Day to Day Practice

dan botwright
dan botwright

Every day in orthopaedics starts with a trauma meeting at 8 am. This is where all the new patients from the last 24 hours are discussed and a plan is made for each patient. It is important all members of the ward team are present at the trauma meeting so everybody knows what the plan is for each patient. You will often be asked to come to the front of the meeting for a friendly grilling, so make sure you’ve had some coffee!

Often consultants/anaesthetists will say they want a specific scan or blood test doing for a patient but not say it to anyone in particular. It is up to the fy1s to pick up on this and make sure these things get done ASAP, as unfortunately you will often be blamed (and sometimes shamed!) if theatre lists are delayed due to these things not being done.

There will then be 2 simultaneous morning ward rounds:

The trauma round – The consultant operating on the trauma list will see each patient for theatre. One junior should go on this round to scribe and ensure any jobs are taken care off. Remember to make sure all patients for theatre are consented, marked and have a completed marking form (including vte assessment)

The post take round – The consultant on call will see all the new admission. Again, one junior should go on this to scribe and do jobs.

The orthogeriatric team will often do wardrounds at various times on various days. It is very useful for one junior to go with them, this will save you so much time when it comes to doing to jobs as you wont have to trawl though notes to see what they want doing!

dan botwright
dan botwright

The Ward Round

Once the morning rounds have finished, the ward team for the day will start the mammoth ward round of all patients (often up to 70!). The registrar will lead this with between 1-5 other juniors following.

Make sure you have a printed list of all inpatients and also an admissions list before you start. Make a note of all jobs during the ward round on your list. Also, annotate your list with any important changes in the patients status and up to date demographic details to make updating the list easier later on.

Important things to check for every patient you see on a ward round:

EWS – Found on patienttrack

Bloods – All preop patients should have set of baseline bloods, all stable patients should have at least weekly bloods. All patients that have had surgery with potential for bloods loss eg, neck of femurs, major trauma, long bone fracture or joint replacements must have bloods day 1 post op.

Wounds – Check dressings are dry and wounds are looking healthy. Check the operation note. Some dressings are supposed to stay undisturbed and there may be specific instructions. If you don’t read the operation note and do the opposite to what is specified, you may get a stern talking to.

Bowels – Most patients under ortho are on opiates, and most patients on opiates get constipated. Make sure the patient is opening their bowels and have adequate laxatives prescribed.

Catheters – Most elderly lower limb injury patients get catheterised in A+E, these are normally left in too long and are a common source of infection. Is the patient able to mobilise to a commode? If yes, take it out!!

VTE – Check all non weight bearing or bedbound patients have dalteparin prescribed at the correct dose, and check calves for swelling and tenderness.

Antibiotics – Are they on the correct antibiotic according to micro results or guidelines? Do they still need IVs? Do they need abx at all? We are always getting told off by pharmacy for using abxs for far too long, and rightly so as we aren’t very good at reviewing them, overuse leads to c.diff and increased resistance.

Pain – Pain prolongs recovery and therefore length of stay, as does over medicating with opiates! In orthopaedics we most commonly use oxycontin/oxynorm for pain relief as it is tolerated better by the elderly population. If someone is using lots of oxynorm, add up the total opiates they received in a 24hour period and increase their oxycontin to equal the total dose of opiates they had the day before.* Breakthough doses should be the total oxycontin a patient receives over a 24hr period divided by 6. If in doubt ask the pharmacist or pain team.

*We have a lot of IVDUs as inpatients, they will always ask for the maximum amount

At the end of the ward round divide up the jobs and get them all done, ideally before 5pm! Prioritise poorly patients and patients needing prepping for theatre. At the end of the day, meet with the rest of the team to ensure everything has been done and update the list together

See the MINIMUM STANDARDS page to see what you should be recording in the notes for each patient

dan botwright
dan botwright

The List

The inpatient list can be found in O:olddocs>ortho handover>ortho ward list. Update it at the end of every day. A well maintained list makes the day run sooo much more smoothly. Copy and paste new admission directly from the admission list. The important things to include in the list are:

Demographics – name, hospital number, date of birth

Admitting problem – Their orthopaedic problem and any operations they have had and the dates of the operation.

Comorbidities

Acute issues – eg, post op complications they are currently receiving treatment for and outstanding ortho issues

Plan/jobs – long term plans such as wb status or length of abx and anything you want to make a note of so tomorrows team can easily see what outstanding jobs there are from the day before.

Leave a Reply