Medicine+Rotation

Medicine In Depth Or- “Just scratching the surface.” CCRMC FP Residency

Go to ICU workroom to check/update board* (*Generally, the overnight staff will redistribute patients, some of whom may still be in the ED) Go to ICU/IMCU (or floor if no unit patients)
 * Daily schedule:**
 * Get in 5:30 or so**
 * See patients:**

+ Try to get a ‘global sense’ of the patient -who are they, why are they here, what are we doing for them, how long will they be here, etc. + Using photocopied H&P, the day’s progress note or (my method) an index card, make a note of vital information: - Chief complaint - Abridged HPI with salient points - PMH- (definitely use Meditech but be time conscious) - Past echo, past EGD, past stress test, past ABG or PFT, Recent, prior admits - Social History (tobacco, EtOH, IVDU, e.g.) - Home Meds - Allergies - Triage and Current Vital Signs - Don’t forget I/O and weight (important in CHF, among others) - Can get a sense of ED Uop by checking Meditech (ED treatments, I think!) - Don’t forget chemstick (glucose) - Sense of admit exam (crackles?, rales?, JVD?, mental status?,etc.) - Important admit labs (creatinine of 5, for example) - Take look at EKG/CXR or if no time, make a copy and check web-1000 later - Current meds o The MAR o Using MAR-view on Meditech o Consider checking MAR for PRNs given o Consider checking Meditech- ER MAR for meds given in ED - Therapies/studies (both pending and complete) o Don’t forget to check ‘MICRO’
 * __Tips For new Patients:__**

+ TALK TO THE NURSE!! Especially with Unit patients- can be invaluable! Plus you’ll earn their respect

+ Say ‘hi’ to the patient: - Try to confirm / clear up important elements of history - Consider eliciting their chief concerns, questions, fears - Consider asking the question, “Do you feel like you understand what’s going on with your body right now?” - Quick, directed physical exam o Always check for JVP (our attendings love this one!) - Also a good time to review: o FOLEY? o LINES? o IVF? o PROPHYLAXIS?

1. Round with Registrar a. Most are flexible in terms of timing… some not b. As a default, present in a formal style though most will get bored with this after about 2 seconds and interrupt you! c. Every registrar unique and special, just like you! d. Especially **for complicated patients, rounding by system** can be very helpful, though **in general rounding is by problem**. 2. Discharges a. Consider starting discharge paperwork before ICU rounds or day before (or on admit if you’re a superstar)- every little bit helps. b. Can dictate later (and I recommend it) but don’t let them pile up c. For Social Issues, your only job is to make Social Work aware of patient and update on any changes in clinical status as well as to periodically check-in on the progress of planning. i. Your Discharge Planner is your ACE-in-the-hole, heartless discharging machine ii. The Discharge Planning nurse can help you pull resources together if you let her know about discharges in advance d. Only in rare circumstances are meds dispensed from pharmacy (cash pay patients, TB, e.g.), else will need RX (co-signed by attending or resident with a license). 3. Write your notes: a. A good (though usually unrealistic) goal is to try and have notes done and in chart by noon; i.e. don’t make your notes a cloud hanging over your head all day. b. Make them brief and to the point c. Many (most?) people use saved notes on computers/flash drives to be recycled daily, apparently can save a lot of time. d. One of our great graduating third years told me that he writes his notes and puts them in the chart while pre-rounding… Man I wish I was that good, unfortunately I usually need my notes to round with! e. Don’t save your notes to be done when you’re on call that night… try it and you’ll know what I mean.
 * 0815**: ICU rounds, see the scoop, don’t worry, you’re awesome.
 * Rest of day**:

4. Admits a. See the Scoop, don’t worry, you’re awesome b. Run admits by your attending, or the attending on call for the afternoon i. See Meditech for Medicine on-call schedule

5. Learn more about, talk with your patients and family members

6. Ordering and Following up studies and procedures - A seemingly simple issue that can be a huge hassle- unless you know the right person to call: i. **MRI**. Order in chart, though often (ok, always) have to talk to LEIBIG (495) to confirm. Follow-up is through same Leibig, or other radiologists if unavailable that day (very rare). Techs are at 4342, but rarely do I call them. ii. **CT**. Again, order in chart, usually no need to talk to Rads unless after hours or stat. Follow-up with MD reading CTs that day (CT reading room or 5808). Consider calling techs at 4324 if wondering, “Where the heck is my patient’s belly CT?” 1. **Note**- for stat studies done after 8 PM, ‘Nighthawk’ will do the read and typically fax the report to the ER. iii. **Xray**: Ordering via chart, follow-up on Meditech or ask CT room (I think) radiologist for official read… try not to bother Leibig or Won too much, though it is fun. iv. **Radiology trouble shooting**: Who’s on call? How do I get this image disk into Web-1000? Why isn’t my patient’s esophagram done? What is the prep for an upper GI series? Best most reliable number is the File Room (4828) where someone always picks up, in general… v. **Doppler/US**: Order in Chart, can get tech’s read by stopping by their office and checking book or by calling 5335. This number is also useful when wondering why US not done yet. Read by different radiologists, though often CT guy or Won (ask tech). vi. **Pthall/Nuc Med:** Tech is Larry (4158) who knows his stuff, can help you understand why Pthall won’t be done, or why it will take two days, e.g. Reading is done by Matthew Falk at the VA (428-3349), who always pages someone (often hard to find exact MD caring for patient…) with prelim read. Can call him if getting late and need to know answers. vii. **Echo/Stress Echo**: Order in chart, and double check Meditech to make sure ordered (a good idea on all important studies…). Call Echo lab (4354) to speak with Tech and prod them to do your MOST IMPORTANT patient (tongue in cheek- this is a very busy lab at CCRMC). Also a good number to call to find out who is reading Echos today and get prelim report from them. viii. **EST**: The medicine registrar on hospital call for the day does ESTs, so always call them to tell them about your patient, confirm that it can/will be done. Also needs to be ordered in chart. They usually page you with results, or you can do the study with them if you have time. ix. **GI (Endoscopy, ERCP):** Call shared among several attendings (schedule in Meditech). Usually will need a day or two advance notice to do an ENDOSCOPY, not really done on weekends or after hours unless URGENT/EMERGENT. Can beg borrow and steal to try and get your patient done faster. ERCP done on certain days of week by outside GI- again, need to talk with GI consultant to arrange, transfer prn urgent study on non-ERCP day. Follow-up on these studies is usually via page from the consultant though occasionally will only leave note. x. **Cath/ Dialysis**: Patient will need to be accepted by a consultant and transferred to an outside hospital for this. Who to call and which hospital varies by insurance type- your registrar can help you with this.
 * 1.** **Will usually need to call GI lab at 4190 or page tech Vanessa (818) to get patient on the schedule after talking with consultant.**

7. Getting consults a. Generally our consultants are great and easily accessible. i. Psych- Starting with the best, John Echols is always on call for Psych M-F during the day with rare exception, pager 652, is on meditech 1. For nights and weekends, psych consult rules are listed on meditech ii. Geropsych- Also the best, Aneela Ahmed will so willingly see all of your patients over 65 yoa who have psych issues or if you’re uncertain they may have dementia. Her pager is 402 iii. ID: A great local group is current ID consults, their pagers and schedules are listed on Meditech. Though I’ve heard rumors that we may be changing… iv. Renal: Another great local group affiliated with John Muir Concord (which you may also hear referred to by its former name: “Mt. Diablo”), also on Meditech 1. Dialysis transfers for most of our patients v. Cards: ANOTHER great local group, also affiliated with Mt. Diablo, darn I always do that…. JOHN MUIR CONCORD…. Can be found in Meditech. 1. Cath transfers for most of our patients, a common call vi. Surgery/Rheum/Heme Onc/Neuro/GI/Ortho 1. A rotating panoply of (sometimes stressed) CCRMC docs, many of whom are CCRMC grads, available 24/7 with schedules on meditech vii. ENT/Ophtho 1. Specialists affiliated with CCRMC, occasionally not available for consult.

8. Go To Clinic: a. Say what? I have to do all of the above and then make it to clinic on time at 1PM? b. Yes and No i. Be aware that you just may not get everything done that you need to on clinic days. ii. Combat this by: 1. Cleaning your plate as much as possible the day before 2. Your senior will try to protect you from getting shellacked on clinic days. 3. Signout as much as possible to be done in afternoon. (make it easy for them!) 4. Prioritize discharges. 9. Always ask for HELP!! a. You are not alone, you are SUPERVISED!! i. Use your attending, make them work for it! (Which they all do, by the way.) ii. Use your 3T, make their lazy butts do some work too! 1. They share a service with another resident and part of their job is to be checking in on you and making sure you’re doing ok, if not- ask for HELP! iii. Use your fellow residents: A friend in need…

10. Signing out a. Sign out all ICU, IMCU and ED patients to ICU resident- even if floor transfer is pending. b. Sign out floor patients with specific issues (follow-up Hgb, e.g.) to 4th or 5th floor resident i. Give simple directive plan on what to do with lab results (transfuse if <7, e.g.) c. Sign out floor patients who may be active overnight i. Again, try to give simple management suggestions for various possibilities 1. E.g.: “Mrs. Smith, a 75 yo F with possible early dementia, here for … has been a little out of it during the evening hours of late. We suspect sundowning, so if you get called on her give 0.5 mg of Haldol. This seems to work well for her and we’ve discussed r/b/a of antipsychotics in the elderly with the patient and family.” d. Understand that the best way for person receiving sign-out to properly care for your patient is for them to ask any questions that they have!

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