TUH Externship Guide
Externship Director: Laura Sansosti, DPM
Welcome
Welcome to Temple University Hospital Foot and Ankle Surgery externship. You’ll find during your month here that Temple has a wealth of pathology and educational opportunities available. The program offers a large volume of surgery and clinics. The month will be busy, and at times difficult. We expect a lot of students who rotate here, so be prepared to work.
Keep in mind, you only have one chance to make a first impression, so make it a good one. This externship is meant to be a rewarding educational experience, but you will only get out of it what you put into it. We hope you enjoy your month and please do not hesitate to approach any of us with questions or concerns.
Externship Requirements
Academic Meetings:
Academics are typically every Tuesday (4:30pm) and Thursday (7:30 am) at the Temple University School of Podiatric Medicine. The academics calendar rotates on a weekly basis to include journal clubs, radiology conferences, attending lectures, resident/student presentations, sawbones workshops, cadaver labs, and more. Once a month the entire TUSPM community is invited to participate in Grand Rounds, which consists of two resident lectures on a particular topic. Please be prepared and be on time for each academics.
One mini-lecture per week:
Topic assigned by 3rd year residents
Should be about 5 minutes in length
No PowerPoint, 1 page handout/outline is sufficient
All handouts should have your name and date on them
Please e-mail a copy to the externship email account for our records
One presentation per month:
Topic to be approved by 3rd year residents and Externship Director
Choose topic during the first week
Should be about 15 minutes in length and done in PowerPoint
Date of presentation will be assigned by the chief residents, but typically will occur during the last week of your externship
Please e-mail a copy to the externship email account for our records
Call:
This residency provides on-call coverage to TUH Main ED, Pediatric ED, and Episcopal ED. In addition to this coverage, there are in-house patients that are on the Foot and Ankle consult service. Taking call with one of the residents gives the extern some insight as to what it can be like to take call in a Level 1 Trauma Center. The required call involves one weekend day (Sat or Sun 12 hour call) and one weeknight (24 hour call).
Skills and Knowledge (you should be able to master the following skills while at this program)
Proper casting technique
Surgical prepping
Be able to write any notes (pre-op,post-op,consults,etc.)
Suture (practice at home, be prepared to perform any type of suture)
Hand ties
Patient management
Local blocks including common peroneal, popliteal
General Foot and Ankle Surgical knowledge
General Radiological knowledge including MRI and CT
General Medical knowledge
TUH Paging
Simply call the page operator at 2-4545, request that person or service be paged and then hang up the phone.
Call Room
Located on the 4th Floor of TUH Rock Pavilion
To get to the call room get off the elevator turn left, go all the way down the hall and make a right. The call room is on the right labeled call room #2.
Travel
Having a car for the externship is not mandatory, but it is very helpful. There are several locations you will be going to throughout the month. The addresses are provided below in order to help you plan accordingly. If you do not have a car there is public transportation that runs to most locations.
Temple University Hospital
3401 North Broad Street
Philadelphia, PA 19140
Temple Foot & Ankle Clinic/Temple School of Podiatric Medicine
8th & Race Street
Philadelphia, PA 19107
Temple Episcopal Hospital
100 E. Lehigh Avenue
Philadelphia, PA 19125
Jeanes Hospital
7600 Central Avenue
Philadelphia, PA 19111
Abington Hospital
1200 Old York Road
Abington, PA 19001
Temple Hospital Externship Guidelines
AM rounding:
It will be your responsibility to see and write notes on the patients you are assigned to each morning, prior to morning sign out. Please write the morning note on a blank progress note and bring it to sign out with you. You will not be responsible for changing dressings unless you are told to do so. If you do change the dressing, please take a picture of the affected areas to show the residents. The note will be a SOAP note and must include the following:
S: Subjective information including problems that may have occurred overnight. Fever, chills, nausea, vomiting, etc. Generally how the patient is feeling.
O: Objective begins with vitals, be sure to include Temperature max (Tmax) for the past 24 hours, temperature current (Tc), pulse, blood pressure, respiratory rate, pulse oximetry, and last documented accu-check if appropriate. The rest of the objective is the physical exam. For consult patients, this involves only a lower extremity exam.
A: Assessment: be specific including laterality and postoperative day number if applicable.
P: Plan: our current plan including antibiotics and day number, dressing changes, consults to other teams, surgical plan, prophylaxis, etc.
**You should use your copy of sign out to assist you with writing your notes as it has all the pertinent information about the patients we are following. You may also use the resident and attending note from the day prior to help guide you.**
OR responsibilities:
If you are assigned to participate in a case you will be responsible for making index cards for the residents scrubbing the case. At TUH the note cards can be found in the PACU. Please place a patient sticker on them. On the card for the first surgical assist you must include the SAPPPPAHEMIC as described in your manual. On the cards for the second assists please include just the surgical procedures performed.
You will also be asked to help get the OR set up for the case. Set the tourniquet to the proper pressure, get the appropriately sized tourniquet, webril and tape. Place chucks down at the end of the table and have a foot stand/bump ready with a chuck. Draw up any local anesthetic needed for the case and be sure to label. Have xrays up in room, if needed. Open all the residents’ and attending’s gloves for the scrub tech. Open your gloves and an extra gown if you are scrubbing. Lastly have a shaver ready for the resident to use.
If you are assigned to a case please prepare for it ahead of time. Let the resident covering the case know that you will be working with them, at least the night before the case. This will also help you prepare for the case as the resident can discuss the case with you. Please also read about the particular procedure being done, especially any articles written by the attending pertaining to the case.
Preoperative Notes:
You will be responsible for writing a preoperative note on inpatients and possibly outpatients. See the Pre-operative note section.
Postoperative Notes:
The residents will show you which forms you will need to fill out following the case. These can be completed both in the OR following the case and in the PACU. If any of the sheets are missing from the chart they can be found in the PACU. If you are not scrubbed in please start the paperwork which helps speed up turnover between cases.
Postoperative Check:
The “post-op check” will usually take place approximately 4-6 hours following the OR case on inpatients. This is done to be sure everything is going smoothly with the patient following surgery. They too will be in SOAP format, however in the subjective section be sure to include postoperative void, po intake, f/c/n/v, if the patient is using his or her incentive spirometer and pain level. In the objective section, do a full physical exam (CV, lungs, etc.) If the patient is on a PCA please note the total amount used.
Consults:
You will be responsible for performing consults on patients both on the floors and in the emergency department. These will be written on red, three page consult sheets which are typically found at the nurse’s stations. They will be in H&P format however only a LE exam is necessary. You may be asked to start the consult on your own and then present the patient to the resident and attending.
Labs/X-Rays:
You may be asked to look up labs for patients throughout the day. You will be given access to Desktop (labs, culture data, medications) and I-Site Radiology.
Sample Notes & Orders
**All notes will be reviewed and co-signed by a resident prior to the note being placed in the chart. Please write all notes on blank progress notes.**
Pre-Op Note Outpatient (Do not leave spaces or skip lines in your note)
CC: 34 y.o. female presents for surgical correction of the left bunion deformity. The pt. has attempted all forms of conservative tx without resolution of symptoms. The pt. requests sx intervention at this time
PMH: DM, HTN
Meds: Glucophage, Norvasc
All: +PCN (Hives)
PSxH: R bunionectomy ‘99
SH: + Tobacco 1 ppd x 20yrs, + ETOH
Labs: EKG findings, Basic met panel, CBC, HCG, Sickle cell trait/dz, CXR
LEE: Pulses palpable 2/4 b/l dp/pt, cap refill < 3sec, Gross neuro and sensory intact b/l, L HAV
A/P: 34F Left HAV deformity
-Sx intervention as per Dr.
-Pt. NPO since MN
-consent signed and in chart
-procedure explained to the patient in detail, all questions answered. No guarantees made as to the outcome of the surgery
Pre-Op Note Inpatient
Pre-op Diagnosis: L forefoot gangrene
Planned Procedure: L TMA
Labs: CBC, BMP, Coags, HCG
X-rays: CXR, foot, etc.
Blood: Typed and crossed, transfused, not needed, etc..
Consent: Signed and in chart
Orders: NPO, IVF, etc.
Sx per Dr. _________
All questions answered, all risks and complications discussed with the patient. No guarantees made as to the outcome of surgery.
Post-Op Check Note
CC: How is the pt doing? Check F/C/N/V & SOB Has the patient voided? Is the patient tolerating PO’s? Is the pain controlled?
Vitals:
CV/Pulm/Abd
LE: Describe the dressing C/D/I, strikethrough, CRT, warmth, gross sensation/motor function - DO NOT BREAK DOWN THE DRESSING
Labs: If applicable
A/P: 54F s/p L TMA POD # 0
- Describe the plan (D/C tom, D/C PCA in a.m., etc.) Ice/Elevation. Incentive Spirometry, etc.
Guidelines for the Review of Articles
It is often difficult to critically review the literature in an objective, yet rigorous fashion. The purpose of this literature review is to provide enough of a description of your article to stimulate discussion of the pertinent issues from the rest of the conference participants. For this reason, during the presentation of the individual articles, it is best to avoid speculating on the authors’ reasons for doing things a certain way in the article. However, please feel free to become involved in the general discussion that follows the presentation of each article. You may be asked to present an article as well.
General Comments:
1. Try to keep article presentations concise and focused. It should not take a great deal of time to summarize key points of an article.
2. It is always better to write your points down on paper rather than highlight them on your copy of the article and attempt to just read the highlights.
3. You generally do not need to go into detailed discussion of the background material that authors may mention in the introduction of the paper.
4. Avoid giving too many numbers during your presentation as it can be confusing, rather highlight major points.
Specific Comments:
1. Begin by noting the title of the study and where/when it was published.
2. Discuss what question(s) the authors were trying to answer and what the study hypothesis was.
3. What study design was used? (case control, randomized trial, case series, etc.)
4. What was the patient population being studied? What was the control group?
5. What were the endpoints being looked at & what was the mechanism of the study? (follow-up at certain intervals, observation until an event, etc.)
6. What were the major results of the study? Again, do not worry about mentioning a lot of specific numbers, instead focus on concepts.
7. What were the authors’ conclusions on the study results and were the conclusions drawn based on statistical significance, clinical significance, anecdotal information, author opinion, etc?
8. How generalizable were the results? Do they apply only to a specific small group or do they apply to a larger generalized group?
9. What are your conclusions about the study? Was it done well? What were the particular problems with the study design or the authors' conclusions of the study?
Externship Tips
1. Be prepared for cases, if you’re assigned to scrub or observe a case the next day, read about it!
2. Know your drugs! Especially the most common antibiotics and pain medications. Make a cheat index card, keep it with you and study from it!
3. Be ON TIME!
4. Have snacks in your pockets as you may not have time for lunch in the cafeteria every day.
5. Be respectful of the OR and nursing staff.
6. What to keep in your pockets: Scissors, tape, blades, cultures, note pad, pens, pen light, suture removal kit, articles, your Temple ID.
7. Always bring articles, etc. to read because some days you will have time to work on academic material and your presentation.
8. Bring money for lunch, unfortunately it is not included.
9. Wear blue scrubs if possible and comfortable shoes.
10. Practice your suturing and hand ties!
11. Be prepared to do 5 minute presentations and a 15 minute presentation during your month. You will choose the topics in your first week, but have some ideas ready. Be interested in your topic!
12. Lastly, be interested, ask questions and have a great time!
1. Be prepared for cases, if you’re assigned to scrub or observe a case the next day, read about it!
2. Know your drugs! Especially the most common antibiotics and pain medications. Make a cheat index card, keep it with you and study from it!
3. Be ON TIME!
4. Have snacks in your pockets as you may not have time for lunch in the cafeteria every day.
5. Be respectful of the OR and nursing staff.
6. What to keep in your pockets: Scissors, tape, blades, cultures, note pad, pens, pen light, suture removal kit, articles, your Temple ID.
7. Always bring articles, etc. to read because some days you will have time to work on academic material and your presentation.
8. Bring money for lunch, unfortunately it is not included.
9. Wear blue scrubs if possible and comfortable shoes.
10. Practice your suturing and hand ties!
11. Be prepared to do 5 minute presentations and a 15 minute presentation during your month. You will choose the topics in your first week, but have some ideas ready. Be interested in your topic!
12. Lastly, be interested, ask questions and have a great time!
Externship Manual
We hope that this manual will be helpful during your time with us. Please keep it with you at all times as a reference for notes/orders etc. We ask you to read and print this before you start your externship. The final page will be signed by you and given to one of the 3rd year residents on your first day. This is just to acknowledge that you understand your responsibilities as an extern as outlined above.
We hope that this manual will be helpful during your time with us. Please keep it with you at all times as a reference for notes/orders etc. We ask you to read and print this before you start your externship. The final page will be signed by you and given to one of the 3rd year residents on your first day. This is just to acknowledge that you understand your responsibilities as an extern as outlined above.
Recommended Externship Articles
1. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift.
J Bone Joint Surg Am. 1976 Apr;58(3):356-7.
2. Mahan KT, Hillstrom HJ.Bone grafting in foot and ankle surgery. A review of 300 cases.
J Am Podiatr Med Assoc. 1998 Mar;88(3):109-18.
3. Radnay CS, Clare MP, Sanders RW.Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? Surgical technique.J Bone Joint Surg Am. 2010 Mar;92 Suppl 1 Pt 1:32-43.
4. Jahss MH.Classic article: foot & ankle 1:15, 1980 traumatic dislocations of the first metatarsophalangeal joint. Foot Ankle Int. 2006 Jun;27(6):401-6.
5. Keiserman LS, Sammarco VJ, Sammarco GJ.Surgical treatment of the hallux rigidus.Foot Ankle Clin. 2005 Mar;10(1):75-96. Review.
6. Collman DR, Kaas MH, Schuberth JM. Arthroscopic ankle arthrodesis: factors influencing union in 39 consecutive patients.Foot Ankle Int. 2006 Dec;27(12):1079-85.
7. Gustilo RB, Anderson JT.Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses.J Bone Joint Surg Am. 1976 Jun;58(4):453-8.
8. Hayashi A, Maruyama Y.Stepladder V-Y advancement flap for repair of postero-plantar heel ulcers.
Br J Plast Surg. 1997 Dec;50(8):657-61.
9. Imai K, Tokunaga D, Takatori R, Ikoma K, Maki M, Ohkawa H, Ogura A, Tsuji Y, Inoue N, Kubo T.
In vivo three-dimensional analysis of hindfoot kinematics. Foot Ankle Int. 2009 Nov;30(11):1094-100.
10. Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, Johns C, Worthington JR. Implementation of the Ottawa ankle rules. JAMA. 1994 Mar 16;271(11):827-32.
11. Yablon IG, Heller FG, Shouse L.The key role of the lateral malleolus in displaced fractures of the ankle.
J Bone Joint Surg Am. 1977 Mar;59(2):169-73.
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