Nithya SwamyChief Resident

A Day in the life…and

Cross-Cover

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

WARDSCall 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

WARDSNon-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- Intern Responsibilities1. Interview Patient: H&P, review labs/imaging & formulate plan with

resident2. Admission orders (Teaching Service Order)3. Present to the Attending4. H&P write up5. Call consults6. Daily progress notes7. Daily orders8. F/u with all attendings9. Cross-cover list/Sign-out10. Discharge summary

On one of your wards months, each of you will be in charge of setting up cases to present for interns conference.

CONFERENCESTo Present:Journal Club: 30min: Two/year: article of your choiceResidents Conference: 1h presentation: Interesting medical topic of your choicePotpourri: 30min: Any Interesting case

To Attend:Noon Conference: 12p-1p: M, T, Th, FInterns Conference: Tuesdays: 11a-12pClinical Grand Rounds: Wed 7:30-8aIM Grand Rounds: 12:15-1:15pCoffee with Cardiology: Fridays: 7:30-8a

Teaching Rounds: M,W,F: 10:30a-12 on Wards monthsID Rounds: Meet with Dr. Goodman 1-3p once a month on wards

ELECTIVES• 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.

ICU ROTATION• 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.

VACATION• 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.

IMPORTANT NUMBERSResidents Lounge Code: 997722Physician’s Dining Room Code: 214Residents Clinic Code: 7802

Jason: 6176Sherie: 7881Page Operators: 8480Calling the hospital from the outside: 214-345-XXXX

Overview - Cross Cover• 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???

How to make your Cross Cover list:

• 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

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

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.

Not Acceptable:• “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!!!

What do I do when I’m called?

• Neuro• Pulmonary• Cardiology• Gastrointestinal• Renal

• Infectious Disease• Heme• Radiology• Death

• Review basics by organ systems today

-Ask yourself, does this patient sound stable or unstable? -Ask for vitals -Is this a new change?

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

Altered Mental Status

• 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 o try a sitter first o then medications

haloperidol 2mg IV/IM ziprasidone (Geodon)

10-20mg IM Quetiapine (Seroquel)

25mg po qhso Restraints (last resort)

**Caution with Benzos/ambien in the elderly

“Move Stupid”• 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

Seizures• Go to bedside to determine if patient still actively seizing• Call your resident• Assess ABCs

o give 02, intubate if necessary o Place patient in left lateral decubitus position

• Labso electrolytes (Ca+/Mg), glucose, CBC, renal/liver fxn, tox screen,

anticonvulsant drug levels, check Accucheck• Treatment:

o Give thiamine 100 mg IV first, then 1 amp D50o antipyretics for fever or cooling blanketso Lorazepam 0.1mg/kg IV at 2mg/min

• If seizures continue;o 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/mino 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)

Falls• 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

Delirium Tremens (DTs)• 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

PULMONARY• Shortness of Breath• Hypoxia

Shortness of Breath• 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

Causes of SOB• Pulmonary:

o Pneumonia, pneumothorax, PE, aspiration, bronchospasm, upper airway obstruction, ARDS

• Cardiac:o MI/ischemia, CHF, arrhythmia, tamponade

• Metabolic:o Acidosis, sepsis

• Hematologic:o Anemia, methemoglobinemia

• Psychiatric:o Anxiety – common, but a diagnosis of exclusion!

Oxygen DesaturationsSupplemental 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 o Start settings at: IPAP 10 and EPAP 5o IPAP helps overcome work of breathing and helps to change

PCO2o EPAP helps change pO2

 

Indications for Intubation• 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

Mechanical Ventilation• If patient needs to be intubated, start with mask-

ventilation until help from upper level arrives• Initial settings for Vent:

o 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

CARDIOLOGY• Chest pain• Hypotension• Hypertension• Arrhythmias

Chest Pain• 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

o Give SL nitroglycerin if pain still present (except if low blood pressure, give morphine instead)

o Supplemental oxygeno Aspirin 325 mgo Cycle enzymeso Call Cardiology if there is new ST elevation, LBBB, or if there

is an elevation in cardiac enzymes

Hypotension• Go and see the patient!!!• Repeat BP and HR, manually• Compare recent vitals trends• Look for recent ECHO/meds pt has been given.• EXAM:

o Vitals: orthostatic? tachycardic?o Neuro: AMSo HEENT: dry mucosa?o Neck: flat vs. JVD (=CHF)o Chest: dyspnea, wheezes (?anaphylaxis), crackles (=CHF)o Heart: manual pulse, S3 (CHF)o Ext: cool, clammy, edema

Management of Hypotension

• Hypovolemiao volume resuscitationo if CHF,bolus 500ml NSo transfuse blood

• Cardiogenico fluidso inotropic agents

• Sepsis: febrile >101.5o blood cultures x 2o empiric antibiotics

• Anaphylaxis: sob, wheezingo epinephrine o benadryl o supplemental 02

•  Adrenal Insufficiencyo check, cortisol/ACTH

levelo ACTH stim testo replace volume rapidlyo Hydrocortisone 50-

100mg IV q6-8h   *Stop BP meds!

  *Don't forget about tamponade, PE and pneumothorax!!

Commonly Used PressorsName ReceptorAffected Dose Action

Phenylephrine(Neosynephrine)

Alpha 1 10–200 mcg/min Pure vasoconstrictor; causes ischemia in extremities

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 andchronotropy; Causes Hypotension

Hypertension• Is there history of HTN?

o Check BP trends• Is patient symptomatic?

o 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: o Manual BP in both armso Fundoscopic exam: look for papilledema and hemorrhageso Neuro: AMS, focal weakness or paresiso Neck: JVD, stiffness o Lungs: crackleso Cardiac: S3

Management of HTN

• If patient is asymptomatic and exam is WNL:o See if any doses of BP meds were missed; if so, give nowo If no doses missed, may give an early dose of current med

• Start a med according to JNC 7/co-morbidities/allergies 

• PRN meds:o hydralazine 10-20mg IV o enalapril (vasotec) 1.25-5mg IV q6ho labetalol 10-20mg IV

  *Remember, no need to acutely reduce BP unless emergency

Hypertension (continued)

URGENCY• SBP>210 or DBP>120 with

no end organ damage• OK to treat with PO agents

(decr BP in hours)o hydralazine 10-25mgo captopril 25-50mgo labetolol 200-1200mg o 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)o nitroprusside 0.25-10ug/kg/mino nitroglycerin 17-1000ug/mino Labetolol 20-80mg boluso Hydralazine 10-20mg o Phentolamine 5-15mg bolus

Arrhythmias

Tachyarrhythmias• Afib/flutter RVR 

o rate control (BB/diltiazem/digoxin if BP low)

o consider anti-arrhythmic (amiodarone)

• SVT/SVT with aberrancyo vagal maneuvero adenosine 6-12mg IV

• Ventricular fib/flutter o check Mg level, replace if

needed (>3.0)o amiodarone drip

Bradycardia• Assess ABCs

o give 02o monitor BP

• Sinus block: 1st, 2nd or 3rd degreeo Hold BB medso Prepare for transcutaneous

pacingo Atropine 0.5mg IV  x3o Consider low dose

Epi (2-10mcg/min)  dopamine(2-10mcg/kg/min)

*Remember, if unstable shock!!

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

Nausea/Vomiting• 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:

o Phenergan 12.5-25mg IV/PR (lower in elderly)o Zofran 4-8mg IVo Reglan 10-20 mg IV (especially if suspect gastroparesis)o If no relief, consider NG tube (especially if suspect bowel

obstruction)

GI Bleed UPPER• Hematemesis, melena• Check vitals• Place NG tube• NPO• Wide open fluids,

type&cross for blood• Check H/H serially• If suspect 

o PUD: Protonix gtto 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!

Acute Abdominal Pain• Go to the bedside!!!• Assess vitals, rapidity of onset, location, quality and

severity of painLOCATION:• 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 Abdomen• 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:

o Pain management—may use morphine if no contraindication

o Remember, if any narcotics are started, use sparingly in elderly, ensure pt on adequate bowel regimen

Diarrhea              Constipation• Is this new?• check stool studies:

o c.diff x 3o cultureo o&po wbco FOBT x 3

• Do not treat with loperamide if you think it might be C.diff!!!

• Is this new?• check KUB• Ileus/bowel obstruction:

o place NPO• Treat:

o Laxative of choice MOM Miralax enema

tap water soap

o Bowel regimen colace 100mg bid dulcolax 5-15mg

RENAL/ELECTROLYTES

• Decreased urine output• Hyperkalemia• Foley catheter problems

Decreased Urine Output• 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:

o UA: WBC (UTI); elevated specific gravity (dehydration); RBC (UTI/urolithiasis); tubular epithelial cells (ATN); WBC casts (interstitial nephritis); Eosinophils (AIN)

o Chemistries: BUN/Cr, K, Na

Treatment of Decreased UOP

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

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)

Hyperkalemia

• 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:o peaked T-waves o flattened P waves o PR prolongation followed by loss of P waveso QRS widening

Treatment of Hyperkalemia• Mild (<6.0 mEq/L)

        Decrease total body storeso Lasix 40-80mg IVo Kayexalate 30-90g PO/PR

• Moderate (6-7mEq/L)        Shift K+ in cells

o NaHCO3 50mEq (1-3amps)o D50+10units insulin IVo albuterol 10-20mg neb

• Severe (>7mEq/L) or EKG changes

        Protect myocardium o Calcium gluconate 1-

2amps IV over 2-5min 

**Emergent dialysis should be considered in life-threatening situations.

**Remember this is a progressive treatment plan, so if your patient has EKG changes you need to treat for severe/mod/mild!!!

Infectious Disease

• Positive Blood Culture• Fever

Positive Blood Culture• You get called by the lab because a blood culture has

become Positive.• Check if primary team had been waiting on blood culture.• Is the patient very sick/ ICU?• Is the culture “1 out of 2” and/or “coag negative staph”? 

o This is likely a contaminant.o If ½ Blood Cx are positive, consider repeating another

set • If pt is on abx, make sure appropriate coverage based on

culture and sensitivity• If you believe it to be true Positive then give appropriate

empiric treatment for organism and likely source of infection/co-morbidities of patient and discuss with primary team in the AM

Fever• Has the patient been having fevers?• DDX: infection, inflammation/stress rxn, ETOH

withdrawal, PE, drug rxn, transfusion rxn• If the last time cultures were checked >24 hrs ago 

o order blood cultures x 2 from different IV sites o UA/culture o CXR o respiratory culture if appropriate

• If cultures are all negative to date, likely no need to empirically start abx unless a source is apparent and you are treating a specific etiology

HEME

• Anticoagulation• Blood replacement products

Anticoagulation• Appropriate for:

o DVT/PE o Acute Coronary Syndrome

• Usually start with low molecular weight heparin o Lovenox 1 mg/kg every 12 hours and renally adjust 

• If need to turn on/off quickly (e.g., pt going for procedure)o heparin drip—protocol in EPIC

• Risk factors for bleeding on heparin:o Surgery, trauma, or stroke within the previous 14 dayso h/o PUD or GIB o Plts<150Ko Age > 70 yrso Hepatic failure, uremia, bleeding diathesis, brain mets

Blood Replacement Products• PRBC:  

o One unit should raise Hct 3 points or Hgb 1 g/dl• Platelets: 

o  One unit should raise platelet count by 10K; there are usually 6 units per bag ("six-pack") use when platelets <10K in nonbleeding patient. use when platelets <50K in bleeding pt, pre-op pt, or before

a procedure• FFP: contains all factors

o DIC or liver failure with elevated coags and concomitant bleeding

o Reversal of INR (ie for procedure)

RADIOLOGY

Which test should I order?• Plain Films• CT scans• MRI

Plain FilmsCXR:• Portable if pt in unit or bed bound• PA/Lateral is best for looking for effusions/infiltrates• Decubitus to see if an effusion layers; needs to layer

>1cm in order to be safe to tap

Abdominal X-ray:• Acute abdominal series: includes PA CXR, upright KUB

and flat KUB

CT• Head CT

o Non-contrast best for bleeding, CVA, traumao Contrast best for anything that effects the blood brain barrier (ie

tumors, infection)• CT Angiogram

o If suspect PE and no contraindication to contrast (e.g., elevated creatinine)

• Abdominal CTo Always a good idea to call the radiologist if unsure whether contrast is

needed/depending on what you are looking foro Renal stone protocol to look for nephrolithiasiso If you have a pt who has had upper GI study with contrast, radiology won’t

do CT until contrast is gone—have to check KUB to see if contrast has passed first

* If you are going to give contrast, check your Cr!!!

MRI• Increased sensitivity for soft tissue pathology• Best choice for:

o Brain: neoplasms, abscesses, cysts, plaques, atrophy, infarcts, white matter disease

o Spine: myelopathy, disk herniation, spinal stenosis

• Contraindications: pacemaker, defibrillator, aneurysm clips, neurostimulator, insulin/infusion pump, implanted drug infusion device, cochlear implant, any metallic foreign body

DEATH• Pronouncing a patient• Notify the patient’s family• Request an autopsy• How to write a death note

Pronouncing a PatientCheck for:• Spontaneous movement• If on telemetry—any meaningful activity• Response to verbal stimuli• Response to tactile stimuli (nipple pinch or sternal rub)• Pupillary light reflex (should be dilated and fixed)• Respirations over all lung fields• Heart sounds over entire precordium• Carotid, femoral pulses

Notify the Patient’s Family• Call family if not present and ask to come in, or if family

is present:o Explain to them what happened o Ask if they have any questionso Ask if they would like someone from pastoral care to be

calledo Let them know they may have time with the deceased

• Nursing will put ribbon over the door to give family privacy

Request an Autopsy• Ask family if they would like an autopsy

• Medical Examiner will be called if:o Patient hospitalized <24 hourso Death associated with unusual circumstanceso Death associated with trauma

How to Write a Death NoteDOCUMENTATION:• “Called to bedside by nurse to pronounce (name of pt).”• Chart all findings previously discussed:

o “No spontaneous movements were present, pupils were dilated and fixed, no breath sounds were appreciated, etc.”

• “Patient pronounced dead at (date and time).”• “Family and attending physician were notified.”• “Family accepts/declines autopsy.”• Document if patient was DNR/DNI vs. Full Code.

Bottom Line:• When in doubt, call your Resident• It is OK to call your attending if over your head• You are Never All Alone ☺

• Write a NOTE about what has happened for the primary team

• Call primary team in the AM about important events.

• Have fun…it’s gonna be a great year!