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
Journal Club: 30min: Two/year: article of your choice
Residents Conference: 1h presentation: Interesting medical topic of your choice
Potpourri: 30min: Any Interesting case
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
Contact the attending you are working with a few days prior to the start of the rotation to get details on their expectations
Cross cover list is kept current on CareGate www.caregate.net
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.
“Patient intubated, sedated, in 1 ICU”… when the pt has been extubated and on the floor for 4 days
Is this a new change? Duration?
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
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
If patient needs to be intubated, start with mask-ventilation until help from upper level arrives
if CHF,bolus 500ml NS
Sepsis: febrile >101.5
blood cultures x 2
Anaphylaxis: sob, wheezing
check, cortisol/ACTH level
ACTH stim test
replace volume rapidly
Hydrocortisone 50-100mg IV q6-8hManagement of Hypotension
*Stop BP meds!
*Don't forget about tamponade, PE and pneumothorax!!
Pure vasoconstrictor; causes ischemia in extremities
Vasoconstriction, positive inotropy; causes arrhythmias
Splanchnic vasodilation ("renal dose dopamine" even though many doubt such effect exists)
Positive inotropy and
rate control (BB/diltiazem/digoxin if BP low)
consider anti-arrhythmic (amiodarone)
SVT/SVT with aberrancy
adenosine 6-12mg IV
check Mg level, replace if needed (>3.0)
Sinus block: 1st, 2nd or 3rd degree
Hold BB meds
Prepare for transcutaneous pacing
Atropine 0.5mg IV x3
Consider low dose
*Remember, if unstable shock!!
Decrease total body stores
Lasix 40-80mg IV
Kayexalate 30-90g PO/PR
Shift K+ in cells
NaHCO3 50mEq (1-3amps)
D50+10units insulin IV
albuterol 10-20mg neb
Severe (>7mEq/L) or EKG changes
Calcium gluconate 1-2amps IV over 2-5minTreatment of Hyperkalemia
**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!!!
* If you are going to give contrast, check your Cr!!!