The clinic is in the main hospital and is in a multiuse clinic space. They have General Surgery, Urology, ENT & GI all in the same clinic but it rarely has more than 2 providers in the clinic on the same day. The clinic has 10 exam rooms, three for general surgery, two for urology, four for ENT, GI has one and 1 procedure room.
The clinic has a full team of front office personnel, referral clerks and an administrative team. General Surgery has 4 clinical nurses that do a lot of pre and post follow-up visits and work with all the providers. I asked Dr. Caufield about the team and she said “They're all solid. Yeah. We have good people here. I would say one of the strongest points and bestselling points is that the people that we work with are all strong. They know what they're doing, and they do a good job.”
Eastern Idaho Regional Medical Center in Idaho Falls can do many things. So that's the number one spot they can transfer to. It’s a Level two trauma facility so all the STEMIs & Strokes get transferred over there immediately. They even have pediatric surgery coverage. Cancer will go to Huntsman Cancer Center in Salt Lake City where St. Johns has an affiliation with the University of Utah for Cancer Center down there. Childrens care that needs to be transferred will go to Primary Children's of Salt Lake, which is the closest Children’s Hospital.
As a department, they are looking at somewhere around 18,000 RVUs per year. Each provider will be looking at doing 6,000 RVUs per year between General Surgery, Wound Care and Trauma.
Both surgeons are doing five to six OR surgeries and 12-15 scopes per week. Sometimes some cases are longer, or more complicated so it would be a little less. And then you probably have anywhere from one to five emergent cases, which is also highly variable. Dr. Wieman phrased it like this, “It can be as slow as any place I've ever worked or just as busy as any place in really a small amount of time.”
Trauma is a big part of what we need, though it is not the surgeon's main job, it will be a small, but important component. A surgeon that has experience in trauma, and that's not afraid to come into a place that does not have a program already built and functioning. We need someone who's willing to help us build something and has ideas around how to build that. Our goal is growth, but keeping in mind the type of community that we have, which is we're still rural healthcare. This person needs to be adaptable, as a lot is still in flux as we build the program. We need someone to help educate and train the team on best practices of trauma care.
For someone who has trauma experience, it'd be great if we had someone who wanted to officially be the Trauma Director. This role would help us mature and grow the trauma program.
And I think it's easy for people to think because it’s Jackson, we have such a large influx of people that come in and out of this town that it feels like it's not as rural, but the medicine is rural medicine. And I think someone that can be adaptable feels comfortable in multiple skill sets and has a background in trauma would really be able to thrive. You're going to be doing everything from colonoscopies, to plating rib fractures to fixing hernias, the primary thing that we see are motor vehicle accidents, Impact Trauma, Internal Bleeding, avalanche injuries, skier injuries mountain biking injuries, horse related injuries, some accidental gunshot wounds and some self-inflicted gunshot wounds.
The vision has been that the Trauma Surgeon (Ortho or General Surgeon) will see the patient and admit to trauma, then the APCs would do all day-to-day management of the patient on the floor. The surgeon would just take the new cases in and spend their time doing surgery and the APCs manage before and the post-acute care.
For the right provider, they could have up to 1/3 of the practice be Wound Care. We would love to have somebody who can oversee the wound care department, and that has experience in it to be the expert. All three physicians will likely see wound care patients, but we would love to have this person be the expert. We have 1 Certified Wound Care Nurse; some of our oncology nurses do most of the ostomy care because we have many patients. And then our rehab team is involved in wound care too, from the outpatient setting. So, we have a lot of practitioners doing it and we do a pretty good job. We do a good job with all these one-offs because we have good people, but we don't have a wound care system in place yet. We do have nurses that are interested we have patients. Again, it needs to expand but right now there's only two so it's kind of overwhelming.
The wound care patients that we have, it's a lot of wound vacs, diabetic foot ulcers had some skin grafts and stuff like that too. But the nurses do a lot of that work like they do to boots and things that compression wraps. Usually, it's kind of a hybrid schedule, the patient would initially see the General Surgeon and plan, then the patient follows up with wound care visits with just the nurses. And then we bring the physician back in as needed to help with big decisions like; do they need an antibiotic? Are they ready to discharge? Are we good to go? Overall, the nurses will operate autonomously most of the time.
The basic schedule is going to be four days per week with 1 Day dedicated to Clinic, 1 Day for Endoscopies and 1 Day in the OR, with the 4th day being a 3-way rotation of clinic, endo, OR. All the General Surgeons are off every Friday, though the provider that is on call for the day will often schedule some cases in the Endoscopy Suite as call is not normally extremely busy.
The schedules for Dr. Caulfield & Dr. Wieman, as well as the anticipated schedule for the incoming provider are below:
Dr. Hannah Caufield:
Monday – OR
5-8 Procedures
Tuesday – Clinic
12-15 Patients a Day
Wednesday – Endoscopy
10 – 15 Scopes
Thursday – Rotation of Clinic, OR or Endoscopy
Friday – Off (If on call, they will schedule some scopes)
Dr. Eric Weiman:
Monday – Clinic
12-15 Patients a Day
Tuesday – Endoscopy
10 – 15 Scopes
Wednesday – OR
5-8 Procedures
Thursday – Rotation of Clinic, OR or Endoscopy
Friday – Off (If on call, they will schedule some scopes)
Incoming Provider:
Monday – Endoscopy
10 – 15 Scopes
Tuesday – OR
5-8 Procedures
Wednesday – Clinic
12-15 Patients a Day
Thursday – Rotation of Clinic, OR or Endoscopy
Friday – Off (If on call, they will schedule some scopes)
The new General Surgery APPs will be focused on inpatient Acute care as their primary scope of practice, second will be clinical Post Operation visits, 3rd would be as a surgical 1st Assist and potentially, they will have them help with Wound Care. The exact detail of their schedule is still up in the air and will be clarified once they get started this summer.
Call is going to be very standard, 1:3. Weekday calls are Monday – Wednesday, and Weekend calls are Thursday 5pm – Monday 7am. They decided to have call set up like this to make it simple and take all the guess work out. Everyone will have their 1 day of call Monday – Wednesday each week so they can make plans and have consistency. The call is not in-house, but you do have to be within 30 minutes. The General Surgery team is also very flexible with covering for each other and swapping days, they just want a third partner who will take their share of the call and be a good team player.
The main cases they find themselves getting called in for are car accidents and internal blunt abdominal. There are very little shots & stabs, but a lot of accidents at high speeds from ATVs, Skiing, Mountain Biking and horse-riding falls. There is a lot of isolated orthopedic trauma. It's not something super common, we probably have four or five major operative traumas here per year.
When I asked Dr. Wieman about the Emergency Department he said, “The ED is very smart, very good at not calling unless it’s an emergency. They don’t call just to call.”
I met Sarah Wilkins, ED Manager, and she told me this about the ED providers. “If the doc in the ER really feels like he needs to bring him in. He will. But he uses that as I've got to bring him in tonight and he's going to see them in the clinic tomorrow and he's going to have surgery. So, they're pretty cautious about that. Because everybody here pays a price to be here. You either pay the price with your drive to get here to work or with your mortgage and rent. And the reason they do that is because we all want to live in this area. So, our work life balance is very important. And that includes every one of our ER Doc's. So, they are just respectful and not to burn anybody else's balance point. Because they're goanna lose them and then we will have a divorce. He's like, they can look at images from home. And they'd say, yeah, hey, do this. Do that for me. And I'll come in and see him in the morning. That's a common scenario.”
Dr. Caufield had this to say about call and the ED team. “Call can be very light can be busy. It's highly variable, seasonally, right. And we have a very smart ED I would say and much better at ciphering out who needs us and who as they know we're a limited resource. When they call us it’s only because they really need us, so I'd say they're very fair. As far as the frequency of coming in, it’s more on the rare side but obviously it's variable, but as a whole as an aggregate it's not that much.”
Jennifer Chiappa, CNO said “We have a really good relationship with when stuff goes upside down here. People come in and it becomes a very smooth orchestrated scene. The volume is enough that when we have really ugly trauma, we do very well. We do it very well. And the teamwork is beyond reproach. You won't find another team that collaborates throughout the hospital like we do. Especially because we don't have a designated trauma team like lots of these big facilities. It's just whoever's working here comes running and we all still do the very same thing. Smooth, respectful, professional, yet we all have a good time and love each other.”
Sarah Wilkins, the ED/ICU Manager has been with St. Johns Health since 2017 and said “I worked here for eight or nine months as a nurse. Then I went into case management then I went into director of case management then I went into we had a weird three person CNO model for a few years and then in January, we went to a more traditional one CNO to Director of nurses and then all of our departments have managers. I took one of those director of nursing positions in January, and my duty of the hospital includes the ED & ICU, so I know all the spaces, all the people and have a good understanding of how the entire hospital operates with the ED.”
The ED has 11 beds, with one shared room, an orthopedic room with two beds, the rest all private suites. They have two trauma bays, and one room is a OBGYN bed.
They have one room reserved as a seclusion psychiatric room. The ED has an average of 23 patients per day and 30% of the ED patients are traumas. That being said most of those patients are single body injuries. About 10%-15% of the trauma patients are admitted with multiple systemic injuries. Dr. Provus (Ortho-Trauma Surgeon) needs support with the management of critical multiple trauma patients in the ICU. They send out head injuries. Although they would like to eventually keep some of those stable ones, and they ship any vessel injury although they do have REBOA for emergency vascular injury.