Helpful Hints for Wards and MICU

FYI: This blog post is FIBI. For Interns, By Interns. Not quite a clothing line but still kind of catchy. Courtesy of our interns who just finished Wards and MICU, we bring you these helpful hints. As Robin Tang says, "It's not about the medicine exactly, like the Yellow Book, and it's not about the rules either, like the Nuts and Bolts - it's just some friendly FYIs about how to be efficient and anticipate pages." With that introduction, here you go. Scroll down further for the MICU helpful hints.

Wards
Pre-Rounding Reminders:
- don't forget to check/replete lytes
- don't forget to renew meds
- don't forget to renally dose your meds
- don't forget consultant opinions and procedure results (echo, scope) are often in paper chart
- the lab doesn't always call you when cultures become positive

Believe It Or Not, You Need Forms For:
- changing an antibiotic dose/timing (antibiotic)
- oral nystatin (antibiotic)
- Lovenox (warfarin)
- nebs and oxygen (respiratory)
- type and screen (blood bank)

Don't Forget:
- Sign verbal orders!
- Specify whether OK to be off monitor for tests
- If you write opioids, write a bowel regimen
- If you write HTN meds, write hold parameters
- If you write Vanc, get a trough before 4th dose
- If you write a prn, specify prn what (ie, nausea, pain)
- If you write for Foley dc, tell RNs what they should do if there's no UOP
- If you want Gram stain in addition to culture, you have to specify that

Essentris Is Your Friend:
- nursing orders (diet, ambulation, etc) are in Kardex Summary Screen
- what lines a patient has are in Invasive Devices Flowsheet
- PCA attempts vs. injections are in Vitals Flowsheet
- Nutrition, PT, RT notes are in Notes Menu

The M.D. Has To Be The One To:
- pull PICC
- do ABG
- push IV antihypertensives

Miscellaneous Help:
- If you forget indications for PPI, look in the Admission Order set
- If you need to know what's on formulary, look in the Lab and Formulary Manual on Mednet
- If you want to enroll people in Coumadin clinic, use form in Forms Portal, specify who the PMD is

Good Numbers Not in the Book: (Chiefs note: Perhaps we will add these to "the Book")
- Rheum Consult 39671
- OR Scheduling 78844
- Swallow Eval 92581
- Speech Eval 93939
- PICC 79793, 92788
- Cross-Sectional IR (Drains, etc) - 78786, 79772
- Send-Out Lab - 41310
- Specimen Processing - 78148

MICU
Pre-Rounds
- Get signout/overnight events from night intern
- Vitals – in Essentris
- All labs: esp CBC, CMP, ABG, VBG (ensure to correlate blood gases with vent/resp. settings)
- Input/Output – Essentris, summary in “A” icon, flow in I/O tab
- Quickly check invasive devices in case of changes/uncertainty
- Ventilator – look at settings in Essentris for details (CTICU tab), ask RT about Peak Pressures, Plateau Pressures, NIFs, RSBIs (latter under Vent and Weaning settings)
- Consult notes in CView (Surgery may use paper chart)
- CXR for intubated patients
- Always look at imaging available – images and reads
  o ET tube 2-5cm above carina
  o PICC and IJ at SVC-RA junction
- Signout with nurses and/or nursing notes
- If you have time in pre-rounds, order PM Labs and next day’s AM Labs

Rounds
- Presentations start with yesterday/overnight events in order of importance
- Attending-dependent, but then: vitals, vent settings, exam, labs, imaging/studies, plan
- If not presenting, write orders for co-intern and bring up imaging
- Order forms can be found on rounding cart
- Do not be afraid to ask questions of team – attending and co-residents/interns alike!
- Present data/guidelines as much as possible

Floor Work
- Daily Progress Notes are intern’s responsibility
  o If patient admitted overnight and note entered after 12:00AM, add addendum on that note
- Order consults – share responsibility with resident
- Update family/patient daily
- “Final rounds” at each patient room – check in with nurse for final needs/updates
- Update signout periodically, especially at end of day
  o “If-then” statements (If Na >= 150 then increase free H2O to 200cc/4H)
  o “Baseline” of patient (Oriented to person and place not time, etc)
  o Access – Tubes, Lines, Drains
- Sign out to call intern, who will stay until 8pm to sign out to night resident
- Sign out pager to 90040
- If you are admitting (Q4), you cross-cover until 8pm, generally do not admit for patients called on after 630 or 700PM
- You do not have to stay until 5pm, leave when your work is done!

Night Float
- Midnight round with resident around 8pm-9pm
- Check vitals, lytes, CBC, blood gases, and make adjustments as necessary
- Always document what you did on written Signout to relay message to day team
- Admissions with overnight resident
- Present new admissions in AM with accepting team (whoever was on call overnight), update signout, initiate floor work, call consults as much as possible
- Leave by 9:00-9:30AM

Image Challenge

A 68-year-old man with alcoholic cirrhosis presents for evaluation of shortness of breath.

After a procedure...

What is the finding on the initial chest x-ray? (2 words)
Hepatic hydrothorax
This patient actually has radiographic evidence of tension hepatic hydrothorax. Hepatic hydrothorax occurs in approximately 5 to 10 percent of cirrhotic patients, and is defined by a pleural effusion in the absence of primary cardiac, pulmonary, or pleural disease. In the presence of tracheal deviation and hypotension, this process is termed tension hepatic hydrothorax. Though this patient has evidence of tracheal deviation, the patient was not hypotensive. Hepatic hydrothorax develops on the right side in approximately 85 percent of patients, while it is on the left side (such as in this patient) in approximately 13 percent and bilateral in approximately 2 percent.

A thoracentesis should be performed to confirm the diagnosis and to exclude alternate causes of a pleural effusion. Spontaneous bacterial empyema has been described in up to 13 percent of patients with hepatic hydrothorax, and is defined by pleural fluid with a polymorphonuclear cell count >500 cells/mm3 or positive culture with exclusion of a parapneumonic effusion.

Chest tubes should not be placed, as they can result in massive protein and electrolyte depletion, infection, renal failure, and bleeding.

The only cure is liver transplantation. Sodium restriction and diuretics are first-line therapy. Repeated thoracenteses can be done for large effusions. In this patient, 2L were drained between the first and second images and there was some improvement in the patient's dyspnea. TIPPS is another option of hepatic hydrothorax is refractory to medical therapy. Chemical pleurodesis does not work very well as it is often difficult to keep the two pleural surfaces apposed long enough for the inflammatory process to result in them sticking together.

Image Challenge

A 32-year-old woman with a history of renal transplant 6 months prior to admission presented with the following findings:

What is the name of the disease (not the etiologic agent)?
Shingles
Shingles, or Herpes zoster, is caused by reactivation of varicella-zoster virus. The FDA recommends that all immunocompetent patients above the age of 60 be vaccinated with Zoster vaccine (Zostavax). Note that this patient would not have been a candidate for vaccination because of the immunosuppression. Why? Because Zostavax is a live vaccine! This is especially problematic because immunosuppressed patients are especially vulnerable to developing shingles, often widespread.

Acyclovir can shorten the course of the acute illness but only valacyclovir and famciclovir decrease the incidence of postherpetic neuralgia. Tricyclic antidepressants, gabapentin, and lidocaine patches may be used adjunctively for pain control. Amitriptyline 10-25mg/day x 3 months gives a 50% decrease in pain prevalence at 6 months (Number Needed to Treat of 5.2!).

Note that there is no role for prednisone in either immunocompetent or immunodeficient patients.

EKG Trivia

A 58-year-old woman with a history of atrial flutter and atrial fibrillation presented with presyncope. Her initial EKG revealed a heart rate in the 170s but after treatment with beta blockers and amiodarone, her heart rate improved to 97 with the EKG below.

What is the EKG finding?
Sinus tachycardia
Atrial tachycardia
Atrial fibrillation
Ventricular tachycardia
Atrial tachycardia
Notice the downgoing P-waves in lead I, which suggest that the source of the P-waves cannot be the sinus node. The rhythm is regular, which means this cannot be atrial fibrillation. The narrow QRS complexes suggest that the rhythm is supraventricular. This patient had atrial tachycardia with a 2:1 AV block, with a ventricular rate of 97 and atrial rate of 194.

Cardiology was consulted. Because the patient had recently undergone ablation, the patient was not felt to be a candidate for further ablation, as atrial tachyarrhythmias happen relatively commonly within the first 8 weeks after an atrial ablation.

With continuation of the amiodarone drip, the patient converted to normal sinus rhythm within 24 hours. She was discharged on oral amiodarone with cardiology follow-up.

Image Challenge

A 55-year-old woman with a history of longstanding diabetes mellitus and previous history of left foot osteomyelitis presented with a 2-week history of lower extremity and bilateral hand skin changes.

What is the diagnosis?
Scabies
The rash was initially concerning for gangrene. Microscopic examination of the patient's skin by dermatology revealed a significant burden of scabies mites, making her diagnosis consistent with crusted scabies, formerly known as Norwegian scabies. Crusted scabies, formerly known as Norwegian scabies, is a more severe form of the infection often associated with immunosuppression.

The disease can be effectively treated with a number of medications. Permethrin cream is the most effective, but expensive compared to other treatments. Crotamiton is less effective, but also nontoxic and soothing. Ivermectin may be used orally and topically. Treatment with lindane preparations has fallen out of favor due to high toxicity and parasite resistance. In order to prevent re-infection, the host's contacts are also often treated.

The patient was treated with permethrin cream as an inpatient as well as PO ivermectin, with which her rash demonstrated significant improvement. She was discharged with instructions to repeat a treatment with permethrin cream in a week as well as ivermectin weekly for 3 additional weeks. She was also given triamcinolone cream to treat the inflammatory component of her rash.

QI Funding for Residents

Are you interested in an exciting opportunity to improve the inpatient and outpatient care at UCLA?  The Department of Medicine is offering funding of $1,500 per project for 3 outpatient and 2 inpatient quality improvement initiatives. The interested residents will submit a brief proposal and the five selected residents will receive mentorship throughout this academic year to ensure successful completion of their projects.

If you are interested in learning more or receiving the application for this opportunity, please contact Nasim Afsar at nafsarmanesh@mednet.ucla.edu by Friday, July 29th at 5 pm.

2012-2013 Subspecialty Match Schedule

Just in case you didn't know, here is the new subspecialty match timeline for this coming year.

Programs Register and Update Information in ERAS Maintenance System: February-April 2012  Application Opens: July 1, 2012 

ERAS PostOffice Opens: July 15, 2012 Match Opens: August 1, 2012

Rank Order List Opens: October 10, 2012

Quota Change Deadline: November 7, 2012

Rank Order List Closes: November 14, 2012

Match Day: December 5, 2012

Unmatched Applicants "Scramble": December 6-7, 2012

Fellows Begin: July 1, 2013