProfessorofOrthopaedicSurgery

ThecurriculumoftheTumorrotationwillconsistofevaluatingpatientsinaclinicsetting,assistingin
surgery,inpatientmanagementofpatients,participatinginsarcomatumorboard,andweekly
interactiveeducationalsessionswiththeOrthoTumorfaculty.

Allresidentsmustadheretodutyhourrulesandrestrictionsandshouldnotifytheattendingsonthe
serviceiftheyareatriskofbeinginviolationtheserules.Also,residentsshouldnotifyattendingsifthey
areexperiencingfatigueorsleepdeprivationoranyothertypeofdiscomfortassociatedwiththeir
responsibilitiesonthetumorservice,sothataccommodationscanbemade.

SchedulegenerallyisclinicMonday09001700,Wednesday10301700,ORis0730onTuesdayand
ThursdayintheMainandstartsat0800FridayintheMainorASC.TumorboardintheCancerCenteris
07300830onFriday.

MondaymorningconferenceandM&M:Monday0730caseconferenceatStanford.

SpinewillalternateeveryotherMondaymorning0730conferencewithFoot&AnkleandTumorservice
forcasepresentations.TheresidentontheTumorservicewillpresentaninterestingcaseanddiscuss
relevantliterature.

Also,M&MTumorservicepresentationsandstatisticalsubmissionofcomplicationsaretobedoneby
theTumorChiefResident.Postopwoundinfections/breakdownscanbebatched,astheyarevery
commononourserviceandofferlittleornothinginthewayoflearningopportunities.

WEEKLYSCHEDULE

Mohler
Avedian

Mon

Clinic

VA

Tues

OR

OR,PedsClinicinPM

Wed

Clinic

Academic

Thurs

OR

Clinic

Fri

OR

OR

ThefollowingaredaytodayrequirementsorguidelinesforresidentsontheTumorservice:

AdailyprogressnotemustbewrittenbyaresidentorPA
Theresidentsareexpectedtoknowandfollowtheprogressoftheinpatientsonadailybasis,and
giveandreceiveappropriatesignout
Theresidentmustrevieweachpatientanddiscussthetreatmentplanwiththeattendingphysician

51

Theresidentmustsignouttheinpatientservicetotheoncallresidentbetween6:00PMto7:00PM.
Thesignoutmustincludethefollowing:
o Identificationandlocationofthepatients
o Allergiesofeachpatient
o Diagnosisandsurgicalprocedureeitherplannedorperformedforeachpatient
o Reviewofmedications
o Reviewofpainmanagementplan
o ReviewofDVTprophylaxisplan
o Identificationofanyactiveandacuteproblemsthatneedtobemonitored
o Identificationofanyitemsthatneedfollowupsuchaslabs,xraysandtheactionitemsthat
mustbedoneafterresultsofsaidtestsareavailable
o Identificationofpersonstocallandcontactinformationifthereanyquestionsorproblems,
e.g.ChiefResidentoncall,attendings,consultservices,etc
Thereshouldbeadischargenoteonthedayofdischarge.Thisnotemustmentionthediagnosis,
procedure,andtheprovisionsforfollowup,withthefollowupappointment
TheresidentontheTumorserviceshouldforwardtheOrthoOncologyghostpager(27145)tothe
oncallJunioreachnight(alongwithsignout)andassignitbacktothemselvesinthemorning
Pleasebedressedandintheappropriateoperatingroom15minutespriortothefirstcaseofthe
morning.Recurrenttardinessmayresultinlostsurgicalprivileges
Whenadmittingpatientstothehospital,makesuretoassignOrthoOncologyastheprimaryteam
(ifappropriate)sothenursesknowwhotocontactforquestions

EDUCATIONALOPPORTUNITIES
ThereisamicroscopeintheResidentLoungeandinDr.Avedian'sofficeinRedwoodCity.The
residentiswelcometousethemicroscopesanytimealongwiththeteachingslidestoreviewcases.
WednesdaysafterGrandRoundsandCORElectureswewilldoteamroundsandseeallthe
inpatients.ThentherewillbeaneducationalsessioninRedwoodCitywheretheresidentwillgo
overarticlesandweeklycaseswiththeattendingstaff.
Thereareorthotumorlectures,OITEquestions,andreviewmaterialspostedontheresident
intranet.

OUTPATIENTCLINIC
Theresidentwillbetaughthowtoobtainapatienthistorythatfocusesononcologybutisinthe
contextofageneralmedicalhistoryandphysical.Also,theresidentwillgetampleexposureto
physicalexamtechniquesrelatedtomusculoskeletaltumordisorders.
Theresidentwillbeeducatedaboutbothnonoperativeandoperativetreatmentmethodstocare
forpatientswithboneandsofttissuetumorsoftheextremities,pelvis,andtrunk.
TheresidentalsowilllearnhowtoperformTruCutcorebiopsies.
Theresidentwilllearntheindicationsforoperativeandnonoperativemanagementofboneand
softtissuetumors.
Theresidentwillbeexposedtosurgicalcomplicationsandwilllearnhowtomanagethem.

SURGERYASSISTANCE
Theresidentwillbetaughtbasicandadvancedtechniquesoftumorsurgery.Wewillteachallthe
elementsofsurgerythatarenecessarytobeingaproficienttumorsurgeon,includingsurgical
planningandaccuratereviewofdiagnosticimagingandpathology,identifyingrelevantsurface
anatomytoensureproperlocalizationofincision,dissectiontechniquestomaintainhealthytissues,

52

howtodevelopappropriatemarginsaroundatumor,curettagetechniquesandadjuvantsforbone
tumors,andboneandsofttissuereconstructiontechniquesaftertumorremoval.
Althoughwedonotexpectaresidenttoleavetheservicebeingabletoperformallaspectsoftumor
surgery,wedoexpectthattheresidentwillbeabletodothefollowingindependently:
o Reviewboneradiographsandrecognizethedifferencebetweenlatentbenigntumors,
aggressivetumors,andfranklymalignanttumors
o Beabletoorderappropriateteststoworkupboneandsofttissuetumorsandtoperform
stagingofsuspectedmalignanttumors
o Recognizetheimportanceofbiopsytechniquesandtobeabletoproperlyperformabiopsy
afterdiscussingacasewithatumorspecialist.Specifically,weexpectthataresidentwill
knowtominimizecontaminationwhendoingabiopsy,beabletoperformaTruCutbiopsy,
andplaceabiopsyincisioninalocationthatwillnotbedetrimentaltothefuturedefinitive
surgicalplan

TUMORBOARD
TumorboardtakesplaceonFridaysat7:30AMintheCancerCenter.

SIGNOUTANDAFTERHOURS
MondayFridayAfterHours:
InpatientsfromtheTrauma,TumorandFootandAnkleservicewillbecoveredbythejuniorresidenton
generalcall.MakesuretoforwardtheOrthoOncologyghostpager(27145)totheoncalljunior(with
signout)everynightandthenpickitbackupinthemorning.Signmustbethoroughanddetailedto
avoidmedicalerrorsduetomiscommunications;seeguidelinesabove.

Saturday/Sunday/Holiday:
InpatientsfromtheTrauma,TumorandFootandAnkleservicewillbecoveredbythejuniorresidenton
generalcall.Makesuretosignoutpriortoforwardingtheghostpager.Thishastypicallybeendonewith
adetailedHIPAAcompliantsecureemail(sentFridayPM)tothejunior(s)oncallfortheFriSundaytime
period(iftheTumorresidentisnotrounding).PleaseccDrs.AvedianandMohlerandLindaJordan
(ljordan@stanfordmed.org)ontheemail.Ifthetumorresidentisrounding,signouttypicallyisdone
overthephoneassoonastheTumorresidentisdonerounding.

Thekeytocoverageregardlessofwhoiscoveringismeticuloussignout.FromMonFri,meticuloussign
outfromtheTumorservicesshouldoccurascloseto6pmaspossibleandforwardingoftheservice
pagershouldbedonebytheresidentsigningout.

Asfortheweekend,thejuniorresident/interncoveringtraumashouldseetheoncalljuniorresidentat
7amsignoutbothSaturdayandSundayandappropriatesignoutshouldoccuratthistime.Asforthe
TumorandFootandAnkleservices,acomprehensivesignoutwiththecoveringresidentshouldoccur
afteramrounds.

TUMORSERVICECONSULTSANDADMISSIONS
Thetumorservicereceivesconsultrequestsfromavarietyofsources.Wegetconsultsfromoncologists,
radiationoncologists,pediatricians,orotherstaffwhocallthetumorattendingdirectly,fromoutpatient
clinics,fromtheED,fromtheTransferCenter,etc.Ultimately,allconsultsmustbeperformedinatimely
mannertoensurepatientsreceiveproperandtimelycare.Thechiefresidentandattendingtumor
surgeonmustcommunicateabouttheconsultassoonaspossible.Thechiefresidentisexpectedtosee
thepatientassoonaspossibleandobtainathoroughhistoryandreviewalldiagnosticinformation.The

53

chiefresidentmayorderadditionaltestssuchasxraysorotherscansattheirdiscretionand/orafter
discussionwiththeattendingphysician.

Afterevaluatingthepatient,writeaninitialshortnoteinchartwithdateandtime.Noteshouldcontain
consultingteam/physician,initialdiagnosis,attending,planandnotetofollow.Pleasealsodothe
following:
MarktheEPICnoteasaConsultation
AssociatethenotewiththeORDERforCONSULTATION(ifdone)
MarkforCOSIGNbyattending

Callsforhospitaltransfersshouldbetriageddirectlytotheattendingorthosurgeonorattendingoncall.

FREEDAYS/VACATIONTIME/RESEARCH
Duringperiodswherethereisnoclinicandnooperation,theresidentsareencouragedtospendtheir
timedoingresearch.Whileitishopedthattheresidentwillbeusingthetimetodoresearchrelativeto
tumors,itissatisfactoryiftheyareworkingonanyresearchprogram.Thisresearchshouldbe
supervisedbyoneofthefacultymembersofthedepartment.

Residentswhoareinterestedineitherclinicalorbasicscienceprogramsandresearchareencouragedto
contactafacultymemberatanytimeduringtheirresidencyaswellasduringthetimetheyareonthe
service.

Vacationandabsencesfromresponsibilitiesfallundertheguidelinesofthosefortheresidencyin
general.Becauseofthepatientloadandtheresponsibilitiesofthisservice,itisimperativethatall
vacationsorabsencesfromtheTumorSurgeryservicebeconfirmedbythefacultyatleastsixweeksin
advance.Vacationswillalwaysbeapprovediftheymeetthedepartmentalcriteria.Thefaculty,
however,mustberenotifiedofanyvacationatthetimearesidentcomesonservicewhetherornot
previousnotificationhasbeengiven.

CONTACTS
DavidG.Mohler,M.D.
Chief,MusculoskeletalTumorService
DepartmentofOrthopaedicsandSportsMedicine
StanfordUniversityMedicalCenter
NewPatientAppointments:6504987555
docmohler@stanford.edu
www.DocMohler.com

RaffiS.Avedian,M.D.
AssistantProfessorofOrthopaedicSurgery
MusculoskeletalTumorService
StanfordUniversityMedicalCenter
ravedian@stanford.edu

Ifanythingisnotcleartoyouabouttheseinstructionsforappropriateserviceduty,youmustspeakwith
Dr.MohlerandhavethisclarifiedbeforethestartoftheservicecallDr.Mohleratpager#10001,his
officeat7217656,oroncellphoneat6508624580.

54

TUMOR:RESIDENTGOALSANDOBJECTIVES

DESCRIPTION
TheLearningObjectivestumorservicerotationwillincludebutnotbelimitedtothefollowingtopics:

Howtoperformanaccuratehistoryandphysicalexaminationonapatientwithaboneorsofttissue
tumor
o Anysymptoms?Duration?Incitingevent?Constantorintermittent?
o Presenceofamass?Gettingbiggerorsmallorstayingthesame?Painfulornotpainful?
o Neurologicsymptoms?(e.g.schwannomaorextrinsicnervecompression)
o Putincontextofoverallmedicalcondition,familyhistory,andpatientexpectations
Knowwhataretheimportantandrelevantimagingandlaboratorystudiestoobtainwhenworking
upapatientandtoavoidunnecessarytests
Recognizethattherearebasicallythreeinitialsurgicaltreatmentoptionsforanygivenpatientand
knowwhentoutilizethem
o Observation
o Biopsyfirstthenobserveordefinitivesurgerydependingonresult
o Surgerywithoutbiopsy
Learntheroleofadjuvanttreatmentssuchaschemotherapy,radiation,cryotherapy,and
bisphosphonatesandiftheycan/shouldbeusedpreoperativelyorpostoperativelyornotatall
Learnhowtoperformabiopsy.Aproperbiopsywillobtainenoughtissuefordiagnosis,butwillnot
excessivelycontaminatesurroundinghealthytissue.Onemustrealizethatanimproperlyperformed
biopsymayleadtohigherlocalrecurrence,limbamputation,oreliminatethepossibilityofan
otherwisepotentiallycurabledisease
Learnthedifferenttypesofsurgeriesthatareusedinorthopaediconcologyandwhattheir
indicationsare
o Intralesionalsurgery
o Marginalsurgery
o Wide(AKAradical)surgery
Learnthepotentialcomplicationsoforthopaediconcologysurgeryandhowtominimizethem
o Softtissueproblemssuchasinfection,woundbreakdown,edema,seroma/hematoma,
muscleortendondysfunction
o Implantcomplications:leglengthinequality,loosening,dislocation,problemswithsoft
tissuerepairtoandcoverageofendoprosthesis
o DVT/PE
o Nerveandvascularinjury

READINGLIST
Rougraff,B.T.Limbsalvagecomparedwithamputationforosteosarcomaofthedistalendofthe
femur.Alongtermoncological,functional,andqualityoflifestudy.JBoneJointSurgAm.1994.
Bielack,S.S.Prognosticfactorsinhighgradeosteosarcomaoftheextremitiesortrunk:ananalysis
of1,702patientstreatedonneoadjuvantcooperativeosteosarcomastudygroupprotocols.Journof
ClinicalOncology,2002.
RougraffBT,Skeletalmetastasesofunknownorigin.Aprospectivestudyofadiagnosticstrategy.
JBJS1993Sep75(9)1276.
MankinHJ.TheHazardsoftheBiopsyRevisited.MembersoftheMSTS.JBoneJointSurgAm.1996
May;78(5):65663.

55

EilberFCetal..Highgradeextremitysofttissuesarcomas:factorspredictiveoflocalrecurrenceand
itseffectonmorbidityandmortality.AnnSurg2003Feb237(2):218.
Mittermayer,F.Longtermfollowupofuncementedtumorendoprosthesesforthelowerextremity.
CORR.2001(388)p167
Unwin,P.S.Asepticlooseningincementedcustommadeprostheticreplacementsforbonetumours
ofthelowerlimb.JBJSBr78(1):5.
SchwartzAJ.Cementeddistalfemoralendoprosthesesformusculoskeletaltumor:improvedsurvival
ofmodularversuscustomimplants.ClinOrthopRelatRes.2010Aug;468(8):2198210.
BernthalNM.Howlongdoendoprostheticreconstructionsforproximalfemoraltumorslast?CORR
2010Nov;468(11):286774.
Mankin,H.J.Longtermresultsofallograftreplacementinthemanagementofbonetumors.CORR
1996.3248697.
FarfalliGL,BolandPJ,MorrisCD,AthanasianEA,HealeyJH,Earlyequivalenceofuncementedpress
fitandCompressfemoralfixation.ClinOrthopRelatRes.2009Nov;467(11):27929.Epub2009Jun
10.
RosenLSetal..Zoledronicacidversusplacebointhetreatmentofskeletalmetastasesinpatients
withlungcancerandothersolidtumors:aphaseIII,doubleblind,randomizedtrialtheZoledronic
AcidLungCancerandOtherSolidTumorsStudyGroup.JClinOncol.2003Aug15;21(16):31507.
O'SullivanBetal..Preoperativeversuspostoperativeradiotherapyinsofttissuesarcomaofthe
limbs:arandomisedtrial.Lancet.2002Jun29;359(9325):223541.

GOALSANDOBJECTIVES
PatientCare:Obtainacumenindiagnosingandproposingtreatmentintheclinicalsetting,andthe
surgicaltreatmentoftumorprocedures.Demonstratecompetenceintheevaluationandworkupof
orthopaedicbonetumors.

MedicalKnowledge:Obtainknowledgeandcomprehensionofcommonsurgicalapproaches,non
operativeandoperativetreatmentoptionsfortumorsurgery.Obtainknowledgefortheworkup,
classification,andtreatmentoptionsforavarietyofboneandsofttissuetumorsofthespine,pelvis,and
extremities.

PracticeBasedLearning:Demonstrateselfimprovementthroughacritiqueoftheirperformanceduring
presentationofM&Mcases.

InterpersonalandCommunicationSkills:Demonstrateinterpersonalskillsandprofessionalismnecessary
toadequatelydiagnoseandtreatavarietyoftraumaticandelectivetumorsurgeries.Demonstrate
courtesyandtimelinesswithcolleagues,patients,andancillarystaff.

Professionalism:Demonstrateinitiativeintheneedsofpatientsandprofessionalstaff,showinghonesty,
compassion,andrespectforthepatientissuesbothintermsofthemedicaldiagnosisandthe
psychosocialramifications.

SystemsBasedPractice:Demonstrateunderstandingofhowtoworkeffectivelyinvarioushealthcare
deliverysettingsandsystemsforpatientswithtumordisorders.Demonstrateanunderstandingofthe
roleofmedicaloncologyandradiationoncologyinthecareoforthopaedictumors.

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VAPAHCS:OVERVIEW

INTRODUCTION
TheVAPAHCSislocatedat3801MirandaAve.,PaloAlto,CA94304(Tel:(650)4935000).

Weprovidemedicalservicestoveteransofthearmedforces,activedutymilitary,andretiredmilitary
withsomecarefordependentsthroughTriCare.Inadditiontopatientsonthesurgicalward,wecare
forpatientsintheSpinalCordInjuryUnitandthePolytraumaUnit.Theorthopedicsurgeryserviceisthe
busiestsurgicalserviceinthehospitalandamongthebusiestorthopaedicservicesintheVAsystem.

STAFF
NicholasGiori,M.D.,Ph.D.
AdultReconstruction
StevenWoolson,M.D.
AdultReconstruction
ConstanceChu,M.D.
SportsMedicine
GeoffreyAbrams,M.D.
SportsMedicineandShoulderReconstruction
RaffiAvedian,M.D.

OrthopedicOncology

DavidSmith,PAC;DavidWebb,RNP;KariannePuetz,PAC;LourdesAlbano,RN;MaryannWilliams;
VirginiaTsai

ROUNDS
FormalroundswithsurgerystaffandhousestaffbeginattheC3nurse'sstation
Mondays
7:30AM
Tuesdays
Between1stand2ndcases
Wednesdays 10:00AM
Thursdays
Between1stand2ndcases
Fridays
Afterthelastcaseoftheday

CONFERENCES
Surgicalplanningconference:Wednesday10:30AMnoonintheSurgicalServicesconferenceroom.The
residentspresentsallsurgicalcasesfromthepreviousweekandalloftheplannedcasesforthe
upcomingweek.Conferenceisattendedbyallorthopaedicclinicalandresearchstaff.

Residentteachingconference:Monday7:00AMintheSurgicalServicesconferenceroom.Various
orthopaedictopicsarediscussedwithaprimaryfocusonadultreconstructionandsportsmedicine.

CLINICS
Monday8:30AMto5:00PMAdultReconstructionfocusDr.GioriandDr.Woolson

Wednesday1:00PMto5:00PMSportsmedicineandShoulderreconstructionfocusDr.ChuandDr.
Abrams

Allnewpatientsmustbeseenbyanattendingphysician.Residentsandfellowsshallseenewconsults,
returnpatients,preoperative,andpostoperativepatients.Residentsandfellowswillreceiveinstruction
onproperdocumentationofattendinginvolvementuponstartingtherotation.Patientencountersmust
befilledoutbytheresidentsandfellowsonpatientstheyseeinclinicasthepatientsareseen.

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SURGERY
OrthopaedicsurgeryhasblocktimeonMondays(oneortworoomsalternatingweeks),Tuesdays(two
rooms),Thursdays(tworooms),andFridays.

UrgentandemergentaddoncasesmustbediscussedandarrangedwiththeORchargenurseandwith
theAnesthesiachiefresident.Anaddonsheet(pinksheet)mustbefullycompletedwiththe
informationonthecaseandgiventotheoperatingroomchargenurse.

Ifspecialequipmentthatisnotkeptinthehospitalisneededforasurgicalprocedure,thecompany
representativeneedstobecontactedandaform(orangesheet)needstobefilledoutandsignedand
giventothechargenursetoalertSPDthattheequipmentwillbedeliveredforaparticularpatients
surgery.MaximumtimemustbegiventoallowSPDtosterilizetheequipmentperVAguidelines.

Nightandweekendemergencycasescanbearrangedbycallingthemainhospitaloperatorat(650)493
5000andtalkingtotheNursingSupervisor,andbytalkingtotheanesthesiaresidentoncall.

ADMISSIONS
Patientsareadmittedfromclinic,fromtheER,fromtheOR,andfromotherfacilitiesthrough
transfers.Duringtheweekday,bedavailabilitycanbecheckedbycontactingtheBedCoordinator,Shelly
Segal.Duringnightsandweekends,bedavailabilitycanbecheckedbycontactingeitherthenursing
supervisorortheAOD.Theycanbereachedthroughthemainhospitaloperatorat(650)4935000.

INPATIENTCARE
Inpatientcareiscoordinatedwithamedicinehospitalistcomanagementservice.Alertthehospitalist
coveringorthopaedicswhenanunscheduledadmissionoccurs(ERadmit,transferfromantherfacility).

DISCHARGES
Dischargesarefacilitatedbyourmidlevelprovidersandbyourdischargeplannerandsocialworkers
whohaveofficesonthesurgicalward(C3).Dischargemedicationsarecheckedbythehospitalist.Each
day,theresidentmustmakecontactwiththedischargeteamtomakesurethatdischargeplansforeach
patientaremovingforwardandthatallneededpaperworkandsummariesarecompletedbythetime
thepatientisreadyfordischarge.

COMPUTERUSE
Allmedicalrecordsareelectronic.Allresidentsandfellowsshouldarrangetogetremote(home)access
totheelectronicmedicalrecord(CPRS)andtotheradiologyimagingprogram(Stentor).Residentsand
fellowsareexpectedtokeepuptodatewithsigningtheircharts.

VACATIONS
ThesearetobearrangedwiththeChiefoftheOrthopaedicServiceattheVAandwiththeStanford
ResidencyorFellowshipProgramCoordinator.

RESEARCHOPPORTUNITIES
TherearemanyopportunitiesforconductingresearchattheVAPAHCS.Weencouragetheresidentsand
fellowstodiscusstheirinterestswithstaff.Wewillmakeeveryefforttofacilitateresidentresearch,
whichmaytakeadvantageoftheuniqueresourcestheVAhastooffer,includingthebiomechanicslab
andtheextensivemedicalrecord.AllresearchmustbecoordinatedwiththeVAresearchofficeand
appropriatetrainingmustbecompletedpriortoinitiatingthework.

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TheOrthopaedicSurgerystaffwelcomesyoutotheVAPAHCSandhopethatyouhaveaneducational
andenjoyablerotation.Wewelcomeyourfeedbackrelatedtoyourexperience,asitisthroughthis
feedbackthatwecanimprovetherotationforfutureresidentsandfellows.

VAPAHCS:RESIDENTGOALSANDOBJECTIVES

DESCRIPTION
ResidentsrotatingthroughthePaloAltoVAhospitalwillbeexposedtoabroadrangeoforthopaedic
conditionsthataffectveterans.Residentswillworkintheclinic,theoperatingroom,thehospitalwards,
andtheemergencyroom.Conferencesincludeaweeklyteachingconferenceandaweeklysurgical
planningconference.Therearealsoampleopportunitiesforclinical,biomechanics,andbasicscience
research.

RESIDENTROLEANDEXPECTATIONS
Inallsettings,residentswillbesupervisedbyattendingstaff.

Intheclinic,residentswillbeexpectedtolearnandpracticetakingthoroughhistoriesandphysical
exams,developthejudgmentneededtorecommendoperativeornonoperativecare,andperform
injectionsandotherminorclinicbasedproceduresasindicated.

Intheoperatingroom,residentswillassistinsurgeryandassumesurgicalresponsibilitiesthatare
consistentwiththeircapacityandleveloftraining.

Residentswillrounddailyoninpatientsandconsults,andwillworkwithmidlevelproviders,ancillary
staff,hospitalistsandconsultants,toprovidetheoptimumcareofpatients.Residentswillbeincludedin
theoncallrotationtocoverafterhouremergencyroomandinpatientconsults.

Residentsareexpectedtoattendallteachingconferences.

READINGS
Lowerextremityreconstructionandtrauma:
RecommendedreadingincludestheOKU,theOKUHipandKneeReconstructionBook,Rockwelland
GreensFracturesinAdults,HoppenfeldsSurgicalExposuresinOrthopaedics.Classicandcurrentjournal
articleswillalsobeassigned.

Sportsmedicineandupperextremityreconstruction:
OKUShoulderandElbow,RockwellandGreensFracturesinAdults,HoppenfeldsSurgicalExposuresin
Orthopaedics.Classicandcurrentjournalarticleswillalsobeassigned.

Orthopediconcology:
OKUMusculoskeletalTumors2
OKUMusculoskeletalInfections

59

GOALSANDOBJECTIVES
PatientCare:Demonstratecompetenceinthesurgicalandpatientmanagementskillsfortheadult
patientpresentingwithjointdisease,ligamentinjury,tumors,andtrauma.

MedicalKnowledge:Knowledgeoftheprinciplesandtechniquesofdiagnosis,operativeand
nonoperativemanagementofadultorthopedicproblemsinlowerandupperextremityreconstruction,
sportsmedicine,andtrauma.

PracticeBasedLearningandImprovement:Demonstrateselfimprovementthroughexperience,critique
ofperformance,andduringpresentationofM&Mcases.

InterpersonalandCommunicationSkills:Demonstrateinterpersonalskillsandprofessionalismnecessary
tomanageandtreatadultorthopedicpatientswithoftencomplexmedicalandsocialproblems.Work
closelywithconsultingservices,hospitalists,andancillarystafftodevelopandexecuteoptimum
treatmentplansforthepatient.

Professionalism:Demonstrateinitiativeintheneedsofpatientsandprofessionalstaff,showinghonesty,
compassion,andrespectforthepatientissuesbothintermsofthemedicaldiagnosisandthe
psychosocialramifications.

SystemsBasedPractice:DemonstrateunderstandingofhowtoworkeffectivelyintheVAhealthcare
deliverysettingutilizingtheelectronicmedicalrecord,anddigitalradiographytofacilitatepatientcare.
Coordinatewithreferringinstitutionstoprovideseamlesstransfersofcare.

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