Some tips for the floors
Phil D
1. Every morning/before you leave at night, you should question
whether your patient needs an IV running (with fluids) and needs a
foley. Many attendings are meticulous about this because increase the risk of UTIs, and running IV’s possibly leads to volume overload.
2. Do medications need to be IV or can they be PO, avelox is also PO,
so is nexium, and lasix, etc. PO meds is the next step before
discharge, and they are cheaper.
3. it NEVER HURTS to ask your patient if he/she is in pain. If you feel your
patient is someone to get a headache, put Ibuprofen/Tylenol as a PRN
so you or your colleagues on call won’t be bugged to put in an order
for Tylenol. Also, before ibuprofen, check creatinine.
4. When I say opioid, YOU SAY BOWEL REGIMEN, OPIOIDS! BOWEL REGIMEN!
Lactulose is one of the best as per up-to-date, it may give some
bloating. Make sure to ask patient/nurse about the last bowel movement!
So let’s review, “hey patients, are you having pain, are you moving
your bowels, are you urinating ok.. without a foley?”
5. Being nice to nurses means making sure to tell them when you put in
a new order, especially antibiotics, if you put in the order at 5:00
pm, and they happen to stumble upon the order at 7:00 pm, this could make THEM look bad
6. Making INR work for you with coumadin is a skill I cannot teach
you, but one you must go out into the world and experience yourself
little bear….
however, Toronto notes references a study that says starting off at 10 mg vs 5 mg was shown to reach therapeutic iNR more quickly without an increased risk of bleeding
7. If you suspect C.diff, don’t wait for the toxin to come back, start
flagyl 500 mg TID PO or IV, you’ll look cool. If c.diff is negative
you still have every right to suspect c. diff (in the right context;
elderly from nursing home or recent c diff). Some nurses claim that C.diff has a very distinct smell, not sure the sensitivity of nurse's noses for c. diff though
Some stats:
- 50% of patients recently having c.diff remain c.diff positive 6 weeks after treatment
- up to 25% of patients with c.diff have recurrence
- the assay is 70-90% sensitive (but cytotoxic assay is 95 plus sensitive)
- fidaximicin is a new drug to decrease recurrence, just know about it. It’s FDA approved but not available everywhere
- 15-20% of hospitalized patients are colonized with c.diff, so don't test it if you don't have suspicion
8. Be an advocate for your patient, call MRI, ask them when Bobby
Brown is scheduled, just cause you put the order in doesn’t mean it
will happen, I get things done by offering my left kidney if they do
the test, people seem to appreciate the humor, or are scared of me.
Either way tests get done on time!
9. Ask yourself everyday, “why are we keeping them here?”
10. Notify nurses if patients are high risk of elopement, let them
sign AMA ahead of time, saves paper work time for the elopers
11. Teach your medical students, there is ample time, they will
appreciate it, and you know more than you think you do, they will work
harder and go that extra effort to help you. If you are not teaching
them, let me know so I can come hurt you :)
12. Know which attendings communicate through diarrhea writing, and
ask them what the plan is. For GI, often you really need to know is
“colonoscopy tomorrow”, and ID “continue blah blah for such and such
days”. Make sure you ask ID how many days to continue the antibiotic,
this usually ends up being the only question we need to discharge
someone.
13. Be careful about doing too many discharges in one day, you’re
asking for allot of work the next day (with new patients)
14. When you sign out to the on call team, don’t talk about the life
story of every patient, but do mention serious things that need to be
followed up, troponins, cbc’s etc., give instruction about what to do,
if potassium is blah, give blah, don't assume everyone knows this
15. potassium will go high, don’t loose it if it’s 5.5, give
kayexlate, it takes 2.5 hours to work AND they need to have a bowel
movement, do not discharge someone with a high potassium. If you need
to DC someone (cause they are medically stable), order a plasma k, it
usually comes back lower and you can sleep well discharging them. However,
6.5 is a ticket to an EKG, and calcium gluc.
16. Your responsibility for admissions may very, I had a pretty lazy
second year so I did most of it on my sub-internship. A few tips, R/O ACS means trops x 3
q6h (edit, this has changed in most hospitals, 2 trops q3 is good I believe!), 24 hour telemetry, 2L nasal canula, BNP (this is ordered in the states to help stratify/identify heart failure, I don't think its ordered much in canada), that should cover most.
For acute renal failure, makes sure you know if its acute, or acute on
chronic. HOLD all diuretics (this is a must!)
17. Someone with previous CVA who is not a/o x 3 should be on a puree
diet until you can get a speech and swallow eval (not that everyone
needs one), even if the family says they eat fine at home, when they
are in the hospital they are YOUR responsibility, aunt betty will be fine with
purree for now
18. Always ask where the patient is coming from, home, nursing home,
the street. It will help when you present to say “62 yo from nursing
home”. Also check all code statuses for severely demented patients. Call
family if you need some history, info is in the chart
19. When you consult other services, often they will NOT put in
orders, always check this. For colonscopy, if they were going monday,
they can have breakfast on sunday, and then at 4 pm they will drink 4
Liters of golytely, and be on a clear liquid, then NPO at midnight.
Make sure you know the patients who are likely to not complete this,
make sure they fully understand what they will have to drink, so they
don’t waste everyone’s time.
20. Make sure you know which patients are diabetic, sliding scale is not totally cool, it reacts to high glucose levels, if they take metformin, this is usually discontinued because it should be stopped 48 hours before CT scan with contrast.
21. Know when to escalate, you cannot be expected to know how to deal completely with heart attack etc., don’t be afraid to escalate!
22. when you get a scary phone call “PATIENT IS HAVING TROUBLE
BREATHING”, calm down, and ask “what is the o2 sat, what is his bp,
mental status, HR, temp”, these are things you need to know and the
nurses can get these. It is ok to ask the nurse to call you back with
these answers if he/she doesn’t know.
23. See the new patients in the morning first, look for past admission
notes, make sure someone signs them out to you.
24. Some attendings like to consult like crazy, don’t be afraid to ask
WHY we need the consult, especially because you don’t want to look
silly when the consult asks YOU, why you need it. Sometimes I felt
like answering “because my attending is incompetent and wants you to
take care of an easy job”
25. Sometimes people will be asking you to do many things at once,
sometimes you need to say “please remind me in 20 minutes”, or “I
can’t do that right now, but…”.
hope anything here is useful, and if you have any tips to add please post them here, especially Canadian protocol related!
Shiraz Elkheir
Behnoosh Dashti
Following the other conversation, I have put orders in my first 3 shifts at emergency so far! nobody told me need to be cosigned, but now I'd rather to be more cautious and remind my supervisor that i'm in AVP!
By the way, the email address I check more frequently is my medportal one: behnoos...@medportal.ca so I'd wonder if you as the admin person of the google group can change that on the list.
Thank you,
This e-mail may contain confidential, personal and/or health information(information which may be subject to legal restrictions on use, retention and/or disclosure) for the sole use of the intended recipient. Any review or distribution by anyone other than the person for whom it was originally intended is strictly prohibited. If you have received this e-mail in error, please contact the sender and delete all copies.