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A Day in the Life… and Cross-Cover Karen Velazquez Alisa Holland Chief Residents Overview: A Day in the Life… • Wards • Conferences • ICU • Electives • Important Numbers WARDS Call Days: • Day starts at 8 am • Call is every 4th night • Admissions: 8a-12a • Night Float admits to cap: 11p-9a • Resident will call with new admissions • Sign-out by 12a on call day • Night Float intern handles all cross cover • Intern can admit 5 patients for call. Intern cap: 10 patients. • Resident clinic patients requiring admission should be followed by the teaching service. • On-Call Team = Code Team (“Code Blue MET”) • Call rooms: 10th floor: B&C are intern call rooms, D is the resident call room WARDS Non-Call Days: • Arrive at 7 am • See patients in order of priority (ICU then floor) • Discuss patients with attendings • Notes in chart early in day (preferably prior to teaching rounds) • Teaching rounds M-W-F 10:30 am-12 pm • Conference 12 pm-1pm • Sign out to cross covering intern • Check out pager at 5 pm on weekdays or noon on weekends unless post-call • Off Days: 4 days per call month (T, Th, Sa, Sun) all pre-call days. WARDS- Intern Responsibilities 1. Interview Patient: H&P, review labs/imaging & formulate plan with resident 2. Admission orders (THR FYI Flag for Teaching Service) 3. Present to the Attending 4. H&P write up 5. Call consults 6. Daily progress notes 7. Daily orders 8. F/u with all attendings 9. Cross-cover list/Sign-out 10. Discharge summaries (within 24 hours of patient discharge) On one of your wards months, each of you will be in charge of setting up cases to present for interns conference. CONFERENCES To Present: Journal Club: 30 min: 2 per year: article of your choice Residents Conference: 1-hour presentation: interesting medical topic of your choice Potpourri: 30 min: Any interesting case To Attend: Noon Conference: 12 pm-1 pm: M, T, Th, F Interns Conference: Tuesdays: 11 am-12 pm Clinical Grand Rounds: Wed 7:30 am-8 am IM Grand Rounds: 12:15 pm-1:15 pm Coffee with Cardiology: Fridays: 7:30 am-8 am Teaching Rounds: M,W,F: 10:30 am-12 pm on Wards months ID Rounds: Meet with Dr. Goodman 1 pm-3 pm once a month on wards ELECTIVES • Contact the attending you are working with a few days prior to the start of the rotation to get details of their expectations • Hours and responsibilities vary depending on the rotation and attending. ICU ROTATION • 6 am -6 pm Mon-Fri • Hamon 3 ICU • Resident works with you • Round on all your patients on arrival • Notes in chart by 10 am • 10 am: Multidisciplinary rounds: Present all patients to ICU attending, nurses, RT, SW • Overnight events, vent settings, vitals, assessment/plan for the day, DVT/GI prophylaxis. VACATION • 20 days per year • Can be taken on any month except Wards, Night Float, and ICU • Max: 5 days/month (M-F; surrounding weekends do not count) • Categoricals: Contact Sonya/Alma in the clinic 1 month prior to let them know you are taking vacation • Vacation Form: signed by subspecialty attending (also by Sonya/Alma if you are a categorical). Turn this into Jason for approval ~30 days prior to vacation. IMPORTANT NUMBERS Residents Lounge Code: 997722 Physician’s Dining Room Code: 214 Residents Clinic Code: 7802 Jason: 6176 Sherie: 7881 Page Operators: 8480 Calling the hospital from the outside: 214-345-XXXX Overview - Cross Cover • Making your Cross-cover list • Emergency vs. Non-emergency • When should I go and see the patient? • Common calls/questions • When do I need to call my resident??? How to make your Cross Cover list: • Log on to www.caregate.net • Go to Cross Cover • Under ―problems‖, put one liner about the patient • Then list all important problems and what has been done about them • Under ―to do‖ section put MR number, pt allergies, important meds, anything for X-cover to follow up on Cross cover list is kept current on CareGate www.caregate.net Cross-Cover List • ALWAYS check out FACE TO FACE • ALWAYS include MR#, allergies, things to do, meds, code status • Update problem list and meds DAILY!!! • Always include consultants on board, so that if something happens during the day the person covering can call someone else for assistance if needed. • Write a progress note if an event occurs overnight. • ALWAYS call the next morning to update on patient list (EVEN if there were no calls). • If there is something important that you need the cross cover resident to do/follow up on, make sure you tell them in person. Not Acceptable: • ―Patient intubated, sedated, in 1 ICU‖… when the pt has been extubated and on the floor for 4 days • Update room numbers • Update DNR/Code Status • Must put pertinent changes in status (e.g., if a patient went into afib or had GI bleed or is having a procedure) • Must put all pending tests on the list • If someone is really sick, include family contact info in the event of a code or critical change in medical status • YOU MUST UPDATE THE WHOLE LIST EVERYDAY!!! What do I do when I’m called? • Review basics by organ systems • Neuro • Infectious Disease • Pulmonary • Heme • Cardiology • Radiology • Gastrointestinal • Death • Renal -Ask yourself, does this patient sound stable or unstable? -Ask for vitals -Is this a new change? NEUROLOGY • Altered Mental Status • Seizures • Falls • Delirium Tremens Altered Mental Status • Always go to the bedside!!! • Try naloxone (Narcan), usually • Is this a new change? 0.4-1.2 mg IV, if there is any Duration? possibility of opiate OD • Recent/new medications • If elderly person is • Check VITALS, Neuro Exam agitated/sundowning • Review Labs: cardiac o try a sitter first enzymes, electrolytes, o then medications +cultures haloperidol (Haldol) 2mg • Check stat Accucheck, 02 sat, IV/IM ABG, NH3, TSH ziprasidone (Geodon) • Consider checking non- 10-20mg IM contrast head CT quetiapine (Seroquel) 25mg po qhs o Restraints (last resort) **Caution with Benzos/ambien in the elderly ―Move Stupid‖ • Metabolic – B12 or thiamine deficiency • Oxygen – hypoxemia is a common cause of confusion • Others - including anemia, decreased cerebral blood flow (e.g., low cardiac output), CO poisoning • Vascular – CVA, intracerebral hemorrhage, vasculitis, TTP, DIC, hyperviscosity, hypertensive encephalopathy • Endocrine – hyper/hypoglycemia, hyper/hypothyroidism, high /low cortisol states and • Electrolytes – particularly sodium or calcium • Seizures –post–ictal confusion, unresponsive in status epilepticus; also consider • Structural problems – lesions with mass effect, hydrocephalus • Tumor, Trauma, or Temperature (either fever or hypothermia) • Uremia – and another disorder, hepatic encephalopathy • Psychiatric – diagnosis of exclusion; ICU psychosis and "sundowning" are common • Infection – any sort, including CNS, systemic, or simple UTI in an elderly patient • Drugs – including intoxication or withdrawal from alcohol, illicit or prescribed drugs Seizures • Go to bedside to determine if patient still actively seizing • Call your resident • Assess ABCs o give 02, intubate if necessary o Place patient in left lateral decubitus position • Labs o electrolytes (Ca+/Mg), glucose, CBC, renal/liver fxn, tox screen, anticonvulsant drug levels, check Accucheck • Treatment: o give thiamine 100 mg IV first, then 1 amp D50 o antipyretics for fever or cooling blankets o lorazepam 0.1mg/kg IV at 2mg/min • If seizures continue; o Load phenytoin 15-20 mg/kg IV in 3 divided doses at 50 mg/min (usually 1 g total) or fosphenytoin 20mg/kg IV at 150mg/min o Phenytoin is not compatible with glucose-containing solutions or benzos; if you have given these meds earlier, you need a second IV! **If still seizing >30min, pt is in status—call Neuro (they can order bedside EEG) Falls • Go to the bedside!!! • Check mental status/Neuro exam • Check vital signs including pulse ox • Review med list (benzos, pain meds etc) • Accucheck! • Examine for fractures/hematomas/hemarthromas • Check tilt blood pressures if appropriate • If on Coumadin/elevated INR or altered—consider non- contrast head CT to r/o subdural hematoma • Consider ordering sitter/fall precautions Delirium Tremens (DTs) • See if patient has alcohol history • Give thiamine 100mg, folate 1mg, MVI • Check blood alcohol level • DTs usually occur ~ 3 days after last ingestion • Make sure airway is protected (vomiting risk) • Use lorazepam (Ativan) 2-4mg IV at a time until pt calm, may need Ativan drip, make sure you do not cause respiratory depression • Monitor in ICU for seizure activity • Always keep electrolytes replaced PULMONARY • Shortness of Breath • Hypoxia Shortness of Breath • Go to the bedside!!! • History of heart failure? Recent surgery? COPD? • Look at I/Os • Physical Exam (heart and lungs especially) • Check an oxygen saturation and ABG if indicated • Check CXR if indicated • Lasix 40mg IV x1 if volume overloaded • Increase supplemental 02, if no improvement start on BiPAP, call resident • Move to ICU/intubate if necessary Causes of SOB • Pulmonary: o Pneumonia, pneumothorax, PE, aspiration, bronchospasm, upper airway obstruction, ARDS • Cardiac: o MI/ischemia, CHF, arrhythmia, tamponade • Metabolic: o Acidosis, sepsis • Hematologic: o Anemia, methemoglobinemia • Psychiatric: o Anxiety – common, but a diagnosis of exclusion! Oxygen Desaturations Supplemental Oxygen • Nasal cannula: for mild desats. Use humidified if giving more than >2L • Face mask/Ventimask: offers up to 55% FIO2 • Non-rebreather: offers up to 100% FIO2 • BIPAP: good for COPD o Start settings at: IPAP 10 and EPAP 5 o IPAP helps overcome work of breathing and helps to change PCO2 o EPAP helps change pO2 Indications for Intubation • Uncorrectable hypoxemia (pO2 < 70 on 100% O2 NRB) • Hypercapnea (pCO2 > 55) with acidosis (remember that people with COPD often live with pCO2 50–70) • Ineffective respiration (max inspiratory force< 25 cm H2O) • Fatigue (RR>35 with increasing pCO2) • Airway protection • Upper airway obstruction Mechanical Ventilation • If patient needs to be intubated, start with mask- ventilation until help from upper level arrives • Initial settings for Vent: o A/C FIO2 100 Vt 700 Peep 5 (unless increased ICP, then no peep) RR 12 • Check CXR to ensure proper ETT placement (should be around 2-4cm above the carina) • Check ABG 30 min after pt intubated and adjust settings accordingly CARDIOLOGY • Chest pain • Hypotension • Hypertension • Arrhythmias Chest Pain • Go and see the patient!!! • Why is the patient in house? • Recent procedure? • STAT EKG and compare to old ones • Is the pain cardiac/pulmonary/GI?—from H+P • Vital signs: BP, pulse, SpO2 • If you think it’s cardiac: MONA o Give SL nitroglycerin if pain still present (except if low blood pressure, give morphine instead) o Supplemental oxygen o Aspirin 325 mg o Cycle enzymes o Call Cardiology if there is new ST elevation, LBBB, or if there is an elevation in cardiac enzymes Hypotension • Go and see the patient!!! • Repeat BP and HR, manually • Compare recent vitals trends • Look for recent ECHO/meds pt has been given. • EXAM: o Vitals: orthostatic? tachycardic? o Neuro: AMS o HEENT: dry mucosa? o Neck: flat vs. JVD (=CHF) o Chest: dyspnea, wheezes (?anaphylaxis), crackles (=CHF) o Heart: manual pulse, S3 (CHF) o Ext: cool, clammy, edema Management of Hypotension • Hypovolemia • Anaphylaxis: sob, wheezing o volume resuscitation o epinephrine o if CHF,bolus 500ml NS o benadryl o transfuse blood o supplemental 02 • Cardiogenic • Adrenal Insufficiency o fluids o check, cortisol/ACTH o inotropic agents level • Sepsis: febrile >101.5 o ACTH stim test o blood cultures x 2 o replace volume rapidly o empiric antibiotics o Hydrocortisone 50- 100mg IV q6-8h *Stop BP meds! *Don't forget about tamponade, PE and pneumothorax!! Commonly Used Pressors Name ReceptorAffected Dose Action Phenylephrine Alpha 1 10–200 mcg/min Pure vasoconstrictor; (Neosynephrine) causes ischemia in extremities Norepinephrine A1, B1 2–64 mcg/min Vasoconstriction, positive (Levophed) inotrope; causes arrhythmias Dopamine Dopa 1–2 mcg/kg/min Splanchnic vasodilation ("renal dose dopamine" even though many doubt such effect exists) B1 2–10 mcg/kg/min Positive inotrope; Causes Arrhythmias A1 10–20 mcg/kg/min Vasoconstriction; Causes Arrhythmias Dobutamine B1, B2 1–20 mcg/kg/min Positive inotrope and chronotrope; Causes Hypotension Hypertension • Is there history of HTN? o Check BP trends • Is patient symptomatic? o ie chest pain, anxiety, headache, SOB? • Confirm patient is not post-stroke—BP parameters are different: initial goal is BP>180/100 to maintain adequate cerebral perfusion • EXAM: o Manual BP in both arms o Fundoscopic exam: look for papilledema and hemorrhages o Neuro: AMS, focal weakness or paresis o Neck: JVD, stiffness o Lungs: crackles o Cardiac: S3 Management of HTN • If patient is asymptomatic and exam is WNL: o See if any doses of BP meds were missed; if so, give now o If no doses missed, may give an early dose of current med • Start a med according to JNC 7/co-morbidities/allergies • PRN meds: o hydralazine 10-20mg IV o enalapril (Vasotec) 1.25-5mg IV q6h o labetalol 10-20mg IV *Remember, no need to acutely reduce BP unless emergency Hypertension (continued) URGENCY EMERGENCY • SBP>210 or DBP>120 with • SBP>210 or DBP>120 with no end organ damage acute end organ damage • OK to treat with PO agents • Treat with IV agents (decrease (decrease BP in hours) MAP by 25% in min to 2hrs; o hydralazine 10-25mg then decrease to goal of o captopril 25-50mg <160/100 over 2-6 hrs) o labetolol 200-1200mg o nitroprusside 0.25-10ug/kg/min o clonidine 0.2mg o nitroglycerin 17-1000ug/min o labetolol 20-80mg bolus o hydralazine 10-20mg o phentolamine 5-15mg bolus Arrhythmias Tachyarrhythmias Bradycardia • Afib/flutter RVR • Assess ABCs o rate control o give 02 (BB/diltiazem/digoxin if BP o monitor BP low) • Sinus block: 1st, 2nd or 3rd o consider anti-arrhythmic degree (amiodarone) o Hold BB meds • SVT/SVT with aberrancy o Prepare for transcutaneous o vagal maneuver pacing o adenosine 6-12mg IV o Atropine 0.5mg IV x3 • Ventricular fib/flutter o Consider low dose o check Mg level, replace if epi (2-10mcg/min) needed (>3.0) dopamine(2-10mcg/kg/min) o amiodarone drip *Remember, if unstable shock!! Gastrointestinal • Nausea/Vomiting • GI Bleed • Acute Abdominal Pain • Diarrhea/Constipation Nausea/Vomiting • Vital signs, blood sugar, recent meds (pain meds)? • Make sure airway is protected • EXAM: abdominal exam, rectal (considering obstruction, pancreatitis, cholecystitis),neuro exam (increased ICP?) • May check KUB • Treatment: o Phenergan 12.5-25mg IV/PR (lower in elderly) o Zofran 4-8mg IV o Reglan 10-20 mg IV (especially if suspect gastroparesis) o If no relief, consider NG tube (especially if suspect bowel obstruction) GI Bleed UPPER LOWER • Hematemesis, melena • BRBPR, hematochezia • Check vitals • Check vitals • Place NG tube • NPO • NPO • Rectal exam • Wide open fluids, • Wide open fluids if low BP type&cross for blood • Check H/H serially • Check H/H serially • Transfuse if appropriate • If suspect • Pain out of proportion? Don’t o PUD: Protonix gtt forget ischemic colitis! o varices: octreotide gtt **Call Resident and GI Acute Abdominal Pain • Go to the bedside!!! • Assess vitals, rapidity of onset, location, quality and severity of pain LOCATION: • Epigastric: gastritis, PUD, pancreatitis, AAA, ischemia • RUQ: gallbladder, hepatitis, hepatic tumor, pneumonia • LUQ: spleen, pneumonia • Peri-umbilical: gastroenteritis, ischemia, infarction, appendix • RLQ: appendix, nephrolithiasis • LLQ: diverticulitis, colitis, nephrolithiasis, IBD • Suprapubic: PID, UTI, ovarian cyst/torsion Acute Abdomen • Assess severity of pain, rapidity of onset • If acute abdomen suspected, call Surgery • Do you need to do a DRE? • KUB vs. Abdominal Ultrasound vs. CT • Treatment: o Pain management—may use morphine if no contraindication o Remember, if any narcotics are started, use sparingly in elderly, ensure pt on adequate bowel regimen Diarrhea Constipation • Is this new? • Is this new? • check stool studies: • check KUB o c.diff x 3 • Ileus/bowel obstruction: o culture o place NPO o o&p • Treat: o wbc o Laxative of choice o FOBT x 3 MOM • Do not treat with Miralax loperamide if you think it enema might be C.diff!!! tap water soap o Bowel regimen colace 100mg bid dulcolax 5-15mg RENAL/ELECTROLYTES • Decreased urine output • Hyperkalemia • Foley catheter problems Decreased Urine Output • Oliguria: <20 ml/hour (<400 ml/day) • Check for volume status, renal failure, accurate I/O, meds • Consider bladder scan (place foley if residual >300ml) • Labs: o UA: WBC (UTI); elevated specific gravity (dehydration); RBC (UTI/urolithiasis); tubular epithelial cells (ATN); WBC casts (interstitial nephritis); eosinophils (AIN) o Chemistries: BUN/Cr, K, Na Treatment of Decreased UOP Decreased Volume Status: Normal/Increased Volume: • Bolus 500ml NS • May ask nursing to check • Repeat if no effect bladder scan for residual urine • Check Foley placement • Lasix 20-40 mg IV Foley Catheter Problems: • Why/when was it placed? • Does the patient still need it? • Confirm no kinks or clamps • Confirm bag is not full • Examine output for blood clots or sediment • Do not force Foley in if giving resistance: call Urology • Nursing may flush out Foley if it must stay in • The sooner it’s out, the better (when appropriate) Hyperkalemia • Ensure correct value—not hemolysis in lab • Check for renal insufficiency, medications (ACEI/ARBs, heparin, NSAIDs, cyclosporine, trimethoprim, pentamidine, K-sparing diuretics, BBs, KCl, etc) • Check EKG for acute changes: o peaked T-waves o flattened P waves o PR prolongation followed by loss of P waves o QRS widening Treatment of Hyperkalemia • Mild (<6.0 mEq/L) • Severe (>7mEq/L) or Decrease total body stores EKG changes o Lasix 40-80mg IV Protect myocardium o Kayexalate 30-90g PO/PR o Calcium gluconate 1- • Moderate (6-7mEq/L) 2amps IV over 2-5min Shift K+ in cells o NaHCO3 50mEq (1-3amps) o D50+10units insulin IV o albuterol 10-20mg neb **Emergent dialysis should be considered in life-threatening situations. **Remember this is a progressive treatment plan, so if your patient has EKG changes you need to treat for severe/mod/mild!!! Infectious Disease • Positive Blood Culture • Fever Positive Blood Culture • You get called by the lab because a blood culture has become Positive. • Check if primary team had been waiting on blood culture. • Is the patient very sick/ ICU? • Is the culture ―1 out of 2‖ and/or ―coag negative staph‖? o This is likely a contaminant. o If ½ Blood Cx are positive, consider repeating another set • If pt is on abx, make sure appropriate coverage based on culture and sensitivity • If you believe it to be true positive then give appropriate empiric treatment for organism and likely source of infection/co-morbidities of patient and discuss with primary team in the AM Fever • Has the patient been having fevers? • DDX: infection, inflammation/stress rxn, ETOH withdrawal, PE, drug rxn, transfusion rxn • If the last time cultures were checked >24 hrs ago o order blood cultures x 2 from different IV sites o UA/culture o CXR o respiratory culture if appropriate • If cultures are all negative to date, likely no need to empirically start abx unless a source is apparent and you are treating a specific etiology HEME • Anticoagulation • Blood replacement products Anticoagulation • Appropriate for: o DVT/PE o Acute Coronary Syndrome • Usually start with low molecular weight heparin o Lovenox 1 mg/kg every 12 hours and renally adjust • If need to turn on/off quickly (e.g., pt going for procedure) o heparin drip—protocol in EPIC • Risk factors for bleeding on heparin: o Surgery, trauma, or stroke within the previous 14 days o h/o PUD or GIB o Plts<150K o Age > 70 yrs o Hepatic failure, uremia, bleeding diathesis, brain mets Blood Replacement Products • PRBC: o One unit should raise Hct 3 points or Hgb 1 g/dl • Platelets: o One unit should raise platelet count by 10K; there are usually 6 units per bag ("six-pack") use when platelets <10K in non-bleeding patient. use when platelets <50K in bleeding pt, pre-op pt, or before a procedure • FFP: contains all factors o DIC or liver failure with elevated coags and concomitant bleeding o Reversal of INR (ie for procedure) RADIOLOGY Which test should I order? • Plain Films • CT scans • MRI Plain Films CXR: • Portable if pt in unit or bed bound • PA/Lateral is best for looking for effusions/infiltrates • Decubitus to see if an effusion layers; needs to layer >1cm in order to be safe to tap Abdominal X-ray: • Acute abdominal series: includes PA CXR, upright KUB and flat KUB CT • Head CT o Non-contrast best for bleeding, CVA, trauma o Contrast best for anything that effects the blood brain barrier (ie tumors, infection) • CT Angiogram o If suspect PE and no contraindication to contrast (e.g., elevated creatinine) • Abdominal CT o Always a good idea to call the radiologist if unsure whether contrast is needed/depending on what you are looking for o Renal stone protocol to look for nephrolithiasis o If you have a pt who has had upper GI study with contrast, radiology won’t do CT until contrast is gone—have to check KUB to see if contrast has passed first * If you are going to give contrast, check your Cr!!! MRI • Increased sensitivity for soft tissue pathology • Best choice for: o Brain: neoplasms, abscesses, cysts, plaques, atrophy, infarcts, white matter disease o Spine: myelopathy, disk herniation, spinal stenosis • Contraindications: pacemaker, defibrillator, aneurysm clips, neurostimulator, insulin/infusion pump, implanted drug infusion device, cochlear implant, any metallic foreign body DEATH • Pronouncing a patient • Patient may be pronounced by 2 RNs • Notify the patient’s family • Request an autopsy • How to write a death note Pronouncing a Patient Check for: • Spontaneous movement • If on telemetry—any meaningful activity • Response to verbal stimuli • Response to tactile stimuli (nipple pinch or sternal rub) • Pupillary light reflex (should be dilated and fixed) • Respirations over all lung fields • Heart sounds over entire precordium • Carotid, femoral pulses Notify the Patient’s Family • Call family if not present and ask to come in, or if family is present: o Explain to them what happened o Ask if they have any questions o Ask if they would like someone from pastoral care to be called o Let them know they may have time with the deceased • Nursing will put ribbon over the door to give family privacy Request an Autopsy • Ask family if they would like an autopsy • Medical Examiner will be called if: o Patient hospitalized <24 hours o Death associated with unusual circumstances o Death associated with trauma How to Write a Death Note DOCUMENTATION: • ―Called to bedside by nurse to pronounce (name of pt).‖ • Chart all findings previously discussed: o ―No spontaneous movements were present, pupils were dilated and fixed, no breath sounds were appreciated, etc.‖ • ―Patient pronounced dead at (date and time).‖ • ―Family and attending physician were notified.‖ • ―Family accepts/declines autopsy.‖ • Document if patient was DNR/DNI vs. Full Code. Bottom Line: • When in doubt, call your Resident • It is OK to call your attending if over your head • You are Never All Alone ☺ • Write a NOTE about what has happened for the primary team • Call primary team in the AM about important events. • Have fun…it’s gonna be a great year!
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