This guest post is from our new Resident Roundup section. Sean Pirkle, MD and Max Coale, MD offer a brief “crash course” for those starting intern year. We look forward to sharing additional posts written by residents, or of special interest to residents, here on OrthoBuzz.
Intern year is difficult. For everything we learn in medical school, no amount of training can fully prepare us for what’s in store starting July 1.
Many challenges arise from the progression of responsibility. We’re juggling new roles and will take on the care of patients with complex concerns. This can lead to a substantial amount of stress (particularly in the first few weeks to months) stemming from a lack of familiarity with the basics.
To help smooth this transition, we have compiled information based on the experiences of current (S.P., PGY-1) and former (M.C., PGY-3) interns at a large academic medical center. While you will likely find that there exist alternatives to those listed here, and that providing optimal patient care includes tailoring decision-making to your specific patient population, we hope this crash course can serve as a launching pad for answers that one day will become second nature.
On the Floor
- Common Abbreviations
- Common Medications and Associated Considerations
- Splint Types and Indication
- Common Surgical Risks (for consents)
- Standard Follow–up Intervals
In the OR
On the Floor
|Abbreviation||What It Means|
|ADAT||Advance diet as tolerated|
|CTM||Continue to monitor|
|Dakin’s||Diluted bleach solution used for wound care|
|GOC||Goals of care|
|GTT||Drip (e.g., heparin, insulin)|
|NSTI||Necrotizing soft-tissue infection|
|OOB||Out of bed|
|PCA||Patient-controlled analgesia (usually IV Dilaudid, less likely morphine; push button with predetermined lock-out intervals, which can be adjusted)|
|PIC score||Pain, inspiration, cough (used for patients with rib fractures)|
|PNC||Perineural catheter (for pain control)|
|Qxhrs||Every x (number) hours (e.g., q8h: administer medication every 8 hours)|
|RFP||Rib fracture protocol|
|ROMAT||Range of motion as tolerated|
|SBT||Spontaneous breathing trial (protocol for extubating patients with endotracheal tube in place)|
|SSI||Sliding scale insulin|
|TID||Three times daily|
|WTD||Wet to dry (wound care)|
Common Medications and Associated Considerations
Heparin: standard trauma dosing starts at 5,000 units q8hrs
- Enoxaparin (Lovenox): standard trauma dosing starts at 30 mg BID, 40 mg BID for patients with a body mass index (BMI) of >40 kg/m2
- Aspirin*: oral, if unable to tolerate the above injectables; standard dosing of 81mg BID (*Varies by attending preference; ask what your attending prefers.)
Therapeutic anticoagulation: patients with coagulopathy, deep vein thrombosis (DVT)/pulmonary embolism (PE)
- Heparin drip: both low and standard-intensity dosing exist; titrated based on patient risk factors
- Lovenox: weight-based but higher than prophylactic dosing
- Warfarin: relatively cheap; requires follow-up in warfarin clinic for international normalized ratio (INR) tracking
- Factor Xa inhibitors (apixaban, rivaroxaban, dabigatran): oral route of administration; potentially more expensive, depending on insurance coverage; longer relative half-lives than injectables
- Cefazolin (Ancef): penetrates bone; frequent perioperative use in orthopaedics
- Ceftriaxone: broad gram-positive and gram-negative coverage
- Methicillin-resistant Staphylococcus aureus (MRSA) coverage: vancomycin, clindamycin, trimethoprim/sulfamethoxazole (TMP/SMX; Bactrim), doxycycline
- Pseudomonas coverage: piperacillin/tazobactam (Zosyn), ceftazidime, cefepime, aminoglycosides, fluoroquinolones, meropenem, imipenem
- Anaerobic coverage: metronidazole (Flagyl), clindamycin, amoxicillin + clavulanic acid (Augmentin), ampicillin + sulbactam (Unasyn), piperacillin + tazobactam (Zosyn), carbapenems
*Consult your local antibiogram for the most up-to-date information.
- Ondansetron (Zofran): QT prolongating
- Compazine (Prochlorperazine): mildly sedating
- Metoclopramide (Reglan): increases gastric motility
- MiralLAX: osmotic laxative; standard bowel regimen for patients taking opioids
- Senna: stimulant laxative; standard bowel regimen for patients taking opioids
- Bisacodyl: stimulant laxative; available in suppository form
- Oral magnesium: potent osmotic laxative
Pain control ladder*
- Acetaminophen (Tylenol): maximum acceptable floor dose usually 1,000 mg q6hrs; consider hepatic function
- Ketorolac (Toradol): IV formula, potent NSAID (nonsteroidal anti-inflammatory drug), negatively impacts bone healing in fracture setting; consider renal function
- Gabapentin: typically prescribed for nerve pain; starting dose usually 300 mg TID, maximum acceptable floor dose usually 1,200 mg TID; consider renal function
- Methocarbamol (Robaxin): typically prescribed for muscle spasms
- Oxycodone: opioid agonist; starting dose usually 5 mg, maximum acceptable floor dose/frequency usually 15 mg q3hrs
- Hydromorphone (Dilaudid): opioid agonist, typically prescribed for breakthrough pain; fast acting/short lasting; maximum acceptable floor dose usually intravenous 0.4 mg q4hrs (also available in oral route)
*See the modified World Health Organization pain control ladder in this article by Pergolizzi et al.
Splint Types and Indication
- Thumb spica: base of thumb fracture (if metacarpal fracture, include thumb interphalangeal joint; if only scaphoid, do not include interphalangeal joint)
- Intrinsic plus: adult phalanx fractures
- Ulnar gutter: 4th and/or 5th digit fractures
- Volar resting: hand pathologies without associated fracture that would benefit from limited mobility (laceration, cellulitis)
- Short arm: wrist fractures (extra-articular distal radius, distal ulna)
- Long arm: intra-articular distal radial fractures, forearm fractures, elbow fractures, distal humeral fractures
- Posterior slab long arm: elbow dislocation
- Coaptation: humeral shaft fractures
- Bulky Jones: calcaneal/foot fractures, other pathology that would benefit from extra padding/protection
- Short leg: ankle fractures, pilon
- Long leg: tibial shaft fractures, tibial plateau fractures
The gauge of a needle refers to the length between the proximal and distal opening of the needle tip. Hence, the larger the gauge, the smaller the needle. An 18-gauge is typically used for drawing up solution quickly (lidocaine, corticosteroid, etc.), whereas a 21-gauge is typically used for injecting into soft tissues (anesthetic prior to traction pin, intra-articular knee injection).
Common Surgical Risks (for consents)
- Clotting (DVT/PE)
- Damage to surrounding structures (veins, arteries, nerves)
- Incomplete resolution of symptoms/possible need for revision surgery
- Complications with implants including need for removal or revision
Standard Follow-up Intervals
(Assuming follow-up course within normal limits)
Operative cases: 2 weeks for wound check/suture removal, 6 weeks for repeat radiographs, 3 months, 6 months, 1 year, 2 years
Nonoperative cases: 1 week for repeat radiographs, then consistent with operative course follow-up
In the OR
Choosing a Table
The most important consideration regarding a fracture table is the ability to obtain intraoperative imaging. Several orthopaedic tables encountered in the trauma setting include the center radiolucent (e.g., Jackson flat) and center radiopaque (e.g., Midmark), with the primary difference between these 2 radiolucent beds being that the center radiolucent has bedposts oriented on the ends, whereas the center radiopaque has its singular post positioned in the middle of the bed. Because of this, the center radiolucent table is ideal for cases in which the C-arm needs to access the middle of the bed (e.g., hip fractures).
A center radiopaque table is ideal for cases in which the patient is positioned at the end of the bed (e.g., ankle fractures).
A third option includes the fracture/Hana table, where the patient’s feet are strapped into the bed without support beneath them. This allows an unscrubbed assistant to adjust traction and position the legs while the C-arm easily accesses the hip, effectively minimizing the assistant’s need to obtain/maintain a reduction.
High-Yield Surgical Instruments
- Pickups: Adson, Jefferson, Debakey, Russian, Bonney
- Hemostat: mosquito, Kelly (half-curved, tonsil), Kocher, Allis
- Retractors: skin hook, rake, Senn, Hand Senn (has weighted middle section), Army-Navy, Langenbeck, Hohmann, Weitlaner, Gelpi, Cerebellar
- Cutting: Mayo, Metzenbaum, suture scissors, Iris
- Elevators: periosteal/freer, Key, AO, Cobb
- Miscellaneous: curette, rongeur, osteotome, pointed reduction clamps, towel clamps, lobster clamps
What’s a mini frag? What’s a large frag?
- Core diameter: inner diameter of a screw (not counting the threads) in millimeters (mm)
- Pitch: distance between consecutive threads
- Cortical screw: screws with threads spaced at relatively narrow intervals (smaller pitch); optimal for higher-density cortical bone
- Cancellous screw: screws with threads spaced at relatively wide intervals (larger pitch); optimal for lower-density cancellous bone for greater purchase in weaker bone
- “Mini frag”: basic ortho set with 2.0, 2.4, and 2.7-mm screws
- “Small frag”: basic ortho set with 2.7, 3.5, and 4.0-mm screws
- “Large frag”: basic ortho set with 4.0, 4.5, 5.0, and 6.5-mm screws
This is a nuanced topic that can be simplified by generic umbrella properties (absorbable vs. nonabsorbable, natural vs. synthetic, braided vs. monofilament). In order of importance, first consider the size of the suture with respect to the strength required to oppose the intended tissue (a smaller number [e.g., 0-0] correlates with larger diameter/greater tensile strength of suture). Second, consider whether the suture should be absorbable.
In trauma situations, deep layers are typically closed with absorbable sutures, while superficial layers utilize nonabsorbable sutures (however, some wounds are closed with running subcuticular absorbable suture). Monofilament sutures have “memory” and are more difficult to control as they retain their coiled shape from the package, but theoretically have a lower risk of infection when compared to a braided suture, which has micro spaces where bacteria can colonize.
We hope this guide can be used as a resource to facilitate a more seamless evolution from medical student to full-fledged doctor. Even still, there may be times when you question your ability or feel like you are drowning in a never-ending list of checkboxes. Through it all, know that this is normal and that you are surrounded by co-residents, seniors, and attendings who have all been where you are and can offer advice and support along the way.
You are not alone. Good luck!
Dr. Pirkle, PGY-1, and Dr. Coale, PGY-3, are with the Department of Orthopaedics and Sports Medicine at the University of Washington in Seattle.
Stay tuned for more Resident Roundup posts. Last month’s post came from orthopaedic surgery research resident Derek T. Schloemann, MD, MPHS: “Insights into Trends in Knee Arthroscopy.”