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Nithya Swamy Chief Resident

A Day in the life… and Cross-Cover. Nithya Swamy Chief Resident. Wards Conferences ICU Electives Important Numbers. Overview: A Day in the life…. Call Days: Day starts at 7a Call is every 4 th night Admissions: 7a-7a Resident will call with new admissions

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Nithya Swamy Chief Resident

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  1. A Day in the life… and Cross-Cover Nithya Swamy Chief Resident

  2. Wards • Conferences • ICU • Electives • Important Numbers Overview: A Day in the life…

  3. Call Days: • Day starts at 7a • Call is every 4th night • Admissions: 7a-7a • Resident will call with new admissions • Sign-out by 1p on post-call day • 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 • Call Jeopardy WARDS

  4. Non-Call Days: • Arrive at 7a • See patients in order of priority (ICU then floor) • Discuss patients with attendings • Teaching rounds MWF 10:30-12p • Conference 12-1p • Sign out to cross covering intern/resident • Check out pager at 5p 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

  5. Interview Patient: H&P, review labs/imaging & formulate plan with resident • Admission orders (Teaching Service Order) • Present to the Attending • H&P write up • Call consults • Daily progress notes • Daily orders • F/u with all attendings • Cross-cover list/Sign-out • Discharge summary • On one of your wards months, each of you will be in charge of setting up cases to present for interns conference. WARDS- Intern Responsibilities

  6. To Present: Journal Club: 30min: Two/year: article of your choice Residents Conference: 1h presentation: Interesting medical topic of your choice Potpourri: 30min: Any Interesting case To Attend: Noon Conference: 12p-1p: M, T, Th, F Interns Conference: Tuesdays: 11a-12p Clinical Grand Rounds: Wed 7:30-8a IM Grand Rounds: 12:15-1:15p Coffee with Cardiology: Fridays: 7:30-8a Teaching Rounds: M,W,F: 10:30a-12 on Wards months ID Rounds: Meet with Dr. Goodman 1-3p once a month on wards CONFERENCES

  7. Contact the attending you are working with a few days prior to the start of the rotation to get details on their expectations • Hours and responsibilities vary depending on the rotation and attending. ELECTIVES

  8. 6a-6p Mon-Fri • Hamon 3 ICU • Resident works with you • Round on all your patients by 10a, try to complete all notes • 10a: Multidisciplinary rounds: Present all patients to ICU attending, nurses, RT, SW • Overnight events, vent settings, vitals, assessment/plan for the day, DVT/GI ppx. ICU ROTATION

  9. 20 days per year • Can be taken on any month except Wards 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 ~30d prior to vacation. VACATION

  10. 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 IMPORTANT NUMBERS

  11. 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??? Overview - Cross Cover

  12. 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 How to make your Cross Cover list:

  13. Cross cover list is kept current on CareGate www.caregate.net

  14. 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.

  15. “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!!! Not Acceptable:

  16. Review basics by organ systems today What do I do when I’m called? • Infectious Disease • Heme • Radiology • Death Neuro Pulmonary Cardiology Gastrointestinal Renal • -Ask yourself, does this patient sound stable or unstable? • -Ask for vitals • -Is this a new change?

  17. Altered Mental Status • Seizures • Falls • Delirium Tremens NEUROLOGY

  18. Always go to the bedside!!! Is this a new change? Duration? Recent/new medications Check VITALS, Neuro Exam Review Labs: cardiac enzymes, electrolytes, +cultures Check stat Accucheck, 02 sat, ABG, NH3, TSH Consider checking non-contrast head CT Try naloxone (Narcan), usually 0.4-1.2 mg IV, if there is any possibility of opiate OD If elderly person is agitated/sundowning  try a sitter first  then medications haloperidol 2mg IV/IM ziprasidone (Geodon) 10-20mg IM Quetiapine (Seroquel) 25mg po qhs Restraints (last resort) Altered Mental Status **Caution with Benzos/ambien in the elderly

  19. 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 “Move Stupid”

  20. Go to bedside to determine if patient still actively seizing • Call your resident • Assess ABCs • give 02, intubate if necessary • Place patient in left lateral decubitus position • Labs • electrolytes (Ca+/Mg), glucose, CBC, renal/liver fxn, tox screen, anticonvulsant drug levels, check Accucheck • Treatment: • Give thiamine 100 mg IV first, then 1 amp D50 • antipyretics for fever or cooling blankets • Lorazepam 0.1mg/kg IV at 2mg/min • If seizures continue; • 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 • 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) Seizures

  21. 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 Falls

  22. 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 Delirium Tremens (DTs)

  23. Shortness of Breath • Hypoxia PULMONARY

  24. 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 Shortness of Breath

  25. Pulmonary: • Pneumonia, pneumothorax, PE, aspiration, bronchospasm, upper airway obstruction, ARDS • Cardiac: • MI/ischemia, CHF, arrhythmia, tamponade • Metabolic: • Acidosis, sepsis • Hematologic: • Anemia, methemoglobinemia • Psychiatric: • Anxiety – common, but a diagnosis of exclusion! Causes of SOB

  26. 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 • Start settings at: IPAP 10 and EPAP 5 • IPAP helps overcome work of breathing and helps to change PCO2 • EPAP helps change pO2 Oxygen Desaturations

  27. 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 Indications for Intubation

  28. If patient needs to be intubated, start with mask-ventilation until help from upper level arrives • Initial settings for Vent: • 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 Mechanical Ventilation

  29. Chest pain • Hypotension • Hypertension • Arrhythmias CARDIOLOGY

  30. 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 • Give SL nitroglycerin if pain still present (except if low blood pressure, give morphine instead) • Supplemental oxygen • Aspirin 325 mg • Cycle enzymes • Call Cardiology if there is new ST elevation, LBBB, or if there is an elevation in cardiac enzymes Chest Pain

  31. Go and see the patient!!! • Repeat BP and HR, manually • Compare recent vitals trends • Look for recent ECHO/meds pt has been given. • EXAM: • Vitals: orthostatic? tachycardic? • Neuro: AMS • HEENT: dry mucosa? • Neck: flat vs. JVD (=CHF) • Chest: dyspnea, wheezes (?anaphylaxis), crackles (=CHF) • Heart: manual pulse, S3 (CHF) • Ext: cool, clammy, edema Hypotension

  32. Hypovolemia volume resuscitation if CHF,bolus 500ml NS transfuse blood Cardiogenic fluids inotropic agents Sepsis: febrile >101.5 blood cultures x 2 empiric antibiotics Anaphylaxis: sob, wheezing epinephrine  benadryl  supplemental 02  Adrenal Insufficiency check, cortisol/ACTH level ACTH stim test replace volume rapidly Hydrocortisone 50-100mg IV q6-8h Management of Hypotension *Stop BP meds! *Don't forget about tamponade, PE and pneumothorax!!

  33. Name ReceptorAffected Dose Action Phenylephrine (Neosynephrine) Alpha 1 10–200 mcg/min Pure vasoconstrictor; causes ischemia in extremities Commonly Used Pressors Norepinephrine (Levophed) A1, B1 2–64 mcg/min Vasoconstriction, positive inotropy; 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 inotropy; Causes Arrhythmias A1 10–20 mcg/kg/min Vasoconstriction; Causes Arrhythmias Dobutamine B1, B2 1–20 mcg/kg/min Positive inotropy and chronotropy; Causes Hypotension

  34. Is there history of HTN? • Check BP trends • Is patient symptomatic? • 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: • Manual BP in both arms • Fundoscopic exam: look for papilledema and hemorrhages • Neuro: AMS, focal weakness or paresis • Neck: JVD, stiffness • Lungs: crackles • Cardiac: S3 Hypertension

  35. If patient is asymptomatic and exam is WNL: • See if any doses of BP meds were missed; if so, give now • If no doses missed, may give an early dose of current med • Start a med according to JNC 7/co-morbidities/allergies  • PRN meds: • hydralazine 10-20mg IV • enalapril (vasotec) 1.25-5mg IV q6h • labetalol 10-20mg IV •  *Remember, no need to acutely reduce BP unless emergency Management of HTN

  36. URGENCY • SBP>210 or DBP>120 with no end organ damage • OK to treat with PO agents (decr BP in hours) • hydralazine 10-25mg • captopril 25-50mg • labetolol 200-1200mg • clonidine 0.2mg • EMERGENCY • SBP>210 or DBP>120 with acute end organ damage • Treat with IV agents (Decrease MAP by 25% in min to 2hrs; then decrease to goal of <160/100 over 2-6 hrs) • nitroprusside 0.25-10ug/kg/min • nitroglycerin 17-1000ug/min • Labetolol 20-80mg bolus • Hydralazine 10-20mg  • Phentolamine 5-15mg bolus Hypertension (continued)

  37. Tachyarrhythmias Afib/flutter RVR  rate control (BB/diltiazem/digoxin if BP low) consider anti-arrhythmic (amiodarone) SVT/SVT with aberrancy vagal maneuver adenosine 6-12mg IV Ventricular fib/flutter  check Mg level, replace if needed (>3.0) amiodarone drip Bradycardia Assess ABCs give 02 monitor BP Sinus block: 1st, 2nd or 3rd degree Hold BB meds Prepare for transcutaneous pacing Atropine 0.5mg IV  x3 Consider low dose Epi (2-10mcg/min)  dopamine(2-10mcg/kg/min) Arrhythmias *Remember, if unstable shock!!

  38. Nausea/Vomiting • GI Bleed • Acute Abdominal Pain • Diarrhea/Constipation Gastrointestinal

  39. 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: • Phenergan 12.5-25mg IV/PR (lower in elderly) • Zofran 4-8mg IV • Reglan 10-20 mg IV (especially if suspect gastroparesis) • If no relief, consider NG tube (especially if suspect bowel obstruction) Nausea/Vomiting

  40. UPPER • Hematemesis, melena • Check vitals • Place NG tube • NPO • Wide open fluids, type&cross for blood • Check H/H serially • If suspect  • PUD: Protonix gtt • varices: octreotide gtt • **Call Resident and GI • LOWER • BRBPR, hematochezia • Check vitals • NPO • Rectal exam • Wide open fluids if low BP • Check H/H serially • Transfuse if appropriate • Pain out of proportion? Don’t forget ischemic colitis! GI Bleed

  41. 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 Abdominal Pain

  42. 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: • Pain management—may use morphine if no contraindication • Remember, if any narcotics are started, use sparingly in elderly, ensure pt on adequate bowel regimen Acute Abdomen

  43. Is this new? check stool studies: c.diff x 3 culture o&p wbc FOBT x 3 Do not treat with loperamide if you think it might be C.diff!!! Is this new? check KUB Ileus/bowel obstruction: place NPO Treat: Laxative of choice MOM Miralax enema tap water soap Bowel regimen colace 100mg bid dulcolax 5-15mg Diarrhea Constipation

  44. Decreased urine output • Hyperkalemia • Foley catheter problems RENAL/ELECTROLYTES

  45. 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: • UA: WBC (UTI); elevated specific gravity (dehydration); RBC (UTI/urolithiasis); tubular epithelial cells (ATN); WBC casts (interstitial nephritis); Eosinophils (AIN) • Chemistries: BUN/Cr, K, Na Decreased Urine Output

  46. Decreased Volume Status: • Bolus 500ml NS • Repeat if no effect • Normal/Increased Volume: • May ask nursing to check bladder scan for residual urine • Check Foley placement • Lasix 20-40 mg IV Treatment of Decreased UOP

  47. 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)

  48. 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: • peaked T-waves  • flattened P waves • PR prolongation followed by loss of P waves • QRS widening Hyperkalemia

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