Acid-base problems

5 simplified steps to solving any Acid-base problem.

1. Look at pH to identify primary disorder... acidosis or alkalasis?  Note, if pH is neutral, look at clinical presentation if you need to suspect mixed disorder
2. Is the primary problem respiratory or metabolic? (respiratory changes pCO2 while metabolic changes HCO3)
3. Calculate the anion gap (AG).  If increased, patient has "gap" metabolic acidosis present.
4. Calculate the delta anion gap. DAG = AG calculated - AG normal (12).
5. Add DAG to HCO3

• if normal, no other metabolic problems present
• if <20 then hyperchloremic, metabolic acidosis is also present
• if >26 then metabolic alkalosis is present

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constipation (adults)

Constipation

-Inevitably, you will often get called in the middle of the night for this complaint

-Most people are on colace 100mg BID – this is basically fiber & does not help people once they are already constipated. It is not a bad thing to put people on when they get admitted to try to keep them regular, but not very effective overall.

-When you order things for constipation, order them standing, NOT prn…..otherwise the patients will only get it when they ask for it, at which point it might be too late. But you should put in the comments “patient may refuse.”

-The following is a list is in the order you can usually prescribe, but everyone has their own style…..
▪ Senna 17.2mg (2x8.6 tabs) PO q12, then q6
▪ Bisacodyl 10mg PO q12 (max 30mg/day) or 10mg PR q12 (max 30mg/day)
▪ MgCitrate 1 bottle daily/q12 (be careful in people with renal failure as this has a lot of Mg)
▪ Tap water enema x3 (~500Ml each)
▪ Lactulose 20mL q6 hrs till BM
▪ Fleets enema (again, not to use in renal failure) x 1 or 2

-ANY patient on opioids should be on an aggressive bowel regimen from day 1 to prevent constipation. In these patients, you can order Colace 100mg PO q12 standing, senna 17.2mg q12 standing & Bisacodyl 10mg PO q12 standing.

hypo & hyperkalemia (adult)

Hypokalemia (K<3.5 mEq/L)

Symptoms: palpitations, muscle weakness or cramping, paralysis, parethesias, constipation, abdominal cramping, nausea, vomiting, psychosis, hallucinations, delirium, polyuria, polydipsia

Signs: Ileus, hypotension, ventricular arrhythmias, cardiac arrest, bradycardia or tachycardia, premature atrial or ventricular beats, hypoventilation, respiratory distress/failure, lethargy or mental status change, decreased muscle strength, fasciculations, or tetany, decreased tendon reflexes

Work-up: BMP, magnesium, calcium, phosphorus, digoxin level if taking med, EKG, consider ABG

EKG: T-wave flattening or inverted T waves, prominent U wave that appears as QT prolongation, PVCs, torsade de pointes, ventricular fibrillation, PACs, atrial fibrillation

Tx:

• Replete Magnesium if magnesium level is low. Serum potassium difficult to replete if patient also has low magnesium. You must correct both magnesium if low in order for potassium to be repleted appropriately.
• Replete when K <4.0 especially in cardiac patients unless patient is on HD
• At UH ICU, you can save sleep by using/signing the potassium replacement protocol sheet.
• Repletion:
  - Normal Creatinine: Replete ~10 mEq per 0.1 mmol/L reduction in serum potassium, with goal ~4.0. Levels <3.2 may need 20 mEq to raise level 0.1 mmol/L
• - Elevated Creatinine: Calculate their creatinine clearance. Multiply the above replacement by the estimated reduction in creatinine clearance, ROUNDING DOWN (so if the clearance is reduced by 50%, then use half or less of the dose).  Take home point is that in pts w/ decreased renal function, 10 mEq KCl will inc serum K by > 0.1 mMol/L, so replete more cautiously!

Amount to Replete: Max of 40 mEq po & 40 mEq IV at one time. If you give more than 40 mEq po at one time, unlikely to all absorb. Some attendings will insist that you give 20meq q2 PO rather than 40meq PO at once.  

Forms: po, IV

po: 10 mEq & 20 mEq tablets or 15, 30, 40 mEq liquid (pills hard to swallow, liquid tastes bad). Remember, >60 mEq po is hurtful to GI tract.

IV: peripheral or central “riders” – i.e small 50 cc bags that you can piggy back onto regular IVF to replete

Peripheral max rate of repletion: 10 mEq/hr b/c will cause burning sensation.

Central max rate of repletion: 20 mEq/hr

Also see UH MICU potassium replacement protocol (pdf 1000kb) for some more guidelines on K correction.

 

Always check/replete the Magnesium when dealing with potassium issues.

- Oral magnesium has relatively poor absorption and may cause diarrhea (magnesium oxide usually used if needed, magnesium hydroxide also available)
- No significant clinical adverse reactions in most healthy patients from mild hypermagnesimia (READ: okay to give IV magnesium without significant fear)
- Usual IV infusion rate is 1 gram/hour, though can be rapidly pushed in a code situation (i.e., Torsades de pointes)

- Mg Repletion:

• - Normal Creatinine: Replete ~1 gram Magnesium sulfate IV per 0.1 mmol/L reduction in serum magnesium, with goal ~2.0

• - Elevated Creatinine: As with potassium, dose reduce based on percentage reduction in creatinine clearance

Hyperkalemia (K>5.5 mEq/L); 5.5-6.0 (mild), 6.1-7.0 (moderate), 7.0+ (severe)

 

Symptoms: fatigue, weakness, paresthesias, paralysis, palpitations.

Signs: Extrasystoles, pauses, or bradycardia, diminished deep tendon reflexes or decreased motor strength, muscular paralysis, or hypoventilation.

Work-Up: BMP, calcium, EKG, digoxin if pt is taking med, ABG if acidosis suspected, UA if signs of renal insufficiency

EKG: Peaked T waves, short QT, ST depression

Treatment: When K+ is >6.5 or patient is symptomatic.

• Put patient on TELEMETRY!
• Evaluate for ABCs.
• Ensure patient has IV access.
• call renal service to give them the "heads up" about this patient who might need dialysis.
• Discontinue any potassium sparing drugs and any potassium supplements.
• Serial potassium levels (check repeat BMP 6-8 hours after initial treatment to see that it is trending down then BID or daily depending on how quickly pt responds)
• Watch for bowel movements

Calcium gluconate: 10 mL of 10% sol IV over 2 min; Stop infusion if bradycardia develops, avoid if digoxin toxicity suspected. Not indicated if only see peaked T waves (i.e. has QRS changes also).

Bicarbonate (Sodium bicarbonate) 1 mEq/kg slow IV push or continuous IV drip; not to exceed 50-100 mEq. Different dosing in children.

Insulin (drives K into the cells) 5-10 units regular insulin and 1-2 amps D50W IV bolus

Glucose (Dextrose/D-Glucose) 1-2 amps D50W and 5-10 U regular insulin IV

Kayexalate (Sodium polystyrene sulfonate; binds K for excretion, watch for bowel movements) 25-50 g mixed with 100 mL of 20% sorbitol po/per rectum

Dialysis Consider renal consult.

Lasix 20-40 mg IV push in patients not already on this drug; double daily PO dose as IV slow push in patients already taking this drug

Albuterol nebulizer (promotes cellular reuptake of potassium), possibly via the cyclic gAMP receptor cascade.q20 minutes as tolerated.

hypo/hyperkalemia (adult)

good review article:
Gennari FJ. Hypokalemia. N Engl J Med. 1998 Aug 13;339(7):451-8.

Inpatient Guide For Diabetics (adults)

Inpatient Guide For Diabetics
Based on Diabetes Facts and Guidelines 2005 by Yale

General Principles:
1. Type 1 patients require at least some basal insulin at ALL times to prevent ketosis, even when they are NPO
2. Review diabetic meds
3. Order fingersticks QID in all pts with diabetes (QAC and HS if eating; Q6 hr if NPO) for at least first 48 hrs. If pt stable and under good glycemic control and if on oral agent or one insulin injection/day, can decrease to BID.
4. In-hospital glucose target in most pt should be <110 mg/dL pre-meal; <180 mg/dL at all other times. Pregnant women and critically ill pt (in ICU) require tighter control (80-110).

5. Revise insulin regimen continuously (every 1-2 days)
↑ AM intermediate-acting insulin (e.g. NPH) to ↓ pre-supper BG (blood glucose)
↑ PM long/intermediate-acting insulin (eg glargine, NPH) to ↓ fasting BG
↑ AM short/rapid-acting insulin (e.g. regular, lispro) to ↓ pre-lunch BG
↑ PM short/rapid-acting insulin (e.g. regular, lispro) to ↓ bedtime BG

6. Don’t leave pt on RISS (regular insulin sliding scale) as ONLY form of treatment. Adding long acting insulin (e.g. glargine) will stabilize glycemic control.

7. Try to approximate at-home regimen as long as possible BEFORE discharge

8. Call diabetes educator to teach pt about managing diabetes

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Oral Agent Patients:
A. The hospitalized pt who is NPO (or in whom oral intake is doubtful)
1. Pt well-controlled on oral hypoglycemic agent (OHA) i.e. sulfonylurea
- D/C OHA and use RISS or lispro SS
- If need SS >24-48 hr, add long acting insulin

2. Pt well controlled on oral agent that does not cause hypoglycemia (e.g. metformin, TZDs)
- D/C metformin (due to contrast studies, dehydration, renal fxn)
- If pills ok, can continue TZD unless have abnl LFTs or new edema

3. Pt poorly controlled on oral agents
- Place pt on insulin; can try SS for 24-48 hr to assess insulin requirements or proceed straight to regimen with long-acting insulin

B. Hospitalized pt who is eating
1. Pt well controlled on OHA
- May continue. Consider dose reduction by 25-50% due to more rigid diet
- D/C metformin if hemodynamic instability, CHF, dehydration, or altered renal or hepatic fxn, or if plan to do contrast studies
- continue TZDs unless abnl LFTs or new edema

2. Pt poorly controlled on oral agents
- Calorie restricted diet
- Then add insulin while adding other orals

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Insulin-treated patients:

A. Hospitalized pt who is NPO
Type I DM
- Can use IV insulin drip
- Can give ½-2/3 of long acting insulin + SS
- Unless very hyperglycemic, give D5W or D5 1/2NS@75-125 cc/hr to prevent catabolism
- Check BG Q6 hr
- Consider short acting insulin if need rapid correction of hyperglycemia

Type II DM
- May be able control with diet restriction and SS
- Can give ½ long acting insulin + SS
- If giving insulin, give D5W or D5 1/2NS
- Check BG Q6 hr

B. Hospitalized pt who is eating
-Continue insulin but consider dose reduction by 25% in controlled pt

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Bedside glucose monitoring:
- Order QID for insulin pt
- If on oral agents alone or only one insulin injection per day, can decrease sticks to BID (pre-breakfast and pre-supper) if good control
- If NPO, do sticks Q6 hr

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Hypoglycemia:
- If pt alert, give 15-30g carbs via:
8 oz juice/soda = 30 g carbs
2 graham cracker squares = 10 g carbs
- 15 g carbs will increase BG by 25-50 mg/dL
- Non-alert pt: give 25 g dextrose IV (1 amp D50) or 1 mg glucagon IM if no IV access and recheck BG after 5-10 min
- If severe or recurrent hypoglycemia, use D5 or D10 drip

methods of supplemental O2 delivery (adults)

Hypoxia

Clinical signs of hypoxia include tachypnea, confusion, anxiety, delirium,
, tachycardia, tremor, restlessness, etc.

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-There are 6 things that cause hypoxia, i.e. decreased delivery of
oxygen into the bloodstream:

1. Shunt: i.e. Pulmonary edema or congenital causes. Cannot completely correct for this with increased FiO2
2. VQ mismatch: airflow obstruction (COPD, asthma), inflammation (pneumonia, sarcoid) or vascular obstruction (PE). Increasing FiO2 will correct for this
3. Decreased diffusion: i.e. interstitial lung disease
4. Anemia
5. Hypoventilation: Will see elevated PCO2…can be caused by oversedation, increased abdominal pressure, neuromuscular disease, paralyzed diaphragm or just a weak diaphragm from profound deconditioning or myasthenia gravis/GBS
6. Decreased Fi02: This is almost never relevant unless you are at high altitude
   

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-Supplemental O2: Goal to get SpO2 above 90%/PaO2 of 60mm hg; they
don’t need to be 99% (in fact you don’t want them much above 92% if
they have COPD as they will be a chronic CO2 retainer)

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Nasal Cannula

• Make sure both prongs are actually in the nose!
• Keep in mind that this won’t work as well for mouth breathers, but should still get some delivery of oxygen.
• Cannot deliver a specific amount of oxygen; 1L/min is ~ FiO2 of 25%-
• each liter above 1 L increases the FiO2 by about 4% (2L is 29%, etc.)
• oxygenation over 4 L --> use humidifier
• regular NC can support only 5 L.  For over 6 L use high flow NC.
• In general, if you need more than 5L via NC, you should consider moving to a different modality

Venturi Mask

• More precise oxygen delivery. 
• therefore useful in patients who are CO2 retainers (e.g. COPD), where too much O2 will be troublesome.
• http://en.wikipedia.org/wiki/Venturi_mask

Non-Rebreather

▫ Usually 80-90% oxygen delivery
▫ Contains a one-way valve maximizes oxygen delivery

CPAP (continuous positive airway pressure)
▫ Great for hypoxia; functions as externally applied PEEP
▫ Indications for CPAP: hypoxic respiratory failure (despite 100% oxygen administation), Pneumocystis carinii pneumonia, PE, dense lobar pneumonia, atelectasis, shunt
▫ Initiate CPAP at 3-5cm H2O & increase by 3-5 up to 10-15cm H2O to
achieve PaO2 at 60 (SAT of 90%)

▪ BiPAP (Bi-level positive airway pressure)
▫ Helps with ventilation by preventing alveolar collapse during
expiration (think COPD flare)
▫ Indications for BiPAP: hypercarbic resp. failure, COPD exacerbation, asthma, CHF, flash pulmonary edema
▫ Start at 5-10cm H2O over 3-5cm H20; increase incrementally as with
CPAP

▫ Note that for CPAP & BiPAP the patient has to be alert, able to protect
their airway & clear their secretions; they cannot eat while wearing
these masks otherwise with positive pressure they can aspirate &
the food will get pushed further down the bronchial tree

▫ CHECK Code Status! - Remember to consider CPAP or BiPAP as noninvasive
alternatives! If you are not going to intubate because of
code status, make sure you confirm the code status with the patient
or family member. If you are not sure about the code status,
always err on the side of intubating – as this can always be undone
(but not the other way around!)

Indications for Intubation/Mechanical Ventilation:
▫ Impaired airway protection (no gag; alt. MS)
▫ Inadequate oxygenation with alternative less invasive methods
▫ Prevention of aspiration & adequate suctioning
▫ Hyperventilation needs (i.e. with increased ICP)
▫ Acute hypercapnea
▫ Apnea
▫ Upper airway obstruction (laryngeal edema)

Pneumothorax

Description

• presence of free air in the intrapleural space (between parietal and viseral pleura)
• types:

1. Spontaneous (primary) pneumothorax.
   • Due to non-traumatic rupture of alveolous, bronchiole, or bleb
   • No underlying pulmonary pathology present
   • Often due to rupture of small subpleural cyst or bleb
   • Occurs primarily in young, healthy patients (ages 15-40yo), with tall and thin body habitus
2. Secondary spontaneous pneumothorax from underlying lung pathology
   • COPD, asthma, cystic fibrosis,
   • infections: necrotizing bacterial pneumonia, TB, fungal pneumonia, PCP
   • neoplasm
   • Interstitial lung disease: sarcoid, pulmonary fibrosis, pneumoconioses
3. Trauma
   • broken rib, ruptures bronchus, blunt trauma, penetrating wound, etc.
4. Iatrogenic
   • central line placement, etc
   • seen in ~3% of ICU patients
5. "Tension pneumothorax"
   • Air continues to enter pleural space through broncoalveolar disruption and becomes trapped via ball-valve mechanism
   • Intraplural pressure then increases
   • venous return to right heart decreases, resulting in decreased cardiac output
   • mediastinum can shift toward uninvolved side, which further interferes with right atrial filling. May note tracheal deviation as well.
   • V/Q mismatch results in hypoxia

• Signs and Symptoms

1. severity of symptoms is proportional to the size of the pneumothorax
2. ipselateral pleuritic chest pain, cough, dyspnea, referred pain to shoulder
3. rapid, shallow breathing
4. moderate to severe: profound respiratory distress, hypotension, shock, cyanosis

• Diagnosis

1. drop in oxygen saturation may be first indicator
2. Upright chest X-ray

• absence of lung markings distal or peripheral to the visceral pleaural white line
  
• displacement of mediatinum
• "Deep sulcus sign"= on a supine chest radiograph is an indication of a pneumothorax. In a supine film, it may be the only indication of a pneumothorax because air collects anteriorly and basally, within the nondependent portions of the pleural space as opposed to the apex (of the lung) when the patient is upright. The costophrenic angle is abnormally deepened when the pleural air collects laterally, producing the deep sulcus sign. (See * on image below)
• Chest CT-- very sensitive for small pneumothorax, but has little practical advantage over CXR.
• 

• Treatment
  
  1. Cardiac monitoring, pulse ox, oxygen 100% via nonrebreather face mask, IV access
  2. Nontraumatic pneumothorax estimated at <15% collapse and no cardiovascular or respiratory compromise can be observed with 100% oxygen support
     
     • consider simple aspiration if increase in size of pneumothorax (still 155- 30%) is noted during observation.  Place aspiration catheter (usually 8 Fr) with 3-way stopcock.  Aspirate air until resistance or 3L aspirated.  If no pneumothorax is visible on two CXRs taken 4 hours apart, then the catheter can be removed.  Repeat CXR 2 hours after catheter removed to see if pneumothorax has recurred.  Consider Hemlich valve or suction if simple aspirationis unsuccessful.
  3. Suspected tension pneumothorax requires immediate needle thoracostomy or chest tube is indicated in an unstable patient
     
     • 14 to 18 guage angiocatheter is placed in second intercostal space at the midclavicular line, or at the 4th or 5th intercostal space at the anterior axillary line.
     • Video:
       http://www.youtube.com/watch?v=4cuotNQPRNc#

      

  4. Chest tube

• Indications: pneumothorax with >30% collapse or cardiovascular instability
• is the definitive therapy after needle thoracostomy
• required if pneumothorax of any size in a patient receiving positive pressure ventilation
• tube size:
  
  • small caliber (7-14 Fr) tube for spontaneous pneumothorax
  • 20-28 Fr for secondary spontaneous pneumothorax
  • 28 Fr when there is detectable pleural fluid or anticipated need for mechanical ventilation
• Following insertion, the tube should be connected to a water-seal device
• Video:
  http://www.youtube.com/watch?v=QM85GdT4ZVY&feature=related

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References:

1. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax. Chest. 2001; 119:590. S193.

2. Sahn SA. Spontaneous pneumothorax. New England Journal of Medicine. 2000; 342:868.

3. Light RW. Pleural Diseases. 4th edition. Lippincott, Williams & Wilkins. 2001.

 

Rules of Medicine

Resident-to-Resident Sage advice

1. Do no harm.

2. Trust no one. (Kinder version: "Trust, but verify")

3. Medicine is an art, not a science. (Corollary: Never argue with an attending, unnecessarily)

4. Never make excuses.

5. Never carry a coffin by yourself.  (Corollary: If you are unsure, ask someone smarter.)

5. Discharge planning must begin at admission.

6. Workups that can happen as an outpatient, should.

7. Never open a can of worms unless you plan to go fishing.

8. Common diseases occur commonly.

9. Before ordering a test, decide what you will do if it is a) positive or b) negative.  If both answers are the same, don't order the test. (Corollary: if a test is unlikely to change your management, don't order it.)

10. When dealing with consultants, remember the Law of Subspecialization: If you are a hammer, the world looks like a nail.

11. The quality of care is inversely proportional to the number of consultants on a case.

12. If it cannot be read, don't write it.

13. Any order that can be misunderstood, will be misunderstood.

14. If a drug is not working, stop it.

15.  If you are not sure what a drug is doing, stop it.

16.  Never see patients on an empty stomach or a full bladder.  Both compromise patient care.

 

 

 

Ward month expectations and tips

Circulated handout below from one medicine attending for having a smooth month.  Makes for a good email to team members at the beginning of the month.  Please feel free to contribute your own wisdom and tips at the bottom.

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Ward Expectations

Medical Students:

1) Preround with your intern and resident. Have your notes written before 8 AM. I don’t expect you to have the correct assessment and plan at this stage, but I do expect you to think on your own. Please read on the pathology you see in each patient. You will add a lot to the team’s care of the patients by gathering data, reading and spending time gathering history from the patient, nurses and the chart.

2) Please gather all the patient charts for each floor, so that we can write orders as we go.

3) Pertinent data to have on all your patients includes: knowing medical history, vital signs, a current medication list and all the labs, xrays and other imaging (Echo, Stress tests) on your patients up to that point in the morning. Maintain some sort of tracking system to follow trends (Hb, Na, etc.). Learn from ancillary services by going to see how the studies are done and talk to the radiologists reading the studies as often as you can.

4) A foundation in internal medicine will serve you will in any field you pursue, so make the most of this rotation. The best student doctors will make the best physicians; theyare on time, honest and care about their patients. They try their best to learn from and about all patient cases on the team, not just their own patients. This involves active time taking notes on all new admissions and being at hand to help at all stages of the patient’s admission, from writing Admission orders to the discharge orders, to calling to arrange outpatient care.

5) If one of the interns has an excessive amount of patients compared to the other, please offer whenever possible to help him/her make consults, track down studies, and write discharge orders.

6) Present one 5-10 minute report on a topic of your choice which is relevant to one of our patients.

Provide a concise handout on the relevant material.

Presentations:

1) Be thorough, but relevant. You are the filter. Your patient may have for two hours, but if he came in with chest pain, your presentation should sum up the characteristics of the chest pain in two minutes.

2) Post-call presentations should be in the following order: HPI, ROS, PMH, SocHx, FamHx, allergies, outpt meds, then the vitals, a full physical exam, and labs. In the assessment and plan - sum up the case quickly then address the big issue first. I would like a detailed problem list and plan, which should conclude with : DVT and GI prophylaxis, Contact with patients PCP (give me a name, and a telephone number if possible) and Disposition (Home, here for these further tests or treatments).

3) Daily presentations should follow a SOAP note format (Subjective, Objective, Assessment and Plan. The subjective should be one or two sentences which tells everyone what happened since we last met and talked about the patient. You may mention here what the specialists recommended and did. If the patient had chest pain o/n, say how it was handled by the on call team. This is especially important when a new physician or student is present, or on a busy service. It gives the other half of the team a chance to remember who your patients are so that they are capable of caring for them in your absence. Next should be the vitals – it is not okay to say vital signs are stable, report what they are. Next report the pertinent exam findings only. If they had lung crackles on admit, are they improving. It is not okay to say exam is essentially unchanged unless the patient had no physical exam findings on admit. Then report only the pertinent labs. Next report the labs, then the imaging or other studies. Then as above, the assessment and plan needs to address the main issue first and systematically address all other problems the patient has.

4) Be aware of how many patients we have on our team. If we have twenty patients to see, and you take 30 minutes to present a simple case of cellulitis, we may be compromising the care of the other 19 patients. Be thorough but be efficient. Direct the team to discuss and see the sickest patients first.

5) Present the plan you have discussed with your intern or resident. Ask them ahead of time if you are unclear of the plan. If you learn something about the patient’s care afterward, let them know before Staff rounds (AS soon as you learn it) so that they are not completely surprised when you divulge that their patient just coded and is being taken to the ICU, for example.

6) For high pass and honors grades, do more than is expected of you – know about the other patients on the team and participate in their care, track down all studies and be able to interpret them and plan diagnostic and treatment measures for your patients, actively participate in all relevant aspects of patient admission- orders, working with social workers, nurses, writing notes and discharge orders, scripts, etc. If you want to know how you are doing and how to do better, ask your resident or staff.

Days Off:

1) You will get four days off for the month to be arranged with your resident. It should really be a weekend . There may be times when you go two weeks without a day off, because of the call schedule.

 

Interns:

Similarly to above, the three basic ingredients to being a good intern and physician this year are showing up (with time to do your work), being honest and caring to do good by and for your patients. Regarding showing up, you should be the first person there on the team. You have the most grunt work in terms of collecting data, talking to nurses, patients and consultants, only to then round with both a resident and then your staff. This comes with the territory of the boot camp year of medicine. You will become more efficient as the year progresses. Ask a senior resident or me for pointers on how to be organized, efficient and for any other problems or areas you need assistance. I do not expect you to be perfect, but do seek help. You will not ever receive a poor report from me for asking for help, both with the aforementioned or with clinical knowledge. Residency is not about having an ego; it is about acquiring as much skill and knowledge to be a great physician. Next, if you do not have some data that I or your resident asks for, DO NOT under any circumstances make it up. I will be making decisions with the wrong information, which may be detrimental for our patients. Just say you don’t have it and someone will get it. Period. As for caring, that comes naturally for some, and may be an acquired taste for others. Often, you are tired and asked to do more than seems humanly possible. We have all been there and empathize. Be there for your co-interns. Try not to let petty personality conflicts come between your professional allegiance to one another and to the care of your patients.

Each of you brings his/or her own strengths and will be invaluable to the other. If one of the interns has an excessive amount of patients compared to the other, please offer, when you have the time, to help him/her make consults, track down studies, etc. This is especially true on clinic days. You should know about ALL the patients both your patients and the other intern’s patients as you will be cross-covering for them. That means we stick together for rounding. The intern not post-call (or the medical student) should be writing orders while we are rounding. Then pass the chart back to the primary intern to see if they have anything else to add/if they approve. Unless there is a big emergency or your staff excuses you, this is NOT time to break off and call consults.

Work Rounds:

1) Teach the medical students how to write orders. If it is not your patient that we are discussing, you should be the one helping the medical student write the orders. When you are finished give the chart to the other intern for review. This is how we double check to make certain things are not missed.

Rounds:

1) Fill in the gaps in the medical student presentations without being abrasive or condescending. You must discuss the plan with them to be on the same page.

2) Review Presentation tips above.

3) Please try to prepare at least one short 5-10 min talk during the month to help hone your ability at presentations and teaching. I can assign topics or you can pick them.

Work time: (After rounds):

1) You are expected to write a daily note on each patient. If a medical student has written a note, you cannot write agree with above. You must document a physician exam and a detailed assessment & plan. You don’t need to re-copy the labs. JHACO dictates that a physician must write a note every day.

2) Get your work done and get out. If you have clinic in the afternoon and don’t get everything done, check it out to the resident or the other intern. Do your best, though, to get as much done early so as not to perpetually rely on others for work which would be reasonable for you to complete.

On Call:

1) You are expected to write an admission history & physical on every patient. You will also write the admission orders unless it is crucial that we get things done ASAP. Write the orders first to get the ball rolling. You can always go back and add more orders if you think of additional things.

2) I expect you to take five to ten minutes and look up treatment information for each patient on UpToDate or some other source. You must develop habits that will serve you and your patients well in the future.

3) This is the time to teach the medical students. Take them with you and let them interview the patient. This is when you can teach them how to ask questions to elicit the answers you need. Teach them about EKG findings. Discuss the differential for shortness of breath or chest pain. Teach them in your own style, but avoid condescension. None of knows everything and being unreasonably tough will make timid students even more timid and no better in the end. You will learn more this way.

Days Off:

4 days a month, to be determined by your resident.

We are a team. We work as a team, and we leave as a team. If one intern is finished and the other has more to do, we all help out.

Residents

You are the leaders of the team and your staff should serve as a consultant. That being said, your staff’s name is on the chart, so should have all the information for making educated consulting opinions. See above, the three criterion for being a good intern or resident. Please preround and make decisions before staff rounds. Have the interns and students write orders. Teach. Please physically see all patients, particularly this early in the year. See the sickest patients first. Develop your own management style, but try to be considerate of your staff’s proclivities. You will have more time for decision making if your interns are gathering the data and you are having more time to think about it all. Do your best to delegate to facilitate this. Plan days off for the team. Know all the patients intimately on both sides of team. Know all the studies, labs and have a solid plan for their care, including good follow-up which won’t result in the patient “bouncing-back.” Use clinical evidence, coupled with standards of care, evidence-based related research and the patient’s particular limitations (uninsured, demented, homeless, etc.) to inform your decision. Please tell your staff, at any time of day or night if you want to run something by me. Also, I prefer to know –day or night—about a death or ICU transfer or if you want to send a patient home from the ER. Set the professional standard for fully integrating the team, i.e, sticking to rounds without breaking off, attending all morning reports and Grand Rounds. Try not to leave an intern struggling by himself post-call. That is not acceptable. You must trouble-shoot to help bring him/her up to speed. Read on all your patients and add your knowledge to that of the team.

Staff Duties:

1)Be on time for rounds and morning report when our team is presenting,

2)Keep rounds as efficient as possible.

3)Maintain a comfortable learning environment for all on the team.

4)Coordinate care with specialists.

5)Coordinate teaching and learning opportunities.

6)Serve as medical consultant for the residents and interns.

7)Provide feedback as often as appropriate and possible to strengthen all team members.

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Further tips:

students should not feel like they have done their AM work until their note has been cosigned.  Student notes should be done very early so a resident can review your note with you before rounds.

- There is no rule saying that you can't write a "skeleton note" the night before.  That way, your AM note is more fill-in-the-blank, rather than an essay.  That can allow you to spend less time being a secretary, and more time being a doctor.

-Start working on discharge paperwork as soon as a patient is admitted.  Have expected prescriptions, clinic referrals, etc. ready in advance.  Keep a typed draft of a discharge summary in your email for each of your patients, that you update daily.  That way, dictating a good discharge summary will be a breeze.

- Whenever ordering a test (imaging, stress test, etc.), call down to the respective office and ask if it can be moved up on the schedule.  The earlier you have the results, the earlier subsequent decisions/discharges can occur.

-Keep the census list as updated as humanly possible.  Add patients fully to the list as soon as they are admitted.

- Place relevant/interesting articles you find in the chart for others to read/reference/learn.  This is a teaching hospital, afterall

- for any patient you are sending to discharge clinic, place their name, diagnosis, and MR number in one of the boxes at the bottom of the list.  This way you will know who to expect, and who to call if no-showed.  Tell your patients to bring their all newly filled prescription bottles to the clinic, so you know they have them, and understand them.  Also, tell your patients to bring their assigned bp, weight, or blood glucose diary to clinic.

- Always ask patients how they expect to get their medicines filled.  If they are not going to be able to afford the meds, then they are no good to them.  Think about cheaper alternatives, and consider starting those as inpatients to evaluate efficacy. Carry a copy of the latest (and often changing!) walmart formulary in your white coat.

- If there is an expensive medicine that they will need, recommend that patients ask the pharmacy they go to (chain stores especially) to "price match" and to "get the price the lowest they possibly can."   Every pharmacy has an absolute lowest price they can charge for a medicine, often based on the amount of local competition that particular store has.  Furthermore, nice pharmacy workers will even apply their employee discounts for patients.  Tell patients to have the pharmacist page you if the price is too high, and mention these type of things to pharmacist.  Pharmacists will often tell you where to get the drug cheaper, even. Outpatient clinics may have samlpes of certain meds, or discount coupons...just call and ask.

- Do not rely on the social workers.  Call nursing homes, home health agencies, etc. yourself.  You would be surprised how easy arranging certain things actually is.  Putting a voice/face to your concerns helps you be a better patient advocate.

- spend at least 5 minutes each day to read something new about each one of your patients.  This habit will enrich both your experience, and the assessment/plan section of your note.

- Call and update family members.  Ask patients if there is anyone they would like you to talk to, and call them.  Tell them about anticipated discharge planning/timelines.  Also, notify family members immediately if a patient's health status suddenly changes, for example if they have been transferred to the ICU.