Duke Vascular Handbook
Duke University Hospital vascular service expectations:
DUH Vascular is an busy service. Our patients are often relatively sick, we run multiple ORs a day, and plans can change dramatically and often. It can be a very fun and rewarding experience when the whole team pulls together - and it can be stressful, chaotic, and dangerous for patients when communication and follow through are poor. With that in mind, we've put together the following expectations to help the service run smoothly and safely.
First, a note about the service structure:
DUH Vascular is currently split into two teams, the "Elective" service and the "Doc of Week" (DOW) service. This is a new service split, so please be patient as we work through all its implications. The "Elective" service consists of (a) patients who are booked through outpatient clinic/referrals for specific surgeon or (b) patients who were inpatient/ED consults that the on-call attending would like to keep. The DOW service consists of patients who are ED/inpatient consults and who are not "owned" by a specific surgeon.
Senior level expectations:
DUH Vascular is staffed by a Vascular Surgery chief and a Vascular/General/Cardiothoracic surgery senior. The chief and senior will do 2 weeks each of "elective" and "DOW" service. The trainee running the "Elective" service will be responsible for staffing patients with attendings each morning, which can be done in person or, more often, on the phone. The trainee running the "DOW" service will be responsible for staffing patients with DOW attending in the morning and as needed as new consults arise during the day. Each DOW attending will have their own preferences for rounding/list running.
The Vascular Surgery chief is responsible for sending out weekly case postings and modifying those as needed over the course of the week. The trainee running each service has preference for cases related to that service (i.e. elective-service cases for the elective trainee & vice versa) except for open abdominal cases and complex endovascular cases, for which the Vascular Surgery chief has preference.
The DUH chief and senior are in the DUH/VA call pool along with the VA chief. Call is Q3. We are trialing a new weekend structure this year to try to better manage the multi-night in-hospital stretches, in which the weekend is divided into Friday + Saturday/Sunday. In addition to staffing consults/cases appropriately with the on-call attending, it is essential that the on-call trainee communicate overnight cases and consults/admissions with the day team via text, email, or call.
Intern level expectations:
Interns are absolutely critical to the smooth functioning of DUH Vascular. Luckily, we have an excellent team of APPs who are experts in the care of vascular patients who can guide you. To derive maximum benefit from your time on vascular, you will need to be an engaged and proactive team player. It is our hope that you leave the service with an appreciation for the acuity of vascular patients and some of the subtleties of their care. In addition, for those of you who will rotate with us as consult/senior residents, your time as an intern will allow you to establish strong relationships with the vascular faculty and APPs.
Your primary role as a vascular intern is to care for vascular surgery patients on the floor. We will need your help in the operating room with some frequency. However, outside of those occasions, we expect you to take care of all your floor work before double scrubbing in the OR – the APPs are not intern replacements but rather intern guides/supports.
You should have full numbers for your patients every morning before rounds, which are at 6am unless otherwise stated. There are a few data we often pay particular attention to (in addition to Is/Os, etc):
Vitals: Our patients tend to be hypertensive, so hypotension/tachycardia are especially notable and can portend clinically significant bleeds.
Hemoglobin: Our patients are often anticoagulated and at high risk of bleeding. Most of them have CAD and get transfused to a threshold of 8. Ask before transfusing and notify the service senior if a patient was transfused overnight.
PTT/INR: We frequently run patients on heparin drips, often titrated to a goal of 60-90. We rarely, if ever, hold heparin for supratherapeutic PTTs – titrate the units/hour down instead.
Creatinine: Many of our patients have kidney disease, we give intra-arterial contrast to many patients, and we also clamp some patients' renal arteries (or suprarenal aortas). We focus heavily on creatinine (and BUN) for these reasons and to understand fluid status.
Micro results: We often debride or amputate infected toes/limbs and patients will remain on broad spectrum antibiotics until we have culture data to guide us.
You and the APP you are working with that day (if any) will divide up work following rounds/running the list. It goes without saying that notes should be accurate; areas of special concern for vascular surgery notes include the pulse/signal exam and anticoagulation status, which must be reviewed and updated every day.
We rely heavily on our "vascular surgery" handoffs. Update them with OR trips, pulse/signal exam, antibiotics, anticoagulation, and 'to dos' daily.
You should over-communicate. On the vascular service, this will require trips to the operating room, as the service seniors will often be operating. To be clear: a text is not communication. Any important data need to be communicated to us in person or on the phone. We will not be upset if you are overly concerned about patients and far prefer that to a dismissive or blasé attitude.
It is essential that when you are told to post/consent/mark a patient for the OR, you do so promptly. Our OR schedule often changes minute-to-minute as acute cases roll in and other patients are no longer stable for surgery – if a patient is not consented/marked appropriately, the entire OR schedule can get derailed. Oftentimes, preop will not page the service pager, but instead the attending, who is usually scrubbed and unable to fix the problem.
Ask questions early and often, as needed. We know that vascular surgery is a little different and more fast paced than some other services – we always prefer that you "bother us" and ask, rather than guess.