Welcome to Orthopaedics at the University of Utah; the department is delighted to have you doing a rotation with us.  Orthopaedics is an operative field primarily involved in the health and well-being of the musculoskeletal system.  Surgery of the spine, upper and lower extremities in both children and adults as well as non-operative management of pathology in these areas are within our scope.  Most of the university orthopaedic surgeons are subspecialty-trained in hand, trauma, sports medicine, joints, tumor, spine, foot and ankle or pediatric orthopaedics, and your rotation will include a combination of at least two of these subspecialties.  In addition to the attending staff you will be rotating with residents, fellows and physician assistants and nurses to further your education.

The expectations while on the orthopaedic rotations on the orthopaedic rotation are clear: medical students are expected to know the anatomy of the surgical cases to be done, to have had some background of the pathology encountered intra-operatively and assist with patient care.  The medical students should go to clinic with their attending as instructed.  Clinic responsibilities change according to attending so ask your housestaff.  This assistance involves writing operative notes, post-operative orders and patient SOAP (Subjective, Objective, Assessment, Plan) notes on the floor.  If you have assisted in a surgical procedure that patient should be on your list to round on daily and help with their paperwork.  The housestaff work very hard; to be great medical students try to assess what are their tasks and them help them get it done.  You do not need to ask first to help with paperwork, although it will need to be cosigned.  Pre-rounding on your patients–knowing their labs, vital signs, medications–before AM rounds is greatly appreciated and will be rewarded.  During surgery, help positioning the patients, writing an outline of the post-op orders or operative note, hanging films or attaining them on the computer are all very helpful.  Also, as stated before, reading the anatomy and some background on the diagnosis of the patient is considered imperative.  Anatomy can be reviewed in Surgical Exposures in Orthopaedics: The Anatomic Approach by Hoppenfeld; ask your housestaff for any other recommendations.  The outline of topics in this syllabus covers many of the most common pathologies encountered and each subspecialty section also includes reference material for your use.

Remember, to be a great medical student think beyond your level, try to imitate and help your housestaff with their duties and your learning will be significantly enhanced.  Call should be undertaken when your housestaff are on call.  Do not expect housestaff to call you in from home – they are busy!  Calling a medical student is a task that may not get done, stay in-house if possible or set up another system to alert you to call activities.

In the above section, SOAP note, orders and op note were mentioned.  Please refer to these outlines for what is expected in each of these formats.

S.O.A.P. note

S: Subjective: How the patient is feeling according to them – pain level, sleep patterns, nausea, etc.

O: Objective: Vital signs here, maximum (over past 24 hours) and present temperature, labs, drainage from drains over last 24 hours, etc.

A: Assessment: Physical exam.  This should always include a neurovascular assessment of the operative limb or distal to spinal operative level.  Mention braces/casts here and how they are fitting.  Swelling should be assessed.  Check pain to passive stretch of fingers or toes (a very sensitive sign of compartment syndrome).

P: Plan: Is the patient staying on IV meds/block or changing to oral meds? When is discharge home planned? Where are they going (home vs. ECF)? What is their weight bearing status (full: FWB, partial: PWB or non: NWB)?  Do they need physical therapy?

Sign your note as MS III or IV and get your housestaff to co-sign.

Post-Operative Orders

  1. Admit: To whichever attending
  2. Dx: Diagnosis and status post what surgery
  3. Condition:
  4. Vitals: How often or per routine.  If patient at risk for compartment syndrome, mention it here and ask for neurovascular checks Q specific intervals.
  5. Allergies:
  6. Activity:   NWB/PWB/FWB.  Is ice needed? Can they get up to chair or walk? Do they need a brace to do so?
  7. Nutrition: Often NPO or clears with increase as tolerated.
  8. IV: D5 ½ NS with 20 mEq KCl is used most often.  In kids for the first 10 kilos: 4cc/kilo/hr, second 10 kilos: 2cc/kilo/hr, after 20 kilo: 1 cc/kilo/hr, a 32 kilo kid therefore 40 + 20 + 2 + 62 cc/hr
  9. Labs: Hct? Are they on anti-coagulation? They need PT/PTT or INR.  Are they on meds that need levels checked (gentamicin, Dilantin, theophyllin)?
  10. Meds: Pain meds can be covered by acute pain service or by ortho.  Ask you housestaff.
  11. Physical Rx: Doe this need to be ordered?
  12. Other: Do they need O2, drains emptied, I&O’s, Foley, chest tube, etc?

Operative Note

  1. Pre-operative diagnosis:
  2. Post-operative diagnosis:
  3. Procedure performed:
  4. Surgeons:
  5. Anesthesia: List anesthesiologist and type (eg: general, endotracheal vs mask).
  6. Findings:
  7. Estimated blood loss: (EBL)
  8. Fluids given: (list IV fluids and blood given)
  9. Tourniquet time and pressure:
  10. Post-operative plan: Very important.  List activity level, follow-up plans, etc.

Please feel free to ask your housestaff and/or attendings if they have any further expectations or other ways for you to help.  The more you are involved, the more you will learn and retain.  Also if you are interested in pursuing orthopaedics as a career and need advice, please call the medical student advisor, Dr. Kristen L. Carroll at 801 – 536 – 3600.  Also, 4thyears students should set up an exit interview with Dr. Kristen L. Carroll at the conclusion of their rotation at the above number.

Work hard and good luck!