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Emergency Medicine Intern Survival

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Emergency Medicine Intern Survival Powered By Docstoc
					UIC Emergency Medicine
Intern Survival Guide
2010-2011
University of Illinois Medical Center
1740 W Taylor Street, Chicago, IL 60612
312-996-8177 (ED)

How to Page: Dial 136
Advocate Illinois Masonic Medical Center
836 Wellington Avenue, Chicago, IL 60657
773-296-5878 (ED)

How to Page: Dial 61-8900

Mercy Hospital & Medical Center
2525 South Michigan Avenue, Chicago, IL 60616
312-567-2200 (ED)

How to Page: ask clerk


MacNeal Medical Center
3231 South Euclid Avenue, Berwyn, IL 60402
708-795-3159
Intern Rotation Information

Rotations
Anesthesia/Radiology – Mercy
CCU – UIH
Emergency Medicine – Masonic
Emergency Medicine – Mercy
Emergency Medicine – UIH
MICU – UIH
OB/Gynecology – Masonic
Pediatric Emergency Medicine – UIH/Masonic
Trauma – Masonic
Emergency Medicine – McNeal
Orthopedics – Masonic


New Rotations
MICU – Masonic




The following information was compiled by the residents in the
senior classes. It is intended to help provide some guidance
about what to expect on each rotation. It is based on our
experiences and things are subject to change, but we hope this
helps ease the transition to being a UIC EM Intern. As always
feel free to contact any of the senior residents with questions.

Welcome to the team and Good Luck this year!
Anesthesia/Radiology at Mercy
Hours: start at 7am
Location: Anes: Surgery Center on 1st floor,
Rads: reading rooms on 1st floor across from ED
***VACATION: Let Dr. Vesley know what week you plan to take
vacation

Anesthesia
 On day one, go to the OR at 7 am and ask for Dr. Vesley. He
   will give you a tour and point you to the right people to get a
   locker, etc.
 You will get access to the scrub machine on the first day
 Not allowed to wear anything under your scrub top in the OR
   and are not allowed to leave the hospital in the green scrubs.
 The white board lists the surgeries, assigned
   anesthesiologist and type of anesthesia to be used.
 Dr. Vesley assigns one room to the 4th year med student on
   the rotation and then you are free to go into any other room.
 Always wear your badge in the OR.
 Introduce yourself to each attending and ask them if they
   would be willing to let you intubate their patient. Not all
   attendings will let you intubate. Avoid the CT surg and peds
   cases
 If possible introduce yourself to the patient in pre-op.

Radiology
 On day one, introduce yourself to the secretary and she will
   introduce you to everyone
 Dr. Sephadari, the department chairman who loves to teach,
   reads films.
 Overnight ER images are read from 7-8:30am. This is very
   useful for EM people. You can try getting an intubation at
   7:30 and go to Radiology for the rest of the overnight films.
CCU at UIH

Hours: 7am every day, usually done by 5-6pm, only come in on
weekends when on call, Q4 call
Location: 6th floor on west side
Team: 1 fellow, 2 seniors, 4 interns
EM Intern Pager: 2555

Misc. Details
 Rounds: Attendings determine times of rounds – usually
   sometime between 8-9am. Some attendings also do
   afternoon rounds.
 Days Off: 4 days off – they are not chosen, but pre-
   determined based on your call schedule. It works out to one
   weekend with no days off, one weekend with both days off,
   and two weekends with one day off each.
 Call: Q4 – usually done by noon the next day. To set
   expectations, you probably won‟t sleep much on this rotation.
   The EM intern always is on-call the first Tuesday of the
   rotation, then has a weekend with no days off, then Saturday
   off the next weekend, a golden weekend, and then the
   Sunday off before the next rotation. Double check that with
   the intern before you or in New Innovations.
 You should get meal tickets from the medicine office. Ask
   your seniors to point you in the right direction.

Rounds
The CCU service covers some cardiology floor patients, as well
as CCU patients. The patients are split up between the interns,
and the seniors cover all of the patients.

For your patients, pre-round on them and collect:
 For unit patients – vitals from flow sheet
 I/O‟s (these are recorded in paper charts)
 EKGs (put originals back in chart later)
   Labs results
   Imaging results (Have a print out of Cath and Echo reports
    …they ask specific questions that might seem logical to EM
    people)

Each attending (and you will likely have two different ones over
the course of the month) has their preferences for how rounds
should go. Notes do not need to be complete until after rounds.

Sign Out
Sign-out to the intern on-call. It may be useful to re-print the
physician rounding report, write a one line pt
summary/assessment on the report and list any to-do‟s. Don‟t
forget to forward your pager to the on-call intern, otherwise you‟ll
get pages all day.

Admissions
        The senior will assign admission to the interns. Usually
the non-call interns do admits prior to 4pm.
        For all admits, see the patient in the ED, get a copy of the
ER EKGs, write an H&P and enter the admission orders. The
next morning on rounds, you will give a full presentation for these
patients.

Discharges
To discharge a patient:
 Complete a medication reconciliation in the computer
 Provide and necessary scripts, print them out to the
   prescription printer (ask how to do that)
 Place a discharge order in the computer – with or with out
   dependencies
 Seniors do discharge summaries for patients >48 hours.
   Interns do the <48 hour discharge summary. This may vary
   by team, so check with your seniors. Include discharge
   meds and follow ups in every d/c summary.
On Call
When on-call, you cover all of the patients on the team and will
get pages about random stuff. It‟s good to know a little about
each patient so that questions don‟t catch you off guard. Most
calls will be about blood pressure, telemetry events, pain,
nausea, and heparin drips, etc. So be prepared to answer these
questions. You always have a senior on call with you for back
up.

Other Tips
 Basic labs include: CBC, Chem7, Mg, Ph
 Keep K>4, Mg>2, Hgb>8 (1 unit of blood ~ 0.7 increase in
   Hgb)
 Floor patients should have 10pm labs from the night before
   drawn by scheduled phlebotomy. Phlebotomy draws labs
   from 6am-10pm on floors any other labs have to be ordered
   as MD/RN collect.
 Unit patients should have 4am labs the day of rounding
   ordered as MD/RN collect.
 If an H&P is started after midnight, you don‟t have to write a
   progress note the next day (this means if you admit a patient
   at 10pm, you can start your H&P in word, then cut and paste
   into the Cerner H&P - don‟t even start the Cerner note before
   midnight).
 For unit patients, know things like I/O‟s, vent settings, drips,
   etc. All information is on written the flow sheets, not in the
   computer.
 Echo reports have to be picked up from the echo lab on the
   2nd floor.
 The call room is just past the doors of the CCU on the right.
Emergency Medicine – Masonic

Hours: 12 hour shifts, 15 shifts/month, 7a-7p or 7p-7a
Location: ED on 1st floor

General Pearls:
 Shifts are long, so be prepared. Use your last hour for dispo
  and charting on your patients.
 Nurses are great, so use them. They are ready and willing to
  help get supplies, etc.
 Ask the clerks to page anyone you need. They'll yell out
  when the calls return.
 Orders are entered on Ibex and then re-entered into Cerner
  by the clerks so if things change, let them know.
 When you draw labs/cultures, write your initials, date & time
  on the sticker, place them in a red biohazard bag and give
  them to the clerk to send to the lab.
 Most of the time, there is a NP that takes care of greens (fast
  track), but when she is not there, the residents have to help
  cover fast track.

Misc Materials:
The department has a number of carts with key supplies – take a
tour and check out what is available.
 ENT supplies including woods lamp and slit lamp, and
    sometimes lidocaine can be found in room 1
 Lac kit/sutures/sterile gloves/flushing kit/syringes/etc can be
    found in the trauma bay and the lac cart
 Ob/Gyne carts are outside of rooms 6, 9, and 12? Be
    prepared to use a bed pan if there is not a gyne bed
    available which happens often

Electronic Charting (Ibex):
 You will get a login form the chief resident
   To pick up patients, click the box next to the patient name
    under the resident column
   The little symbols to the right of that (V, L, M) are direct links
    to labs, vitals, etc
   To order meds, click on MedSvc tab
   For general orders, click on Orders tab
   Click Rx tab to write prescriptions which print on pink tamper
    proof paper
   You can look at previous visits to the ED by clicking on Visits
   Discharge instructions can be written by clicking DCI tab or
    Dispo tab
   The comments section is also useful for communicating
    patient status
   If you click on MyCharts tab, you can see all of your patients
    archived charts so you can finish charts/sign charts after the
    have been discharged if needed
   After you are done charting on a patient make sure you sign
    the chart (there is a red pen at the top left side of chart to
    click)

Admitting/Consults:
This location has a lot of private MD‟s so you will be calling them
directly for admission and to find out who they want on consult
for specialists.
 Find out who is the PMD
 Call PMD to discuss the admission and ask who they would
    like on consult if necessary then call private resident for the
    admit
 Note: if the PMD uses hospitalists, call hospitalist on call to
    discuss the admission and ask who they would like on
    consult, and then private resident for the admit
 If no PMD call service resident for the admit.
 If consult needed, page resident on call, NOT the specialty
    attending
   NOTE names of who you spoke with and all discussions in
    the doctors notes
   After you have spoken with the accepting MD, the ED
    attending will put in the bed request

Discharges:
For patients who are going to be discharged:
1. Provide discharge prescriptions – they print to a special
   printer
2. Provide discharge instructions via Ibex
3. Give follow up instructions – if they don‟t have a PCP provide
   them with a clinic contact number (Family Practice (FP) or
   Internal Medicine Associates (IMA)), but everybody follows
   up somewhere.

   When everything is ready, you can place them on the chart
    and put it in the discharge rack. If nurses are busy (e.g. with
    a trauma), you can send pts home after they sign their d/c
    papers, but make sure you let the charge nurse know so that
    they can prep the room for the next pt.
   Check their vitals before sending them home! If their initial
    vitals were abnormal, re-vital and note them in the chart
    before d/c.
Emergency Medicine – Mercy

Hours: 10 hour shifts, 18 shifts/month
Ussually days (10am – 8pm) or nights (6pm – 4am), with an
occasional swing shift (2pm – 12am)
Location: ED on 1st floor, west side of building
Dress: Note that at this site the dress code is smart casual with
ties for the guys

General Pearls:
 ED lounge is across the hall behind the ER. It has a fridge,
  microwave, and a bathroom. The code to enter it is 3-1-1.
 There is an automatic sliding door in the middle of the ER
  (next to the water dispenser). To enter through that door, the
  code is 9-1-1.
 There are 25 rooms and they are divided among several
  nurses. It is important to know who the nurse is for a
  particular patient (so you'll know who to ask/remind about an
  order, etc.).
 The clerks sit in the center of the ED. Orders that have to do
  with another dept (e.g. radiology, ultrasound, admit) go
  through them.
 To page someone, ask the clerks to page them for you (you
  don't do your own paging).
 The techs wear light brown scrubs and will do EKGs, put on
  splints, and help out when you need an extra hand
 Find a computer within one of the alcoves and setup camp
  there. You'll log in and assign yourself to available patients
  (as indicated by a green dot).
 Most attendings prefer that you Present  Put in orders.
 At Mercy, you do not sign patients out to other residents at
  the end of your shift. You should stop picking up new
  patients that you think would keep you longer than your shift.
  Some attendings will clean up your patients.
Misc Materials:
 There are two Suture & two Gyne carts in the ED.
 For suturing, you have to ask the nurse for meds such as
   lido/epi, etc.

Admissions/Consults:
This location is a private hospital so all patients are assigned to
private MD‟s that you will be calling directly to accept the patient
and to find out who they want on consult for specialists, if
needed.
 Find out who is the PMD
 Call PMD to discuss the admission and ask who they would
    like on consult if necessary
 If no PMD call the attending on call for the admission
 If consult needed, notify the resident on call of that request,
    and you may need to call the consulting attending if they do
    not have residents in-house for that service
 Note names of who you spoke with and all discussions in the
    doctors notes
 After an attending has accepted a patient you put the admit
    order in Cerner to request a bed. You have to then call the
    floor resident on-call

Discharges
For patients who are going to be discharged, double-check the
discharge diagnosis with the attending. Then:
1. Put in discharge prescriptions – they print to a special printer,
    stick it in the chart/clipboard
2. Provide discharge instructions via Cerner
3. Give follow up instructions – if they don‟t have a PCP send
    them to the Family Health Center, but everybody follows up
    somewhere.
4. Enter a discharge order in Cerner
Emergency Medicine - UIH

Hours: 10 hour shifts, 18 shifts/month
Usually days (10am – 8pm), swing shift (2pm – 12am) or nights
(6pm – 4am)
Location: ED on 1st floor, code to get in from elevator bay is: 3-
5-7-3-*

General Pearls:
 Patients at UIH can be very complicated, so don‟t be afraid to
  ask for help from the seniors or attending
 Room 19 is the “trauma room” – all resuscitations occur here.
  Take a tour of this room before your first code in here
 Watch the rack in the center of the ED for new patients and
  sign up for them in First Net

Misc Materials:
 You will usually need to ask the nurses to get any supplies
   (including Kleenex) since they are all locked away
 Heme-occult cards and developer are in the Binders on each
   side of the ED (by room 4 & 15)
 ENT supplies can be found in the ENT room, keys are at the
   clerk‟s desk
 Room 12 is a gyne room and patients can be brought there
   for the pelvic and then returned to their bed. Talk to the RN
   to do this for the pelvic

Admitting/Consults:
 For all admissions, you will call the admitting service
  fellow/resident. You may need to make multiple calls. For
  example, to admit to cardiology, you call the fellow and then
  if they accept, you call the CCU resident.
 After a service has accepted a patient, you will need to enter
  a PIN (patient intake notification) in Cerner.
   For many services, once the patient has been signed out,
    they should be entering orders and the nurses will call them
    for further management. But you will still want to keep an
    eye on the patient and check in on them occasionally.
   For consults, call the resident on-call for the service. Make
    sure to follow up with them regarding their recommendations
    for dispo.

Discharges:
For patients who are going to be discharged, there are four
things you need to do:
1. Provide discharge prescriptions – they print to a special
    printer
2. Provide discharge instructions via Cerner
3. Give follow up instructions – if they don‟t have a PCP provide
    them with a clinic contact number, but everybody follows up
    somewhere.
4. Go to the tracking list, right click on the patient, and select
    “Depart Process”, then you print out discharge paper work,
    asking the patient to sign the top sheet.
MICU at UIH

Hours: 7am every day, usually done by 4pm, only come in on
weekends when on call, Q3/Q5 call
Location: 6th floor on west side
Team: 1 fellow, 2 seniors, 4 juniors (2 anes, 1 EM & 1 IM)
EM Intern Pager: 8027

Misc. Details
 Rounds: Attendings determine times of rounds – usually
   sometime between 8-9am.
 Days Off: 4 days off – pre-determined based on your call
   schedule. Some will end up with a schedule that has no
   golden weekends, so you may be owed a weekday off.
 Call: Q3/Q5 – usually done by noon the next day. The calls
   alternate between Q3 and Q5, one call you admit, the other
   you cross cover your team‟s patients only.
 You should get meal tickets from the medicine office. Ask
   your seniors to point you in the right direction.

Rounds
Attendings vary on how they run rounds, some do walking
rounds, others do table rounds followed by walking rounds.
 Pre-round – vitals (ranges), I/O‟s, vent settings, drips, etc. All
    information is on written the flow sheets, not in the computer.
 Sedated patients may need their sedation held for rounds so
    you can get a good exam. Discuss timing with your team
    since it will vary based on when the attending rounds
 All intubated patients get daily CXR‟s
 Unit patients should have 4am labs every day ordered as
    MD/RN collect

Sign Out
Sign-out to the intern on-call. The intern on call usually knows
the patients so just make sure they know of any outstanding
issues and any plans (e.g. if this person‟s bp drops, we are
starting...).

Admissions
The MICU has two resident teams which alternate admission
days. Every other day, your team will admit. You are on call
with a senior when you admit.

Transfers/Discharges
MICU patients are usually transferred to another serivice. The
seniors will usually call the accepting service and sign out the
patient. You will need to:
 Place a transfer order in Cerner
 Write a Transfer Note – same info as PN plus the admission
    H&P and the MICU course.

If a patient dies, you will need to
 Complete a “Death Routing Form”, which includes calling the
     Gift of Hope (organ donation). Ask the RN for the form.
 Write a death note in the computer
 Discharge the patient in Cerner (select patient expired).
 Sign the death certificate with the cause of death - usually
     you will get a call to go to admissions to sign it or they will
     bring it up to the unit for you to sign when it is ready

On Call
 It‟s good to know each patient so that questions don‟t catch
   you off guard.
 You can always ask the other team‟s senior for help or call
   the fellow on call with questions.
 Your pager does not get code blue pages, but you should go
   to the codes when you hear them overhead.
 There is always an anesthesia resident on-call in the MICU.
   Make friends with them and you may get to do the
   intubations on your patients.
OB/Gyne at Masonic

Hours: 6:30 to 5pm, call scheduled by dept
Location: Mother Baby Unit & L&D on the 2nd floor
EM Intern Pager: 9220, when you are on call you also carry the
Mother Baby pager #5241

L&D‟s is on the 2nd floor, 61-5250
OB triage on the 1st floor, 61-5262

   The call room is on the 3rd floor and it is reserved for the off-
    service resident on call – you can leave your stuff here
    during the day.
   The code to the 3rd floor stairwell door is 1-3-5 (all pressed
    separately).
   The chief should give you a folder with all pertinent rotation
    info. They provide a template for every note you have to
    write.
   You need to get your name badge set up to swipe into doors
    and stairwells for you since everything on OB is secure. The
    office to do that is on the ground level where you got your
    IDs during orientation.
   Scrubs – in the sterile area of L&D near the ORs. An RN or
    someone will get you your first pair. Then just get a pair
    every day so you can change in the call room before Mother
    Baby Unit (MBU) rounds.
   On day one, have an RN on L&D set you up with an
    OBTraceVue account. You will need this to monitor the
    patients & get info for your delivery notes.

Mother/Baby Rounds
On Monday show up at 6:30 on the 2nd floor at the Mother/Baby
Unit. You can take elevator 5 to the 2nd floor until you get your
badge activated for the OB floors. There are 2-3 other off-
service residents who can explain which patient to see, etc.
Usually we are not required to see c-sections, but if it's really
busy you might pick up a few. We never see CNM patients
(midwife), they see their own. When you go the first morning,
one of the residents can show you how to figure out who‟s who
from the white board.

Labs to check on include: pre and post Hgb for all postpartum
day 1s, esp cesareans. Also check their Rh status, Rubella
immunity, varicella immunity, etc to make sure that they are
getting the proper orders/workup. Usually the delivering resident
orders everything needed immediately after delivery as part of
their admission orders. Get I/Os on the C/S pts on POD 1.

All NSVD receive Motrin postpartum and upon discharge. All C/S
receive Motrin and Vicodin postpartum and discharge. You will
be called by the RNs at MBU to do the med recs…a big pain in
the ass but not too difficult. Actually if you know someone is
going home, do it while you are rounding on the unit so you don‟t
have to go back later.

After you see all of your patients on MBU in the AM, usually
everyone goes to breakfast. Brenda, the coordinator for the
rotation will set you up with meal tickets.

L & D Rounds
At 0815 you meet in the back kitchen, L&D 2nd floor, for rounds.
From there you will go to L&D and pick up a laboring patient.
Again, ask the residents who are the best ones for you to see.
Usually you don‟t follow FP pts. You also don‟t really follow the
CNM patients, but if you are desperate for deliveries, you can
ask them if you can assist them. Most of them are great and do
not mind. You are not required to do C/S, but you may if you
wish. They may ask you to help them out on a section if they are
short handed with med students.
OB Triage
Triage is located on the first floor. This is where all the pregnant
ED patients go if they are >20weeks. You are welcome to help
with H&Ps. However, they don‟t really expect you to, but it is
something to do when there is down time and can be helpful
when the place is busy.

Clinics
You are only required to go to U/S and MEA clinics. U/S is on
Mon and Wed. MEA is also on Wed. Obviously you‟ll only cover
one or the other. Remember to log your U/S if you get to do the
scans. The MEA clinic covers the etopics and missed abortions
that we send for follow up from the ED. Both clinics are VERY
pertinent to EM.

General OB clinic is usually taken care of by the other off-service
residents and you don‟t have to cover it, but you may if they are
short.

Sign Out/Call
The day usually ends around 5 pm unless you‟re told to go home
earlier. Sign out is at 5ish in the back kitchen of L&D. You only
have to go to sign out if you are on call.

Calls are laid back. You can do as much as you like. They won‟t
usually page you for deliveries so just watch the board and
check on your patients. You will get MBU pages, but usually not
too many. Most attendings buy dinner for the call team so you
eat well on this rotation (not necessarily healthy, but well…).

How much you work is dependent on you. You can do very little
and get your 10 deliveries or be more active and learn some
other good stuff too. Bring reading – there is lots of down time.
Peds EM – Masonic & UIH

Hours: usually 8 - 5 at UIH
Location: UIH Peds ED; possibly at Masonic as well
Contact: Dr. Nicholas Furtado - furtado@uic.edu
***VACATION: Let Dr. Furtado know what week;

General Pearls:
 Know the peds dosing for meds, especially:
  o Tylenol: 10-15mg/kg q6-8hr (160mg/5ml)
  o Motrin: 5-10mg/kg q6-8hr max 40mg/kg/day (100mg/5ml)
  o It‟s the same number of teaspoons (5ml) that‟s why it has
      different concentrations.
 ALWAYS check ENT. Hold the kids down if you have to, but
  look.
 Don't forget to ask about sick contacts, immunizations UTD,
  recent illnesses, PO intake and urine output/#wet diapers.

General Process:
Pick up all peds patients (under age of 18)in Cerner.
H&P  Present  Orders

Discharging Patients:
1. Provide discharge prescriptions – they print to a special
   printer
2. Provide discharge instructions via Cerner/Ibex
3. Give follow up instructions – if they don‟t have a PCP provide
   them with a clinic contact number, but everybody follows up
   somewhere.
4. UIC: Go to the tracking list, right click on the patient, and
   select “Depart Process”, then you print out discharge paper
   work, asking the patient to sign the top sheet.
   Masonic: Select DCI to print “Discharge Instructions”.
UIH Peds EM
 Peds beds are number 22 – 25, but from 9am-noon patients
   will be placed in any ED beds
 Shifts are usually from 9-5P. You will work with any ER
   attending from 9A-2P, and then the peds ER attending after
   2P.
 You‟ll be the only resident seeing pediatric patients until
   noon, when a senior pediatrics resident comes. Another 2-3
   peds residents plus med students come around 1-2pm. This
   makes for a crowd, so your afternoons are good times to
   catch up on charts, procedure logs, reading, and to make
   friends.
 There is a refrigerator behind the peds section of the ER with
   popsicles in the freezer. This is a good way to calm kids
   down, give them a PO challenge, or soothe mouth sores.
   You‟ll do this a lot.

Masonic Peds EM:
 The Peds EM attending is Dr. Singh, so your schedule will
  usually match with hers
 See all pediatric patients and present to attending
 Make sure to let both the fast track nurse practitioner and the
  ED teams know you are there for peds, otherwise, they will
  see your patients and you will miss out.
 At times there may not be many pediatric patients, so bring
  some reading.
 Dr Singh prefers that you only see peds, but occasionally you
  can help other ED residents/attendings out with sutures and
  procedures when peds is slow.
Trauma at Masonic

Hours: 5:30 am – varies, usu done by 4p. ~Q3 call.
Location: General Surgical Floor 7th floor
Team: 3 interns (incl. EM) +/- med students
EM Intern Pager: 9903

Duties:
 Caring for the trauma floor patients, seeing trauma consults,
   and responding to “Code Yellows” (emergent trauma calls) in
   the ER.
 The two seniors and trauma fellow run the SICU and are
   really only there for help if you need it. You will see them in
   the trauma bay on Code Yellows.

Q3 Call. Usually out by noon post call and 2pm on non-call
days. Essentially once you finish up the work for your patients
you go home. The on call person takes care of new stuff.

Key Scheduling Notes
 Pre-round: 5:30ish
 Morning report: 7am (MWThF), 6:45am (Tu) in 5th floor
   surgery office. This is very low yield for us.
 Attending Rounds: between 8-9am
 Trauma clinic is on Monday at 10am east side of the hospital
   on the 5th floor.
 Trauma interdisciplinary rounds is on Tuesday at noon in the
   SICU conference room (3rd floor). Interns should be able to
   do a one liner on ALL patients.

Rounds
Here are the things you should know for all of your pts:
 Admission – date, time, mechanism of injury, PMH/PSH, lab
   results, imaging
 Last BM
   Diet
   Vital Signs
   I/O – IVFs (type and rate), urine output (per shift), drain
    output (per shift, also note color)
   Incentive Spirometry
   Medications – home and inpatient, know PCA amount for 24
    hours
   Laboratory – if trending specific value, use Care Connection
    to print graph
   Imaging results
   Consults – specialty, name of doctor, and recommendations
   PT/OT and Speech Therapy – notes/recommendations are
    located in form browser in Care Connection

Progress Notes
Have your notes done before 7am (before morning report) and
write them on the Physician Summary Report. Make a vertical
line down the middle to divide the blank portion in half and write
on the left half (attendings write on the right). You don‟t need a
note on a pt admitted after midnight.
In care connection, when you open a patient chart, click „task‟,
then „report‟, click on physician summary and print. This sheet
will be your soap note. It includes the most recent vitals and lab
results, you just have to add the subjective, events overnight,
physical exam and the A/P.

To find out which attending is rounding, go to IMMC home page.
Select Smart Web Paging/On Call Schedule. Select On-Call
Calendar. For name, enter Trauma.

Certain attendings round with certain protocols:
 Dr. Mellet doesn‟t call the Trauma phone. She meets the
   team on the highest floor at 815am. Notes go in the chart.
 Dr. Rico calls the phone. Notes in chart.
   Dr. Fantus calls the phone. He wants all the notes collected
    in a pile and placed on the blue clipboard (on the chart rack
    on 7th floor) in order of highest room to lowest. Then meet
    him at the highest floor after he calls.

When you round, present your patients and note what the
attending wants to do. It may help to have a computer on wheels
(COW) with the team while rounding so the intern that isn‟t
presenting can enter orders and find information quickly if
needed. After rounds, put in orders first and complete any other
time-sensitive work. Before the day is over, sign-out to whichever
intern is on-call. Then forward your pager to the on-call intern,
otherwise you‟ll get pages all day.

On-Call
When on-call, you cover all of the patients on the team and will
get pages about random stuff. It‟s good to know a little about
each patient so that questions don‟t catch you off guard. Most
calls will be about pain, nausea, diet, etc.

You will also have the “Trauma Phone”: a cordless phone (61-
3498) to which attendings and others will call you, and from
which you can return pages. Keep it charged and with you at all
times.

Code Yellow
When a Code Yellow is called, the intern on call should go to the
trauma bay in the ER on the 1st floor. When you arrive, take off
your coat etc. and put on a lead apron and cover it with a blue
plastic gown, mask, and gloves. Make sure you have shears to
cut off clothes.

Get involved. At first, you‟ll just be cutting off clothes and helping
check for signs of trauma. You then will do FAST exams and
might get some chest tubes. You will help with the exam and
whatever else needs to be done. You may have to accompany
the patient down to CT if they are unstable. Once a prelim
reading comes back, the patient will either go to the GSF or
SICU. Be sure to grab a sticker to add them to the Trauma
Team‟s List in Care Connection.

Admissions
1. A patient admitted to the GSF should have (at least) the
   following orders:
   a. Admit order
   b. Pain meds
   c. IVFs
   d. NPO
   e. SCDs
   f. Incentive Spirometer
   g. Any consults
   h. If you are ruling out cardiac contusion EKGs and cardiac
        enzymes q6-8h x 3 (incl. the ER set)
2. Daily labs and imaging varies patient to patient. Most
   patients don‟t need daily labs.
3. All patients should have a complete physical exam done and
   documented if not done in trauma bay

The “Trauma List”
One of the… strangest duties you‟ll have on this service is the
editing of the daily Trauma List. Its an excel spreadsheet on the
Trauma PC in the corner on the 7th floor. It is used for billing and
has a very specific format to be followed.

See the Appendix for step by step instructions to update the
Trauma List. After you have updated it, you have to e-mail it out
by 7am in the morning (the duty of the post-call intern).

Email – do not use personal email to send out the list. Must
email using iPlanet e-Mail:
   Go to IMMC home page and click on Top Applications. From
    the drop down menu, choose iPlanet e-Mail
   username: IMMC-TraumaServices@advocatehealth.com,
    password: trauma
   Addresses – use trauma list (In new message, select
    Addresses. Select Show Mail Lists. Select Check All.
    Select Insert Selected Contacts.)
   Subject and body should be Trauma List Month XX XXXX
    (format should be month name, day #, year # with no dashes
    or decimal points)

Discharges
1. All discharges need:
        a. Medication reconciliation
        b. Prescriptions
        c. Discharge summary sheet
        d. Trauma Outpatient Clinic form
        e. Dictated discharge summary
2. Follow-up appointments (with the exception of trauma follow-
   up appointment) should include the following information:
        Specialty, Name of doctor, Phone number to call for an
        appointment
3. All trauma patients need to follow-up in trauma clinic in 7-10
   days. To allow for scheduling flexibility, do not write a
   specific date (except if patient has sutures)
        a. Facial sutures (3-5 days)
        b. Scalp sutures (10-14 days)
4. If a patient wishes to leave AMA, the trauma attending on call
   must be notified
5. Blood alcohol decreases by 20 every hour. BAL needs to be
   less than 80 for patient to legally make decisions (i.e. can not
   leave AMA)
6. Get your discharge summaries dictated ASAP. (See
   Appendix for instructions and sample format)
Misc. Trauma Information
 The call room is on the 8th floor. You need to take elevator 3
   to get there and your ID should give you access. Each call
   room is locked so, you‟ll need a key. Talk to Helen in the
   Surgery Office on floor 5 about the key. You usually share
   the room with general surgery resident. It has a laptop on
   which you can do some work and put in orders.
 See Emy Mendoza, the trauma secretary for your meal
   vouchers - you should receive two $5 meal vouchers for
   each call day.
 When rounding on 7 Stone, charts should be organized on
   cart
 Patient's meds should be reviewed daily and if taking po,
   meds should be transitioned from IV where appropriate.
 You will be required to give one 20-30 minute talk during the
   month. See the schedule or talk to Dr. Mellett for your
   specific topic assignment.
 Review the FAST Exam:
   http://www.sonoguide.com/FAST.html
 Know your GCS scores cold
 Know your patients well, that's what is expected of you
 When presenting, do not point to the anatomic location. You
   must describe the location in medical terms.
 Give direct answers to questions, and for a yes/no question,
   answer "yes", "no", or "I don't know."
Orthopedics at Masonic
***2 week VACATION: First or last 2 weeks of the rotation

Hours: 6:30am to whenever they tell you to go home
Call: variable dependent on your senior

 Objectives:
1) Master the examination of the extremity
2) Learn Splinting techniques for common fractures
3) Practice the closed reduction of common dislocations

General tips
 Meet up on 7 stone around 6:30 to round on floor patients
 Go grab breakfast with the team (get your meal tickets from
  surgery coordinator)
 You can go to the OR or go to the library and wait for Ortho
  consults.
 If you choose not to go to the OR then most teams will want
  you to stick around until one of them is out of the OR.
 Some people took call and some people didn‟t and it
  depended on your senior.
 In general its one of the easiest rotations so you might try to
  study for Step 3 or get some general reading done.
   Emergency Medicine – MacNeal

You will get a formal orientation at the site on the first
Monday of the rotation.

Hours: 18 – 10 hour shifts. Each shift you are assigned to
a specific attending so when they stop seeing new patients,
you stop seeing new patient.

Location: 3249 Oak Park Ave, Berwyn, IL 60402
Parking: Free at the parking deck across the street with
hospital ID. (Make sure you get your ID from Denise)

Objectives:
1) Develop H&P exam skills appropriate for the emergency
department setting
2) Experience community based emergency medicine
3) Participate in the care of critically ill emergency
department patients

General Pearls:
   Your main objective is to see as many patients as possible.
    You will document the H&P part of the chart and the
    attending with finish the A/P
   There is potential to get lots of procedures so paying
    attention to other patients in the department (always got to
    the room where they page “Respiratory Therapy to ED
    STAT”)
   Polish up on your medical Spanish or get used to paging the
    interpreter because it is a predominantly Hispanic population.
Appendix
Airway Tips & Meds

Preparation – monitors, BVM, laryngoscope/ETT/ stylet/syringe,
suction, IV, meds
Preoxygenation with 100% oxygen (5 minutes OR 2-6 Vital
Capacity breaths) - denitrogenizes alveoli and allows more time
before desaturation occurs.
Pretreatment (LOAD)
 Lidocaine (1.5mg/kg) for RAD or ↑ICP
 Opioid (fentanyl 3mcg/kg) for ↑ICP/CAD/ dissection – to blunt
   sympathetic response
 Atropine (0.02mg/kg) for kids under 10 y/o to prevent reflex
   bradycardia
 Defasciculation (10% of paralytic dose - vec 0.01mg/kg; roc
   0.06-0.1mg/kg) for ↑ICP, penetrating eye injuries
Paralysis
 Induction
       o Etomidate 0.3 mg/kg
       o Thiopental 3-5 mg/kg
       o Midazolam 0.1 mg/kg
       o Ketamine 1-2mg/kg (good for RAD)
 Paralytics
       o Succinylcholine 1.0-1.5 mg/kg
       o Rocuronium 0.6-1.2mg/kg
       o Vecuronium 0.08-0.15mg/kg
Protection - cricoid pressure when start paralysis
Position for laryngoscopy
Placement with capnography and auscultation
Post intubation management (hemodynamics, sedation and
paralysis, vent settings)
Intubation Scenarios
Generic (Sample sequence for 70kg adult)
Zero – 5 min: 100% oxygen
Zero:         Etomidate 20-30mg
              Succinylcholine 100mg

Increased ICP (Sample sequence for 70kg adult)
Zero – 5min 100% oxygen
Zero – 3min Lidocaine 100mg
             Vecuronium 1mg
             Fentanyl 200mcg
Zero          Etomidate 20-30mg
             Succinylcholine 100mg
Reactive Airways/COPD (Sample sequence for 70kg adult)
Zero – 5min 100% oxygen
Zero – 3min Lidocaine 100mg
Zero          Ketamine 100mg
             Succinylcholine 100mg

Post Intubation – Sedation
 Propofol – Load: 0.25-1mg/kg, Drip: 25-75mcg/kg/min -
   Watch for hypotension
 Lorazepam – Load: 0.02-0.06mg/kg, Drip: 0.01-0.1 mg/kg/hr
   - Consider if patient hypotensive
 Midazolam - Load: 0.02-0.1 mg/kg, Drip: 0.04-0.2mg/kg/hr.
   Max 25mg/hr. Avoid in renal failure. Consider if patient
   hypotensive
 Fentanyl - Loading Dose: 0.5-2mcg/kg (start low). Infusion:
   25-100mcg/hr. Max of 150mcg/hr. Option for patients still
   hypotensive on benzodiazepines.
Trauma Presentations

Student Info: This template is helpful to give the students you will
present with in morning report. The info is also on Adajar's
student website: (www.adajarsurgical.org. login:surgery.student
and password is the same).

HISTORY
“Last night at ____AM/PM we received a XX y/o male/female s/p
_____ (MVC/Bike vs. Auto/fall from roof, etc.)”
Specifics to the event:
 Speed, Driver/passenger, seat belt/air bag/LOC/EtOH
 Mechanism: T-bone/head-on, Height of fall, type of weapon,
   etc.

PRIMARY SURVEY (ABCDE)
“Airway, Breathing, and Circulation were intact”
If not:
     Intubated and why
     Decreased breath sounds
     Diminished pulses
GCS (for Disability)
“On Exposure, ____ was noted”
     Describe size/shape of wounds
     Describe location of wounds (without pointing!) using
        anatomical landmarks

SECONDARY SURVEY
“On secondary survey, no additional findings were noted.”
Mention positive findings by system: HEENT, Chest, CV, Abd,
Extremities, etc.
WORKUP
“A standard trauma series was performed which was
unremarkable (or which revealed ______)”

“A FAST was performed because of _____ which was
unremarkable/which revealed”

“A CT of _____ was performed because of ______ (indication)
which revealed _______”

“Due to exam/diagnostic imaging findings, the patient was taken
to OR because ______”

TREATMENT PLAN
“To summarize, we have a XX y/o male/female s/p _____ with
______ injuries. The plan for this patient is ______”
Updating the “Trauma List”

   Trauma computer is on the 7th floor (by PACS computer) in
    the corner.
   List is located in folder Trauma Lists
   List should reflect changes in the 24 hour period from 7:00
    am to 7:00 am
   All code yellow patients are assigned DOE #. This number
    follows the patients name in Care Connection
   Update all information including room numbers.
   1st person on every floor should be gray (fill)

1) Admissions (for past 24 hours) – The admitting attending is
   Fantus, Mellett, Rico, Nikolich, Dahman, Katilius, or
   Mbekeani
       Trauma – Code Yellow
       Transfer – Code Yellow, transferred from outside hospital
       ED – Patient was evaluated in ED and the admitting attending
        is a Trauma attending
2) Consults (for past 24 hours) The admitting attending is not a
   trauma attending
       Identify Type - NS, OB, CV, Ortho, Med, ED
3) Discharges (for past 24 hours) – If discharged in same 24
   hour period as admission/consult, needs to be listed under
   both
       Disposition (home, rehab, NH, jail, etc.)
       Sign off
       DOA – No vitals on admission (DOA needs to go under
        admission and discharge)
       DIH (Death in Hospital)

Email by 7 AM – do not use personal email to send out the list.
Must email using iPlanet e-Mail Here‟s how you email it out:
 Go to IMMC home page and click on Top Applications. From
   the drop down menu, choose iPlanet e-Mail
   username: IMMC-TraumaServices@advocatehealth.com,
    password: trauma
   Addresses – use trauma list (In new message, select
    Addresses. Select Show Mail Lists. Select Check All.
    Select Insert Selected Contacts.)
   Subject should be Trauma List Month XX XXXX (format
    should be month name, day #, year # with no dashes or
    decimal points)
   Include the same info above in the body of the email (This is
    so the email shows up on Fantus‟s IPhone)
Discharge Summary Dictations at Masonic

1. Dial 5533 (inside hosp)
2. Enter 4 digit physician ID: 9903 (pager #)
3. Enter 2 digit work type: 05 (d/c/ summary)
4. Enter 8 digit MRN (including leading zeros)
5. Begin Dictation at prompt
    This is Dr. ______________ (state, then spell your name)
        dictating a discharge summary for (patient name, state
        and spell), medical record number (patient‟s MRN).
    Admitting Date:
    Discharge Date:
    Admitting Dx:
    Discharge Dx:
    Attending:
    HPI (helpful to use trauma bay H&P)
    PMH, Allergies, Meds
    Hospital Course
    Imaging/Procedures
    Disposition (e.g. “the patient is discharged home in stable
        condition with follow up in 7-10 days in trauma clinic.”)
6. If dictating more than one report, Touch 5 at end of first
   report and then repeat steps 3-5.
7. Press 9 to End

Other helpful keypad controls
Press 2 to dictate
Press 4 to pause
UIH Electrolyte Replacement Guidelines

NOTE: These guidelines are to be used ONLY in patients with
normal renal function

POTASSIUM (also check Mg and correct) Goal is >4 in cardiac
patients
3.0-3.5 mEq/L  KCl 40 mEq PO or IVPB
2.5-2.9 mEq/L  KCl 80 mEq PO or IVPB, recheck potassium
level in 4 hours
< 2.5 mEq/L  KCl 120 mEq PO or IVPB, recheck potassium
level in 4 hours

If serum chloride > 110 mEq/L, give Potassium Acetate instead
of Potassium Chloride.
If phosphorus < 3.0 mg/dl, use Potassium Phosphate

Oral: preferred for mild-moderate hypokalemia (3.0-3.5 mEq/L).
Although oral doses of > 40 mEq can be given, GI adverse
effects may be diminished by giving no more than 40 mEq and
repeating every 2-3 hrs until the total dose given.
IV replacement max rate is 10mEq/hr and can be painful for
patient

CALCIUM replacement
8.0-8.5 mg/dL and alb>3.5 (or Ionized Ca 3.5-4.0 mg/dL)  1g
Ca Gluconate (4.5 mEq) IV over 15-30 mins

< 8.0 mg/dL and alb>3.5 (or Ionized Ca < 3.5 mg/dL)  2g Ca
Gluconate (9 mEq) IV over 30 mins

Recheck Total Calcium or Ionized Calcium in 2 hours

If Albumin < 3.5, and the Ionized Calcium is not available:
Corrected Ca++ = (4- serum alb) x 0.8 + total Ca++
MAGNESIUM (replace Mg before K)
1.6-1.8 mEq/L: 8-16 mEq (1-2 grams) MgSO4 IVPB
1.2-1.5 mEq/L: 16-32 mEq (2-4 grams) MgSO4 IVPB
< 1.2 mEq/L : 24-32 mEq (3-4 grams) MgSO4 IVPB, Recheck
Mg in 4 hours after dose

If there are sx of bronchospasm, EKG changes, can give 2
grams over 15min.
If asymptomatic, give no faster than 8mEq/hr.
May be administered through a peripheral or central line

PHOSPHATE replacement
2.6-3.0 mg/dL and K < 4.0 mEq/L  KPhos 15 mmol IVPB over
3-6 hours
2.6-3.0 mg/dL and K > 4.0 mEq/L  NaPhos 15 mmol IVPB over
3-6 hours
1.5-2.5 mg/dL and K < 3.5 mEq/L  KPhos 30 mmol IVPB over
6-8 hours

Recheck phos level 4 hours after replacement. Replace phos
until > 3.0 mg/dL
Note: 3 mmol of Potassium Phosphate delivers 4.4 mEq of
potassium; 3 mmol of Sodium Phosphate delivers 4 mEq of
sodium. Can also give packets of neutra-phos or neutral-phos-
potassium orally (both contain Na).
Parking

Masonic
Parking – free lot at Sheffield and Wellington. You have to go the
parking office on the west side of the visitor parking structure to
get a decal to put in your window. Otherwise you‟ll get towed.
You can opt to pay for parking in the garage as well.

Mercy
Free!!! Need ID to access the lots

3 LOTS:
1.) Directly in front of the ER. We can park there after 2pm, so it
works for swing/night shifts.
2.) Across Michigan Ave, is another lot where we can park any
time. This is where you should try to park for morning shifts.
3.) Michael Reese lot which is one block west of Mercy, along
MLK Blvd. After parking there, a shuttle will take you from there
to the hospital.

UIH
Parking can be purchased via Parking Services in the garages
near the hospital. You can arrange to have this taken out of your
paycheck and put this on hold when you will not be at the
university.

Free street parking close to the VA hospital (south of Taylor,
west of Damen). This area fills up in the morning by 8am. Also
you can park at the Juvenile detention center parking deck for $4
/ day. The parking deck is further south and west in the street
parking area.

Meter parking on the south side of Roosevelt that allows you to
pay for up to 10 hours at a time. Park here at your own risk –
many cars have been vandalized in this area.
Notes / Stickers for procedures

				
DOCUMENT INFO