Attending or Senior Resident assigns the days' cases
Review the first case and ensure workup and orders are in place, obtain consent if an inpatient.
Know your patients, know the procedure. Review with the attending if there are questions.
Patients arrive at 0645, and will be prepared for procedural consent by 0700. The Resident/Fellow and NP/PA are expected to be in the IR area by 0700 to perform the consent and pre-procedure physical exam. Please ensure you have read the workup of the patient you are consenting, so you can provide an informed consent. Consents are to be finished by 0715 so you can attend morning conference.
Informed Consent process includes
Ensure the patient's understanding of the procedure aligns with what we plan
Review the major steps of the procedure
Describe analgesia/sedation plan,
When did they last eat/drink anything
determine code status
Discuss risks and benefits: major complication and outcome success rates
Inform them of approximate length of procedure and recovery.
Document with check-list and update H&P
Morning conference begins at 0715, where we discuss the day's cases. Be ready to present your patients for the day. If any issues come up during the conference which require further investigation, the Resident/Fellow should address them whenever possible. Be prepared to present the inpatients you are following .
The day's first cases should be in the rooms, and ready to go at 8:00.
Following conference investigate the status of your first case. Address any issues.
If there is time, review room set up with the technologist. Make sure you can move the table so that fluoro can cover the entry and target areas, and that you can adjust the angle of the fluoro for obliques.
Plan to be in the room, scrubbed, before the attending.
Throughout the day, if there is time before "your" case starts, the work priority is :
please see if there are any other patients who have arrived and may need consent/checklist,
if there are any "add-on" cases which need working up
or assist the TOAD with the next day's workups.
After your case is complete, write appropriate orders
For chest tube placement, write, "Chest tube to -20cm suction"
For drains, write "Drain care" orders regarding output recording and flushing
Nursing care and discharge instructions
For in patients, use 'Nursing Communication' order rather than 'Discharge'
Between cases, please attend to patient flow as in #3: your next case, other cases not yet in rooms, pending add-ons, and then next day cases. to any procedures which have been added on. Check with the TOAD and see if they need assistance.
Add-ons should be worked up and then presented to an Attending or Associate Provider to determine acuity.
Please answer the phone if the scheduler is on another line or away. This is an expectation of all the staff.However, it is not necessary to investigate ongoing management issues from scratch, if there may be someone familiar with the situation or process. Saying, "please hold" and referring is often the time-efficient solution.
When doing workups, if you cannot find any patient information in notes, please check the scanned documents (in eDH), and if not there, please call the referring provider and/or the PCP to obtain the patient's current medical history, PMH/PSH, medication list, and lab work. This information may have been acquired by the nurses, so check with them first.
Though requests are entered as orders, we address them as consults. The pre-procedure workups should be thorough and address the following questions:
What procedure is being asked of us?
What is the indication—general diagnosis and the specific signs, symptoms the procedure is to address
Is this the appropriate procedure for the patient's problem?
Is there anything in the patient's current or past medical/surgical history, including medications (i.e. Coumadin/Plavix/Heparin) labs, and recent imaging which would require further investigation, require accommodation, or be a contraindication to the procedure? If so, discuss with the attending as needed, and address this in the impression & plan section of the note.
Moderate Sedation: If more than a simple needle puncture, patients may receive Fentanyl +/- Versed during the procedure. Sedation requirements restrict any food for 6 hours prior to procedure, and any clear liquids 2 hours prior to procedures for Fentanyl + Versed. (If patients have eaten they can receive analgesia (ie, Fentanyl only). There may be some patients in whom bypassing Versed would be inappropriate.
Use of Anxiolytics NOT requiring NPO status include Haldol, Ativan, Xanax etc. Should be discussed with the nursing staff.
If Fentanyl cannot be used due to allergy or some other reason, an alternative narcotic may be used (Dilaudid, Morphine, etc).
Each patient receiving Moderate Conscious Sedation requires an ASA and Mallampati score prior as part of the pre-procedure physical exam. There are charts (in flip page file folder on the desk with the printer) delineating the categories for each. These must be included on the pre-procedure note/note addendum which also includes the PE.
Many of our procedures require a single dose of an antibiotic. The complete list of procedures for which we administer prophylactic antibiotics are listed in the flip page file folder on the desk with the printer.