Pearls of Cross Cover Jason B. Martin

1. Pearls of Cross Cover Jason B. Martin

2. What is cross cover? • Covering for your partners • other interns who are off • teams signed out to you at night • You are the patient’s primary physician after hours • labs, consult recs, consent (blood) • family concerns • ALL medical and nursing issues • The sign out sheet • BRIEF explanation of why patient is here • Just the facts! Don’t editorialize. • Pertinent demographics (name, age, MR, room #) • allergies • CODE STATUS (and keep this up to date)

3. What NOT to sign out: • Routine daily responsibilities • get your notes done before rounds • Subjective comments • Results that won’t affect patient care • Non-specific plans • RESTRAINT RENEWALS

4. Responding to pages • Be prompt, especially with tagged pages • Your tone • Irritated? Hurried? Rebuking? • Be polite • What does the nurse REALLY want? • Reassurance? Appease patient or family? • Empower the nursing staff • What do they think is going on? • What should WE do about this issue? • Come to a decision and ask for read-back • Leave tracks in the chart, sign-out sheet

5. Giving Medications • Do I really need to give a medication? • Does the patient have a medication on his/her list that I can use, or dose early? • Review allergies • Consider renal and hepatic function • General principles • shorter-acting agents are better in the middle of the night • PO > IV • lowest dose to achieve • think about patient comfort and nursing care • Use phenergan and ativan with caution in older patients

7. You are not alone • Use your resources  nurses and techs, residents, fellows, attendings • ALWAYS call your resident if something’s not right • ALWAYS call early • Trust your instincts

8. Common Questions on Call Disclaimer: This list in NOT comprehensive. Even seasoned veterans can be surprised on call

9. Common Questions on Call • Insomnia • Constipation • Diarrhea • N/V • Electrolyte problems • Fever • Loss of IV • Decreased UOP • Confusion • EtOH withdrawl • Dyspnea • HTN • Hypotension

10. Insomnia • Probably the most common call • Consider prn orders at admission • Why can’t they sleep? • pain • anxiety • noise • sundowning • What normally works for the patient?

11. Insomnia • Antihistamines • Diphenhydramine (Benadryl) • 12.5, 25, or 50 mg (IV or PO) • Benzos • Temazepam (Restoril) 15-30 mg PO  great for older pts • Lorazepam (Ativan)  0.5 mg PO, IV • Avoid alprazolam and valium • Zolpidem (Ambien) 5-10 mg po qhs prn

12. Constipation • Review medication list  review with AM team • Iron • CCB • Laxatives • Bisacodyl (Dulcolax) • 5 or 10 mg pr • Docusate Sodium (Colace) • 100 mg po BID • Milk of Magnesia • 30-60 mL PO • Metamucil

13. Constipation • Lactulose 10-20 grams (15-30 mL) • Go easy • Tastes bad • Dramatic results • The Green Bomb: Magnesium Citrate (300 cc bottle) • Fleet’s Enema • Don’t order it • Just use soap suds • Avoid Mg-containing compounds in renal failure

14. Constipation • Attention Interns: • The patient may need manual disimpaction.

15. “Diarrhea – Cha! Cha! Cha!” • Is it diarrhea or just loose stools? • Associated with fever or leukocytosis? • c.diff? Start empiric flagyl? • hemorrhagic colitis? • Leakage around an impaction? • Avoid anti-diarrheals acutely • Immodium or lomotil if needed

16. Nausea and Vomiting • Promethazine (Phenergan) • 12.5 – 25 mg PO/IV q 4-6 hours prn • Caution in elderly • Metoclopramide (Reglan) • 5-10 mg PO • Lorazepam (Ativan) 0.5 – 1 mg PO • Serotonin antagonists (Anzemet, Kytril, Zofran) are available • generally second-line ($) • oncology patients • refractory cases

17. Hypokalemia • Hypokalemia • normal range is 3.5 – 5.0 • replace PO/per tube when possible (immediate and SR forms) • can replace IV if necessart • be aware of patient’s renal function • be aware of any standing K orders • conisder empiric Mg replacement if refractory

18. Hypokalemia • KCL immediate release  orally 40-60 meq is a standard dose • powder/elixir  rapidly absorbed • tastes terrible; patients with nause may not tolerate • Kdur tablets • slower onset, longer-acting • IV KCl  it hurts • slow replacement (10 meq/hour peripherally) • takes the IV port

19. Hyperkalemia • Hyperkalemia can kill a patient (arrhythmia) • Order EKG (and call your resident) • Does it fit the clinical setting? Hemolysis? • Swift action may be required

20. Hyperkalemia • Calcium gluconate  rapidly stabalizes the cardiac muscle membranes; effect is transient • Insulin (10 units IV) with 1 amp D50 • drive K into cells • onset 15-30 minutes • Bicarbonate • transient cellular shift • Beta agonists • Dialysis

21. Fever • ALWAYS EXAMINE THE PATIENT • Draw cultures prior to abx • You will rarely be faulted for choosing broad abx; just think about the possible sources • Don’t forget about allergies • Renally dose medications  Use Sanford Guide

22. Loss of IV • Does the patient need an IV? • Any meds scheduled for tonight? • Ask for IV therapy to assist (at VU) • Attempt yourself? • Can you convert to PO? • What about a central line?

23. Low UOP • Is the Foley placed properly? • Flush the Foley • Reposition it • Assess patient’s volume status and read the history • volume overloaded  Lasix • crackles, elevated JVP, S3, edema • volume depleted  NS • orthostasis • hypotension • tachycardia • Get your resident involved if unsure

24. Chest Pain • Huge differential diagnosis  from annoying to life-threatening • Always evaluate CP in person  get out of bed • Have the nurse get EKG while you are on your way • Think about GERD, PE, MI, dissection, anxiety • Assess vital signs, careful physical exam • diaphoretic? • dyspnea? • acutely ill-appearing? • pleuritic?

25. Chest Pain • EKG changes? Call for help  Time is myocardium • Cardiac enzymes • CXR • Transfer to another unit? • If you think it’s cardiac: • ASA • nitro spray or SLNG  in new pts, ask about sildenafil use • O2 • morphine • βBs

26. Dyspnea • Always examine these patients in person • Vitals (RR and sats) • Huge differential • failure, edema • bronchospasm • PE • ptx • MI • pneumonia • bronchospasm • acidosis • anemia

27. Hypertension • Urgency, emergency, or no big deal? • Physical exam • BP in both arms • funduscopic exam • rales? • neuro exam • Labs / Imaging • BMP • EKG • UA • CXR • AMS or focal neuro deficits  CT head without contrast

28. Hypertension • Is the patient in pain? Anxious? • Use current medications • early dosing • increase doses • Clonidine  it works, but no style points • 0.1 mg to 0.3 mg po • Nitro paste • IV push (with consultation): labetalol • IV gtt (with consultation): cardene, nitroprusside

29. EtOH Withdrawl • Can be life threatening • Be suspicious: agitation, tremor, hypertension, tachycardia in a drinker • Treat with IV benzos • Start low, titrate rapidly to achieve effect (Protocol in place?) • Ativan IV: 2 mg  4 mg  6 mg  10 mg • MVI, thiamine, folate • Consider transfer to a monitored unit

30. Confusion / Delerium • Check VS, sats, glucose, consider ABG • Discuss with nursing staff, family  what’s the baseline? How acute is the change? • Why? • hypoglycemia • recent fall? CT head? • infection? • medications? • ICU or hospital-induced delerium • EtOH withdrawl • iatrogenic (phenergan is a common offender)

31. Confusion / Delerium • Sundowning • very upsetting to families • can worsen with ativan • best therapy  family and reassurance • restrain for patient / staff safety • try some haldol

32. AVOID • Demerol • Major changes in plan without consultation • Treating patients without examining them • Short temper with nurses • Calling for help too late

33. Intern Companions • Hemoccult cards, developer (and a gentle touch) • Opthalmoscopes and tropicamide (Mydriacyl) • Motivated medical students • A supportive resident: • “ If the horse dies, the cowboy walks.”