Intern Survival Guide 2009-2010

Admissions (how it works and what your role is)

Contents: 1. The Resident is called by the MAR/MAA with an admission
General Info
Admissions 2. Resident gives you a brief story
Daily Activities 3. Quickly review the patient’s old DC summaries, labs etc on Cerner
Signout 4. Go see the patient in the ED, get full H&P
Code Blue -Be sure to get home meds/doses, meds/IVF received in ED, family
Death Pronouncement contacts, code status on all patients
Calling Consults
Electrolyte Repletion/IVF
5. Until you get a chance to present to your Resident, you can:
What to if you’re called for… -Put in basic admission orders, including VS, nursing orders, diet,
activity, prophylaxis, etc.
-Add the patient to Signout
General Info: -Start on your note
- Contact your resident on Sunday for signout and to figure out which 6. Present what you think are major points and discuss your plan with
intern you are taking over for. your Resident
7. Finish putting in orders
-Your monthly schedule (days off, call, etc) will be determined on the first 8. Finish Signout and Note
day.
General points:
-The purpose of the information provided in this manual is to serve as -The order of your priorities should be: orders, signout, note.
reference and guidelines to help you do well on Wards. If in doubt about Having your signout done before your note allows you to sign out to the
anything, ask your Resident. NF interns when they arrive, so you’re not getting paged by nurses while
you’re finishing your work. You will be doing multiple admissions at one
-Team Members: 1 Attending, 1 Resident, 2 Interns, +/- Pharmacist and time, so try to get the orders in for each pt as you get them, and work on
Med/Pharm Students your signout and notes in-between. The best way to not get slowed down is
to keep from getting paged, and nurses won’t page you because your note
-Nurses are our colleagues, and they can make or break you. Keep them in isn’t done, but they will page you for orders.
the loop, ask their opinions, and trust their instincts. If a nurse is being -You will usually get paged when the patient arrives on the floor.
unreasonable, just smile and notify your Resident. It’s a good idea to stop by when you get a chance to be sure they’re stable
and nothing has changed.
-If you put in a STAT order, be sure to tell the nurse(by phone or in -As you gain more experience, you will start to feel more
person). This is an expectation! comfortable putting in more orders before you talk with your Resident.
That’s great, but if you’re in doubt, just wait. If you think something may
-If you feel overwhelmed it’s not a weakness to ask your Resident for need to be done acutely, page your Resident.
help. It shows intelligence and humility to put patient care first, and
Things Not to Miss (if appropriate)
you always have support.
-NPO p MN (if pt is getting a study the next day that requires NPO)
-q6hr cardiac enzymes (if ruling out MI)
-Be patient with your patients, your resident and fellow interns. Everyone
-AM labs
has bad days once in a while.
-PT/OT (err on the side of ordering it if you’re unsure they’ll need it)
-If there’s a chance your pt may need a transfusion or procedure, be sure to
-Don’t forget to eat!
order coags, type & screen, and get consent done before you leave.
Daily Responsibilities (for non-call days)
1. Pre-Rounding: get to the hospital between 6-6:30 to get signout.
-Check AM labs and replete if necessary
-Go see your pts. Be sure to note overnight events, VS, I/O, PE, IV
access/tubes/catheters, review meds (if appropriate note PCA usage,
telemetry, weights)
2. Your Resident will be there around 7:30 to discuss any issues
3. Between 7:30 and 9:00 is your dedicated work time (call consults, place
orders, get tests/studies arranged, start writing notes)
5. Rounds at 9:00
6. After Rounds: finish notes, do procedures, f/u on consults and work on
Signout
7. At 7:00 signout to night float
General Points:
Before you leave, be sure to:
-have T&S/coags ordered and consent if your pts may need
transfusions or procedure
-have AM labs ordered
-check if any of your pts need to be NPO p MN
Depending on your attending, you may or may not have to have your notes
done by rounds. You should always have the information needed to
present to the attending even if your notes aren’t done.
Signout (one of the most important parts of good pt care)
Your signout should convey all of the important information about your
patient in as concise a manner as possible. The goal is to provide
information regarding the major issues and events that would affect how
NF cares for your patients. You will learn quickly during night float how
much signout can help or hurt you (and the patients). The NF team does
not know the patients well, and should be able to use your signout to help
them handle any routine and urgent issues overnight. Your Resident will
review with you the basic layout of signout, but there are some things that
should always be on it:
-code status (Do I call a code?!) -allergies
-bed location (The pt is coding but I don’t know where!)
-important aspects of HPI and PMH
-important meds (especially anticoagulation, antibiotics, steroids)
- any changes in management (ie-increased dose of lasix, NPO p MN, etc)
Code Blue
Codes can be overwhelming and confusing for everyone, especially as an
intern. Your basic role in a code is to support the Resident running the
code (usually this is the MRICU/CCU or NF Resident). Everything needed
for a code can be found in the code cart, including ambubag, code meds,
central line kits, intubation tools, etc.
-What do I do when I first walk in the room? Put on gloves and be ready
and willing to help. If it’s your pt, be able to provide a quick summary of
why they were admitted and any notable issues.
-What if I’m the first person there? Remember-ABC’s. Go straight to the
airway/start bagging if someone hasn’t already started. If the code cart
isn’t there, ask someone to get it. If the patient doesn’t have a pulse, then
be sure someone is doing chest compressions (or do them yourself if your
not on the airway)
-What you may be asked to do: Bag, Chest Compressions, Ordering
labs/chest xray, page stat consults/attendings/fellows, perform ABGs and
central lines (with help), and anything else possible
-If there are already multiple residents and interns present, ask if they need
more help. If they don’t then it’s best to leave the room and stay out of the
way.
Death Pronouncement
At some point you will get paged to pronounce a patient which is
never easy. The following are general guidelines on what to do:
-Ask the nurse if the family is present and prepare yourself before you enter
the room.
-Introduce yourself and explain why you’re there.
-Feel for the carotid pulse, listen for heart/breath sounds and look for
respirations. Check the pupils for reactivity.
-Express your condolences to the family. Ask if they would like to the see
the Chaplain. Ask if they would like an autopsy.
Afterwards, you will have to fill out the death certificate (provided
by the nurse). You also need to put in a “DC as Expired” order and write a
death note (eg, “called to bedside at__. Found pt to be without pulse or
spontaneous respirations. Pupils were dilated and nonreactive. Time of
Death ___”). Send the Attending and Resident an FYI page with the
patients name, time of death, your name, and a contact number so they can
get in touch with you if they have any questions.
Calling Consults: With all consults, be sure you have a SPECIFIC
QUESTION that you would like the Consultant to answer. If a patient has
outside records that are pertinent, be sure to have them in the chart before
calling the consult. There are specifics for each service that will make
things run more smoothly, which are detailed below.
1. Cardiology: in general, you should always have a current ECG (and an
old one if possible) when calling a consult. If appropriate, have cardiac
enzymes sent before calling, and be able to tell the fellow/resident current
labs and lab trends, what medicines you have given and pertinent history
@MCV: 1. Gen Cardiology-for most non-urgent consults
2. EP: only if you’re sure it’s an EP question
3. CCU: for acute consults page CCU Resident
4. Procedure Fellow: for midnight STAT procedures only
@VA: 1. Gen Cardiology
2. EP
3. CCU Resident
2. GI: for GI bleeds, be sure you can tell the fellow current CBC, coags,
pertinent history, stool appearance (black stool/BRBPR/trace heme
positive), amount of blood vomited. Note that unstable GI bleeders are
only acutely scoped in the MRICU.
@MCV: 1. General GI
2. Biliary
3. Hepatology
4. Nutrition Fellow (PEG Tubes, etc)
3. Renal: There are only two renal services to consult.
1. General Renal
2. HD Fellow
4. ID: when calling ID consults, be able to tell the fellow bacterial
sensitivities, current and previous antibiotics. It also helps to know what, if
any, previous MDR infections a patient has had, and don’t forget to point
out if the patient is immunosuppressed in any way. Also, whenever a pt
has fungemia, you will need to call an ophtho consult as well.
1. General ID
2. AMT: for antibiotics needing approval. This pager is covered by
the ID fellow at night and on weekends. They will typically expect
the same information as a general consult.
5. Heme-Onc: There is only one consult service. When calling for a
possible transfer, never say “we’re consulting for a transfer.” Give the
history and ask for recommendations and then you can ask if the pt may be
better served on the HO ward team.
6. Pulmonary: This is the general consult team for non-acute consults,
which usually includes recommendations for pulmonary infections and
possible need for a Bronchoscopy.
7. MRICU: For acute consults only. The assumed question when you call
the MRICU Resident is “does this pt need to be in the MRICU.”
8. Other Medicine Specialties: Endocrine, Rheum, Derm, Ophtho.
9. Surgery: Ortho, Neuro, General, ENT, Urology, CT Surg, Hand. In
general, you should always have a recent CBC, coags and if appropriate a
type and screen before calling a surgery consult.
If you are calling Ortho, you can wait and let them tell you what
films to order, or make your best guess as to what they may want.
For general surgery, be sure to know what an acute abdomen is. If
someone has intractable abdominal pain, N/V, involuntary guarding,
rigidity, and appears unstable, it’s probably an acute abdomen. You should
have at least a KUB, and if appropriate the patient should have an NG tube
to suction, lactate level and other surgery labs.
10. Psych
11. IR: have recent coags and labs available, let them know why the pt
needs the procedure and how urgent is it (today or tomorrow)
12. Other Services:
-Substance Abuse
-PICC Team. If a pt is on Coumadin, be sure to ask what level they
would like the INR to be in order to have a PICC line placed.
-Virginia Smith: the consultant for Sickle Cell patients. She knows
them all well, and you would be well advised to follow her recs.
Electrolyte Repletion
Potassium (goal 4-4.5)-do not replete if pt is on HD
In general 10mEq of potassium raises a pt’s serum K by 0.1mmol. If a pt
has renal failure, then cut the dose you would give by ½.
PO: tabs (big pills) vs. liquid (tastes gross, faster than tabs)
IV: Can be painful through peripheral IVs. Slow! (takes an hour to
get in 10mEq)
If a patient is profoundly low (<3), the most you would typically give at
one time would be 40mEq PO now and 40mEq IV over 4 hours.
Magnesium (goal>2)-do not replete in HD
1 g of Mg will raise Mg level by 0.1.
PO: Mag Oxide
IV: 1-2g Mag Sulfate IV runs (slow but not painful like potassium)
Phosphate (goal 3-4.5, usually replete if <2.5)-do not replete in HD
In a pt with chronically low Phos, be sure to check for Vit D Deficiency.
An acute drop in a pt that was NPO for days-weeks may indicate Refeeding
Syndrome.
PO: typically “2 packets of neutra-phos”
IV: NaPO4 (4mEq Na and 3mmol PO4 in 1mL)
KPO4 (4.4 mEq K and 3mmol PO4 in 1mL)
Calcium (goal 8.5-10) –don’t replete in HD unless dangerously low and
renal fellow is aware. Remember to correct for hypoalbuminemia! Can
send ionized calcium to avoid correction for albumin (but expensive). Be
careful repleting when the Calcium*Phos product is >55.
PO: Tums, Calcium Carbonate (OsCal)
IV: Calcium Gluconate 1-2g IV runs (1st choice for peripheral IV)
Calcium Chloride 1-2g IV runs (through central IV’s only!)
What to Do If You’re Called For…
-In general, whenever you’re called by a nurse for concerning symptoms,
always ask for a set of vitals to be given over the phone (and if they haven’t
been done recently, ask for them to be done while you’re en route).
-the recommendations below are meant to help you with the initial
management. When you’re starting out, it is always better to evaluate the
patients to help you learn when patients need to be seen immediately. If
you are asking yourself if the pt needs to be seen, then it usually means you
should go see them. When in doubt, call your resident.
1. Insomnia: A very common call. Can give Ambien or Benadryl, but both
can cause AMS in the elderly. Trazodone is an alternative that doesn’t
cause as much AMS.
2. Fever: If not done in the last 24 hrs, get a chest x-ray, UA/urine cx, and
peripheral blood cultures. Can give Tylenol PRN. If the patient is
neutropenic, then give cefepime empirically after drawing blood cultures
(+/- vancomycin if there is concern for a line infection or h/o MRSA).
3. Nausea/Vomiting: Another common call, and can be due to meds,
chemo, underlying illness, reflux, etc. Evaluate a patient when they have
new-onset vomiting, persistent vomiting, or blood in their vomit. For
symptomatic control, you can give compazine or zofran. Phenergan is
another option but is becoming less popular because of its association with
AMS.
4. AMS: Always evaluate promptly and do a quick exam to determine if
the situation is acute (nonresponsive, blown pupil, acute decrease in
orientation in otherwise normal individual). Check the airway-if pt can’t
maintain their airway, then call the MRICU. If they can maintain their
airway but appear short of breath, check an ABG (inc CO2 can cause
AMS). Stat labs that can be ordered: blood glucose, BMP, cultures, CBC,
LFTs (ammonia). Decide quickly whether or not the patient needs a
noncontrast head CT. Call your Resident early when you are called for
AMS!
5. Chest Pain: Always evaluate promptly. If the pt appears unstable, call
your Resident. ALWAYS get and ECG. If you are even slightly
concerned for an MI, send cardiac enzymes. If the ECG is suggestive of
ischemia, give the pt aspirin 325mg, SL nitroglycerin (up to 3 doses in 15
minutes), morphine, and be sure the pt is on oxygen. Your goal is to get
the pt chest pain free. If the pt is not CP free after 3 doses of SLNG and
morphine, and has suspicious ECG findings, then the CCU resident should
be notified. Be sure to notify your Resident before you decide to give
heparin or lovenox, and call the CCU Resident to come evaluate the pt.
Remember that time is muscle when it comes to cardiac ischemia/infarct.
6. SOB/Hypoxia: Again, evaluate promptly. Since there are so many causes
of SOB, you’re first question should be to ask for vitals. If their vitals
sound unstable (breathing 30x/minute, tachy, hypotensive, sats are <90) go
immediately to the bedside. Assess the patient’s breathing (can they talk?
Are they maintaining their airway? Do they look like they’re getting tired-
ie using accessory muscles, diaphoretic, etc?). Get an ABG to see if
they’re truly hypoxic or hypercarbic. If they’re hypoxic, be sure they are on
enough oxygen to keep their O2 sats above 90% (if they’re on a
nonrebreather and still hypoxic, then call your resident). If they’re
tachycardic get an ECG to r/o arrhythmia. If the pt is in impending
respiratory failure, call your resident immediately. If you are concerned, it
never hurts to ask the nurse to be sure the code cart is nearby. Lots of
things can cause SOB, including tachycardia/arrhythmia, pneumonia,
COPD exacerbation, sepsis, asthma, PE just to list a few. Your resident
will help you decide the best course of action.
8. Hypotension: As with tachycardia, initial management depends largely
on whether the patient is symptomatic. If they are symptomatic or have
had a significant drop in their BP, the pt should be seen immediately.
Different causes include hemorrhage, CHF, sepsis, arrhythmia/tachycardia,
PE, MI and medications just to list a few. Starting a fluid bolus is usually
safe, as long as they are not in a CHF exacerbation or have acute renal
failure. If the pt appears unstable, it’s always better to call your resident or
the MRICU resident to come evaluate the pt. If the pt appears stable, take
the time to look at what meds they recently received. If they are septic,
consider adding additional antibiotics coverage. Per the surviving sepsis
guidelines, if a pt is still hypotensive after 6 L of fluid boluses, then they
need to be started on pressors and the MRICU resident should be notified.
9. Hypertension: Efforts should be made to acutely lower a pt’s BP if they
are symptomatic or their BP is >160/100. If they are symptomatic (ie-
having CP, SOB, AMS, etc), then call your resident-symptom of end organ
damage is considered hypertensive emergency and should be handled
immediately. Medicines that can be used acutely include nitropaste (1 or 2
inches), IV diltiazem/metoprolol/labetolol, and IV hydralazine just to name
a few. If the patient is not symptomatic, check to see when their next
antihypertensive medicine is scheduled to be given. If they are due for
their next medicine in the next few hours, it’s ok to ask the nurse to give it
early.

7. Tachycardia/Arrhythmia: Your first question should be to ask the nurse  

for the pt’s BP and if he/she is symptomatic. Be sure to ask the nurse to get
an ECG while you’re on the phone. If the BP is low then the patient should
be evaluated immediately. Always feel the pt’s pulse-if they don’t have
one call a code. Management of tachycardia depends on whether the pt is
hypotensive and/or symptomatic-if they are you’re job is to figure out what
the rhythm is and why they’re tachycardic and correct it as soon as
possible. If they are in Afib with RVR, you can try rate control with IV
diltiazem or labetolol, but be careful using these medicines as they can
worsen hypotension. If they are in VT and have a pulse, call your resident
for assistance immediately (again, if there is no pulse, call a code). If it is
difficult to tell what the rhythm is but it appears to be SVT or Afib or
Aflutter, call your resident to help decide if pushing adenosine would be
helpful.