Otorhinolaryngology (ORL) Rundown

Team structure

There are two teams – acute team and head & neck team. Each team has two HOs, one junior reg, and one senior reg. There is also a Head and Neck fellow and a Laryngology fellow.

The head & neck team looks after head and neck cancer patients, thyroidectomies, parathyroidectomies, laryngology patients and complex airway issues (e.g. epiglottis at risk of intubation).

On the acute team you can help assess patients in ED with the acute registrar. The turnover is very high on the acutes team - expect 5-10 new patients per day.

The ORL Nurse Educator Felix Mariano is very knowledgeable, especially re: trache sizes, suturing, and dressings. Save his number on your phone.

Daily routine

0700-0715 ward round

0820 rapid round. HOs meet in the POD and discuss plans with nursing staff and MDT. Generally, you will finish your jobs reasonably early if you are on the acute team. This leaves you with plenty of time to either go to theatre or help the acute registrars in ED. This is an excellent learning experience as you will learn simple ORL procedural skills.

1400 elective patients arrive for admission on the ward. There are no pre-admission clinics. The ward clerk will direct them to level 6 Labtest for admission bloods if you write up the lab forms in the mornings. A quick medical admission is expected once they return from their blood test. (For any flap patients it is important the bloods/IVL pre-op are not put in the arm being used for the flap!)

Update the teams throughout the day – best to do this in the whatsapp chat as the registrars are often away at clinic or in theatre. Any concerns that require an immediate response just go up to theatre directly and ask them.

At the end of the day most registrars will want to run the list with you. The head and neck team in particular likes to do this in person as they will often round on a few patients again at this time. The acute team does not do a PM round.

Weekly events

Friday mornings there is an ORL MDM where all North Island based patients get assessed by the team of ORL surgeons and medical and radiation oncologists. One of the head and neck HOs is required to be present to scribe for the ORL examinations. If this is a Friday where one of the ORL HOs is on nights (usually no cover), then tell your registrars that you may not be available, although often one of the acute HOs can cover the ward duties while you attend.

Every Thursday there is a laryngology theatre list and the Laryngology Fellow would be available to answer questions regarding post-op care and write post-op instructions (e.g. voice rest, and type of diet).

Head and Neck tips

Head and neck patients are very complicated. There are multiple surgeons involved in their operations - including plastic surgeons. The surgeons are very particular and may dictate different plans for specific wounds. Absolutely any concerns MUST be discussed with the head and neck fellow/registrar immediately (often in the whatsapp chat). The nurses are very experienced and if they have concerns with a patient you should take it seriously and review/escalate as appropriate.

Aim to arrive on the ward before 7am to prepare the list, check the drain outputs and obs charts and check specific blood tests before the round.

Blood tests: Hb + Hct for flaps, Calcium + PTH for thyroidectomies + parathyroidectomies. You will often be expected to know these at the drop of a hat on ward-round.

The expectations of HO on the head and neck team are high. In addition to above you will be expected to stay to run the list with the registrar or fellow at the end of the day. This can sometimes end up being quite late particularly if there is a complex theatre case that day. Alternate staying to run the list with your off-sider - one of you should aim to get home on time each day.

Whilst this is a busy run, you swap teams after 6 weeks so things balance out as the acute side is generally significantly lighter on jobs and you will be able to head away on time.

On Call

After hours you cover ORL patients on your long days; the neurosurgery HOs cover ORL from 10PM

Clinical tips

Head and neck flap surgeries: watch out for re-feeding syndrome (include phosphate and magnesium in post-op bloods) as these patients may have reduced oral intake pre-op secondary to cancer location.

Check whether the surgeon would like to restart Aspirin post-op, and duration of antibiotics.

There is a calcium and PTH protocol on the wall for post‐op thyroidectomy patients however do not follow this – discuss preferred management with a senior as this may vary. Mr. McIvor may stop PTH testing earlier than other consultants. Check with your registrar when unsure whether more Ca/PTH tests are indicated.

In discharge summaries, you have to document if head and neck patients can do neck and shoulder exercises + weight bearing status (it is boss dependent).

There is an expectation that if there are no students at least 1 house officer will be in theatre. Fridays regularly require house officer in theatre (it’s a good list).

Expectation that discharges (if been in >48 hours) are prepped in general.

Make sure list is updated Friday PM.

For general – the transition lounge is used a lot very early, if discharge not done by 9am patient will be in transition lounge.