Intern Conference

1. Intern Conference July 11, 2012

2. Welcome! • Ask anything here • Today • First Night on Call • Top 10 Surgical Intern Calls

3. Top 10 Intern Calls • Fever • Chest pain • Hypotension • Respiratory Distress • Pain • Tachycardia • Hypertension • Electrolytes • Insomnia • Agitation • Death

4. First Night on Call • You are never alone at the hospital! • Ask up front “when should I call?” • If you don’t know- ask • If you are worried- ask • Who? • Your senior resident, Your attending, ICU nurses, charge nurses, pharmacists, cardiology fellow, ICU on call resident

5. When to call your attending • Call an Attending directly (or positively ascertain that an Attending has been notified) upon the following situations: • Death (even if expected) • Cardiac arrest • Respiratory failure either requiring intubation or significantly increased O2 demands • Severe respiratory distress • Airway issues • Transfer to ICU or higher level of care • Concern that patient needs a procedure or operation • A new need for acute dialysis • Bleeding requiring transfusion • Hypotension/hemodynamic instability • Symptomatic and severe hypertension • Significant new arrythmia

6. Suspected MI • Suspected PE • New onset severe chest pain • New onset severe abdominal pain • Abrupt deterioration in neurologic exam or profound decreased mental status • Significant change in neurovascular exam of extremity • Patient or family wishes to speak to the attending • Patient wishes to be discharged AMA • PLUS • Any other significant change in clinical status of patient that is of major concern. • Any new admission. • The arrival of a patient accepted in transfer from another institution.

7. Service specific items • KTU: abrupt loss of urine output in recent kidney transplant pt that was previously making urine; ultrasound showing vascular/ureteral problem. • LTU: ultrasound showing absence of hepatic arterial flow • VASCULAR: loss of a pulse or Doppler signal that was present earlier • PLASTICS: abrupt change in signal /duskiness of free flap

8. First Night On Call • 8:45 pm on your first night call of intern year & you are paged to the 9th floor nurses station. • You: “Hi, this is ____ from Surgery returning a page.” • RN: “Thanks for calling back. Are you taking care of Mr. Johnson in Room 13?” • You: “Uhh…Mr. Johnson…(flipping through papers)…yes! What is going on? • RN: “Well, I’m calling because Mr. Johnson just spiked a temperature to 39.2.”

9. What do you ask?

10. What do you ask? • Vital signs

11. What do you ask? • Vital signs • Vital signs are always vital • Ask for vital signs with any new complaint • Get complete set of vital signs • Gives you critical information (sick vs. not sick)

12. Which patients to see? • Any major new vital sign change • New altered mental status • If the nurse asks you to come see the patient • If you are worried about something • If someone who signed out to you is worried about something • Unless it’s immediately life threatening, see the patient before calling someone. • Err on the side of seeing everyone

13. Looking at your signout… Mr. Johnson is a 28 yo M with UC who is POD3 s/p total colectomy. NTD.

14. Looking at your signout… Mr. Johnson is a 28 yo M with UC who is POD3 s/p total colectomy. NTD. Do you want to go see the patient?

15. In the Elevator… • Differential Diagnosis

16. In the Elevator… • Differential Diagnosis • 5 Ws

17. In the Elevator… • Differential Diagnosis • 5 Ws • Wind • Water • Walk • Wound • Weird/Wonder drugs

18. In the Elevator… • Differential Diagnosis • 5 Ws • Wind • Water • Walk • Wound • Weird/Wonder drugs • Drains? Dressings?

19. Wind

20. Water

21. Walk

22. Wound

23. Wonder Drugs

24. Back to Mr. Johnson… • T 39.2 HR 108 BP 120/72 R18 O2 sat 99% RA • General appearance- • Lungs- • CV- • Abdomen- • Extremities- • Mental status-

25. Physical Exam • T 39.2 HR 108 BP 120/72 R18 O2 sat 99% RA • General appearance- Awake, watching TV, NAD • Lungs- crackles at bilateral bases • CV- mildly tachycardic • Abdomen- dressing c/d/I, no staining. JP drain serosang fluid, scant • Extremities- no edema, no calf tenderness • Mental status- alert, oriented

26. What do you want to do? Do you take off the dressing? Do you probe the wound? It depends, but in general, yes. Look at the wounds, even early.

28. What do you want to do? • Blood cultures • UA, Ucx • Sputum cx • CXR • BLE US • Wound exploration • Antibiotics • CT scan- Abdomen/pelvis? PE protocol? • Incentive spirometry • Tylenol

29. Who do you want to call? • Report the data • Convey a plan

30. Next case • 54 yo F POD4 s/p lap gastric bypass. RN calls to tell you patient is febrile to 38.5.

31. Next case • 54 yo F POD4 s/p lap gastric bypass. RN calls to tell you patient is febrile to 38.5. • HR 110 BP 117/68 R20 94% RA • You go to see her • Having a lot of pain • Started taking PO yesterday • Hasn’t been OOB

32. What are you worried about in this patient?

33. What are you worried about in this patient? • DVT/PE • Atelectasis • Anastomotic leak

34. Next case… • 62 yo F POD 5 s/p lap appy for perforated appendicitis. Febrile to 39.0. On Ertapenem.

35. Next case… • 62 yo F POD 5 s/p lap appy for perforated appendicitis. Febrile to 39.0. On Ertapenem. • Looking back, patient has been spiking fevers for >24h. • Pancultured last night. All pending.

36. Next case… • 62 yo F POD 5 s/p lap appy for perforated appendicitis. Febrile to 39.0. On Ertapenem. • Looking back, patient has been spiking fevers for >24h. • Pancultured last night. All pending. • Do you need to resend cultures? • When do you get a CT scan?

37. Electrolytes

38. Electrolyte Repletion • This is your job as an intern! • Labs often not resulted before other members of your team go to the OR • All patients do not need AM labs every morning

39. Electrolyte Repletion Hypokalemia • Check Creatinine! • Is patient taking PO? • Is patient on IVF with KcL? • Is patient on any diuretics? • NGT? • Diarrhea?

40. Electrolytes Hypokalemia • In general- replete K for < 4.0 • Give PO if patient taking PO, and if K is >3.3 • 3.8-3.9, give 20 mEq of KCL • 3.6-3.7, give 40 mEq of KCL • 3.4-3.5, give 60 mEq of KCL • 3.2-3.3 , give 80 mEq of KCL • 3.0-3.1 , give 100 mEq of KCL • If <3.3 or there is a reason they will continue to waste potassium, recheck K after repletion

41. Electrolyte Repletion Hyperkalemia (K >5.3) • Is specimen hemolyzed? Call the lab/repeat draw • Check ECG, Creatinine, BUN, electrolytes • EKG abnormalities (peaked T waves, reduced P waves, widened QRS • If ECG changes  • Calcium gluconate 1ampule IV over 3 min • Can repeat in 5 min if ECG does not improve • Call your senior!

42. Electrolytes Hyperkalemia • Think about: • Is patient taking PO potassium? Dietary? • Is patient on IVF with KcL? • Is patient on TPN? • Is patient on any K sparing diuretics, ARBs, ACEis? • Necrosis? Burns? Tumor lysis? Rhabdo?

43. Electrolytes Hyperkalemia • Regular insulin10 units IV (with 50ml of 50% dextrose to prevent hypoglycemia) • NaHC03 1 ampule (50mEq) IV over 5 minutes • Albuterol 10mg neb over 15-20 min • Kayexelate 15-30mg PO or PR • Lasix 40-80mg IV • Hemodialysis Shift potassium into cells Excretion/elimination

44. Electrolyte Repletion Magnesium • Replete for < 2.0 • If taking PO • Mag oxide 400- 800 mg PO – may cause diarrhea • If repleting IV • Mag 1.8 -2 -> give Mag sulfate 1 g IV • Mag 1.6-1.7 -> give Mag sulfate 2g IV • Mag <1.5 -> give Mag sulfate 3g IV

45. Electrolyte Repletion Phosphate • Replete for < 3.0 • Give PO when possible • NeutraPhos 8mmols per packet • K Phos 4mmols per tablet • Repletion guidelines • Phos 2.5- 2.9 Replete PO if possible- NeutraPhos 2 packets PO • Phos 2.0-2.5 Give NaPhos 15 mmols IV over 4 hours • Phos 1-1.9 Give NaPhos 21- 30 mmols IV over 4 hours. Recheck after repletion • Phos <1 Give NaPhos 30mmols IV over 4 hours. Recheck, may need to repeat.

46. Questions?