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Resident Orientation Manual

Produced by Galveston Shriners Burn Hospital and
The University of Texas Medical Branch Blocker Burn Unit.
Contributors:  Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Ray J Nichols Jr. MD

 

Introduction & Table of Contents

   Welcome to the University of Texas combined Burn Services, which consist of the Shriners Burns Hospital-Galveston and the Blocker Burn Unit.  The purpose of these burn care facilities is the care and treatment of persons afflicted with dangerous and potentially disabling burns from the time of the initial injury through rehabilitation.

   As a burn care team consisting of physician-surgeons, nurses, physical and occupational therapists, dieticians, pharmacists, social workers, psychologists, child-life therapists, prosthetists, medical sculptors, ward clerks and a variety of technicians and assistants, we provide care and support to the patients and their families.  Our philosophy of care is based on the concept that each patient is an individual with special needs.  Each patients' care, from the day of admission, is designed to return him/her to society as a functional, adaptable and integrated citizen.

   Shriners Burns Hospital-Galveston provides care to children through the philanthropy of Shriners Hospitals for Children.  The Blocker Burn Unit (J2D) is a part of John Sealy Hospital at the University of Texas Medical Branch-Galveston and provides care to adult burn victims from the entire state of Texas.  Both facilities provide care through a multidisciplinary team approach.  The burn unit residents provide an essential part in coordinated patient care.

   The 2 units, though separate in nursing staff and administration, should function as one from a physician standpoint.  This is because of cross coverage issues on call and the need for additional staffing at times on either side to accommodate large caseloads.  Hence, both teams should round together each day.


Table of Contents

Section 1:  Life on the Burn Services
A.  Educational Objectives
B.  Resident Responsibilities
C.  Student Responsibilities
D.  Paperwork
        Documentation
        History and Physicals
        Progress Notes
        Operative Notes
        Clinic Notes
        Discharge Notes
        Orders
E.  Presentations
        Daily Rounds
        Discharge Rounds
        Rehabilitation Rounds
        Chief Rounds
F.  Getting Started
        Taking Referrals
        Arrival Checklist
        Standard SBH Orders
        Consents
        Clinical Research Protocols


Section 2:  Acute Burn Management
Introduction
Definitions
        Burn Injury
        The Burn Syndrome
Emergency Treatment
        Initial Burn Management
        Burn Assessment
Burn Shock
        Fluid Resuscitation
        Monitoring
Post-burn Hypermetabolic Response
        Nutritional Support
        Patient Support
Post-burn Infection & Sepsis
        Control of Infection
        Topical Antimicrobials

        Biological Dressings
Closure of the Wound
        Surgical Techniques
        Skin Substitutes
Regional Considerations
        Facial Burns
        Hand Burns
        Other Regional Burns
Rehabilitation
        Splinting
        Control of Scarring
        Psychosocial Recovery
Inhalation Injury
Electrical Injury
Chemical Injury
Future Developments & Conclusions


Documentation for Special Studies


Psychological and Psychiatric Services to Children and Families
        Clinical Services
        Clinical Research


Nursing Service Resident Orientation
        Unit Operations
        General Information
        Daily Rounds
        Referrals
        Patient Condition Reports
Out Patient Clinic
        Housing & Food for Parents & Outpatients
        Day Surgery Program
        Scheduling OR Cases
        General OR Information
        Parent Beepers During OR Procedures
Pain Management Protocol
        Background Pain
        Bowel Regimen
       
Benzodiazepines for Baseline Anxiety
       
Procedural Pain Relief and Anxiety Management
        Deep Sedation & Analgesia for Major Invasive Procedures
Post-Operative Management of Nausea in Reconstruction Patients
        PACU Nausea Management Only
        Reconstruction Unit Nausea Management
Acute Stress Disorder (ASD) & Post-Traumatic Stress Disorder (PTSD)
        Imipramine - A Tricyclic Antidepressant (TCA)
        Fluoxetine - A Selective Serotonin Reuptake Inhibitor (SSRI)
Management of Itch Due to Inflammatory Response in Burn Scar Area
        Topicals
        Diphenhydramine (Benadryl)
        Hydroxyzine (Atarax)
        Cyproheptadine (Periactin)
        Loratidine (Claritin)


Rehabilitation Services Resident Orientation
        Child Life
Media Resources

Occupational/Physical Therapy
Basic Treatment Procedures


How to Use the Dictation System
Safety in the Workplace and Accident Prevention
Fire Safety
Safe Medical Devices
Radiation Safety
Electrical Safety
Medical Emergencies Including Cardiac Arrest
Prevention of Sharps Injuries
Prevention of Needlesticks
Latex Allergies


SECTION ONE:  Life on the Burn Services

RESIDENTS/STUDENTS EDUCATIONAL OBJECTIVES

1.  Learn assessment and classification of burn wounds, including estimation of burn size and depth, and reduction of related morbidity and mortality.

2.  Gain an appreciation of stress response to acute burn injury, including hemodynamic, metabolic, nutritional and immunologic sequelae.

3.  Learn initial management of the acute burn patients, including fluid resuscitation, nutritional support, wound care and ventilatory management.

4.  Learn wound management of burn patients including an understanding of wound healing, wound sepsis, topical antimicrobial agents, biological dressings, skin substitutes and skin grafts.

5.  Develop fundamental surgical skills in treatment of burn patients, including wound debridement, wound dressing and splinting, skin grafting and scar contracture release.

6.  Gain an appreciation for burn rehabilitation, including physical/occupational therapy, psychosocial support and reconstructive needs.

7.  Improve communication and leadership skills through interactions and coordinated discussions with patients and their families, attending physicians, medical personnel, medical students and fellow residents.

8.  Learn principles of management of special problems, including inhalation injuries, chemical burns, electrical injuries and toxic epidermal necrolysis.

RESIDENT RESPONSIBILITIES

1.  Admit all new patients to the burn units, including initial assessment with burn diagram, history and physical, and initial orders.

2.  Take primary responsibility in coordinating all efforts toward daily patient care of all acute inpatients.

3.  Assist in the evaluation and treatment of outpatients.

4.  Be available on call 24 hours daily for assistance with new admissions, emergency referrals and acute patient transport.

5.  Participate in all operative cases of burn patients, including major excisions and gratings, and early post-burn reconstruction cases.  You are expected to get to the OR before faculty and formulate an operative plan.  Cases should only be started with proper faculty supervision (emergencies excepted).

6.  Document patient management in an accurate, thorough and timely fashion in the medical record.  A written history, physical exam and burn diagram should be completed upon arrival of every patient, with dictated H & P completed and on the chart within 24 hours.  Dictation of operative summaries and discharge summaries are required within 24 hours from event.  Justification for laboratory and x-ray requests should be documented in the progress notes, as well as acknowledgement of abnormal findings.

7.  Assure all admission cultures are collected in a timely manner.  This includes blood, urine, sputum and wound cultures.

8.  Keep the attending physicians aware of any significant changes in patient conditions and discuss proposed changes in treatment prior to initiation, when appropriate.

9.  Assist in the education of the assigned medical students.

10.  Make all preparations for surgical cases, including daily scheduling, notification of anesthesiologists, blood bank, and skin/tissue bank.  Obtain informed consent and appropriate perioperative planning.

11.  Notify the clinical research nurses of all admissions and assist in collection of study data, therapeutic approaches or application of experimental variables as requested.

12.  Attend all required surgical housestaff conferences including:

                 a.  Surgical Grand Rounds
                 b.  Multidisciplinary Conference
                 c.  Surgical M & M

13.  The courtesy to remind Burn Services faculty of scheduled vacation times already approved by the Department of Surgery is appreciated.

STUDENT RESPONSIBILITIES

1.  Assist in the care of assigned patients as directed by the senior resident or burn fellow.

2.  Contact the senior resident of burn fellow for all questions or concerns relating to changes in patient condition or care.

3.  Present assigned patients' hospital course on daily rounds, including significant physical exam, labs, tests, cultures, medications, I/O's, etc.  A suggested format is included in this document.

4.  Alternate with fellow students in assisting the resident with new admissions.

5.  Notify the senior resident or burn fellow in cases of illness, accidents or other excused absences as well as the Department of Surgery Student Education Office.

6.  Demonstrate self-motivated, on-going learning by review of pertinent medical literature as evidenced by acceptable daily patient care and intraoperative performance.

7.  Assist on operative procedures as directed by the senior resident or burn fellow.

8.  Attend all required surgical student conferences including:

                 a.  Surgical Grand Rounds
                 b.  Surgical M & M

 

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