Chief Resident Overview

June 14, 2013

Welcome Interns!

Your Chiefs

Crystal Lantz-DeGeorge, M.D.

• Hometown: Tiffin OH • Undergrad: The Ohio State University• Med School: Wright State University Boonshoft SOM• Professional Interest: Primary Care • Mommy of identical

twin 8 month olds

Sumit Bose, M.D.

• Hometown: Pittsford NY • Undergrad: Johns Hopkins University• Med School: GWU • Professional Interest: Allergy/Immunology • Can do an amazing dance with a

wheeled walker

Kamal Shemisa, M.D.

• Hometown: Westlake OH • Undergrad: Kent State University• Med School: NEOMED • Professional Interest: Cardiology • Lover of cats and cardiology

Claire Sullivan, M.D.

• Hometown: Rocky River OH• Undergrad: John Carroll • Med School: University of Cincinnati • Professional Interest: Cardiology • Obsessed with Cleveland

Navin Vij, M.D. (Med/Peds)

• Hometown: Bloomington, MN • College: Rice University• Med School: Baylor • Professional Interest: Health Policy • Former professional Bhangra dancer

Roles of the Chiefs

• Rotate every 3 months

• UH Chief - #31250 – Claire Sullivan • Office in DOM 3rd floor

• VA Chief - #31533 – Kamal Shemisa • Office on VA 4th Floor

• Ambulatory Chief - #31529 – Sumit Bose • Office on VA 4th Floor

• Patient Safety & Chief - #36644 – Crystal Lantz-DeGeorge• Office in DOM 3rd floor

Roles of the Chiefs

• We are your ADVOCATES• Call us with any problem or issue that arises in a TIMELY and

SPECIFIC manner • We can’t help you if you don’t let us know the problem

• We are your MENTORS• We embrace the opportunity to provide support for you -

professionally, educationally and psychosocially

• We have been in your shoes! • We remember well the struggles of intern year and are here to

help you in any way we possibly can

Block Zero

• June 24th-June 30th • No days off • Many extra interns on teams to divide the work and

admissions • Constant senior supervision due to rotating extra senior

helpers who will work with non-call teams from 5pm-10pm • Ask questions!

UH Campus

UH teams

• Ward Teams • 2 General Medicine

• 6 Sub-Specialty

• MICU

• CICU

• UH Nightfloat Team

NaffGen Med

WearnGen Med

CarpenterID

DworkinGI

WeismanHeme/Onc

RatnoffHeme/Onc

EckelNephrology

Hellerstein Cardiology

ICU Rotations

• At UH • MICU • CICU

Other UH Rotations

• Geriatrics• 2 week rotation

• Jeopardy• Rotate on a consult service while on back-up call for any

absence on UH or VA wards/clinics• MUST have pager on 24/7 including weekends

• E Team• Work 1:1 with hospitalist during winter months • Back up Jeopardy

Team Caps

• UH ward teams cap at 10 patients per intern except for the Seidman teams which cap at 8

• VA ward teams cap at 8 patients per intern• No short call on weekends• Intern + AI @ VA = 10; AI+AI paired together = 10 if one senior,

12 if two seniors• Intern + AI @ UH = 12 when 2 seniors; 10 when 1 senior

Intern Call/Duty Hours

Call Schedule: Long Medium Short Happy

• Long Call admits 3 patients - Last patient no later than 7:00 pm

- Interns should be done staffing patients and sign out to NF by 9:00 PM

- Must be out by 11:00 PM

Intern Call/Duty Hours

• Medium call admits 2 patients

- Last patient by 4:00 pm.

- Holds the Team Pager until 7:00 pm

- Signs out to NF at 7:00 pm.

Intern Call/Duty Hours

• Short call admits 2 patients

- By 12:00 PM at UH and 1:00 at the VA

- MICU and Night float patients ONLY at UH

- Can be new patients at VA

- No patients on clinic days or if intern has 8 patients

- Signs out to Medium call intern as early as 4:00 pm

Call Sequence

UH MICU

- 4 interns and 5 residents per rotation; Interns paired with resident for long call

- Interns will get last admission by 7 pm, should leave by 9 pm, must leave by 11 pm

- Patients admitted by the NF will be distributed by the MICU fellow in AM to keep teams even and optimize work flow in the MICU

- The post call resident will present and leave, sign out to the post call intern

- The helper resident will supervise the post call intern and will help until the intern has completed their work, usually around 5pm

The New CICU for Interns

• 2 interns scheduled in the CICU:

-Day intern: works 7 AM-7 PM. May follow/admit one

to two patients under supervision of senior resident.

-Night intern: works 7 PM-7 AM. Helps with cross-cover,

gains valuable night ICU experience including procedures, and possibly allows for on-call resident to take a nap.

• Interns will do one week of nights and one week of days during two week rotation

• Both interns have Sunday off (accommodate switch days and

transition from nights to days)

Intern Call/Duty Hours• All teams will have double seniors until block 3-4

• Orphan coverage: When you are on call and your team senior isn’t • On Call interns will be covered by the assigned

orphan resident• Ask your seniors how to look this up • Always page the senior as soon as you get an

admission to speed up the process

Typical Day• 6:45-7:00: Get sign out from NF on Tower 5

• 7:00-7:45: Pre-round on your patients• Get patient assignments from NF seniors

• 7:45-8:00: Run overnight events with senior resident Address any major issues before rounds

• 8:00-10:30: Rounds with attending

• 10:30-11:30 : MR for residents (MWF) and interns (T/Th)

• 12:00-1:00: Noon Conference

10:30-12:00: Time to get C.O.L.D.• C: Call your consults

• The later you call, the more angry the consultant will be• Ask your senior for advice on how to call the best consult

before your first one

• O: Order Entry• Enter any orders that were not entered on rounds

• L: Labs• Run your labs!

• D: Discharges• Get them out!• At UH, dictate your day of discharge note in your

discharge summary• At the VA, type the discharge summary on the day of

discharge

Conferences - UH• Intern Morning Reports – Residents hold the pagers!!

• Tuesday AM report from 10:30 – 11am! ** NEW ** • Thursday 10:30am-11:30am

• Noon Conference• Monday, Wednesday and Thursday 12-1pm (with food)

• Grand Rounds• Tuesday 12-1pm

• Morbidity & Mortality (M&M)• Friday 12-1pm

• Agre Society• Occur monthly on Wednesdays

Typical Day

• Afternoon: Follow-up on studies, consults • Sign out to co-intern/resident and attend clinic on clinic days • Admit new patients and staff with team resident or on call

resident • On long call day sign out between 9-11pm • On medium call day sign out at 7pm • On short/happy day leave as early as 4pm

Sign Out

• Sign out is an exchange of information to ensure excellent patient care

• As an intern sign out • What is important?

• FU CT PE If positive, start heparin• FU ECG and troponins If troponin positive, treat for ACS• FU I/O’s, goal 1L negative If not at goal, give 80 IV Lasix• FU H&H If Hb <7, transfuse 2U PRBCs

• What is not important? Avoid having the NF do your work• FU Nutrition recs• FU CT A/P done for cancer staging• FU ANA• ANYTHING THAT WILL NOT CHANGE OVERNIGHT MGMT

Intern Expectations

• Interns have primary care responsibility for all patients assigned. These responsibilities include:

• performing a complete admission history and physical

• formulating a diagnostic and therapeutic plan with the resident and attending

• When surveyed, patients almost always identify the INTERN as their primary provider while they were hospitalized

Intern Expectations

• The admission history and physical must be on the patient’s chart within 24 hours of admission.

• The Intern is responsible for all day-to day management issues, which must be reflected in a daily Intern progress note (limit copy pasting)

Intern Expectations

• All patients assigned to the intern are • to be examined by the Intern every day

• Interns have primary responsibility for discharge summaries, but this should also be shared with the resident depending on work load and workflow

• If the intern is off, the discharge summary must be done by the covering resident, or the attending

Intern Expectations

• Interns should report any significant change in status of patients under their care to the supervising resident

• These include significant • change in vital signs• change in mental status• change in status requiring a rapid response team (=code

white)• Interns have 24/7 in house supervision by residents,

fellows, or attendings

Intern Expectations

• Discharges are the primary responsibility of the intern, but residents frequently help, especially early on

• DAY OF DISCHARGE dictations – ask your seniors for help

• Do not hesitate to ask your senior especially early on

Intern Expectations

• ANESTHESIA INTERNS MUST LEAVE BY 9 PM IF ON CALL!!!

• ACGME rules for anesthesia are different from those for categorical and preliminary medicine interns

Resident On-Call

• Are responsible to staff their own teams if the patient is available prior to 4:00 pm.

• On call residents stay until at least 9:00 PM • Weekend team covering resident staffs until at least 1:00 PM

On call senior will staff “orphan” interns after 4:00 PM during the week and after 1:00 PM on weekends

Days OFF!

• Dworkin, Carpenter, Wearn, Naff, Ratnoff, Weisman, and VA Wards• Short And/Or Happy Days on Saturday or

Sunday • In a 4 week block, 4 days off:

• 1 “Golden” – Sat AND Sun off • 2 “Silvers” – Either Sat OR Sun off • 1 “Black” – No weekend days off

• Eckel and Hellerstein • Happy Day Friday through Monday • 1 Day off per week

Days OFF!

• Night Floats• UH: 3 interns are scheduled but only 2 are on each night;

work out days off with each other!• Email your days off schedule to ambulatory chief

• VA: Saturday night is off

• UH MICU• Short call day off Friday through Monday

UH Team Pagers

• Each team (Eckel, Wearn…) has a team pager• Held by medium call until 7 pm

• Pager signed out to NF Intern at 7 pm • Long call intern signs out their patients at 9 pm

• Held by intern nightfloat 7pm-7am

• Team pagers are also code pagers – on-call interns should go to all codes (‘Code Blue’)

• Team pager numbers are listed on the pager card in your bags

Meet the DACR/NACR/Admissions Coordinators…• DACR = Day Acting Chief Resident

• NACR = Night Acting Chief Resident

• PGY3 helps admit and triage new admissions, runs codes, manages medicine consults

• Admissions Coordinators = Toni, Lisa, Kathy

• Direct phone 67121

• Pager 30512

• Work Room 42508

• Distribute admissions to you during the day

• Be nice to them!

UH Miscellaneous

• GME Housestaff Lounge• Located on Lakeside 6th floor, next to GME office• ID Badge required for entry• Has coffee, bathrooms, T.V., foosball table, computers

• THE P.I.T. Fitness Center• Basement of Lakeside • Free card entry, TV's, towel service, open 24/7!

UH Resources

• Your Senior Resident

• The DACR/NACR

• Other Residents

• The Night Floats

• The Chief Resident

Louis Stokes Veterans Administration Medical Center

VA teams

• 4 General Medicine Teams • VA Orange • VA White• VA Blue • VA Green

• VA MICU

• VA Nightfloat Team

VA Wards

• 1 resident + 2 interns per team – may have acting interns/medical students

• Ward 4A: Orange/White (sister teams)

• Ward 4B: Blue/Green (sister teams)

• PCU: telemetry 2nd floor

VA Lounge

• Located on the 2nd floor

• Fridge: frozen dinners, ice cream, sorbet, string cheese, muffins, fruit, yogurt, milk, PBJ uncrustables

• Coffee machine

• Cabinets: Trail mix, gold fish, peanut butter crackers, pretzels!

VA Conferences

• Monday: Noon conference

• Tuesday: Grand Rounds televised from UH at noon

• Wednesday: M&M at noon

• Thursday: Intern Morning Report @ 10am-11am! • Your resident will take your pager• Be on time!!

• Friday: Noon conference

VA Miscellaneous

• Garage parking is free! Just need to get a parking sticker from VA police dept

• VPN access for home CPRS access

• Codes at VA are called ‘Dr. Heart’

VA MICU

• 3 interns and 2 residents per rotation• Interns are q3 call. • Day senior 8a-8p • Night senior: 8p-8a

• Interns will get last admission by 7 pm, should leave by 9 pm, must leave by 11 pm

• Sign out to night senior

• Patients admitted by the night senior go to the intern on call the next morning

Nightfloat Rotations

The UH NIGHTFLOAT TEAM

NACR

Nightfloat Resident Nightfloat Resident

Nightfloat Intern Nightfloat Intern

NIGHTFLOAT TEAM

Nightfloat Intern

Rotating MSIII

UH Nightfloat Intern

• Works from 7 pm-7 am

• Meets the NACR and NF Residents in the KACR

• Gets sign out from teams (mediums at 7:00 PM and Longs at 9:00 PM) and manages cross cover issues

• Work with the NF resident to help answer questions/manage ill patients

UH Nightfloat Intern

• PGY3 NACR and 2 PGY2 NF Residents are always available if you need help - questions regarding your admissions, extra set of eyes to see a sick patient

• You may be asked to admit 1-2 patients on busy nights and staff with NF resident.

• NF interns must go to Code Whites on patients you’re covering• Senior residents must go in the first 6 months • Alert them immediately

VA Nightfloat Team

• One Nightfloat Intern who manages cross-cover • 7pm-7am• Day off Saturday

• One Nightfloat Resident who does overnight admissions

Intern Saturday Coverage

• One or 2 Saturday Nights when on ambulatory, UCC, COE or elective, you will be asked to cover from Saturday 7pm to Sunday 8am for the VA intern nightfloat to get a night off

Ambulatory Medicine

• Continuity Clinic

• Urgent Care Center

• Primary Care Block (PCB) / Ambulatory Block

• Clinical Skills Block (CSB)

Continuity Clinic• One afternoon per week at either the VA or the Douglas

Moore Center at UH• During ambulatory or elective, up to 2 clinics per week

• Always the same day each week and with the same attending preceptors

• You will develop a set of patients that you follow over 3 years

• Clinic cannot be canceled by anyone except the Ambulatory Chief Resident

Continuity Clinic Rules• No clinic when

• Medium call or on long call days• Vacation• Holidays• ICU’s• Night Float

• You DO have clinic when on Elective!!!

• Cannot switch clinics amongst yourselves; all schedule changes need to be approved by ambulatory chief resident

Urgent Care Center (UCC)• The VA “Emergency Room”

• Staffed by at least 2 seniors plus variable number of interns• One or two attending physicians• Hours are 9-6 with “on-call” resident to arrive at 0800• Fast track: sees low acuity issues, med refills….

• Great learning opportunity in seeing the “undifferentiated” patient

PCB / Ambulatory

• Introduction to Outpatient Primary Care

• Introduction to DMC and the Firm Continuity Clinics

• Morning Clinical Conferences: 8am daily

• 8:45-12:00: Subspecialty VA Clinics

• Some Full UCC Days

• Subspecialty or continuity clinics in the afternoon

Clinical Skills Block• 2-week outpatient rotation in the Spring • Hands on activities• Simulation models at the simulation skill center• Humanities in Medicine• End of life care• Cultural Competencies• Learn presentation skills • Mock Codes • Learn procedural skills

• Back up Jeopardy

Code Blues

Code Whites (UH)

** 1ST six months – an upper level must go to all Code Whites with an intern**

• Sick or decompensating patients on the floor

• Initial response from ICU nurse, intern, and PGY

• DACR/NACR for level 2 code white

• If you want to transfer to MICU, call MICU fellow

• Always write a Clinical Event Note!

Code Blues• Check your own pulse first!

• “Too many chefs spoil the soup”• One person leads the code• Make sure you get involved – Line up for CPR!• Maintain a calm quiet atmosphere• Run labs for the resident

• Keep the ACLS cards in your pocket until you are comfortable with the protocols• Usually not expected to run codes until PGY2 year, but you may be

the first responder!

• Make sure your BLS and ACLS are up to date

• Code leader writes a CODE BLUE NOTE and someone must notify family

Professionalism: Attire

• Men• Shirts and ties

• Women• Professional

• Keep white coats clean• No denim• Do not show up to Morning Report

looking sloppy

Professionalism: Absences

• Referral to RECC• If you have to call in sick > 1 day, you will need a doctor’s note from

the Bolwell Family Practice clinic • You will be able to get a same-day appointment

• If you are sick for > 2 days and do not have a doctor’s note, you will be assigned extra weekend coverage and/or weekend jeopardy

• Call-offs: You must PAGE 31529 the Ambulatory Chief• DO NOT EMAIL• DO NOT TEXT PAGE• DO NOT CALL THE CELL PHONE OF THE CHIEF YOU KNOW

Professionalism: Electives

• While on elective, you are expected to attend all Grand Rounds and M&M’s

• Please note that when you are on elective, you are back up jeopardy!!

• You are expected to have your pager turned-on throughout your elective rotation

• If you are going out of town for the weekend, please notify the ambulatory chief prior to leaving

• Elective should not be treated as vacation• Please email Barb 2 weeks prior to starting your electives

Professionalism: Conference Attendance

• Be on time!

• Noon conference: • UH: Mon-Wed-Thurs • VA: Mon-Thurs-Fri

• Grand Rounds on Tuesday: UH & VA

• M&M Fridays @UH, Wednesdays @VA

Professionalism: Discharge Summaries

• Do them the day of discharge• Do them for your intern• Do them for your friends• Do them for your patients• Weekend coverage is responsible for discharge summary

Coverage and Schedule Switches

• All coverage arrangements and schedule switches must be approved by the Ambulatory chief

• Switches must be arranged before 1 week of rotation starting

• Weekend Coverage switches before 48 hours of day

Finally Friday

• Weekly newsletter containing must read info! • Sent out Thursday evening • Announcements • Upcoming events • Weekend coverage assignments • Board Review

Other Resources

• Department of Medicine Website • Medicine.case.edu

• “Like” us on Facebook!• Facebook search “CWRU Department of Medicine”

Annual Events

• Intern Welcome Dinner (next Monday!)• Intern Mini retreat (Oct)• Bronson Day (May)• Holiday Party (Dec)• Spring Dinner (May)• Intern Retreat (June)• End of the year picnic (June)• End of Internship (last week of June, vacation!)

Intern Welcome Dinner

Intern Retreat

Bronson’s Day

Spring Dinner

We’re a family

We have fun!These will be your cool senior residents

Scott, Caroline, Vivek and Angel

Pie Eating contestBut sometimes when you’re not looking…..

Yep

Let’s get him

Pie Eating Champion!You might end up like Yogesh

Friendly Advice• Catch up on your sleep when you have a chance

• Talk to a chief or program director before personal problems

get out of hand – we are here for you!

• SUPPORT EACH OTHER!

• Maintain personal and family relationships outside of the hospital; make new friends while you’re here

• Take care of yourself; it’s the only way you will be able to provide good care to your patients

Things to do in Cleveland• Indians• Cavs • Browns• Lake Erie Monsters• East 4th• West 6th

• West Side Market• Little Italy • Art Museum• Bodies Exhibit• Edgewater Park• Metroparks• Zoo

• www.clevelandindependents.com• www.coolcleveland.com

• Goodtime 3• Wineries• Great Lakes Brewery• Larchmere• Shaker Square• Chagrin Falls• Lakeview Cemetery• Rock and Roll Hall of

Fame• Cleveland Orchestra• Blossom Music

Festival• Lola

• Winking Lizard • Panini's• Cain Park• Luna Bakery• Playhouse Square• Aurora Outlets• Cedar Park• Kalahari Water Park• Put n Bay• Kelley’s Island• Air show• Rib Festival• Etc Etc

Final Thoughts

SCHEDULES!

NaffGen Med

WearnGen Med

CarpenterID

DworkinGI

WeismanHeme/Onc

RatnoffHeme/Onc

EckelNephrology

Hellerstein Cardiology

Questions?

We are looking forward to a great year together!!! -VBLSS