VA

First day: Show up for rounds on Monday at 5:30 am. The VA you will be working at is at 1400 VFW Parkway in West Roxbury (not the Jamaica Plain VA). Go to the 3rd floor of building 2 (also known as spinal cord building entrance). You will not need an ID to get in at that time, those doors are open. From the entrance, turn right and then left to get to the elevators. Exiting the elevators, take a left. The resident room where we meet for rounds is the door on the right just before SICU double doors. The combination is 1-2-3. the door sticks, so just knock if you can't get in, knock. The trick to opening the door is to do the combo, pull towards you, then turn the handle and push the door open.

You will round and then go to morning report. At 7:30 you will go to computer training. Other tasks for the first day: 1. Go to the police for your ID. You will need to show your Brigham ID. If you wear your Brigham ID close to your VA ID, your VA access will not work, so make sure to separate them when you are trying use your card access.

2. Go to 4D-126A to get a white coat. 3. Go to C-119 (first floor across from the original main entrance in a hallway labeled Surgical Services Administration) to get your free lunch tickets. Be warned: the cafeteria closes at 3pm and is not open on weekends and it is awful anyway.

4. Try to get ahold of the yellow cards that have the useful phone numbers on them. I got mine from a student, so I don't know where they come from, so I would try to ask various admin people your first day. I photocopied mine and left them in the "Students Helpful Stuff" bins that are hanging on the wall on the left in the resident room.

General tasks for every day: 1. Get sign out from night person and round with the chief. The night person or the students have gotten the vitals already.

2. Morning report 3. Site mark and consent the first cases of the day if the 2nd/3rd year residents didn't do it. The night-person should take care of this.

4. Put in orders 5. Call consults: To find out who is on, open internet explorer. If you are not on the VA homepage, press the home button at the top of the browser. Click on Calenders/Schedules, then on "On Call Schedules".

6. Discharge--many people need to be discharged early because they have to catch shuttles to Maine. There are instructions for how to discharge people at the VA on a shared drive: Go to "My computer" then go to the S drive, then the "Surgical" folder, then to the "Resident Sign out" folder, then to "Resident Instructions" and open the "How to Discharge" document. There are other useful things in the folder and the "Resident Sign out" folder, for example in the "DC instructions Gen, Gyn, Vasc" folder, there are discharge summary templates and discharge instructions you can copy and paste. You can import appointments, medications, and other info: Press "Templates" at the bottom left. Go to the "Patient Data Objects" folder. Double click on whatever you want. This works for progress notes too.

7. Check in with the care coordinators to warn them who will need services/rehab. 8. Check/replete labs 9. Round at around 1pm to check/gather vitals/examine the patients. 10. Post-op checks 11. Update the list if the students haven't: Go to "My computer" then go to the S drive, then the "Surgical" folder, then to the "Resident Sign out" folder, then to "Current vasc-gen lists". You MUST close the spreadsheet after you edit it or no one can alter it.

12. Sit down rounds with your chief whenever they get out of the OR, usually 3-7pm. The students usually gather the vitals and update the list.

13. Check whether you are assigned to OR cases the next day:  The assignments are tacked to the bottom right hand corner of the bulletin board in the resident room.

14. Print out assigned readings and questions:  Go to "My computer" then go to the S drive, then the "Surgical" folder, then to the "Resident Sign out" folder, then to "Core Curriculum Papers"

There is a work room with 4 computer stations right next to the 3N ward. I agree with Katerina that during the day this is by far the most convenient place to get your work done because you'll be closer to your patients than if you use the resident launge that the PGY-2 and chiefs use (they use the launge because it is close to the ICU and the OR's where they spend most of their time, as opposed to the ward). The nurses need repeated reminders to get things done and if your base is this little work-room you can just walk over and motivate them.

New admits require: - admit orders - home medications (except oral anti-hyperglycemics and anti-coagulation. Double check with chief whether to continue drugs like ASA)

- if preop, they will need labs, CXR, EKG, NPO past MN, maintenance fluids past MN - add to the list

Care coordinators are Patricia and Janet(VNA service coordinator). Keep communication open with them regarding the progress of the patients so they can start discharge planning early (e.g. find them a bed at rehab, etc).

Do not assume that no news is good news. The nurses at the VA are a mixed bag. Therefore it is wise to check your patients yourself, especially on nights. Fluids can get hung 8-10 hours after you order them, medicaitons can be "saved" for when the nurse thinks the patients need it (like ativan or metoprolol) and you really need to follow through on getting things done. Fortunately, this is really easy to do if you use the intern workroom.

Clinic for general surgery is every Tuesday. Clinic for vascular surgery is every Thursday. You will need to dress up for those.

Conferences happen every so often throughout the week. Sometimes you will have a patient assigned to you for preop conference and/or M&M. In this case be prepared to give a history and/or hospital course and the attendings will use this as a jumping off point.

Use pharmacy for drug-related questions.

Call for any imaging, study you order. General rule of thumb for VA is follow through on every order, don't assume its done.

On nights: 1. Bring your own food or be prepared to order delivery. The cafeteria closes at 3PM. 2. Get sign out at 6pm. 3. Put in orders 4. Meet the patients. 5. Check end of shift vitals after midnight. 6. Maybe sleep in the call room: Room 3D-127, next door to the care coordinators. The code is 5-3-1 7. Round and check 4-5am vitals. The students usually make up the list with vitals for morning rounds. 8. Round with your chief. The students present the patients, and you fill in any gaps. Other stuff: Supply room code is: 5-1 OR schedule: Open internet explorer. If you are not on the VA homepage, press the home button at the top of the browser. Click on "Services", then on "Surgical Service" and then on "OR Schedule".

We've been starting rounds at 5:50 in the back of the workroom with sit-down rounds. The night second-year makes a daily list and gathers vitals and I&Os for the SICU and PCU (Progressive Care Unit- like intermediate care). We run the list with the General Surgery Chief and then do walk-around rounds. Once we present the SICU and PCU for Gen Surg, the Vascular Chief will come to the SICU or PCU and we present their patients. The Gen Surg list is bigger so they round oppositely. Gen Surg starts with the units while Vascular starts on the floor so that by the time Vascular is done with the floor, they're ready to go over the units.

Morning Report: At 7AM, we meet in the Surgery Conference Room which is on the third floor walking away from the SICU/OR area, past the PACU and PCU and before the wards on 2South. Where the hallway makes a "T" at the visitors waiting room/vending machine room, take the hallway away from the vending machine room and it's on the left, can't miss it. On Fridays, Morning Report is after Grand Rounds, which is held in the auditorium at the end of the same hall as the surgery conference room. During morning report, the Chiefs present the SICU and floor patients. Then, we present the consult patients we saw, alone or however it was divided up.

Clinic: Tuesday and Thursday mornings from 8:30 to anywhere from 1 to 4PM, Tuesday is General Surgery, Thursday is Vascular Clinic. We're expected to dress up for at least Tuesday clinic. Clinic starts off in one area by the ED near the administration desks and then after noon, it changes over to another area by the main entrance, the nurses will show you where. The nurses have rolling carts with special equipment such as sutures, dressing supplies, and instruments that the wheel back and forth to the different sides. Another cart has things like anoscopes and rigid sigmoidoscopes.

Cafeteria: Closes at 3PM. The hot food closes at 2:30, the deli closes at 2:45. We get weekly packets of meal tickets in $4 and $2 slips.

Imaging reports are either under the "labs" tab on the bottom of the page and clicking on the "imaging" heading in the window on the left. Or, if the person had imaging at another VA, the images and reports are on the "Vista Web".

The way to get outside image reports, outside labs, outside anything from another VA is by clicking the "Remote Data" button in blue lettering at the top of the CPRS window. After clicking that, we click on the "Vista Web" button right above it. That will open the Vista Web program which brings up all outside data. Its not as organized as the CPRS. Under the laboratory data link, all the labs by date will come up in no organized fashion except by date. The same is the case for the progress notes. The progress notes will have everything there, consult, notes, some procedure and image reports, it just takes a lot of sifting through. If it doesn't show you enough records, change the date range at the top of the page, and set the number of records shown to like 200 or even 500 if you need. The default is only 50 records.

To see outside images like CT scans and xrays, without getting reports most of the time, but just to see the actual images on the good PACS screens, we can use the PACS system in the call room, the SICU, or the ED. Local films are on this computer under WX images. All outside films in the New England VA system are on the "JP PACS" icon or folder on the PACS computers. Jamaica Plain VA is a clearing house for all images from the other VAs, so luckily, we have access to it.

To access PACS, if the computer is completely off or if you have to log in completely from the beginning, the username and password we use is "access" and "access". If the program is already running and it is asking you to log in, the username and password are "resident" and "resident". If you're not sure where you are in the system, try either.

Once in, you have a choice of WX images or JP images. Click on "search" and in the blanks on the right, enter the first initial and then in the next area for med rec number, we put in "*" and the last four of the social security number/med record number. If you need images from the JP PACS system, you might have to put in the whole social security number WITH DASHES. It won't work without the dashes.

Admits: Admit orders are entered under "delayed orders" which is a tab on the left side of the Orders tab in CPRS. Clicking on the "Surgical Service" heading on the left brings up things we usually order and there are quick order links for things like SQH and IVF. Careful of the times on lab orders, the default for most orders is "Now" and have to be changed. Morning SICU labs should be ordered for 4AM so they come back by 5 or 5:15.