Shadyside Service Guide

Shadyside Service Guide

Pre-rotation To-dos

  • You should already have parking automatically
  • Email Missy about badges / scrubs
  • Get access to SHY lists from APPs
  • Add all of the MD consultants below to a SHY consults favorites folder (alternatively steal "SHY consults" from Hussein's favorites) because consults are not placed by name of service at SHY, but by the specific MDs on that service.
  • Email Jamie Kriner and Jessica Sarno to be added to the SHY A/B distribution list which is a daily email that tells you which heme / onc providers are covering each patient.
  • Pager:
    • you should automatically be added to get pages for the group NSGY pager 37305 while you're here. Some people will still page you to your personal pager but it's impractical to keep up with what is your personal pages vs. group pages so go ahead and forward your personal pager to 37305 during your time at SHY so that your personal pages aren't ignored (e.g. PACU and pharmacy always page your personal pager)

SHY TRAC template

Use this TRAC template for all oncology patients.
Attg
Dx: new L temporal met

O1 L crani (absorbable)
+ Dx: LUL NSCLC dx 10/2023
+ Prior/current: platin therapy, last 10/24
+ Neuro-axial hx: 3cm R frontal met
+ Surgery (attg, date): R crani (KGA 10/2024)
+ significant PMHx: COPD, HTN
+ home AP/AC: Eliquis (provoked DVT)

Lines:

Meds:

Diet:


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Notes:

SHY Consults Folder

  • At SHY you do not consult a service by searching the name of service, you use the same MD consult and put in a doctor. Usually it's one doctor for every service and no matter who is on call it will get funneled to the covering team.
  • You need to make a folder for SHY consultants where you put the name of service and person to consult in the special instructions text so you have it readily available.
Behavioral Medicine: Altman, Sharon
Oncology: look in MedTrac for who is on call
Cards (pre-op clearance): Ricci Minella
Ortho: Adolf, Yates, Mcgough, Richard
Cardiac surgery: Gleason, Thomas
Palliative: own consult order
Endocrine: Sachin Bahl
PRS: Jeffrey Gusenoff
ENT: Gillman, Grant
PM&R: Maryanne Henderson
Geriatric Medicine: Shuja Hassan
Psych: Sharon Altman
Gen Surg: Matthew Holtzman
Pulmonology: Yee, Emily
GI: Howard Dubnar
Radiation oncology consult is its own order
ID: Edward Verdream / Volosky / Perez
Renal: David Levenson
ICU: Clute, Steve
Stroke consult is its own order
Medicine: Crimson Hospitalist consult (own order)
Thoracic surgery: Neil, Christie
Neurology: Andrew Levin
Urology: Joel Bigley
Neuro-oncology: Jan Drappatz, Megan Mantica, Frank Lieberman
Vascular: Tillman, Bryan

How Oncology Works at SHY

In general if you need to contact oncology for any patient, wherever the patient is located, the secretary or huk on that floor will have a list of daily APP/Attg assignments. Theoretically when people are working, they will have same patient for 3 days in a row.
NOTES AND DEFINTIIONS
  • All the below teams switch the consult pager, which is 37833 (ONCOLOGY CONSULT SHY)
  • PCI = A team, B team = solid tumors
  • Liquid tumors includes
    • H team: lymphoma and MM
    • Leukemia team: leukemia
    • BMT team: all BMT patients
  • There is a nocturnist team of hospitalists who admit for all of heme onc overnight and you will have frequent engagement with these people, they are who is admitting your stable brain tumors to HO overnight with you seeing them in the morning
 
TEAM
WHAT THEY DO / HOW TO CONTACT
A team
• This is a team of APPS / attendings only
• never has a patient cap
• this is mostly who we interact with 
• 38770 is admission pager, but also preferred that you just find a direct pager/number from SHY A/B distribution list (or call Huk as above)
B team
• This is a teaching team made up of residents
• they have a patient cap beyond which they defer to A team
• Pager is 37439
Admitting nocturnists
From 7pm - 7am, this group of hospitalists take care of admissions and alsocover the admitted patients for all team A and B. 

This is who you call when ED is giving you a hard time overnight and you want to circumvent them entirely (or if ED won't engage them quickly enough just do it).
Neuro-oncology
- do not have a forwarded pager
- you just have to look in medtrac to see which attending is on
- Attgs: Drappatz, Mantica, Liberman (Retiring?) 
- APPs: Gina
- they never admit, only consultants
Radiation oncology
Atttgs: Burton, Zureick
APPs: Katie Sigal 412-613-6595
Pager 39124 and this can be used
Benign heme 37778
ㅤ
Leukemia 37229
ㅤ
BMT team 37616
ㅤ
H team 38181
ㅤ

Attending Preferences

Operating days

  • Monday: Abdullah / Wecht / Bayley
  • Tuesday: Wecht (in AM), Zinn
  • Wednesday: Bayley
  • Thursday: Abdullah / Zinn
  • Friday: Wecht (private practice day)

Universal booking instructions

  • Book all cranial cases with the following-addons: Ultrasound, Brainlab, Kusa, Microscope
  • Not infrequently, vascular surgery does a pre-op IVC filters on our high-coagulopathic state patients. Need to book the case with “IVC filter,” don’t assume vascular will do it.
  • If any concern for glioma, will need the two research consents (Zinn and Abdullah patients)

Pascal Zinn

Pre-op
  • 2 x Research consents needed for all patients w/ primary brain tumors, particularly gliomas
    • bio-banking consent for all tumors
    • no research consent needed for biopsy
  • Booking:
    • Spinal instrumentation Depuy Synthes for vendor, ultrasound
    • Craniotomies: all booked Medtronic Stealth navigation
    • Stereotactic biopsies: horseshoe & AxiEM Medtronic image guidance, no fiducials needed for navigational scans.
  • Dr. Zinn may request MEG scan prior to surgery. These patients need to be transported to Presby and then back. Case management needs to be engaged early as they will arrange for all this. Email Dr Niranjan and Andre Pereira (412-587-3003) pereiraal@upmc.edu to arrange for this.
  • Neurocognitive testing: if this is part of the plan, you email the neuropsychologist Dr. Natalie Sherry and copy Dr Zinn and team (sherrynk@upmc.edu) stating when surgery is and she will tell you when she will see the patient.
  • AWAKE craniotomies: email Shiv Goel, Adam Hill, Dan Sabo, Robert Lorah, Scott Rusiewicz so they can coordinate.
Post-op care:
  • MRI B w/wo for all primary brain tumors early am on POD#1.
  • All spines with with instrumentation: AP/lateral XR
  • Keppra 500 bid x 7d.
  • dex 4q6 w/ 5-10 days tapers.
  • SQH on POD1.
Discharge
  • New gliomas seen in MDC clinic (nsgy, neuro onc, rad onc) ~10-14 days post op. MDC coordinator will reach out to family/IPR to schedule
  • VP shunts will need CTH with post op appointment
  • post op brain mets seen in rad onc if they don't get pre op SRS. Rad onc office will coordinate. If d/c to IPR, f/u after IPR d/c

Kalil Abdullah

Pre-op
  • In general, co-sign all consents with a family member even on intact patients.
  • Will occasionally request NPH research consent with VPS (attached). 
  • 1 x Research consent needed for all patients w/ primary brain tumors, particularly gliomas (attached) - just the biobanking. even for biopsies
  • LITT consents: use a General Crani and Special Procedures form.
  • Booking LITT: include varioguide and brainlab. 
  • Pre-op Brain MRIs: include DTI and SPGR sequences
 
Post-op
  • SQH always (never SQL)
  • NPH patients never go home on POD1, at least POD2 after PT/OT clears
  • Post-op shunts, get a CTH at 2 week post-op visit.
  • New post op gliomas seen in MDC clinic (nsgy, neuro onc, rad onc) ~10-14 days post op. MDC coordinator will reach out to family/IPR to schedule
  • post op brain mets seen in rad onc if they don't get pre op SRS. Rad onc office will coordinate. If d/c to IPR, f/u after IPR d/c

Daniel Wecht

Pre-op
  • Crani for tumors booked with Stryker navigation, microscope, US
  • All shunts need to be booked 1st case (infection control)
Post-op
  • Orders: Dr Wecht himself may occasionally do orders, but be ready to do them. Do NOT use standard post-op orders from Presby, instead copy the following folders from Hussein's favorites: “Wecht ACDF,” “Wecht Lumbar.”
  • DO NOT automatically order PT/OT the next day without asking Dr Wecht. He will only do it on people who he thinks might need rehab.
  • IMAGING
    • C-spine XR lateral and AP with the patient sitting upright in PACU as soon as awake
  • prefers Norco over oxycodone for his post-ops
  • SQH universally (no SQL, even for spines) 
Follow-up
  • There is a Wecht discharge list for his PA (Gina Shaffer) to be able to keep track of outpatient follow-ups when he is on call.
  • Otherwise, Gina Shaffer (or Ed Shaffer) handle Dr. Wecht’s next day discharges for his scheduled surgeries.
Incision care
ACDF
  • Shower post op day 2 using a waterproof dressing
  • Remove waterproof dressing after 5 days
  • Leave steri strips intact. They will curl up and fall off on their own
      • Lumbar Lami / MCD:
  • Shower post op day 2
  • Use waterproof dressing when showering
  • Keep incision covered for first 5 days
  • Remove dressing after 5 days
  • Soap and water can come in contact with incision after 5 days. Do not scrub
  • Staples will be removed in 10-14 days

James Bayley

Post-op
  • Uses SQL (not SQH) for DVT ppx at all times
  • Any fusion w/ instrumentation should have an X-ray at that level at some point post-op
Incision care
  • Can shower on POD2 (don't soak in bathtub or scrub incision)
  • Can remove dressing on POD2 and leave open to air (if continuous drainage, cover with dry dressing)
  • No tub baths or submerging incision site under water
  • Exofin (clear covering overtop incision) will fall off on its own over time, do not pick off yourself
  • Do not apply anything topical to the incision site (creams, ointments, etc.)

VP Shunt Assistance

  • Email Dr. Matthew Holtzman first, if not available then email Dr. Haroon Choudry. Last resort, call the gen surg PICCL and see who is on call and if they can assist.
  • DO NOT PUT IN A GENERAL SURGERY CONSULT - just email Holtzmann directly.  

SHY H&P/Consult Note Template

 

Random SHY Tips

  • In general do NOT get post-op MRIs on metastatic brain tumors, will show clinically insignificant strokes and doesn't really change management; only usually do AM MRI on primary brain tumors.
  • How to transfer SHY → PUH
    • Staff w/ presby attg and confirm
    • Call medcall 412-647-7000 and tell them PUH attg has approved
    • Call Dr Barrington (CMO at SHY) for approval, 412-337-0339
    • Call charge on floor and let them know about transfer
    • Call AOD
    • Email all residents w/ a TRAC-type info of diagnosis, course at SHY, plan from attg, attach consents as applicable to email
  • How to schedule MRI under deep sedation / GAS
    • Order the MRI
    • Call the Anesthesia secretary at 412-623-2167 usually name is Darcy the lady who coordinates it with MRI

Signing off at SHY

General Template

Do not sign off a patient without all of the following addressed. When getting plans from chief, all of these items need to be addressed. You will inevitably be re-paged and reconsulted if you don't take a few seconds to answer these questions while staffing the patient anyways. In fact, you should make a dot phrase in Powerchart called "signoff" to remind yourself to sign off no other way
  • No acute neurosurgical intervention
  • Diet: cleared from NSGY standpoint for diet
  • DVT ppx: cleared from NSGY standpoint for SQL/SQH, defer to primary. If there are hemorrhagic mets, go the extra mile and specify "Benefits of DVT ppx override the risks of further bleeding in known hemorrhagic met" - you will be repaged either by a nurse or primary team asking "really are you sure" if you don't do this.
  • Anticoagulation / Antiplatelet restart: clear from NSGY to start AP/AC on date XYZ.
    • If this is a post-op patient, do not just say "post-op day 7", say the exact date that would be e.g. Ok to resume home ASA81 on POD7 (5/25/2024).
  • AEDs: specify duration (e.g. Keppra until POD7) or defer to Neurology/Neuro-oncology if patient actually has seizures that are being managed by a neurologist.
  • Dex plan: even if NSGY has not been the service to have started, specify if there is need for steroids from our standpoint or defer to primary / NO / RO otherwise we will get repaged.
  • Activity: Clear to be OOB with assistance for PT/OT: Many services will think "this person had neurosurgery" so will let patients lie in bed for 1 week on bedrest without seeing PT/OT.
  • Incision care:
    • firstly this should be in depart for when they go home as is standard
    • in addition, many people will stay in hospital long after we sign off, so you need to specify to nurses / primary team exactly how to deal with wound or you will 1000% be dealing with q48 hr pages every time a new nurse comes on. place the dot phrase .woundCare in the sign off note and ALSO put in a CONTINUOUS nursing communication order saying "please refer to NSGY sign-off note on DATE for wound care" instructions
 

Stereotactic radiosurgery

When you staff a consult w/ Dr Abdullah and it's SRS lesion and he says "SRS we'll take it from here" it means you can sign off and put the following in your depart, add to the SHY Discharges list then you're done. 

How to limit re-pages:
  • clear for DVT ppx, especially if hemorrhagic lesion
  • document a Keppra plan from KGA (or state “can continue Keppra until f/u in SRS clinic”)
Template
  • No acute neurosurgical intervention - ok for diet / DVT ppx but deferred to primary
  • Images reviewed w/ Dr Abdullah, lesion appropriate for stereotactic radiosurgery, not open resection.
  • MRI brain w/wo contrast ordered
  • Rad onc consult for SRS
  • Defer dex dosing and taper to rad-onc
  • Continue Keppra until follow-up for SRS
  • Dr Abdullah's team will contact patient to schedule SRS.
  • NSGY to sign off
 

Wound Care

Surgical incision closed with:
Surgical incision is dressed with: (nothing, ok to be open to air) vs. (primapore, please change q48h)
Drain wounds: these were covered with a prima-pore when the drain was taken out, ok to remove primapore after 24 hrs or to change daily q24h if patient prefer
May sponge bath on day (//2024):
May shower on day (//2024):
General guidelines
  • Do not direct high pressure water directly on wound, ok to gently run soap/shampoo and then water over incision
  • Do not scrub the incision directly
  • Always quickly but gently pat dry the incision with a new clean towel after washing
  • Follow the above instructions above for approximately 3 weeks or until incision is completely healed (no open area or redness in area of incision)
  • Keep watch on incision site for signs of infection - these include frank purulent expression, redness, swelling, excessive drainage (some scant drainage of blood/serosangenous fluid is normal), repage if concerned
 

Bracing

When we recommend a brace on a non-primary patient, go ahead and leave the contact info of the bracing companies as most people at SHY do not know how to do this, they will either get a very poorly fitting off the shelf brace from the hospital or just not do it.
Options for order spinal braces as recommended by neurosurgery:
  • Call De La Tore Orthotics (412)-599-1138 OR 412-665-1900
  • Call Hanger Prosthetics & Orthotics 412-431-3553
 

Neuro-oncology consult service guidelines

Background: Neuro-Oncology Faculty availability
Scope of Consultations:
Primary and Metastatic Brain Tumors: CNS disease assessment and neuro-oncologic management ( i.e. weighing in on oncologic treatment for CNS disease) Neurologic Complications of CAR-T/Cellular Therapy Other Neurologic Complications of Cancer/ Cancer Therapy: After initial General Neurology Consultation.Tips for directing consults:
Neuro-Oncology: when the consult question involves  evaluation for CNS directed oncologic therapy ( for example, a patient with recurrent glioblastoma requiring an evaluation for  medical therapy) General Neurology:  when the focus is on evaluation and management of symptoms  but   an opinion on  CNS directed oncologic therapy is not required ( for example,  a patient with breast cancer and stable brain metastases who presents with breakthrough seizures)
Consult Schedule:
Business Days (MON-FRI): No change. In-person consults by Neuro-Oncology 24/7. Weekends/Holidays:
  • General Neurology manages urgent neurologic issues in all patients.
  • Place consult requests directly under General Neurology (Dr. Andrew Levin). Consults will transition to Neuro-Oncology on the next business day.
Weekend Protocol:
o   For established consults, Neuro-Oncology will provide detailed anticipatory guidance on Friday.
o   For patients with new and/or severe neurologic symptoms, seizures or cerebral edema  (established and new consultations):
o   General Neurology will follow/ manage active neurologic issues  in  established patients and  provide initial management recommendations for new consults (AEDs, steroids, imaging recommendations, and CSF work-up if needed).
o   Neuro-Oncology to finalize treatment plan on the next business day.
o   For patients with less severe symptoms, and when the main question is oncologic therapy of CNS disease, please order imaging work-up and hold consults for Neuro-Oncology until next business day (aligning with similar practice for Radiation Oncology).
Emergency Virtual Availability:
Neuro-Oncology available via email/phone at all times. Primary contact: Dr. Jan Drappatz (pager 37699, cell: 617-515-7374), with Dr. Mantica as backup.