Intern Orientation Guide
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The Intern’s Commandments 1. PLAY AS A TEAM: Work hard to help your team; demand that your team works hard to help you. Work with nurses, techs, etc. - treat everyone with respect 2. BE HONEST: Never lie to your patients, or to your team. If you forgot to order or check a lab test, own up to it and try not to let it happen again. You might be chastised, but it will be far less severe than the consequences of lying about it. 3. SHOW UP: You are paid a salary, but most of your payment pa yment still comes in the form of education. Every time you skip a conference, you’ve elected to take a cut in your “pay.” Go to your conferences; teach your colleagues. 4. PREPARE: Show up when necessary to see your patients when on the team and be ready for attending rounds - whenever that might mean to you. It might mean signout, signou t, it might mean beforehand. Read up on your clinic patients ahead of time, and know what you’re going to ask, advise, order, and write ahead of time. It’ll It’ll pay off. 5. MAKE DECISIONS ON/BEFORE ROUNDS: When you make decisions and they’re correct, you learn through that reward of doing d oing right for your patient. When you make decisions and they’re not right, you learn even deeper out of a concern to never make the same mistake again. Either way, make decisions & don’t wait for upper levels or attendings to make them for you. 6. DEVELOP GOOD METHODS, AND BE THOROUGH: Ask your upp er levels to teach you their methods and thought processes for the clinical cl inical problems they encounter. Once you have mastered a method, be consistent in its application 7. READ: Read somethings daily. A journal, a biography, biograph y, escapist fiction, a comic book. Just read. 8. WRITE GOOD NOTES: A good note tells other physicians ph ysicians exactly what you have found, what what what you think, and what you plan to do. Whether in clinic or on the team, don’t simply write notes to check a box - use it as a tool every time. 9. COMMUNICATE: Sign out all patients appropriately to the night float on t he team. Staff all patients to attendings, refer back to Rule 2 10. SHOW RESPECT: Your residents/attendings have been down a road you have yet to travel. So have the nursing staff. Respect the position, even if you don’t like the person. 11. TAKE OWNERSHIP: The best way to predict the future is to be a part of creating it. If there is a problem (with patients, with clinic, with residency), be a part of the solution. 12. KEEP SOMETHING FOR YOURSELF: Whether it’s a relationship with a loved one, working out, video games, or reading, make mak e sure that the rigors of residency don’t take everything from you. 13. KEEP YOUR HEAD: You only have so much energy; don’t waste it on needless ne edless squabbles or panic. Take a deep breath, remind yourself why you woke up today (#13). 14. DON’T LOSE PERSPECTIVE: Your patients need you; you; you need your patients to teach you. Residency is only 3 years; get the most out of the experience as possible while you can.
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Dr. Norman McSwain’s Rules of EMERGENCY Patient Care 1. Death is your adversary and competitor - fight to win 2. Treat the patient as if they were your mother, father, or child 3. Each minute has only 60 seconds. Do not waste any of them 4. Assume nothing, trust no one, do it yourself. 5. Know anatomy cold 6. Be technically quick. 7. Do not panic in the face of blood. 8. Work with physiology, not against it. 9. Maintain energy production. 10. Know what to fix and what to leave alone. 11. Know when to run. 12. Paranoia prevents disasters. a. The patient’s disease is out to embarrass you. b. The patient does not tell you the whole truth. c. The most severe injury is under the unremoved unremov ed clothes. d. The infection is hidden by the dressing. e. The patient has a problem that you do not know about. 13. Never 13. Never talk a patient into or out of any operation. 14. The nurses’ notes do not say what the nurse told you. 15. Do not procrastinate. Make a decision and carry it out. 16. Learn from your successes and from your failures. 17. Always question everything you do. 18. Don’t whine, just get the job done. Rules from the House of God 1. GOMERS don't die. (Satirical - Untrue!) 2. GOMERS go to ground 3. At a cardiac arrest, the first procedure is to take your own pulse. 4. The patient is the one with the disease. 5. Placement comes first. 6. There is no body cavity that cannot be reached with a #14G needle and a good strong arm. (Satirical - don’t try this!) 7. Age + BUN = Lasix dose. (Semi-satirical - Untrue!) 8. They can always hurt you more. 9. The only good admission is a dead admission. (Satirical - Untrue!) 10. If you don't take a temperature, you can't find a fever. 11. Show me a Medical Student who only triples my work and I will kiss his feet. (Satirical only if you’re doing it right (teaching them) do they the y add work. Usually they decrease it!) b oth see a lesion on the chest x-ray, 12. If the radiology resident and the medical student both there can be no lesion there. 13. The delivery of good medical care is to do as much nothing as possible. (Often 100% true)
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Topics for Intern Year By the end of intern you you don’t need to be a specialist-level specialist-level master in all of these, but you should shoot for being at least competent in all of them. 1. Acid-Base 2. Acute Renal Failure 3. AFib/AFlutter 4. Alcohol/Benzo Withdrawal 5. Altered Mental Status 6. Anemia 7. Antibiotics 8. Asthma/COPD 9. Bradycardia 10. Chest Pain - Angina vs. ACS vs. v s. CAD 11. CHF Exacerbations 12. CHF in Clinic 13. Diabetes (Insulin Independent & Insulin Dependent) 14. End of Life - Code Status, LAPOST, 5 Wishes, differences between Hospice & Palliation 15. GI Bleeds 16. Hepatitis 17. HIV - Opportunistic Infections & Prophylaxis 18. Hypertension in Clinic 19. Hypertensive “Emergency” 20. Liver Enzyme Assessment 21. Meningitis 22. Pneumonia 23. Potassium 24. Shock - Differential 25. Shock - Pressor Initiation 26. Shock - Resuscitation 27. Sickle Cell Anemia 28. Sodium 29. Stroke 30. Syncope 31. Tachycardia 32. Thrombocytopenia 33. Thyroid Disorders 34. Weakness
Patient Satisfaction You’ll hear a lot of things, from a variety of o f people, including administrators, care management, Joint Commission, etc. None of that matters to the medicine in treating the patient having a stroke, but it does affect how they see you (and the hospital at large).
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ene rgy goes into their care 1. Bedside rounds: When patients see how much intellectual energy they’re typically amazed, and often appreciative. Up to the attending, but something to consider as you see different techniques. Consider minimizing table rounds and emphasizing bedside discussions to involve the patient. 2. Sit down: Whether on a chair, the bed, or just kneeling nearby, sit in a patient’s room. When you do, patients think you’re in the room for twice as long. Standing Standin g relays a mental cue of you wanting to leave, which results in patients rating you as being b eing in the room half as long as you are. So sit down (that said, stand if your attending is in the room and standing - don’t look lazy or uncaring). 3. Uncross your arms and face the patient: Use open body language at all times. When in your patient’s room, try not to be on your computer the whole time. Keep your hands h ands at your side or in front of you, gesture with an open palm & not just a finger. 4. Use Names: Ask the patient how to pronounce their name, remember it, and use it. If in doubt? Put the pronunciation in the HPI! Try to remember their significant other’s names! 5. Touch People: Not just a physical exam; touch their hand if they’re upset, their leg if discussing a relevant diagnosis there, etc. Don’t be Don’t be inappropriate - it’s hard to explain what’s inappropriate and what isn’t, but it’s something that you know when you see it. 6. Smile: Sincerely. Unless you’re talking about a serious event, bad news, or it’s uncomfortable, smile. People respond to it. 7. Treat people like people, not like patients or diseases: Patients are people first. They’re not a 45 y/o female w/ h/o CHF. They’re a human woman with a disease process. Connect emotionally and you’ll win the hearts and trust of your patients. This one is vague, and likely an advanced adv anced skill for many, but ultimately what will fend off your replacement. No, I’m not talking about immigrants taking your job - think IBM’s Watson. o n/off. 8. Give them choices: Lights on/off, covers up/down, thermostat high/low, TV on/off. They have no autonomy when they’re in the hospital! They eat when the meal trays come, they get their meds (which they the y may have self-administered for years) when the nurses come by, they’re woken every 2 hours all day long, they have no control. Allow them to get some back - this t his is how you should ask them about their code status, as well. 9. Don’t Stress: You’re going to mess things up - whether ordering something wrong and having to correct it, or saying something awkward and putting your foot in your mouth. There will be patients who don't want to see you again. When this happens, reflect: did you do something preventable to cause c ause this? Can you avoid it in future? Then comply: let it roll off your shoulders - some people are just that way, and you’re seeing them on some of the worst days of their lives.
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How to Apologize
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Errors in Clinical Reasoning For more information, read Thinking, Fast and Slow by Daniel Kahneman. This is just a primer. The novice employs analytical (type 2) reasoning because there’s been insufficient experience to “feel” a diagnosis. Every Ever y piece of information might be important; each is carefully calculated to determine whether the differential diagnosis is right or wrong. More experienced physicians employ intuitive (type 1) reasoning - that is, they react. They’ve had sufficient experience to “smell the CHF” or “hear the subclinical seizures.” This comes with thousands of patients and tens of thousands of hours of experience The best physicians utilize intuitive reasoning but are savvy enough to know when something isn’t right and know how and when to employ analytical reasoning . The weakest physicians never get past intuitive reasoning , using pattern-recognition for everything. Nurses, PA’s, NP’s utilize this frequently. They’re often right, but not always which is why we must do more. Anchoring Bias : The most dangerous of all errors. This is when you prematurely decide on a diagnosis and ignore all other information that’s counter to your decision. Each intervention, intervention, lab, and diagnostic test is another data point. In anchoring, ancho ring, the recurrent drug-seeking chronic pain patient pa tient who’s “just looking for narcotics” gets sent home from the ED the one time he has a ruptured appendix. Recency Heuristic (aka Availability Heuristic) : Common when running a busy ward. This happens when you just saw something in another patient and allow it to become more likely in THIS patient. Each patient must be considered in isolation of all other patients. Things do not “come in waves” - anything to the contrary is just a contradiction or a coincidence. Severity : “We have to rule out a PE because it’s so deadly.” So is smallpox - how many times have you ruled that out in a rash? More deadly doesn’t mean more likely. The ED is ED is most often guilty of this. Full disclosure, lawyers like to practice medicine this way, so documentation is vital. Confirmation Bias (i.e. Consultant-Said-So Bias) Just because the ED signs out a patient to you with pneumonia doesn’t mean that it is. Some hospitals don’t have signout for patients from the ED to the inpatient team unless they’re critical and going to the ICU - in order to not cloud the diagnosis. Go looking for what they tell you the patient has, and you’ll find evidence for it somewhere. somewhere.
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Journal Analysis Descriptive Study 1. Was this study INTERESTING? NOVEL? RELEVANT? (to your practice) 2. What is the incidence of disease in your study? 3. What is the prevalence of disease in your study? Control Study 1. Was this study INTERESTING? NOVEL? RELEVANT? (to your practice) 2. What is the study question? 3. What is the disease being studied? 4. How were the case/control subjects selected? Did this introduce sampling bias? 5. Who is the patient population being studied? Is this similar to the patient population you intend to take care of? 6. How did the investigators determine which patients had been exposed to the risk factor? (i.e. did the investigators ask the subjects to tell them, or was it objectively determined?) Do you think this introduced recall bias? 7. Calculate the odds ratio 8. What does this (the odds ratio) mean? 9. How would this study change your clinical practice? Cohort Study 1. Was this study INTERESTING? NOVEL? RELEVANT? (to your practice) 2. What is the study question? 3. What is the risk factor (or exposure) being studied? 4. How were the cohort & comparison subjects selected? Do you think this introduced sampling bias? 5. Who is the patient population being studied? Is this similar to the patient population you intend to take care of? 6. How did the investigators determine which patients had been exposed to the risk factor? (i.e. did the investigators ask the subjects to tell them, or was it objectively determined?) Do you think this introduced follow-up bias? 7. What percentage of the cohort/comparison groups followed-up? Did this introduce dropout bias? What is an acceptable amount of drop-out in a clinical study? 8. Calculate the relative risk for your study. What does this mean? 9. Calculate the relative risk reduction for your study? How c an a relative risk reduction be deceiving? Why is absolute risk reduction more meaningful? 10. Calculate the absolute risk reduction for your study? 11. What is the number needed to treat? What is the number needed to harm? Why is comparing the two useful? 12. Why is relative risk a better statistic than an odds ratio? If relative risk is so valuable, why not use it for case-control studies instead of using an odds ratio? 13. How would this study change your clinical practice? 14. What are two ways of controlling for confounding in the design phase? 15. What are two ways of controlling for confounding in the analysis phase? Experimental Studies
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1. 2. 3. 4. 5.
Was this study INTERESTING? NOVEL? RELEVANT? (to your practice) What is the study question? (What with what in whom?) What is the intervention being studied (the independent variable)? What is the outcome variable (what are they the y measuring)? Who is the patient population being studied? Is this similar to the patient population you intend to take care of? 6. How good was the randomization 7. What are the results? What is the chance that this result was due to chance alone? 8. How clinically significant are the findings? What does the confidence interval tell us? How do you calculate a confidence interval? How is a confidence interval different for odds ratios vs. relative risk reduction? How does the confidence interval help you evaluate the power of a negative trial? 9. Calculate the relative risk reduction of your study 10. Calculate the absolute risk reduction 11. What is the number needed to treat? What is the number needed to harm? Why is comparing the two useful? 12. Were there sources of bias in your study? Drop-out Drop-ou t bias? Cross-over bias? 13. How would this study change your clinical practice? Meta-Analysis Studies 1. Was this study INTERESTING? NOVEL? RELEVANT? (to your practice) 2. What is the study question? (What with what in whom?) 3. What is the intervention being studied (the independent variable)? 4. What is the outcome variable (what are they the y measuring)? 5. Who is the patient population being studied? Is this similar to the patient population you intend to take care of? 6. How were the articles in the meta-analysis selected? 7. Are the articles in the study similar? Did the authors test for homo geneity? 8. Do you think the investigators adequately adequatel y excluded the possibility of publication bias? If yes, how did they do it? 9. Is a single randomized controlled trial possible with this topic? 10. How would this study change your clinical practice?
360 Feedback This is uncomfortable for a lot of people, but bu t I think it’s an important supplement to the learning and growth you do on your own, and everyone benefits from it. We will try to eke out half an hour towards the end of the second week you’re with me to go over everything. the upper level will remind you, but you should be have an idea of what you want to say in advance so that this doesn’t take an extended period of time. The format will be this: the upper level will start, in o rder to make things easier. they will say one thing that they’ve done well during this period, and one thing that they want to work on in particular. They will then tell the next person one thing they’ve been impressed by/want to emulate/want to encourage, and one thing that they think could be improved. They’ll do this for everyone in the group, and then the next person in line will take their turn and so the same.
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Financial Planning Basics: ● Gross salary is fixed; apart from moonlighting this can’t be increased. ● All your work needs to be on the “defensive” side - budgeting and controlling expenses. ● Roth vs. Traditional ○ Roth - Taxes are paid upfront when putting money into the account, not taxed upon withdrawal; useful when in a low tax bracket (like right now, hint hint ) ○ Traditional - Non-taxed when putting money into the account, taxed when withdrawing; useful when you’re in higher tax brack ets. ets. ● IRA vs. 401k ○ IRA - Individual Retirement Account - currently capped at $5,500 ○ 401k - run through employer. Often include a “match” up to 2% of your basic income. Ordinarily if you don’t invest up to 2% of your own income to get the most of this, you’r e leaving money on the table. In the case of my residency: ■ 403b - very similar to 401k, except run by nonprofits. Can often have more investment restrictions, and can allow for higher contributions. ■ “Vesting” - if you depart from a position before being be ing “fully vested” in the retirement account, the matched portion is withdrawn so you’re left only with the money that you put in. ■ My residency’s 403b is, as of 2017, requiring 5 years’ full-time full-time employment in order to become fully vested. Unless you plan on working here after residency, there are better options for your money than the hospital retirement system. Intermediate: ● PAYE vs. REPAYE - Pay As You Earn vs. Revised Pay As You Earn. Two methods to make IBR (Income Based Repayment) on student loans. The benefit is that it scales with income; you won’t be expected to pay $8,000 per month while in residency. These payments can qualify you for PSLF, but do not automatically. Benefits of this plan: low payments, can pay extra against the principle in months you want to, after 20 years your remainder will be “forgiven.” Downsides of this plan: cannot refinance loans through private vendors, the “forgiven” lump sum is taxed as a gift and can be hefty. ● Public Service Loan Forgiveness - If you document working for a nonprofit nonpro fit (certified in advance) for 120 months, paying the minimum of your interest payments, the remainder is “forgiven” at the end of the 10 years with no tax implications. This is unlikely un likely to be in effect in two years, let alone ten, but b ut it’s worth putting worth putting the work in so that your 3 years of residency count just in case. ● Consolidating vs. Refinancing loans - Consolidating loans averages avera ges all of your interest rates then rounds up to the nearest 1/8th of a percentage point. Refinancing is taking out a new loan from a private company compan y to get a substantial discount on the interest rate. Look at both, but typically refinancing is the better option. Interested? ● Read White Coat Investor, by Dr. Dahle, for more complex information (also check out his website)
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Professional Interpersonal Relationships The Art of Fighting Without Fighting First Rule: you’re both wrong . If one person was obviously correct, there would be no argument. The patient in septic shock who also is having an M.I. M. I. is getting admitted, the 18 y/o with anxiety and no clinical or vital sign abnormalities is going home. It’s the middle ground where fights happen (refer to “The Devil in the Gaps”). Your job is to find out where you’re wrong, or where the miscommunication occurred. Second Rule: emotion always loses . “I think” and “I feel” lead nowhere - in these arguments, the person with the loudest, strongest emotions will win. You don’t want to get steamrolled, and you don’t want to be known as someone to avoid either. Don’t get me wrong, you’re not you’re not supposed to be a machine (let off steam in the conference room, commensurate with the staff, high-five high-five nurses). Just don’t do so in an argument. Look for facts and find common co mmon ground. Third Rule: when you win, you lose. Effectiveness, social capital, your relationships with colleagues - all of these are taking takin g a hit if you win too handily.This can be true no matter how tactfully you win - remember that the other side is i s emotionally attached to their position. Fourth Rule: get help. If no compromise can be reached, step back. This is the benefit of being in training. “I’m sorry, I’m just an intern/resident; I’ll have to run that past my resident/attending and then get back to you.” There’s always someone to fall back on. Don’t be a doormat by always getting getting stepped on, don’t be a menace by biting everyone’s head off, and don’t be a snitch by running to your upper level/attending every time you come into conflict. With that said, if a resolution can’t be reached TALK TO THE ATTENDING!
Top 10 Practical Pointers for Winning Arguments 1. Talk in a soft, monotone voice. Don’t show emotion. You’re about facts. No condescension, sarcasm, or patronizing. 2. Stand with your arms straight and at your sides. Gesturing is threatening (non -verbal emotion) and crossing your arms is condescending. The person will hear you body bo dy language much louder than your words. This goes for phone-cameras as well. 3. Listen. 4. Empathize. 5. Listen. 6. Listen. Don’t hear or anticipate what you’re going to say next. Debates are about a bout retorting and twisting twisting the other person’s words against them - don’t debate. In an argument about a patient (or WITH) a patient, accept acc ept that there’s a strong chance you could be wrong. At a minimum, even if you know you’re 100% correct, their opinion still matters. They’re looking looking out for the patient, so find common ground there. 7. Admit it when you’re wrong. If you have a problem with that, say to yourself “the truth matters to me more than being right or wrong, I want what’s best for the patient.” 8. Agree first. Find out where you line up, and say that out loud. Use it to build rapport and have a chance to talk. 9. Give them a way out. You’ve listened and figured out where the miscommunication occurred, but their ego is too tied up in their position. Do that for them. “I’m “ I’m not sure if sure if you had a chance to check that CT scan, but it seems to me that they may need surgery.” “Sorry to interrupt your day, but I was hoping hopin g you would explain a little for educational purposes why you’re making this decision so that I can understand in future.” 11
10. If all else fails, lose the fight. You’ve read about the emotional burden, this issue of ego. Assume that they haven’t. If you keep that th at in mind, you won’t see it as a loss or be drained by it. You’re doing them a favor by giving them the gratification of gratification of winning (but don’t patronize them!) Then, knowing you’re right, follow Rule Four and call your attending.
Recommended Resources Apps ● Medscape/Epocrates/Pharmacopea - med dosings ● ePSS - for screening guidelines
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● LDL-C Manager - for ASCVD risk ● Doximity Dialer - for spoofing your cell phone to look l ook like it’s calling from clinic, calling patients back ● FP Notebook - for basic ddx, ddx , workups, & treatments ● MedCalX - for all those formulas we forget ● Gout Diagnosis - what it says on the title ● Canopy Speak - for translating simple phrases ● Fast Facts - for studying Palliative Care ● AACE Diabetes Algorithm - regimented guidelines for management of Diabetes ● AACE Osteoporosis Algorithm - for management of Osteoporosis ● Anemia - for regimented guidelines of management/workup of anemia, developed by a Heme/Onc working with a Family Practitioner ● Anki - for creating study decks out of AAFP & ABFM questions ● RSSF App of your choice - for compiling blogs, videos, etc. into one easily accessible place ● GoodRx - pricing, coupons, and common dispensing amounts for meds
Podcasts ● The Curbsiders Internal Medicine Podcast - internal medicine PCP/hospitalists who interview experts in various fields (e.g. Dr. Robert Centor about p haryngitis) ● American Family Physician Podcast ● The Grayscale - humanity in medicine; a mix of o f NPR’s story hour & a morbidity/mortality conference ● FOAMcast Emergency Medicine - Free Online Access Medical education podcast
Blogs ● 2 Minute Medicine ● Db’s Medical Rants - more on the medical education side of things, Dr. Robert Centor describes the academic setting of UAB ● Dr. Smith’s ECG Blog - as described ● ECG of the Week - as described ● EM in 5 - quick & to the point, a compilation of 5-minute videos breaking down presentations/workup/management of common ED complaints ● IM HEAT - an internist breaking down groundbreaking medical medi cal studies in an entertaining but thorough way ● Precious Bodily Fluids - a nephrologist’s blog, this is a bit more specialist-specific specialist -specific but still has some good pearls ● Pulmcrit/EMCrit - ED/Critical care blog discussing goods ● Taming the SRU - a busy academic ED discussing topics regularly. Very thorough. ● Curbsiders - the blog attachment to the podcast
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Websites/Online Resources ● Bilitool.org - interactive bilirubin nomogram for newborns ● Mdcalc.com ● Palliation ○ ePrognosis (http://eprognosis.ucsf.edu/) ○ Home - Vital Decisions Decisions (vitaldecisions.net) ○ American Journal of Hospice and Palliative Medicine®: SAGE Journals (http://journals.sagepub.com/home/ajh) ○ The Conversation Project (http://theconversationproject.org/ http://theconversationproject.org/)) ○ End of Life Literacy (http://endoflifeliteracy.com http://endoflifeliteracy.com)) ● Wiki Journal Club - summarizes landmark trials & studies (https://www.wikijournalclub.org/wiki/Main_Page https://www.wikijournalclub.org/wiki/Main_Page)) Books ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
When Breath Becomes Air - Paul Kalanithi (Humanism in medicine) Being Mortal - Atul Gawande (The importance of palliative care) Extreme Measures - Jessica Zitter (The importance of palliative care) House of God - Samuel Shem (The frustrations of healthcare; dated but timeless) The Death of Ivan Ilyich - Tolstoy (End of life discussions) Tuesdays with Morrie - Mitch Albom (End of life discussions) The Man Who Mistook his Wife for a Hat - Oliver Sacks (Fun neurocognitive cases) The Spirit Catches You and You Fall Down - Anne Fadiman (Cultural competency) The Immortal Life of Henrietta Life - Rebecca Skloot Sk loot (Patient consent, hx of medicine) Trauma Stewardship - Laura van Dernoot Lipsky (Take care of yourself in medicine) White Teeth - Zadie Smith (Interracial (Interracial relations and cultural biases in America) Thinking, Fast & Slow - Daniel Kahneman (Dichotomy of intuition/analysis in practice) Finite & Infinite Games - James Carse (Philosophy of day da y to day life) America’s Bitter Pill Pill - Steven Brill (History of health care policy in America) Am erica) American Pain - John Temple (The establishment of narcotic epidemic & “pill mills”)
Movies ● How to Die in Oregon ● Dallas Buyer’s Club ● Extremis
Wards Expectations 1. Clear roles are important, especially at the first half of the year and the first time you’re on a new rotation.
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2. Subintern/Acting-Intern/Audition-Intern/Elective: a. They’ll start with 2-3 2 -3 patients, then quickly move to four. The goal will be for them to handle 4 patients at or close to the level of an intern by the end of the second week at the latest. They should know all labs, vitals, and history. b. Interns should emphasize emphasize that they’re not involved in grading the students; this will help foster their ability to ask questions and propose ideas. c. Admits: i. With admits, an intern should go and listen/type while they perform the history, as time allows. If they take more than 30 minutes to take a history you can prompt them, but bu t it’s important that they learn for themselves. Do the physical exam together, step out, and discuss the plan. 1. If you have time, ask them “what do you want to do for this patient? What do you think their their diagnosis is?” 2. If you don’t have time, tell them what you would like to do for the patient, and see if they have any ideas, suggestions, or questions ii. The student should present the patient to the attending, with you listening/putting in orders ready to jump in if they skip anything major or d. The upper level will let them know that they should expect to work the hours that interns do at baseline. If you feel confident con fident that nothing’s going on AND they’ve gotten some teaching for the day, da y, you’re free to send send them home at 1400 (assuming you check with the other intern first). 3. Interns: a. These are your patients. Your job is to get get nearly ALL the work done for your your patients (orders, documentation, discharge, calling consults and following up on their recs, making appointments, following up post-discharge tasks, updating the list, coordinating with social work, sign outs, transfers of care, and unfortunately, sometimes, making sure that other people do their job). The upper level will help you figure out how to do this, and if we don't know, we will try to help you find out. But a lot of it will be beating your head up against the wall figuring out how to get things done. i. Orders: are often canceled by nursing or done don e incorrectly, so make sure to err on the side of paranoid. Check to see if things have been done. Recheck if it’s vital! ii. Documentation: Notes should be started before rounds, but unless the attending is particular, they don't need to be done until the end of the day. Always finish your notes for the day, though thou gh discharge summaries can sometimes wait until the next day. You'll also be responsible for for transfer of care notes from inpatient → SNF/Rehab iii. Discharge: Starts on admission, with a Consult Care Management order for discharge planning. If there’s even a chance that they’re going to leave on the weekend, you need to set up (or have the medical student set up) a follow-up the Friday before. The appointment can be cancelled if they end up staying. iv. Calling consults: If you consult someone, you should sho uld call them to let them
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know. If they give you a hard time, let us know and we'll handle it. Almost all are incredibly friendly and open to talking with interns, but have your facts straight before you call. b. You will have some teaching responsibilities, and will do some supervision of the students, but the responsibility for that is mainly mine, the third year’s, and the attending’s. How much you do depends on your preference. You SHOULD make time (even 5 minutes) to discuss plan of care with the student(s) covering your patient(s) before rounds; if they have no idea what they’re talking about, it looks as though nobody does. c. Your job is also to learn, so we'll step in at times to help with your work so you can go to conference, read about your patients, patients, etc. This does not mean we don’t trust you to do your work! Rather, we respect you enough to let you focus on yourselves sometimes instead of putting in simple orders for the hundredth time. d. In the early stages, stages, please check in with us before before making big moves. we'd rather you ask 10 “dumb” questions than make 1 mistake from taking a guess from not wanting to bother someone. Your autonomy will grow as as the year goes on, and you'll be in the hospital hospital plenty to do your growing. Other residents will be available to help, and the attending should be too during those times, so don't feel like you're ALL alone. 4. Resident: a. The second year’s job is to run the team. That means we'll be helping set the schedule, seeing the critical patients & any an y problems briefly in the morning (either with you or separately), assigning patients to students (and if necessary, to you), going over every patient with one of you and coming up with the initial plan, keeping track of all the things that NEED to get done for our patients, helping remove obstacles to discharge, troubleshooting, coordinating with the attending, and seeing all patients admitted after you. If things are are busy we'll admit overflow. If you feel overwhelmed, LET US KNOW. We can’t help you if you bottle up your stress, and it doesn’t help anyone if you panic. b. We’re also responsible for teaching the students, although some interns interns really enjoy that and we don't want to take your chance to grow as a teacher away from you. So let us know where you're at at on that spectrum. c. We’re also responsible for providing clear expectations, coaching, ove rsight, and meaningful feedback to everyone on the team, as well as being ultimately responsible for patient care, which is our end goal. 5. Attendings are attendings, and no two are alike. We may end up having to modify these roles and expectations for certain attendings, whereas others really do defer to the resident in terms of running the team, which is the way it is designed to be. 6. Everyone: a. Have a tracking system so that you have the most critical information available at all times and can retrieve retrieve it at a moment's notice. We can show you ours, but everyone finds their own over time.
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Despite all of these details and schedules, providing excellent c are to some of the sickest patients in America America is our job. That's our duty and if we have to deviate from the structure to do so then we will - if the attending, consultant, or program director gives you flak about this let the upper level know and they will handle it. If the second-year second-year gets in the way of this, let the third year know (we’re not perfect and can get short-sighted). c. If there are any conflicts between us or with other services, please share them with the second-year openly. We'll always try to to be open to criticism, but if you don't feel comfortable speaking with us directly, talk to your clerkship director (med students) or one of the chiefs (interns).
b.
Regular day structure: 1. AM sign out: By 0630 or earlier, the whole who le team should arrive for face to face sign out. The third year may or may not attend sign-outs. 2. If you would like, you can run your plans and questions by the second-year prior to attending rounds. If you have questions, try to ask before table rounds to look up any uncertainties first. first. In general we want to be collaborative about designing the day and our role is to run the team. In general, there will be some residents who are pretty type A about stuff like this, so it'll probably probably be good to start with some structure. We’re familiar with the intern's jobs, and want to make life as easy for you as possible. 3. In your mind, it can help to triage your patients. Mentally run your sickest patients first, followed by those who are being discharged, followed by those who have critical timesensitive tests needed to move their care forward (The Three Th ree D's: disability, discharge, diagnosis ). 4. Attending rounds 5. Noon conference - lunch and learning, if possible. If you are overwhelmed, you can step out to deal with time-critical time-critical tasks. Try not to miss conference if at all possible. If there’s a conference you’re particularly interested in, the upper level can hold the pager during during this period. 6. Finishing rounds after lunch. 7. From finishing rounds to signout at 1700, this is your prime work time. You'll be getting the work, finalizing notes, and we'll be doing some of that as well, and teaching the students. We will typically run the list right after after attending rounds and if necessary whenever else 8. 1630 - try to finish up what you’re doing, and look over your patients. Review labs, changes from the day, etc. Depending on available time the upper level will try to check in with each of you regarding what you feel you need more help with the next day. 9. 1700 - Signout 10. Unreferred days: Every four days. No real changes chan ges to the schedule, other than trying to get through rounds as fast as possible.
MS-4 Handout: Welcome To the Team!
(Print for Students)
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For a sub-I/A-I/elective rotation working with the inpatient team will be very similar to internal medicine. We see a lot of pathology here, and have on occasion newborns to cover as well as end-of life care and just about everything in between. We have an open ICU, which means that we follow our patients from the floor to the ICU if the need arises. We also have access a ccess to our own Skilled Nursing Facility & Rehab floor so patients pa tients of all levels of acuity are seen by b y the team. Schedule The door code from the walkway to the clinic building is 2442# - it will be locked early in the morning. Sign-out changes daily but typically is held between 0600-0630. This is followed by daily assignments, pre-rounding, and then meeting the attending & team for table rounds. Again, this is attending-specific but is between 0800-0830. We go from table rounds to walking rounds, with a break for lunch. As a fourth-year student, you will be expected to see an average of 4 patients and present them on rounds. On Tuesdays there are grand rounds, but otherwise we have daily conferences - either food will be provided, you’re welcome to tag along to the doctor’s lounge for a plate, or Ms. Linda can give you meal ticket vouchers vouch ers for the cafeteria. After lunch we finish rounding on patients & accomplish tasks for the day. Your primary goals are to help make follow-up appointments appo intments in our clinic, to follow up on lab results & consultant reports on your patients, and to write discharge summaries su mmaries for the patients you have been bee n following. The latest you should be expected ex pected to stay is 1700, but if nothing is going on in the afternoon then you may get to take off early. Expectations! This is a laid- back rotation for the majority of the time. There’s a high patient load, and ever yone yone works hard, but as long as you approach every day as a learning opportunity you’ll do great. Every fourth day, the team is “unreferred” meaning that every patient who comes to the hospital and who isn’t treated by a hospitalist h ospitalist group that works here, gets admitted by our team. Every day of the week we admit patients from our clinic that come to the emergency room, and occasionally those that are directly admitted from clinic. You will be expected to do the interview and physical exam for all of these patients, with an intern in the room to interject if necessary. The interns do not decide your grade! There’s no reason to hold back questions or ideas because they might “seem stupid.” Trust us; we’ve been there before and our only goals are to help the patient and help you to learn. You will give a presentation! Talk with Ms. Linda or one of the team members to help schedule it. It should be a case presentation, including a review of literature/pathology as appropriate, and should last approximately 45 minutes to 1 hour. You will be doing this in front of the residency as well as potentially staff, but we are easy-going and so this should not be a high-stress project.
Powerchart Tips! Cerner (Powerchart) is a relatively intuitive program that helps us to man age our patients. Ms. Susan should be able to set you up with a username/password within the first day or two, which
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will make your life much easier. If you haven’t hav en’t used it before, ask ask one of the members of the team to give you a quick tutorial on how everything works. The most important tabs for you are: ● Dynamic Doc - this is where you’ll see notes written about the patient. Two quick tips are to toggle back and forth between “All Notes” to see PT/OT, speech therapy, the rapy, nursing notes, and “Physician Notes” to easily find consultant reports amongst the clutter. ● Results Review - pretty self-explanatory; self- explanatory; the “Labs” tab will allow you to look at all labs from admit to the current date which is useful. Microbiology can also be found under this tab. “Radiology” can be found in the results review as well.
Hospital Locations ● Inpatient Routine - if the patient doesn’t fit any other category categor y ● Inpatient Telemetry - if the patient is more acute, or has one of the following conditions ○ Anemia with bleeding ○ Arrhythmia (unless chronic stable AFib unrelated to presentation)
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○ Hypoxia with continuous pulse ox ○ AMS if plenty of Tele beds available; otherwise, general floor with sitter/camera Critical Care - If the patient is more acute than Tele, or you/another doctor feel uncomfortable with them on the floor. If the nurse tells you that they “look like they need ICU” you should have strong reasons if you keep them on the floor. ○ When in doubt, use the “12/24-hour“12/24-hour-surprise” surprise” rule: if you wouldn’t be surprised in 12-24 hours that the patient was on pressors, intubated, or something else critical, they should be in the ICU. ○ Anyone requiring vasopressors, or who you believe is close to needing them ○ Anyone you have a high suspicion of crashing shortly (especially drug overdoses) ○ Anyone with hypoxic cerebral events (this fits into the above category) ○ Hypoxic failure potentially needing intubation soon. Skilled Nursing Floor - All patients who don’t need medication management or medical changes daily but don’t qualify for rehab. Potential P otential for up to 14 da ys here per insurance. insurance. ○ Longer IV antibiotics courses ○ PT for patients who can’t qualify for rehab Rehab - the cadillac of post-acute floors. Medically 100% 100 % stable, but require a large amount of rehabilitation in multiple modalities (e.g. physical, occupational, speech, swallowing, cognition). Must be able to tolerate rehab for 3 hours daily, so overly frail patients may not qualify. We are not primary here; neurology takes over and consults us. ○ Best example is the 40 y/o patient with a debilitating stroke that’s otherwise perfectly perfectly healthy. Work them hard and long lon g and try to get them back to ADL’s. LTAC - changing, new rules to follow. Possibility for long-term care for patients that require too much medical management for them to qualify for SNF. ○ Try to avoid this if possible. Good for maintaining care if it’s ours vs. an outside LTAC, but the nurses aren’t as well trained and aren’t as transparent with patient status so high risk for medication mishaps or benign neglect. ○ Trach/Vent, BiPAP, refractory respiratory failure ○ Long-term antibiotics (think the IVDU with osteo - can’t send them home with a PICC, so 6-8 weeks of IV antibiotics on LTAC) Geriatric Behavioral Hospital (GBH) - run by Dr. Sydney Smith, we are not primary here so we are consulted for medical management. We are also often consulted “for an H&P.” Depending on the attending we either do it or fight them, but it’s quicker & easier just do write the H&P.
Efficiency Tricks Favorite Orders How To: To favorite orders, type in the order that you want and select it. Change all the parameters you want (you can leave the supervising physician alone), but change priority,
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specimen type, indication, frequency, or whatever whateve r you want it to be. Before B efore you click “sign,” right click on the highlighted order and then “Add to Favorites.” You can create folders to organize them (highly recommended), and develop ease of access this way. Good luck! Favorite Dailies ● CBC Daily (Ordering this and you need to check it ; you shouldn’t always order this!) ● BMP Daily (Ordering this and you need to check it ; you shouldn’t always order this!) ● CMP Daily (Ordering this and you need to check it ; you shouldn’t always order this!) ● HgA1c 1x, routine ● Magnesium level 1x, routine Electrolyte Repletion ● MgSO4 2g IV, routine (This is the standard to replete Magnesium) ● KCl 40mEq oral tablet (Remember, this is a horse pill! p ill! Not for patients with dysphagia!) ● KCl 40mEq oral liquid (Remember, this tastes awful!) Hyperkalemia (Or utilize the power plan) ● Albuterol 2.5mg/0.5ml, 10mg, Stat nebs over 1 hour ● Insulin human regular injection 10 units ● D50, 50cc vial (“1 amp”) ● Kayexalate 30mg oral suspension (Remember, this causes diarrhea! Warn your patients to avoid making enemies!) ● Patiromer 8.4g packet (Doesn’t cause diarrhea, but takes slightly longer to work ) ● Sodium bicarbonate 8.4%, 50mEq injection Supportive Care Package ● Supportive Care, routine, end-of-life care ● Pet therapy ● Pastoral Care therapy PT/OT ● PT Consult, routine, daily (Remember not to just order it Mon-Fri!) ● OT Consult, routine, daily (If you consult PT, you must always consult con sult OT!) Pain Control ● Tylenol 1,000mg q8 scheduled, not PRN (controls baseline pain better) ● Oxycodone 5mg q4h PRN
Plans for Workup (Remember, this isn’t an excuse to avoid thinking about what you’re ordering!) AMS ● Ammonia level ● B12 level ● CT Head w/o contrast
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● ● ● ● ● ●
Urine stat drug screen (cath) LDH MRI Brain w/o contrast RPR, serum Tylenol level B1 level
Anemia (Remember to check these before transfusion ! Afterwards they’re meaningless) ● B12 level ● Ferritin ● Iron/TIBC, % Sat ● Folate level ● Occult blood, feces Hypercoagulable Workup ● Cardiolipin antibody screen ● Factor V (5) leiden ● Lupus anticoagulant, dilute russel ● MTHFR DNA mutation ● Protein C ● Protein S ● Prothrombin gene mutation 20210A Liver Workup (Remember, it doesn’t have to be a zebra! Are they drinking? Are you sure?) ● AFP ● ANA screen ● Banana bag (w/ NS) ● Banana bag (w/ D5 ½NS) ● Ferritin ● Iron/TIBC, %Sat ● Hepatitis panel Unknown Sepsis (Obviously more thought goes into this, but for stat labs on your way to assess a patient this improves efficiency) ● Blood culture, 2x instances, 10 minutes apart ● DX chest 1 view portable ● Lactic acid ● Respiratory culture (endotrachial tube) ● UA - Cath sample (Remember, if they’re female >50 they the y need a cath or it’s no use!) Clinical Pearls (General) Common Medications by System “The young physician starts life with 20 drugs for each disease. The old physician finishes life with one drug for 20 diseases.” - Osler
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Heart Failure ● Metoprolol Succinate - Start 12.5mg, Max 200mg - Once daily ○ Titrate to pre-syncope or bradycardia <50, then back off. ● Metoprolol Tartrate - Start 12.5mg, Max 200mg - Twice daily ○ Titrate to pre-syncope or bradycardia <50, then back off. ● Carvedilol - Start 3.125mg, Max 25mg - Twice daily ● Lisinopril - Start 5mg, Max 40mg - Once daily ● Valsartan - Start 40mg, Max 320mg - Once daily ● Furosemide/Lasix - Start 20mg, Max 80mg(-ish) - Twice daily ● Spironolactone - 25mg - daily ● BiDil (Hydralazine/ISDN) - 37.5-25mg - Three times daily Max the beta blocker and the ace inhibitor before adding spironolactone or BiDil. Do not titrate Spironolactone or BiDil in heart failure.
Coronary Artery Disease ● Metoprolol Succinate - Start 12.5mg, Max 200mg - Once daily ○ Titrate to pre-syncope or bradycardia <50, then back off. ● Metoprolol Tartrate - Start 25mg, Max 100mg - Twice T wice daily ○ Titrate to pre-syncope or bradycardia <50, then back off. ● Carvedilol - Start 3.125mg, Max 25mg - Twice daily ● Lisinopril - Start 5mg, Max 40mg - Once daily ● Valsartan - Start 40mg, Max 320mg - Once daily ● Aspirin - 81mg or 325mg - Once daily d aily ● Rosuvastatin - 10mg low, 40mg goal - Once daily ● Atorvastatin - 20mg low, 80mg goal - Once daily ● Copidogrel (Plavix) - 75mg - Once daily Everyone with CAD needs to be on Asa, Statin, beta-blocker, and an ACE-i. Other meds are used for anti-anginal property or HTN control.
HTN ● ● ● ● ● ● ●
HCTZ - 25mg - Firstline, Causes electrolyte abnormalities Lisinopril - 40mg - Causes hyperkalemia, angioedema, cough Valsartan - 320mg - Causes hyperkalemia, more expensive ex pensive than Lisinopril Amlodipine - 10mg - Anti-anginal, most expensive cheap HTN med Labetalol - 200mg tid - Useful in ESRD Spironolactone - 25mg - Only if other options have been tried Clonidine - 0.1-0.3mg - Terrible antihypertensive; causes rebound HTN, can treat withdrawal - get patients off of this ● Labetalol - 10mg IV - Only inpatient, obviously; obv iously; for PRN control ○ Don’t use PRN’s unless patient is having side effects ● Hydralazine - 10mg IV - Only inpatient, obviously; ob viously; for PRN control ○ Don’t use PRN’s unless patient is having side effects
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Hospital goal: <180/110
Clinic Goal: varies, but generally <140/<80
COPD ● Albuterol - 90mcg - PRN ● Tiotropium (Spiriva) - 18mcg - Once Daily ● Budesonide/Formoterol (Pulmicort) - It’s a disk, puff twice daily ● Fluticasone/Salmeterol (Advair) - It’s a disk, puff disk, puff twice daily ● Prednisone - 40mg - PO, only during exacerbations ● Albuterol/Ipratropium (DuoNebs) - 2.5/0.5mg - q4h PRN SOB ● Methylprednisolone (Solumedrol) - 125mg IV ● Doxycycline - 100mg PO bid Recognize that the same meds med s used in the outpatient setting are also used for inpatient exacerbations. You just add on more when an exacerbation happens. To get inpatient criteria, use solu-medrol. No increased effect from IV vs. PO steroids DPE-4 inhibitors exist; try to use them in severe COPD patients.
Asthma ● All the same medications as COPD ● Magnesium - 2g IV - Salvage, if in status asthmaticus ● SubQ Epinephrine - 0.1mg SubQ - Salvage, if concern for respiratory failure
Constipation ● Colace/Docusate - 100mg bid - Stool softener, opiate prophylaxis ○ Suppository - takes 15-30 minutes for onset of effect ● Senna - 8.6mg bid, 17.2mg bid - Pro-motility, opiate prophylaxis ● Senna-S - Combination of Colace/Senna - Can cause melanosis coli ● Apple Juice - Firstline in children, sugar osmotic ● Prunes - Castor oil derivative (motility agent), fiber, and sugar osmotic ● Lactulose - 20mg/30mL PRN - Motility, acute constipation con stipation (Less effective than miralax with more bloating and discomfort) ● Milk of magnesia – magnesia – magnesium magnesium stays in, watch for hypermagnesemia h ypermagnesemia in renal failure patients ● Amitiza (lubiprostone) – (lubiprostone) – chloride chloride channel activator ● Linzess (linaclotide) - expensive (72mg & 145mg doses must be diagnosed with “CIC” 290mg must be diagnosed with “IBS“IBS-C” to be covered) ● Relistor (methylnaltrexone) - Opioid receptor partial agonist, useful for narcotic-induced constipation ● Other Strategies ○ Your Finger - Disimpaction - Scoop the poop & stimulate the bowel.
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○ Enemas - Fleet < soap suds enemas for strength - Nurse driven, loosens up stool. Uncomfortable with patients; never order without telling them them you’re ordering it. Emesis ● Ginger supplementation - whatever dose, whatever route - It won’t hurt them, but it probably won’t help them either. ● Diphenhydramine - 25mg - Dehydrates them subjectives, makes them loopy (especially elderly), and may or may not not help their nausea. May not be ideal, but it’s cheap and available OTC. ● Scopolamine Patch - same as above, but longer acting for prolonged nausea. ● B6 w/ Doxylamine (Diclegis ) - Useful in pregnancy, pregnanc y, available OTC in places ● Reglan - Useful if concerned about low lo w motility, gastroparesis - increases absorption of lithium however ● Ondansetron (Zofran) - 4mg IV, 8mg PO - If refractory nausea, can schedule this when inpatient and use Phenergan as PRN. ● Promethazine (Phenergan) - 12.5mg IV, 25mg PO (6.25mg if frail & small) - mind altering; best med for breaking already-established nausea cycle. ● Dexamethasone (Decadron) - 8mg, 10mg - When nothing else will work; many systemic effects but it is effective. ● Trimethobenzamide (Tigan) - 300mg PO, 200mg IM - cannot be given IV, only IM. does not prolong QTc; all others do. Strength increases as you go down the list.
Opiate Withdrawal ● Tramadol 50mg q8h - Opiate Agonist ● Valium 5mg q8h - Distress (Be cautious with this) ● Bentyl 10mg q12h - For GI cramping ● Imodium 2mg PRN - For diarrhea ● Clonidine 0.1mg q12h - For autonomic instability (be cautious with this) Obviously after an addiction medicine consult is put in, if available.
Appetite Stimulants ● ● ● ● ●
Megace 400-800mg daily - Caution against high incidence of DVT Periactin - Useful for depression too Marinol - 5-10mg bid - Useful for nausea as well Mirtazipine (Remiron) - Useful for nausea too Oxandrolone (Oxandrin) - 2.5-20mg in divided doses do ses 2-4 times daily - Limited course of 2-4 weeks ideally - Boxed warning of o f hyperlipidemia, liver cell tumors, & peliosis hepatis
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Clinical Pearls (System Specific) Pain Control The World Health Organization developed an Analgesic Ladder in 1986. Unfortunately the world has changed since then with the prevalence the prevalence of narcotics, and the original didn’t take into consideration patients who were critically ill. This is a revised non-neuropathic Analgesic Ladder for inpatient care, with caveats.
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Tylenol: ● Healthy patients can (should) get 4 grams daily dail y without harm. ● Unhealthy or elderly patients can (should) get 3 grams daily without harm. ● Cirrhotic patients can (should) get 2 grams daily without harm. h arm. ○ Tylenol is less harmful than NSAIDs in cirrhosis, and is preferred by hepatologists. ● When on the Analgesic Ladder, giving opioids by themselves (instead of mixed formulations of opioid/acetaminophen mixtures) is easier to titrate the opioid and allows for higher doses of Tylenol ● IV Formulation is available intermittently; don’t abuse this. this. Just because you can order it IV doesn’t mean you should. Only for if patient is hard-NPO hard-NPO (aspiration risk; comatose), and suppository route is unavailable (rectal tube, colorectal surgery, skin breakdown/fractures in pelvis). ○ It does have benefits to offset the increased cost: cost: ½ hepatic “first“first- pass” pass” metabolism, so safer in cirrhotics & elderly. Opioids ● Morphine ○ 1mg IV = 3mg PO ○ More likely to cause itchiness, nausea than newer new er synthetic opioids ○ Half-life 2-4 hours; longer dosing will leave gaps in analgesia ○ Board question answer: answer: use this to control “air hunger” in hospice patients ● Hydrocodone ○ 1mg Hydrocodone = 1 Morphine Equivalent
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○ Can only be obtained in “Norco” - Hydrocodone w/ Acetaminophen ○ Double-blinded patient trials have shown equivalent analgesia an algesia between hydrocodone & oxycodone ○ Half-Life 7-8 hours; still dose q4-6 hours Oxycodone ○ 1mg Oxycodone - 1.5 Morphine Equivalent (despite the last point above) ○ Can be obtained on its own as well as in mixed “Percocet” and “Vicodin” formulations ○ Useful when using the Analgesic Ladder ○ Half-Life 3-4 hours; dose q4-6 hours Hydromorphone (Dilaudid) ○ 1mg Dilaudid = 4 Morphine Equivalents ○ 1mg IV = 5mg PO ○ Typically what the ED uses as it avoids wasting time with re-dosing or titrating; if possible, de-escalate from this when admitted ○ Half-Life 2-3 hours; dose q4 hours, but flexible in this Fentanyl ○ 1mcg Fentanyl = 2.4 Morphine Equivalents ○ Given IV frequently intra-operatively ○ Half-Life: varies depending on dosing. ■ IM - 1-2 hours ■ IV - 0.5-1 hour ■ Transdermal - up to 72 hours from patch removal depending on adiposity, duration of use, etc. Methadone - Requires a special license to prescribe which we don’t have. Extended Release ○ OxyContin - “Contin” for “continuous”. Extended release; dose bid ○ MS Contin - “Contin” for “continuous”. Extended r elease; elease; dose bid ○ Fentanyl Transdermal - useful for hospice when patients p atients are in pain but cannot swallow reliably ○ Buccal Patches (Primarily given by pain management manageme nt as outpatient); dangerous due to exceedingly long half-life. Musculoskeletal Pain
● Do NOT start narcotics in these patients unless a fracture is present. Instead, u tilize the following: ○ NSAIDs (see below) ○ Lidoderm Patches ○ Hot packs/Warm compresses ○ Physical therapy ○ Muscle Relaxants ■ Flexeril - first-line but causes delirium ■ Robaxin - Not always covered by insurance, least likely to cause delirium ○ Spinal Compression Fracture - Calcitonin ■ 200u intranasal alternating nostrils is cheap, but off formulary. ■ Subq injections are outrageously expensive, but on formulary. 28
○ Post-Dialysis Cramping - Carnitor (L-Isomer) - dosed after dialysis NSAIDs ○ Aleve, Ibuprofen, Advil - Firstline, OTC ○ Motrin (Ibuprofen 800mg), Naprosyn (Naproxen 500mg) - Prescription-level ○ Ketorolac (Toradol) - Only useful IV/IM. 10-15mg is EQUALLY EFFECTIVE as 30-60mg. 30-60mg. Don’t overuse this, as the only effect will be worse effects on kidneys. kidne ys. ○ Etodolac (Lodine), Nabumetone - NSAIDs - NSAIDs that patients aren’t familiar with, with, so useful in the ED. ■ “We can’t give you normal narcotics, but this Lodine (rhymes with codeine) is VEEEEERRRY strong so be caref ul ul with it!” Neuropathic Pain ● Neuroleptics in general are useful in a ⅓:⅔ distribution: distribution: ⅓ of the total daily dose in the AM, ⅔ of the total daily dose in the PM. Improves sleepy & tolerance of higher doses. ● Gabapentin (Neurontin) ○ Causes peripheral edema, somnolence ○ Technically an antiepileptic drug, so abrupt withdrawal of high doses is dangerous ● Pregabalin (Lyrica) ○ The big brother to Gabapentin. ○ Head to head trials show no change in efficacy ○ Most common cause of Prior Authorization headaches ● Amitriptyline (Elavil) ○ Effective for anxiety & migraines as well, which are common como rbidities Cardiovascular
CHF 1. Determine the type of heart failure: Heart Failure with Preserved Ejection Fraction (HFpEF) or Heart Failure with Reduced Ejection Fraction (HFrEF). Systolic vs. Diastolic CHF is a term of the past in modern mode rn journals. a. HFrEF Clues: S3, Prior Echo with Poor LVEF, Ischemic Coronary Disease b. HFpEF Clues: HTN, Tachycardia, Diabetes 2. If HFrEF, look for causes: Nonadherence to medications medi cations or diet (high salt), increase in blood pressure, renal failure, ischemia , arrhythmia, valvular disease, CV stress (infection, anemia, hyperthyroidism) 3. Begin Treatment: a. Rule out arrhythmia, MI, & renal failure b. If blood pressure is adequate, reduce the preload p reload with a diuretic or nitrates c. If blood pressure is still adequate, reduce afterload with an ACE-i 4. Optimize Long-Term Meds: a. Spironolactone, in NYHA Class III & IV (See RALES Trial)
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b. Beta Blocker: Carvedilol & Toprol XL are proven to be beneficial. Improves symptoms and decreases the risk of sudden death. d eath. Start at low dose, titrate up until patient is almost pre-syncopal or bradycardic, then go down one step c. ACE-i: Reduce afterload and inhibit the disordered myocardial m yocardial remodeling that leads to disease progression d. Diuresis: Loop diuretics such as furosemide & torsemide are frequently used, with bumetanide substituted for those on high doses. Metolazone can be added to augment the diuresis. This is for symptomatic control, however renal function and electrolytes must be checked regularly (and often potassium must be repleted) Note: BNP is released when the ventricles are stretched. All patients with reduced contractility contractility will compensate by increasing preload - thus, expect elevated BNP even in asymptomatic patients with poor contractility. Do not reduce BNP to normal, but instead manage symptoms. Use last asymptomatic point as a baseline. This is renally cleared and kidney failure can complicate the picture Further Reading: ● CONSENSUS - Enalapril reduced mortality (27%) in Class IV CHF ● VA CO-OP Hydralazine-Prazosin reduced mortality (38%) in CHF ● VHEFT (VA COOP 2) Enalapril superior to Hydralazine-Prazosin in CHF ● SOLVD - ACE-i decreased mortality (16%) in Class 3-4 CHF ● DIG - Digoxin decreased hospitalizations, but did not change chan ge mortality (pro-arrhythmic) ● RALES - Spironolactone decreased mortality (30%) in CHF ● Promise - Milrinone increased mortality by 36% ● MERIT - Mortality reduced by low-dose beta blockers ● COPERNICUS Carvedilol reduced mortality (RR 0.65) ● ELITE II - No difference between Captopril & Losartan ● MADIT II - AICDs improve survival in ischemic HFrEF < 30%
Pulmonary
Community Acquired (And other) Pneumonia Community Acquired Pneumonia This is a syndrome, not a diagnosis. It consists of pneumococcal pneu mococcal pneumonia in which the patient has fevers, rigors, and a unilobar consolidation on x-ray, x-ray, as well as atypical (or “walking”) pneumonias.
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A combination of Ceftriaxone with Azithromycin will adequately cov er the vast majority of these patients. Antibiotics only for 5 days, unless the patient is in the ICU! -Penicillin allergy? Discuss with the patient: approximately 90% of all PCN allergies are false, and third generation cephalosporins are so rarely cross-reactive c ross-reactive as for it to be a non-issue. -Bradycardia? Antipsychotics or SSRI’s on Board? Worries about QTc? Substitute Doxycycline in the place of Azithromycin -Want to use fluoroqinolones? Have a reason. Remember black box warnings exist for a reason. -DO get blood cultures. DON’T get sputum cultures cultu res (unless intubated, they’re meaningless) Atypical Patients -Ones with Gram (-) rods in a gram stain, patients with structural lung chan ges (bronchiectasis, COPD, etc.), or immunocompromised - consider adding Pseudomonal Pseudomona l coverage (specific betalactams such as Piperacillin-Tazobactam, or Cefepime. -Ones with End-Stage Renal Disease, IV Drug Use, recent influenza, or cavitary lesions seen on imaging should be covered for MRSA Non-CAP? Unsure what to call it? ● HCAP - no longer a diagnosis! No such thing as Health-Care Associated Pneumonia. ● HAP - Hospital Acquired Pneumonia. Occurs 48 hours h ours or more after hospital admission, with no sign of incubation at time of admission ● VAP - Ventilator Associated Pneumonia. Develops 48-72 hours h ours after intubation ● Aspiration - Alcoholic, Dementia, other Altered mental status - must differentiate between pneumonitis and pneumonia! Inflammation is normal after foreign body aspiration; only some people need antibiotics (Zosyn for IV, Augmentin for P O) How to assess these patients? ● CURB-65: Easy to remember, easy to assess with basic labs. Not as p recise. ED Favorite ● PSI: Most precise; if patient “looks well” then ABG pH can be estimated be estimated as normal. Requires more intensive labs/CXR/workup Core Measures: Cultures before antibiotics. Antibiotics before 6 hours. Oxygen assessment (SpO2, ABG). Smoking Cessation. Vaccines. Do all of these before the patient leaves the ED.
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● Welker JA, e. (2018). Antibiotic timing and errors in diagnosing pneumonia. - PubMed NCBI . Ncbi.nlm.nih.gov. https://www.ncbi.nlm.nih.gov/pubmed/18299488 ● Bhattacharya, S. (2018). The Facts About Penicillin Allergy: A Review. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3255391/
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GI “Liver Function Tests” 1. 2.
3.
4.
5.
6.
“Liver Function Tests” include bilirubin, albumin, & PT/INR - they demonstrate the function of the l iver, but frequently are used erroneously erroneously to mean “Liver Enzyme Tests” Liver Enzyme Tests include Aspartate Transaminase (AST) & Alanine T ransaminase (ALT) which are released from damaged hepatocytes a. AST is also found in other tissues & may be released by muscle injury (e.g. myositis, M.I.) b. ALT is more liver specific (think (thi nk “L” for Liver) Alkaline phosphatase (ALP) is an enzyme found in hepatocyte membrane and is elevated when there is a lack of bile flow (cholestasis). a. Gamma-GlutamylGamma-Glutamyl-Transpeptidase Transpeptidase (GGT) can confirm that it’s from liver, not bone, intestine, placenta, or kidney disease. High GGT without other signs/symptoms of liver disease means little. Questions to ask a. PMHx - Obesity, diabetes, HLD, HTN (all associated w/ NAFLD); cardiac or pulmonary disease; autoimmune or rheumatic disease; immunization status (specifically HAV & HBV) b. Medications - Including prescriptions & integratives (check https://livertox.nlm.nih.gov/ (check https://livertox.nlm.nih.gov/)) c. FHx - Hemachromatosis; Alpha-1 Alpha-1 Antitrypsin Deficiency, Wilson’s, HBV (vertical transmission) d. Social Hx - EtOH (CAGE questions), IV & other recreational drugs, sexual practices e. Country of birth (1/12 worldwide have chronic HBV or HCV) Assessment a. Repeating liver enzyme testing is not efficient - 84% of results remained abnormal after 1 month, 75% after two years. b. ALT and/or AST increase > ALP → hepatocellular trauma i. NAFLD is #1 cause of mild ALT elevation 1. N Nearly early ⅓ of the population may have ALT >30 for men or >20 for women, and this is usually due to NAFLD 2. AST 2-3x 2-3x ALT → be concerned for EtOH. This can also occur if the patient has cirrhosis -> check for thrombocytopenia, APRI (AST to Platelet Ratio Index) 3. If due to alcohol, NAFLD, or A1AT deficiency, ALT is rarely > 300 a. Look for coexisting liver conditions (viral hepatitis, autoimmune, or drug induced) c. ALP (confirmed w/ GGT) > ALT and/or AST → cholestatic pattern → you must get an ultrasound in this case. If bile If bile ducts are dilated, it’s extrahepatic. If not, intrahepatic cholestasis i. Extrahepatic → ERCP is often required for confirming diagnosis and to relieve blockage 1. Cholelithiasis, biliary stricture, PSC, worms/flukes, malignancy ii. Intrahepatic → order antimitochondrial antibody (AMA, positive in 95% of Primary Biliary Cholangitis), an MRI/MRCP to rule out Primary Sclerosing Cholangitis 1. Liver biopsy may be required to establish diagnosis 2. EtOH, PBC, PSC, sepsis/infections, TPN, congenital, cirrhosis, All patients with chronic elevation ele vation of liver tests should be assessed for liver fibrosis (liver bx or FibroScan) (alternatively: NAFLD Fibrosis score: http://nafldscore.com http://nafldscore.com))
Classification
Diagnosis
Screening
Confirmatory/Additional
Viral
HBV
HBsAg
HBVDNA, HBeAg, anti-Hbe
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HCV
Anti-HCV
HCVRNA, genotype
Toxin
EtOH
History (AST = 2x ALT; high GGT, high IgA)
Biopsy if uncertain
Metabolic
NAFLD
None
Biopsy if uncertain
Autoimmune
AIH
ANA, ASMA, high IgG (all non-specific)
Biopsy required for diagnosis
PBC
AMA (note: high IgM)
AMA is diagnostic
PSC
None (ANCA)
MRCP
HH
Fe/TIBC (TS) >45%, Ferritin >1000
HFE gene testing (C282Y)
A1AT
A1AT Level
A1AT phenotype (ZZ)
WD
Ceruloplasmin (low)
24h urine copper, slit lamp (KF rings)
Genetic
Mild-Moderate Hepatocellular Management
● ● ●
NAFLD - exclude other chronic liver diseases; control risk factors, weight loss, Vitamin E EtOH - CAGE; abstinence is essential Viral - Remember 1/12 individuals worldwide chronically infected with HBV or HCV ○ HBV, consider nucleoside/nucleotide analogues or pegylated interferon ○ HCV, confirm with HCVRNA, refer to GI for direct acting antiretrovirals ○ Acute hepatitis - tx w/ supportive care ● Drugs - Withdrawal of offending agent (re-challenge NOT recommended) ● Hereditary Hemochromatosis - 1/250 caucasians but limited penetrance; tx w/ phlebotomy ● A1AT Deficiency - 1/2,500; no specific treatment ● Autoimmune - 1/6,000, more common in women; tx w/ prednisone +/- azathioprine ● Wilson’s Disease - 1/30,000; tx w/ chelation with penicillamine or trientine and zinc Severe Hepatocellular Pattern
● ● ● ● ●
Drugs - Acetaminophen overdose is #1 cause of liver failure in North America - tx w/ NAC, follow INR, watch for encephalopathy (Call poison control for guidelines) Ischemia - Doppler U/S to look for clot of hepatic vein, tx w/ supportive care & anticoagulation if BuddChiari syndrome Autoimmune - see above Wilson’s disease - see above; will not recover without liver transplant Pregnancy - HELLP syndrome, tx by immediate delivery of the baby
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Medications Commonly Associated with Elevated Liver Transaminase Levels
●
Antihypertensives: ○ Lisinopril, Losartan ● Antibiotics: ○ Ciprofloxacin, Isoniazid, Ketoconazole, Pyrazinamide, Rifampin, Tetracycline ● Chemotherapeutics: ○ Imatinib, Methotrexate ● Analgesics: ○ Tylenol, Allopurinol, Aspirin, NSAIDs ● Psychiatric: ○ Bupropion, Risperidone, SSRI’s, Trazadone, Valproic Acid ● Other: ○ Acarbose, Amiodarone, Baclofen, Herbal/Dietary Supplements, HAART, Omeprazole
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GI Bleeds So the patient rolls into the emergency emergenc y room with a GI Bleed. “Is it upper or lower?” the med student asks you. “Unless they have hematemesis, there’s no way to know,” you astutely reply. “What should we order?” You gently pimp the student. “Well… ● 2 Large bore IVs (18 gauge or o r bigger) ● IVF Bolus of 1L Lactated Ringers or Normal Saline ● IV Protonix - No difference between 40mg IV bid and continuous infusions IV ● GI Consult - this is what will fix them; an EGD can be done while inpatient and they can stop any upper GI bleeds. Lower is less likely to be brisk, and thus more likely to be b e done at follow-up.” follow-up.” “And?” “If they’re cirrhotic… ● Add IV Rocephin & Octreotide” Seriously though, these are the patients that will crash from bleeding overnight. They’ll appear stable, and then have a coughing spell, and all of a sudden their pressure will be 60 over ov er doppler and the nurse will be asking if they the y should be transferred to the ICU. Here’s what you do. 1. Tell them to call the house rep and transfer them to the ICU 2. Tell them to call GI Stat and update them 3. Tell them what you’re going to put in, then put it in (it’s faster this way) a. 2-3u PRBC b. 1L Normal Saline or LR c. If giving >3u PRBC, call your attending. You will also start giving a ratio of 3u PRBC to 1u FFP to 1 unit platelets, platelets, so that you don’t dilute their clotting factors with the massive transfusion. d. You’ll get a CBC & CMP immediately e. You’ll get another CMP in 4 hours, to check their calcium after this massive transfusion. 4. THEN go to see the patient. If the nurse was wrong (rare, but it happens), cancel your orders. If they’re right, it’s worth the extra 15 minutes lead-time lead-time you gave them. Causes: Peptic Ulcer Disease most common, but also: posterior p osterior epistaxis swallowed, oropharyngeal lesions, esophageal varices, esophagitis, gastritis, Arteriovenous malformations, Polyps, Diverticulosis, Hemorrhoids, Malignancy.
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Renal CKD 1. 2. 3. 4. 5.
GFR: > 90 ml/min but with evidence of underlying disease GFR: 60-89 ml/min GFR: 30-59 ml/min - at this point patients should be getting referrals & co-managed by nephrology GFR: 15-29 ml/min - at this point all patients should be seeing a nephrologist GFR: < 15 ml/min (The aging process causes slight reduction in GFR; t his should not be classified as chronic kidney disease. Approximately 1mL/min is lost per year after age 40.) The two most common causes of renal disease are diabetes & renal disease, but also i nclude glomerulonephritis, hereditary diseases, & recurrent AKI. As it’s the result of a systemic disease, it’s it ’s important to assess that disease.
● ●
Patients with diabetes - Evidence E vidence of other end-organ damage should be assessed Patients with lupus nephritis or vasculitis - ask about flare symptoms sympto ms (joint aches, rashes, chest/pleuritic pain) - ask about any immunosuppressants they may be on ● Patients with nephrotic or nephritic syndromes - ask about swelling, shortness of breath, and hematuria ● Regardless of the cause, medication lists should be reviewed carefully Early CKD is typically asymptomatic, later stages (usually stage 4-5) warrant questioning for uremic symptoms
● ● ● Labs:
Have you had any new or persistent nausea or vo miting? Has your appetite changed? Are you still able able to do your usual ADL’s? Have you noticed fluid gains (swelling, unusual weight changes), shortness of breath, or difficulty breathing with just a small amount of exertion? Have you or your family noticed any episodes of confusion, concentration difficulties, or lack of energy?
●
BMP ○ Na - shows renal handling of water; Potassium is a direct end-point ○ Serum bicarbonate - shows acid loads ○ Anion gap - unmeasured anions ○ Serum Creatinine/BUN - indirect assessments of GFR ● Hg, Hematocrit, Ferritin, & Transferrin ○ To assess for extent of anemia, as well as underlying iron deficiency ● Vitamin D (25-hydroxyvitamin D), calcium, phosphorus, intact PTH levels ○ Bone and mineral abnormalities occur due to accumulation of phosphorous, reduced activation of Vitamin D, & development of secondary hyperparathyroidism ● Urine studies ○ Quantification of urine protein is important; reduction of proteinuria is a target for renal function ■ Goal of under 500-1000mg daily ○ Hematuria and an active urine sediment also suggest active inflammation, pointing to ongoing glomerulonephritis Referrals - Send to a nephrologist for evaluation i f:
● GFR < 30 ● Serum creatinine 1.5-2.0 ● A sustained decrease in GFR of 25% (or decrease of 15mL/min) or more within 12 months ● Uncontrolled hypertension ● Renal artery stenosis ● Need for renal biopsy Managing sequelae:
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●
Reduced clearance of solutes and generated acids increases the risk of edema, hyperkalemia, and metabolic acidosis, which may require the initiation of diuretics, bicarbonate supplementation, and dietary modifications ● Retention of phosphorous and reduced activation of 25-hydroxyvitamin D stimulate production of the parathyroid hormone, leading to secondary hyperparathyroidism. Though not acutely life threatening, this process disrupts ongoing bone and mineral metabolism and requires control of phosphorus (through dietary restrictions or phosphorus binders and vitamin D replacement. ● Anemia is also common - either from iron deficiency or reduced production of erythropoietin. In iron deficiency anemia, oral/parenteral iron supplementation of iron should be utilized. EPO-stimulating agents can be considered when hemoglobin levels fall below 10 g/dL. As the disease progresses, patients need to be educated on the various options available once ESRD occurs. Indications for initiating some form of di alysis vary depending on the nephrologist, but include acidemia, electrolyte disorders (most commonly, hyperkalemia), fluid overload, and uremia (nausea, vomiting, lethargy, confusion). Although patients may not develop these signs or have symptoms until their GFR reaches 10-15 mL/min, discussions should be initiated much earlier to provide ample time for decision-making and preparation.
●
Transplantation is often the most desirable solution but frequently the least attainable. Extensive pretransplant evaluation and education is necessary, as well as behavioral assessments for adherence to diet & adherence to anti-rejection meds. ● Dialysis which utilizes extracorporeal techniques to provide clearance of toxins and ultrafiltration of fluid the most widely used method of managing ESRD ○ In-center hemodialysis - strict schedule, few responsibilities and decreased non-adherence ○ Peritoneal dialysis - increased autonomy and independence, but requires absolute personal responsibility on the behalf of the patient for their treatment and care. ● Palliative care is an option for those who are either disinterested in being on dialysis or whose comorbidities limit the benefit they may gain from being on dialysis. di alysis. Management of such patients focuses on making sure symptoms are controlled and the patient is as comfortable as possible. Cockgroft-Gault equation is based on approximately 80 patients in the VA (no women included), and it was used to approximate creatinine clearance. Thus, it yields an approximate of an approximate.
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Urinary Retention & Foley Catheters
If you’re concerned about the patient having urinary retention, do a bladder scan. There aren’t exact numbers about when to do an in & out catheter vs. to place a foley, because you have to take the whole patient into consideration. When in doubt, 350 cc’s is approximately a coke can, and that amount can get uncomfortable if the patient is unable to void it. A rule of thumb is to trial an in & out catheter once or twice before placing a foley, but some patients can have in & outs with scheduled bladder scans for several days. Look at the patient’s medication list for meds that might that might make voiding more difficult. ● Benzodiazepines ● Narcotics - not just fecal stasis! stasis! ● Anticholinergics - especially in the elderly, but affects everyone If you insert a foley into a patient because be cause they are having retention, you should also start Tamsulosin (0.4mg daily). The only exception is if their blood pressure cannot handle the slight decrease. If the patient’s discharge is coming soon (as an aside, you should never be surprised by by a patient’s discharge), they need to have a voiding trial at a minimum minimum once the day before discharge. Sending someone home with a foley is a recipe for disaster, especially in patient populations where being lost to follow-up is more common. Reasons to start a foley catheter: ● SIGNIFICANT skin breakdown (not just a single sacral decubitus ulcer, n o matter the stage) ● Urological procedures ● Urinary Retention Reasons to NOT start a foley catheter: ● “Because they’re in the ICU” - unless on pressors, volume status can be assessed without pinpoint I/O accuracy; they don’t need another nidus for bacteria ● “Because they’re bedbound” - unfortunate for the patient, but I can all but guarantee that they’d rather have to use a bedpan or even a pad than to get an infection or sepsis from UTI ● “Because they have an ulcer” - they should use a bedpan or their pad should be changed! ● “Because they prefer it” - unless they’re in hospice they can deal with it. This isn’t a hotel ● “Because they’re female” - this isn’t the 1800’s ● “Because they’re diuresing” - use weights, instead!
Endocrinology DKA/HHS 1.
Type 1 diabetes (DM1) occurs by autoimmune destruction of beta cells
41
2.
3. 4. 5.
6. 7.
8.
9.
10.
a. Occurs at any age b. Typically lean body type & normal lipid profiles Type 2 Diabetes (DM2) a. Typically obese & insulin resistant b. Eventual fat deposition in pancreas destroys insulin pro duction 15-20 years after onset of DM2, leading to absolute insulin deficiency Triad of DKA = Hyperglycemia, Ketonemia, Acidemia Primary rule of DKA - Follow an Algorithm DKA occurs with total lack of insulin → inability to utilize glucose a. Simulated starvation occurs, and counter-regulatory hormones kick in b. Free fatty acids are broken down for fuels c. Keto acids are made as a byproduct, leading to acidemia DKA can occur in DM2 if overwhelming infection or infarction (MI or CVA), but even a little insulin can prevent true DKA. Dehydration is a cardinal issue in DKA from osmotic diuresis a. Serum glucose >180 & the nephrons can’t resorb glucose → glucosuria → osmoti c loss of fluids b. Frequently up to 6-8 liters down Ketones a. Beta-hydroxybutyrate (BHB) is the predominant ketone in DKA b. Urine ketones measure acetoacetate (strongly) & acetone (weakly), and can’t measure BHB at all c. Best blood test is direct beta hydroxybutyrate if available Chronicity of Insulins a. Insulin drip - insulin is out of the patient’s system within within minutes of the drip being stopped b. Subcutaneous insulin - depends on type; can “stack” if repeat doses given SGLT2 Inhibitors (Farxiga, Jardiance, Invokana) can lower blood glucose in the absence of insulin leading to possible “euglycemic DKA”
Outpatient Management! 1. Sick Day Rules! a. Type 1 Diabetes i. Early contact with the healthcare team ii. Reduce, but do not discontinue insulin during the illness 1. Instead, drop basal insulin by 20% whether subQ or basal rate on pump 2. Keep mealtime insulin dose the same, but skip if not eating iii. Check frequent fingersticks iv. Use antipyretics to manage fever, push the fluids v. Educate family members about signs/symptoms of DKA Basic Algorithm: ● Fluids: 2L Bolus, then NS (250/hr) [usual deficit is 100-200 cc/kg, or an average of 9L in adults] ● Insulin drip (only after K+ is > 3.3 ● Labs: Q1 AccuChecks, Q4 bmp, replete K+ aggressively ● After Glucose drops below 200, change fluids to D5 ½NS w/ 20KCl @125 ○ Give amps of D10 if necessary to avoid hypoglycemia ● When Anion Gap closes, add basal insulin (subQ) so that it overlaps 2 hours with drip ● After 2 hours: Discontinue D5 ½NS, add SSI, restart NS if not eating, & transfer out of unit
American Family Practice Algorithm
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Assistance: ● AACE Type 2 Diabetes Management Algorithm 2016 - App for iPhone
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Neurology CVA At many hospitals, typically these patients are identified by ER staff and neurology is called at the same time or even before we are. In the real world, you may be diagnosing this. Look up the NIHSS (National Institute of Health Stroke Scale), familiarize familiarize yourself with it, and use it to quantify sx. Diagnosis/Calculation apps frequently have NIHSS add -ons to use “in the moment” Core Guidelines: For each, if it isn’t documented in at least one note it didn’t happen! 1. VTE Prophylaxis - like all other patients , must have venous thromboembolism prophylaxis on board or a reason why all forms are contraindicated documented. 2. Discharged on Antithrombotic Therapy - Aggrenox, Plavix, or Aspirin 3. Anticoagulation Therapy for AFib/Flutter - must be on anticoagulation (Coumadin or a NOAC), unless directly contraindicated. If contraindicated, this must must be documented. 4. Thrombolytic Therapy - Largely out of our hands, h ands, however tPA window of 3 hours within onset (4.5 if witnessed ) vs. thrombolytic therapy (direct intravascular tPA administration) which can be performed by IR vs. neurosurgery neu rosurgery within 12 hours. 5. Antithrombotic Therapy By End of Stay - Refer to point 2. Start before discharge. 6. Discharged on Statin - the technical guidelines are an LDL of >100 (>70 if concomitant DM), or if lipid panel is not performed. In reality? You need to have a good goo d reason to not put every single patient on high-dose statin therapy by discharge. 7. Dysphagia Screening - largely a result of nursing intervention; part of the powerplan for admits. Nursing bedside bedside swallow & documentation works, but if they fail fail they need a speech therapy eval (for more information, look at the “Burke Dysphagia Screening”). 8. Stroke Education - Discuss risk factors, long-term effects, prevention, and follow-up 9. Smoking Cessation/Advice Counseling - Patient needs documented cessation counseling (At some hospitals, there is a smoking cessation team you can consult) 10. Assessed for Rehabilitation - All stroke patients should have some combination of Physical Therapy, Occupational Therapy, or Speech Sp eech therapy ordered. Typically the first two on all patients, and Speech Therapy only as necessary. Additional Pearls ● New evidence suggests SSRI’s improve outcomes both in depressive patients (approximately 40% of acute CVA patients) AND non-depressive non -depressive patients alike. ● No specific blood pressure control; for 24-48 hours utilize guidelines for for permissive HTN ○ Ischemic stroke: Keep BP < 220/120 for 24-48 2 4-48 hours, then use oral medications medica tions ○ Hemorrhagic Stroke: Keep BP < 160/80 to avoid exacerbating the bleed
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Documentation CMS Documentation Pearls What you mean to say → what you should write down 1. Infectious process → sepsis or not sepsis? 2. Urosepsis → sepsis secondary to UTI 3. Altered Mental Status (AMS) → Acute Acute Encephalopathy 4. AKI → Acute Renal Failure 5. Nausea and Vomiting → Intractable nausea and vomiting 6. Pain → Intractable pain 7. Failure of outpatient therapy → failure of outpatient therapy 8. The patient is getting better → resolving 9. The patient’s better → resolve resolve 10. The patient’s getting worse → worsening 11. The patient’s probably going to die → Prognosis Pro gnosis is grim/critical/poor a. Never be the last one on a case to put this in a note, unless you know you’re right. 12. Any reason that they’re going to need oxygen, at any time, for any reason → acute hypoxemic respiratory failure 13. Retaining CO2 → Acute (or chronic) hypercapnic h ypercapnic respiratory failure 14. Low albumin (<3) → Moderate protein calorie malnutrition 15. Really low albumin (<2) → Severe protein calorie malnutrition 16. The patient is weak → debility 17. The patient is weak and from the ICU → Critical Illness Myopathy 18. CHF exacerbation → Acute vs. Chronic vs. Acute on Chronic, systolic vs. diastolic vs. combined heart failure, with vs. without exacerbation. Include LVEF 19. If the troponin is elevated elevated and you think it IS an NSTEMI → NSTEMI 20. If the troponin is elevated and you think it ISN’T an NSTEMI → demand ischemia Keep in mind that whatever you write in the discharge summary overrides and trumps everything you wrote, every day, for the entire stay. ***If they have something on day da y one (“sepsis”) they must have it on the discharge summary or they never had it at all*** The medical documentation people who will page and send queries are trying to help you, trying to help the hospital, and trying to help the patient get things paid for by insurance. They have a hard job, so be nice to them and answer their queries quickly with polite language. Include the dot phrase “ - thank you for your help resolving this, please let me know if there’s anything anything else we can do to t o clarify!” into your set, and after responding to each e ach query put that in.
Get the discharge summary right with the right CMS language! Dot Phrases
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Histories & Physicals Chief Complaint: This is not a diagnosis. This is not a differential. This is what brought the patient to the emergency room or to the clinic. Use their quotes if necessary.
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HPI: Use whatever acronym you need – need – some some schools teach “FARCOLDER” (Frequency, Associated sx, Radiation, Consistency, Onset, Location, Duration, Exacerbating/Relieving Ex acerbating/Relieving factors), other schools teach other methods. Whatever you use, be consistent and get the necessary information. For ALL patients: document tobacco/ethanol/drug history, the name of their PCP, and the name of their relevant consultants (even if they’re not being consulted! If a CHF exacerbation comes in they don’t need derm, but bu t they may need pulmif they need n eed respiratory support). Document living situation if at all possible! Living at home? ADL’s? This doesn’t matter in the hospital but makes discharge SO MUCH EASIER. Physical Exam: Be thorough with this. Even if you copy/past further exams (which you shouldn’t do), do ), don’t use a dot phrase. Include absolutely everything, uncover uncove r all bandages, assess all signs necessary. This is the reference for the entire hospital stay, so you’d better be sure you document accurately. Assessment: This is not the same as the chief complaint! This is your evaluation of good/stable/poor/critical condition, their #1 diagnosis, and anything incredibly pertinent. -Family involved? Get their phone numbers, and PUT THEM IN THE A/P with names! -Be thorough with this, but keep in mind that someone will be using this as a template for future progress notes. Don’t write unnecessary unnecessary paragraphs about what may happen if and when X, Y, or Z happens. Tomorrow is another note. Daily Documentations -Document their DVT prophylaxis! (And double-check double-check it! Nobody should be on SCD’s with Lovenox, or Heparin with Xarelto, and very few should be on absolutely nothing) -Either don’t document their diet, or be prepared to update it when it changes. One or the other. -Document their disposition. Hint: it’s not “good.” Their disposition is “pending improvement from respiratory standpoint” or “pending establishment of home health” o r “after last dose of ABx on X Date.” “Anticipate discharge tomorrow” or “pending approval to SNF/Rehab” is acceptable too. Let others reading your note what you’re expecting to happen. -Code status. Whether admitted for a hip fracture or an AKI, you MUST have the conversation and must document it both within the H&P as well as put the order in. This is discussed elsewhere. Discharge Summaries Perfection is the enemy of the Good. Discharge summaries need to be done within 48 hours. That’s not an exaggeration, no matter what other o ther residents say it is not an acceptable practice. You are being paid for the work you do, and it impedes medical care if these aren’t completed. Notes for Follow-Up is the most essential essential piece of this documentation. Delineate exactly what needs to be done in the clinic. If the patient was anemic? Write “Check CBC for anemia.”
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If they were non-adherent non-adherent to their meds? Write “review med list & check che ck compliance.” You get the idea. “Discharge Summary: Patient Name: Admission/Discharge Date: Admit: Discharge: Attending Physician: Dr. Dictated by: Primary Care Physician: Dr. Consulting Physician(s):
Final Diagnosis: .diagnosis_dis
Procedures/Laboratory/Data:
History of Present Illness - Please see H&P for further details "" Hospital Course
Notes for Follow-Up:
Discharge Medications Please refer to discharge medication reconciliation for full list Discharge Instructions: Patient to maintain regular diet, with gradual return to unrestricted activity as tolerated. Discharged to home, in stable condition. Follow up Appointments:
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Patient to follow up with XXXXX within 1 week Return to ER if: Temperature over 101, persistent nausea or vomiting, v omiting, or unable to tolerate food”
Codes & End of Life Conversations Patients tend to overestimate their chances of surviving arrest b y 60.4% on average. Per the American Heart Association: In 2016, approximately 24% of all adu lts with In-Hospital Cardiac Arrest survive to discharge. No statistics on morbidity and long-term disability. This is for ALL patients - not just the 80-year-olds with multiple co-morbidities co-morbidities like our patients. First: When admitting a patient in the emergency room, you should ask them what their code status is. If they’re going to the ICU, you need to ask them what their code status is. If they’re
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psychotic, altered, unconscious, or insensate then it should be done within 24 hours of the patient becoming alert & oriented. “If the worst case scenario were were to happen and your heart were to stop beating, meaning that you were dead, would you want us to push on your chest knowing that it would break your ribs, to try to revive you?” “ resuscitate but do not intubate.” If they say this, it is your job to Note: There is no such thing as “resuscitate educate them that there is a negligible chance of success without respiratory measures, and while intubation doesn’t mean they’ll be stuck on a ventilator, we cannot in good conscience resuscitate them without helping them breathe too. Next: Put it into the chart. The order is “Do Not Resuscitate” or “DNR” (regardless of the outcome of the conversation). If the patient’s on Tele, T ele, select “Treat Stable Dysrhythmias” - even if the patient is Do Not Resuscitate, that doesn’t mean that they’re ‘Do Not Treat.’ If they end up up with a short run of VTach, or slip into AFib w/ RVR, they deserve to be treated too. Lastly: document the conversation. At the bare minimum put an addendum to your note that their code status is “Do Not Resuscitate” or “Allow Natural Death” Chan PS, Krumholz HM, Nichol G, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med . 2008;358:9-17. Meaney PA, Nadkarni VM, Kern ● KB, Indik JH, Halperin HR, Berg RA. Rhythms and outcomes of adult inhospital cardiac arrest. Crit Care Med . 2010;38(1):101-108. Quill TE, Arnold R, Back AL. ● Discussing treatment preferences with patients who want “everything.” Ann Intern Med. 2009;151(5):345-349. Tulsky JA. Beyond advance ● directives: importance of communication skills at the end of life. ●
JAMA. 2005;294(3):359-365.
Death Pronouncements As a courtesy to the hospitalists, from 1700-0700 we pronounce death in all patients pa tients that pass away. Of course this only includes the patients who were previously DNR, as if a code was run the physician in charge will put in a code note & a death pronouncement if necessary. If it’s our patient, we will pronounce them whenever they pass. When called, this is a priority. If you have a patient crashing and need to be there then let the nurse who calls know, but ideally you should be pronouncing death within 10 minutes of receiving the call. This is both for logistical purposes of clearing up beds as well as humanistic purposes because frequently the patient’s family will be there and unable to start processing/accepting things until they hear it from a physician. Their doctor may or may not
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have prepared them in the slightest, they may have seen this coming for years or be totally broadsided by it. When called by the nurse, ask the patient’s name and bed number to confirm . Ask if there’s family at bedside so that you can prepare yourself, make sure you have a stethoscope & pen light, and go assess. Talk to the family, if there. You don’t have hav e to give specifics, but explain what wh at you’re there to do. “Hello, I’m Dr. X. I’m here to do one last exam on your loved one. That will consist of me calling their name, listening for their heart, and shining a light in their eyes. You can stay if you’d like, or you can step into the hall - whichever will make you more comfortable.” After the exam, put the note in right away. Save a death pronouncement dot phrase so you don’t have to think of what to say in the middle of the night or when you’re a little shaken up by your patient passing away. Make sure to note the time that you were called and the time that you performed the exam. Forward the note to the patient’s attending for for co-signature. co-signature. If it’s not our patient, our attending shouldn’t sign it.
“I was called to bedside at XXXX by b y the RN for a change in status. When I arrived, patient patient appeared to have passed away. On exam, the patient was unresponsive to both name and painful stimuli (sternal rub). Patient was noted to be pulseless (by both palpation and auscultation), apneic without breath sounds, and without pupillary light reflex. The patient was pronounced dead at XXXX.”
Program Logistics & Requirements ● Questions: ○ 30 AFP Board Review Questions per month. Take some time on an easy rotation (NICU, Ambulatory Peds), or on an overnight shift when it’s quiet, and knock these out. Do all of them and you’ll be covered for residency and get back up to speed from the “fourth year slump” ○ 5 American Board of Family Medicine (ABFM) Self-Assessment Modules (SAMs) per year. These are a pain in the butt to complete, but when you do make sure to make a document with all of the explanations because they’re the y’re very helpful. If you get a chance to do them all, do them all. In particular, Hospital Medicine, Diabetes, Hypertension, Pain Management, and Preventative P reventative Care will set you up
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○
○ ○ ○
well for residency (but they’re all good). Found at: https://portfolio.theabfm.org/Login.aspx?ReturnUrl=%2fMCFP%2fModules.aspx %3ftab%3dsam&tab=sam Log all procedures. Just do it. It’s aggravating but it’s better than getting to the end of your residency having to make the tough call of whether to make something up or Log your patients, as necessary. Not during inpatient inpati ent months thankfully, but just about every other rotation. Go to lectures. Don’t complain about the lack of education or feeling unprepared unless you’ve attended every single lecture possible. Go to your rotations. It’s your job, you’re paid you’re paid for it. it. It’s also for your benefit, and you’re you’re representing all physicians/your med school/your residency/all family physicians, so when you skip work you make them all look bad.
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Questions, Recourses, Life If you have any problems, know that you’re not alone. People have been through issues such as relationship issues, housing problems, deaths in the family, and “simply” struggling to k eep up with the workload. Be friends with your class, and rely on them - they’ll be the ones who most understand what you’re going going through. Meet up outside of work for a drink, for a walk in the park, for some board games, whatever. Make sure that you’re filling up your “social” tank outside the hospital. If that doesn’t work, ask your chiefs . They are your end-all, be-all for problems and concerns within the residency whether whe ther that’s interpersonal relationship troubles, rotation frustrations, or problems with staff. They are there to help you! Take time for significant others. If they’re in medicine, they ma y be struggling too. If they’re not in medicine, they may be struggling because they don’t understand what’s going on in your life. Remember why you do what you do and take care of yourself first, so that you’re in a good place pla ce to take care of others. Lastly, keep in mind that that mental health is an important part of life. A lecture le cture on “make sure you sleep” and “try to stay upup- beat” beat” won’t help when you’re on a 2828-hour call with a pager that won’t stop going off. Suicide risk for medical residents and physicians in general is significantly higher than that in the general population, pop ulation, and this can be attributed to lack of sleep, isolation, extreme stress, and focusing too much on others. If you’re struggling, please ask for help from the chiefs, from your clinical psychologist, or from an anonymous anon ymous line. The National Suicide Prevention Lifeline is 1-800-273-8255 - it’s not just for patients, or for “other people.” Take care of yourself. Be pro-active, pro-active, as well. If you’ve suffered from anxiety or depression in the past, that’s okay! You You don’t need to hide it, but do be aware that these months may bring those symptoms out again in force. If you’ve been on medication for this in the past, consider restarting or at least establishing with a physician in the area so that you can have that resource ready if life gets overwhelming. Many residents see other residents as their PCP, others see loc al internists, and your program coordinator can give you other recommendations if you want to get established.
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Bibliography This is not for publication or for profit, and so I shameless stole from multiple sources. They include, but are not limited to: ● Online MedEd Intern Guide, by Dustyn Williams, MD ● Tulane Internal Medicine: “The Wiese Book”, By Book”, By Weise, MD ● The House of God, by Samuel Shem, MD ● Precious Bodily Fluids: Musings of a Salt Whisperer, by Joel Top f, MD ○ E-mails with Dr. Topf ● UpToDate ● Curbsiders - Podcast & Blog http://thecurbsiders.com/ ● Various Lectures, Hospital Policies/Protocols, and Handouts
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