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
