hands - web viewnight float – includes sign out and how to think through common issues/pages

Baystate Scutpuppy – Guide to Intern Year

TEXAS (To EXcel At Surgery)

Table of ContentsGeneral infoVascularPediTraumaACSColorectalBlueGreenSICU – Includes Weaning Parameters and SICU Pearls.Night Float – includes sign out and how to think through common issues/pages

Pearls for Answering Pages

Surgical CricothyroidotomyLeg CompartmentsArm Compartments

Vasoactive Drugs and Receptor Activities for the Treatment of Shock

Clinical Pulmonary Infection Score

Not typical intern services, but ones you may be cross-covering over the weekend:ThoracicTransplantPlasticsRed

Research FellowshipSurgical Mission Trips (during your vacation)Interviews

TextbooksRecommended Reading for greatness ______________________________________________________________________________________________________________________________Goals established by the Intern Class of 2011:

1. Maintain firm faith in yourself and your peers2. Speak kindly3. Constantly push yourself to improve4. Aim high5. Be a team player

Teaching points that will take you far:1. Hierarchy exists and must be respected at all times2. Be a team player and help your colleagues out whenever you can3. Always have each other’s back4. Don’t complain and always go the extra mile5. “Take every opportunity to be excellent.” – Peter Wu, MD (Class of 2013)

"To cure sometimes,to ameliorate often,to comfort always."

- Sir William OslerThis is merely a guide to the lands, it is not a textbook. You must still use your clinical judgment and study every day. Sources include Parkland Trauma Manual, Top Knife, The Physiologic Basis of Surgery, my notes from throughout the year (lectures, what I was frequently pimped on, etc.), notes from UTSW.

Created by Saiqa Khan2

Congratulations, you’re a surgical PGY1!General Info:Floor WorkYour floor duties consist of whatever your chief tells you they are. Typically you get sign out in the am from another intern who was on overnight, you prepare the list (post op days, diet, abx, imaging results, consult recs, drain outputs, culture results, etc), and print copies for your team in the am. Present the new patients and overnight events to the team. Round with a “medical student” if you have a dressing-heavy service. (A medical student is a dressing change bag full of dressing supplies). After rounds, you will do chartwork (explained in next section), and you will continue to run around and take care of the floor. As you become more confident/competent, you will be rewarded with more work/responsibilities because you will be trusted more.You will be responsible for knowing everything about your patients from past medical/surgical history to what meds they take at home to when their last BM was. Work hard, with enthusiasm.

Chart Work (CIS)Part of your floor work as mentioned above is to write daily notes on your patients. These are similar to the SOAP notes you wrote as a medical student. You are also responsible for entering in orders based on what was discussed on rounds – advancing diets, hep locking IVFs, lab orders, imaging orders, etc. On most large services such as Blue and Green, notes can be written in the rooms on the in-room computers. Usually in this situation, the list is run after the completion of rounds, and the work is divided up according to what is left. Of note, orders are more important than paperwork – get your orders in and call your consults etc before you write your notes. Patient care before documentation. It’s best to put in your own orders instead of asking the nurses to do it for you. The order in which you should perform your am work is as follows: Call consults orders review and replete labs paperwork. As Dr. Nate Conway (class of 2012) once said – “my goal as an intern was to make the PA’s job obsolete.” Our PAs are amazing and we could not survive without them, but you must TRY. Do not depend on the PAs/NPs, you should approach floor work as if you had NO PAs, because sometimes you wont (they might be on vacation or have a day off) and you need to be ready to take care of a large service alone without the help of your senior residents who will usually be in the OR anyway.Do NOT copy/paste notes.

Admission H+Ps are also part of chart work. Usually on services likes Vascular, ACS, Pedi, and Trauma, you will have consults to see and admit. H+Ps include HPI, PMH, PSH, Home meds, Allergies, Social History, Family History, ROS, Vitals, PE (this must include if there is hepatosplenomegaly per Dr. Earle), labs, radiologic studies, impression, and plan.Most services have special admit order sets in CIS which you can use. However, here is the mnemonic: ADC VAN DISMALAdmit: location (reg bed, tele, intercare, SICU) Diagnosis: admitting diagnosisCondition: stable, poor, criticalVitals: include here how often you’d like the vitals to be checked. This includes weight (the order for weight checks can be every am before breakfast for example)Activity: ad lib, bathroom privileges, bedrest, non-weight bearing to a particular limb, C-collar precautions, etc.Nursing Procedures: bed position (ex. HOB 30 degrees), respiratory care, foley, dressing changesNotify resident if: this is where you put in what you want to be notified for (temp, pulse, RR, SBP, UOP, etc, below or greater than certain values.Diet: regular, NPO, CLD, renal, cardiacIns and Outs: how frequently you want them checkedIVFs: LR, NS, what rateStudies/Special Orders: EKGs, XRAYs, imaging, etcMedications: which home meds do you want to continue at this time, and which new meds need to be ordered (Zofran, bowel regimen, pain meds post op)Allergies: in CIS, list the allergies or mark NKDALabs: CBC with diff, BUN, Cr, lytes, divalents, UA, etc. you can also order these to be drawn daily for the next 5 days or so.


Make sure to enter in admitted diagnosis and review home meds under “orders” “admission”

You will also have to write discharge summaries. It is helpful to start these when the patient is first admitted and just add to the hospital course throughout the admission period. This is easier than having to write a hospital course from scratch upon discharge of a patient’s that’s been in house for 30days. Discharge summaries also include procedures and consults. There is a template that can be filled out in CIS as well as templates for H+Ps, consult notes, progress notes, and procedure notes.In the discharge summary, you will also include diet, activity restrictions, follow up instructions, wound care instructions, reasons to call the office or return to the ED, where the patient is being discharged to and in what condition, as well as discharge medications – what meds do you want the patient to continue to take. You might want them to take all of their previous home meds, just a few, or start taking the new ones you’ve written scripts for. If you know a patient will be discharged soon, it is useful to have the discharge summary up to date and the scripts in the chart so you can tell your team the patient is “clickable.” This means anyone can click them out just by signing the summary and putting in the discharge order.

When a patient dies, you must also sign your completed discharge summary. Please make sure that there are no statements such as “follow up with PCP” in these death discharge summaries. Attention to detail is key. And call the Medical Examiner and fill out the death certificate.

Procedure Notes – chest tube, wound exploration/debridement, I+D. (use Ad Hoc button in CIS for lines)Procedure:Indication: (diagnosis)Position, prep, anesthesiaMaterials/equipment, what you did in your procedure, resultSpecimens sent and tests orderedHow the patient tolerated the procedure (blood loss, complaints, complications such as pneumothorax)Again, as mentioned above, there are templates you can easily fill out in CIS for all of these different types of documentation.

Prescriptions Med: Drug name and concentrationSig: dosage, method of administration, and how frequently, PRN/or scheduledDisp: total volume or number to dispenseRefill or no refillExample:Benadryl 25mg1 tablet PO q4-6hrs PRNDisp: 10 (ten) Refils: 0

Presenting on RoundsThe only proper way to present is the way the presentee (chief or attending) wants it done. Start with an introductory sentence followed by the diagnosis (I’ve learned the hard way that this is what will capture the listener’s attention). Emphasize the aspects of the history, physical exam, lab values, imaging results, etc that are relevant to the case and will support your argument in what you think is going on and what your plan is. Mention abnormal values and pertinent negatives. You can always discuss your plan and what you think the diagnosis is with an upper-level before you present to your chief or attending. The goal is to be as prepared as possible and to always do what’s best for the patient and demonstrate that you care. The priority is to mention the key facts and be succinct. Don’t try to give too much information, if you leave something out, they will ask you for it, and you better make sure you have the answer at the tip of your tongue. Maintain good eye contact if you’re in person and do the majority of the presentation from memory. If you are talking to them over the phone, have CIS pulled up to the labs, etc. Example with opening statement: “40yo F with one day history of right upper quadrant pain consistent with acute cholecystitis” physical exam labs ultrasound results assessment and plan.“Do not say VSS. There’s nothing more stable than a corpse.” Dr. Earle.


How to look like it’s not your first rodeo in the OR, even if it is:Prepare before each case. Know the patient, recent lab values, history, indications for the operation, possible obstacles you might encounter or need to watch for based on anatomy/prior operations. Look up imaging prior to the case and see if you can bring up relevant images and leave them up on the OR screens before the case starts. Practice your skills as much as possible before the case, especially if you’re operating with an attending for the first time. If you demonstrate you have excellent skills, they will trust you and let your do MORE. This means, GO TO SIM LAB as much as you can. Be compliant with your scheduled appointments with Ron Bush and practice like an animal. The OR is NOT the place to practice your skills, this is the place to demonstrate how excellent you are because you have spent so much time outside of the OR practicing. Look up the actual operation before the case as well on the SCORE surgery curriculum website, youtube, or other virtual surgery sites (Websurg.com) so that you know all the steps and could perform it on your own if you needed to. ANTICIPATE! Always be three steps ahead and know what’s going to happen next so you can be ready to assist. By being a helpful assistant you prove that you understand the steps of the operation and can drive it forward. Adjust the lighting, be ready with the suture scissors and always have two instruments in your hand. Do everything you can to prep the patient before the attending gets there – clip the hair, position the patient (although some attendings like to do this themselves), and make sure all the equipment you will need is in the room (it may take time/experience to get this one down). Help move the patient before and after the case.During the case, ask questions when the time is right, not while there’s audible bleeding. Be confident. Don’t drink coffee before a case where you’ll need your fine motor skills – thyroids, pedi cases, vascular anastomosis cases. It will be helpful to get loupes early in the year. You will use these for pedi, vascular, and thyroids. OR etiquette – do not finish scrubbing before your chief/attending if yall start at the same time. Allow them to gown and glove first so they can start draping how they wish. Help get everything set up – keeping the cords on the field and passing off the cords that need to be plugged in. Do not speak out of turn. Do not joke around. Control your enthusiasm (learned this the hard way as well). Be as excited as you want after the case, but remain professional around the OR staff and attending. Don’t sing along to the music, as Nate Conway says – “This isn’t karaoke.”Overall, be as prepared as possible, knowledge wise and skills wise. The more prepared you are, the more you will learn and the more you will be taught. Genuine interest and gentle enthusiasm go a long way.Getting to actually perform an operation instead of just assisting is a privilege (not a guarantee). This privilege is earned through demonstrating adequate preparation consistently.

My favorite quote and what I repeat to myself when I catch myself trying to hurry (whether it’s in the OR or on the floor) – “Fast is slow. Slow is steady. Steady is fast.” – Navy Seals

The subsequent sections will describe each rotation. All of the attendings are great teachers and a ton of fun to work with. You will really enjoy all of them. They are very interested in you as a person and in your growth and development as a surgeon, physician, and human being.

Some great advice Dr. Ahmad once gave me – “You should see every moment as an opportunity to demonstrate your professionalism.” This is true, especially when you think no one is looking.


VASCULAR SURGERY:

Most of the vascular patients are located in the HOF (also called hospital of the future, heart and vascular center, M6/M3, Mass Mutual Building). After you meet with your team and run the list, as mentioned above, you will usually split up and round on all the patients in small teams. Vascular is dressing change heavy. There is a dressing change cart with dopplers that you will push around from room to room. A “Medical Student” is sometimes helpful on vascular, but more so on Green since we don’t have a dressing change cart for Green. It is your responsibility to ensure that the dressing change cart is stocked and ready to go and that the dopplers and out and ready with gel bottles and paper towels in the attached trays. Be ready to do a good Doppler exam on each foot – DP, AT, PT. Know whether the signal is monophasic, biphasic, or triphasic (palpable). Record these results as you will have to tell the whole team later and it will be put in the AM note. If a patient does not have distal pulses, this could be an emergency if they previously did have pulses and then all of a sudden lost them. You need to see where there are pulses in that leg – check the pop and femoral because this will indicate where the pathology could possibly be and where the vascular surgeon needs to make their access point. You will learn through rounding what is needed for the different types of wounds. Usually betadine is used on dry ulcers and groin incisions. Xeroform and aquacel are some other favs. You’ll get the hang of it as you go. The PAs are absolutely amazing. They will be your main teachers on vascular. Pay close attention to them and do exactly what they say. You can never learn enough from these fine ladies and as much as you try, you will never be as incredible as they are.

5 A’s of Vascular Surgery taught to us by PAs Kristen Kaiser and Lauren Flink: (good things to ask your attending at the end of a case so you know what post-op orders to put in and what to sign out to your team and NF comrade)

1. Activity (wt bearing status, leg elevation)2. Anticoagulation (LMWH vs. lovenox vs. heparin gtt vs. nothing till the AM or s/p PTT level is back)3. Assistance (consults)4. Antibiotics5. Adios (when can they leave)

Keep Mg at 2, Phos at 3, and Potassium at 4. Avoid morphine since renally cleared. Use dilaudid for pain control in renal patients (small doses in elderly). Avoid LR in renal patients as well, use NS instead. Make sure to renally dose antibiotics.

Main topics to be prepared for:AAA Carotid stenosis and CEAVascular anatomy (TPT, PT, AT, DP etc)Compartments of the leg (see attached leg compartment section)Mesenteric ischemiaLeriche (aortoiliac insufficiency)ClaudicationRest painABIs and how to measure them and what the values mean


PEDIATRIC SURGERY:Developmental Milestones (1-12 months)1 Social smile2 Vocalize3 Head control (no head lag)4 Hand control (hold toy)5 Roll over (back to front)6 Sit alone7 Crawl8 Prehension (thumb/forefinger)9 Pull up to standing10 Walk with support11 Stand alone12 Walk alone

Vital signs by AgeAGENewborn1 month6 month1-2 years

HR94-145115-190110-180100-160

BP (systolic)50-7070-9059-11966-126

RR4024-3024-3020-24

On Pedi, you will run the list with your team and then round with your chief. Your patients are located in the NICU, PICU, Adolescents, and Infants and Childrens. After you run the list, you’ll be in the OR as will your chief most likely. You will try to get notes done as soon as possible before you start your case and in between cases. You also get to see pedi consults. Ann Marie, the pedi PA is extremely helpful and will also teach you a tremendous amount. And she will give you a handout with everything you need to know including dosing info for drugs.Only use NS for IVFs in kids with pyloric stenosis, otherwise use D5LR or D5 ½ NS. Remember 40, 20, 10 rule.Pain meds:Tylenol infantsOxycodone (5mg/5mL) kidsOne Percocet q4-6hrs teensTylenol with codeine elixir: No longer usedMorphine: 0.1mg/kg/dose q4h

Common topics:HerniasHydronephrosisReflux (of urine from the bladder back into the ureter requiring a Deflux procedure to bolster/butress the vesicoureteral junction)AppendicitisCholesystitis (in the really obese kids)UCAbscessDog bitesVACTERL“What do Russians do with foreskin?....... They plant it and grow dictators.” Dr. Moriarty“Take it. Take it.” Dr. Konefal


TRAUMA SURGERY:

Know your ABCDE’s, primary and secondary surveys. When a trauma comes in, you run to the trauma bay if you are assigned to the bay that day and you get CIS pulled up. You put the orders in take down notes and help out with the exam and get things moving as quickly as possible and do whatever you’re told to do. Call CT to see when they’ll be ready and get the patient on the monitor and ready to roll out of the bay when the time is right. Always be three steps ahead. Trauma is something you have to get the hang of through participating in a few. Then it’s the same thing every time and you’ll be a pro. The main thing is to anticipate and get things ready – Chest tube, OR, lac repair, wound exploration/irrigation, calling consults (ortho, optho, etc). Write your Trauma H+P in the CT room while you’re waiting. Otherwise, same thing as above – meet with your team, run the list, and conquer and divide. Perform tertiaries when needed and don’t forget to consult social work and cog when indicated. Of note, you will get a formal orientation to trauma by the attendings when you start your month. Karen Karens, the Trauma PA is outstanding. You will learn a lot from her. Respect her as you respect attendings. And this goes for all PAs/NPs. You should think of them all as your attendings because they are extremely experienced and know everything.

GCS<8 = intubate, ICP monitor if head trauma.Hot Topics:Penetrating chest traumaBlunt chest traumaPenetration abdominal traumaBlunt abdominal traumaFalls while on Coumadin/aspirinEpidural/subdural/subarachnoid hematomasZones of the neck and what you do for an injury in each zoneBlood at the urethral meatusFAST exam

Stab wound to the abdomen in a stable vs. unstable patientFractures with diminished pulsesPelvic fracturesHemothorax/pneumothoraxChest tube outputs and OR indicationsGCSIndications to intubateParkland Burn Formula

Rib Fracture Protocol: (you will get a card to keep in your pocket)Make sure you get a value on IS prior to initiating meds. PFTs, CT w/ 3D recon.800 TID ibuprofen scheduled300 TID Neurontin (gabapentin) scheduled650 q4 tylenol scheduledoxy IR 5 q3 PRN for breakthrough pain


ACS (Acute Care Surgery):

After you get sign-out and RTL (run the list) with your chief, you put in orders and finish your notes. Sometimes your chief will be in the OR and you will be doing all the floor work alone and seeing the consults that come in alone. ACS has an NP, Ali. You are never really alone. There is always back up through the trauma 3rd year and 4th year and there are plenty of others who can help when you get slammed or have a sick patient.

After you see a consult, you can go to the OR and staff it with the attending. If you think the patient is sick or you need help making this decision, you can also call an upper level resident for help and to see and examine the patient with you. The fun of ACS is that you get to see a patient, get the story, do your own exam, review the labs, and imaging on your own and create your own assessment and plan and then present it to your chief or attending and see if you’re right.

Medical Students:Help on rounds by auscultating heart/lungs, being prepared with plenty of dressing changes in your pockets, taking notes so you can help write am progress notes. You will be provided with one or two patients to pre-round on and present to your team. Usually students will follow the patients they helped operate on. Scrub as many cases as you can. Read and prepare for cases and read for the disease processes of the patients you have on the service. Pay close attention to history and physical for new consults because you will have the chance to do your own history and physical exams. Try to find the balance between education and service. Do not take things personally when things are very busy and communication is short. It’s the nature of the beast. Ask you senior when there is downtime to take you through a scenario “oral boards” style. In this way, you can learn how to workup common pathologies we are consulted for.

Topics:CholecystitisCholangitisGallstone pancreatitisHerniasSmall bowel obstructionAppendicitisDiverticulitisAbscessSepsisDuodenal ulcersAcute abdomenNecrotizing soft tissue infection


BLUE SURGERY:

As above, after you get sign-out and RTL, you will either round as a team or conquer and divide depending on how large your census is. This is one of the rotations where the PAs or intern will use the in-room computers to write notes/put in orders during rounds. The PAs, Jess and Tammi, are amazing.

After rounds, you will RTL as a team and the chief will go to the OR. Sometimes you will go to the OR as well.It is important to touch base with the PAs before they go home. Most PAs leave at 4pm. If you and the rest of the residents on your team will be in the OR during this time, ask the PAs ahead of time to either email you the events of the day that you might’ve missed, or to make notes of the list next to each patient’s name and leave it in the OR for you.

Blue is a great operative month. Sharpen your skills and it will pay off.

Of note, you will get a handout at the beginning of your blue rotation with the drug preferences for each attending according to the procedure performed. This handout will also describe specific OR preferences etc. It’s a great handout that you’ll refer to frequently.

Topics:GallbladdersHerniasLipomasGastric bypass Gastric sleeveLaparoscopyLipomasHemorrhoidsGallstone pancreatitisSmall bowel obstructions

“What does the patient want?” – Dr. Earle.


GREEN SURGERY and Colorectal Surgery:

After getting sign-out and RTLing, you will round with your team. The PAs are of course amazing – Lauren Wheeler and Cindy Lucas. This is the rotation where the “Medical Student” will be useful. Prepare your dressing change bag ahead of time and stock it the way you feel fit. There is a green canvas “medical student” in the resident room which you can use if you’d like, I donated it after I realized how useful it is.You will RTL again as a team after rounds and the chief will go to the OR and you will handle the floor or operate.

Green can become large at times, therefore, it is important to stay organized and know your patients well.

Treatment of Anal Fissures (as per Green Instructions):1. Spread the glutei and assess for fissure – usually anterior or posterior midline. If present DO NOT

perform a digital rectal exam2. Send the patient home with the following regimen:

a. Nifedipine 0.2% ointment compounded lidocaine 5% ointment. Dispense 60g. Apply pea sized amount to anus BID

(This must be specifically made at a compounding pharmacy – Western MA Compounding in West Springfield or Lewis and Clark Bernie Avenue)

b. Anusol HC 25mg suppositories 1per rectum twice a day for 2weeks. Limit duration due to tissue thinning of the skin with topical steroid

c. Colace 100mg PO BID to soften stoold. Soak in a sitz bath or warm tub twice a daye. Call for followup with colorectal surgery office at 413 794 7020 if symptoms persist

Topics:Thyroids/ParathyroidsAdrenal massesColorectal CancerBreast CancerDiverticulitisPancreatic CancerWhipplesHemorrhoids Gallbladder CancerLiver CancerSegments of the liver

“Trust no one. Everyone is trying to kill your patient and screw you over in the process.” - Dr. Kutayli


SICU (SURGICAL ICU)

You will learn a lot during this rotation. It is mainly run according to your chief. One resident will be on SICU NF per week with the rest of the residents on during the day. When you arrive in the AM, you will round on each patient as a team with the attending as the NF resident presents each patient and overnight events. You will then write your notes and put in your orders. You will follow the ICU progress note template that’s in CIS.There is usually a lecture during the day. Then you will afternoon round. (Of note, you afternoon round on all the services discussed above. Sometimes you will be in the OR and your team will be rounding without you.)You will hopefully become a pro at placing A lines and central lines during your SICU month. Hot Topics:There is a SICU folder on the eworkplace website – click on the “Policies” tab at the upper right hand corner and then scroll down and click on the “trauma/critical care/ess” button to view the folder. Here you will find powerpoint presentations, articles, etc on everything you need to know to do well in the SICU.VentsAPRVSepsisNutritionExtubation parametersSOFA – sepsis related organ failure assessment score (aka sequential organ failure assessment score); based on resp, cardiovascular, hepatic, coagulation, renal and neuro systems. MD calcs online. Predictor of outcomes. An increased SOFA score during the first 24-48hrs in the ICU predicts a mortality rate of at least 50% - 95%. Scores less than 9 give predictive mortality at 33%. Scores above 11 can be close to above 95% mortality.Weaning Parameters:Tidal Volume 5-8cc/kgRR <20Minute Ventilation = RR x Tidal volume (10-15L/min)Vital Capacity 10-12cc/kgRSBI (Rapid Shallow Breathing Index) = RR/tidal volume

<110 80% extubation success<100 90%<85 100%

NIF (negative inspiratory force) = < negative 25 – 30A patient must have an adequate neurological status to ensure he will be able to protect his airway s/p extubationFailure of SBT (Spontaneous Breathing Trial):

1. Inadequate gas exchangea. O2 sat <85%b. PaO2 <50c. PH < 7.32d. Elevated PaCO2

2. Increased respiratory rate3. Hemodynamic instability

a. Tachycardiab. Pressorsc. SBP >180 or <90

4. Changes in mental status coma, anxiety, agitation5. Increased work of breathing

If there are increased airway pressures postop (ex 38), the patient either has a tension pneumo or abdominal compartment syndrome

Low end tidal C02 1. Air embolism2. PE

High end tidal CO2 Malignant hypertension Dantrolene


NIGHT FLOAT:

This is when you cover a few services overnight. You will get sign-out from your colleague at 6pm Mondays-Thursdays; and Sunday at 6am. You will leave to go home Mon, Wed, around 6am; Tue, Thurs around 8am after education.

How to survive your first night on NF without a lasso or a saddle:- When on NF, many (if not most) of the patients you are responsible for will not be very familiar to you

in the beginning. Therefore you must depend on your colleagues to tell you what you need to know about these patients. During sign-out, you should be told what changes were made during the day and what the current issues are and what might indicate that this patient is getting sicker overnight and what you should do if this patient were to begin to show signs of getting sicker. Once your colleagues leave, it’s all up to you.

- Always remember the golden rule: “sign out unto others as you would have them sign out unto you.”- If you are stuck and have no clue what’s going on, you have upper-levels as resources. Start with your

PGY2 and work your way up the ranks. “Load your boat.”- If you have a patient that is sick, make sure you notify your team and discuss the patient with the

other NF residents in case there is something you missed, or if the attending should be notified, or if the patient should be transferred to the SICU vs. OR. Sometimes there are certain things only a wiser more experienced resident will pick up on.

Common Issues/Pages and how to think through them:Key to all pages – you will never be faulted for going to the bedside and evaluating the patient yourself. You should try to go and see every patient you are paged about if possible, especially when you are starting out. You will be faulted for not going to see a patient if it turns out you should’ve.Don’t be afraid to ask for help.

1. Pain a. Explained vs. Unexplained? Improving? Worsening? Appropriate considering hospital

course/recent operation?i. Postop – inflammation is worst in the 1st 48hrs and then should decrease

ii. Get history of pain – find out if this is a chronic pain player or if this patient is opioid naïve

iii. Somatic pain (skin) – lidocaine, analgesic, ibupropheniv. Deep somatic pain (joint/muscle) – nociceptive C-receptor pathway, use opioids (mu-

receptor)v. Visceral pain

b. When to call upper level – i. New pain, changed pain, after you’ve done what you should’ve and its still not

working. Call APS if patient has an epidural/PCA or something that APS is in charge of. Do not adjust medications in a patient whose pain meds are being managed by APS (Acute Pain Services).

ii. In general, for any issues – call an upper level if you’ve tried an intervention and it has failed. Bump it up a level after each failed intervention, working your way up the hierarchy towards the chief and then the attending.

c. Post op Pain – morphine, dilaudid, percocet prn. Lidocaine/Marcaine intraop at incision sited. Non-Opioids – toradol (no dependency, nonsedative, can use with opioids, does not cause

ileus. Bad on stomach/kidneys – check BUN, Cr, fluid status. Don’t use in a patient that might have a bleeding tendency. Do not use for over 48hrs post op.

e. If patient has a PCA that is not managed by APS, you can ask “does the dose help the pain and it just doesn’t last long enough, or does the dose not even touch the pain” – and then you can decide if you need to increase the dose or increase the frequency. Always watch for sedation and think about Narcan (0.4mg IV) if you get a subsequent call saying your patient is less responsive.

f. Opiods – oral vs. IVi. Morphine 2-4mg IV, may repeat 2-4hrs prn


1. Starting dose: weight/20.a. Example: 60kg/20 equals 3mg. Start with 3mg and increase from

there if needed.ii. Oxycodone 5-10mg PO, may repeat q4hrs prn

iii. Dose adjustments:1. Start with low doses in the elderly or in renal/hepatic dysfunction patients2. Use caution in patients with respiratory illness3. May have to use higher doses in chronic pain players – try NOT to under

treat a patient’s pain. You must listen to the patient because all you know is what the patient is telling you his pain is. Everyone feels pain differently and has different thresholds for pain tolerance.

4. PO:IV conversion of morphine is 3:15. Again, remember Narcan if you give too much

iv. Acetaminophen1. 650mg PO/per rectum2. Avoid in liver dysfunction3. Good for fever4. Regular strength 325mg5. Extra strength 500mg

v. Opioid/acetaminophen combinations1. Percocet – Oxy 5mg/APAP 325mg. Norco 10/325. Lortab 5/500. Lorcet

10/6502. Lortab/Vicodin: hydrocodone 5-10mg/APAP 500mg

vi. Implications:1. 2 Percocet q4hrs (6x per day) = 3900mg APAP2. Max dose APAP in 24hrs is 4g

vii. NSAIDS:1. Naproxen 500mg PO q12hrs2. Ibuprofen 800mg PO q8hrs3. Toradol 60 mg IV once, then 30mg IV/PO q6hrs. cannot use for >5days4. Avoid in renal dysfunction (acute or chronic) or uncontrolled HTN.

viii. Narcotic-Induced Post-op Ileus:1. Alvimopan (mu-opioid antagonist) - best if initiated before the operation.

This is not something you start on your own without discussing it first with your attending, but you can suggest it in a patient with unresolving post-op ileus. Really cool drug.

2. Nausea/Vomiting a. DDX: bowel, enteritis, post-op ileus, drug induced, diverticulitis, gallstones, pancreatitis,

postop anesthesia, obstruction (history of surgery)b. Other DDX: pregnancy, viral/bacterial gastro/entero/colitis, migraines, otitis media, motion

sickness, bulimia, gaggingc. History – recent anesthesia? Abdominal pain character and quality. History of

hernia/cancer/trauma/DM/chemo/radiation, recent medications, obstipation, mental status changes

d. Physical – does the patient look sick/critical? Vitals (tachycardic, desating?) Mental status. Abdomen: distension, TTP, BS, hernia, tympanic to percussion, peritoneal. Neuro – evaluate for head injury, look at pupils

e. Obvious and expected:i. Causes – post anesthesia, <4-5 days postop, 1st attempt at advanced diet, recently

clamped NGT and not tolerating, Meds (K, narcs, chemo), known illness (Cholecystitis, appendicitis, SBO, etc.)

ii. R/O deterioration/decompensating – changes in vital signs, MS changes, abdominal, neuro exam changes

iii. If NO deterioration


1. Unclamp NGT2. Back off diet3. Try a different narcotic (morphine to dilaudid, but remember dilaudid is

6times stronger than morphine)4. Different form of K5. Zofran, max is 4mg q66. Scopolamine patch if seems to be motion related7. Phenergan if patient is young and healthy8. Consider Reglan/erythromycin for ileus (only after discussing with team)9. Alvimopan as mentioned above (only after discussing with attending).

f. Unexpected casei. Causes:

1. Obstipation/hernia/previous surgery may require acute abdominal series or possible CT scan

a. Make sure NGT is working. If it is not, reposition and flush with air.2. >4-5 days post-op (or previously tolerating diet) acute abdominal series,

possible CT scan, be concerned about possible intra-abdominal abscess, SBO, stress gastritis, GI bleed. Make sure to check the wound

3. GI bleed – NGT, saline lavage4. CNS etiology (stroke/trauma) – noncontrast head CT5. History of DM EKG, cardiac enzymes, rule out MI6. Is patient hypotensive? Check lytes and correct derangements and bolus.

g. Metoclopramide (Reglan)i. 10mg IV/PO q6hrs prn

ii. Stimulates gut motility1. Avoid in suspected bowel obstruction or diarrhea

iii. Can be sedating in some patientsiv. Use half dose in dialysis patients or elderlyv. Dystonic reaction treat with Benadryl 25-50mg IV

h. Ondansetron (Zofran)i. 4mg IV q6 to 8hrs PRN

ii. Safest side effect profile for elderlyiii. Best effect in chemo induced nausea

3. Insomnia a. Benadryl

i. 50mg POii. 25mg IV

iii. avoid in elderly (anticholinergic effects)b. Trazodone

i. 50-100mg qhsii. safe in elderly

iii. side effects: hypotension, priapismc. Ambien

Created by Saiqa Khan

Neurogenic

PainSympathetic afferent stimuli (acute MI)Drugs w/ CNS effect

Injury (CNS, stroke, spinal, operation)

GI

Lytes – K, Ca, Mg, PhosInflammatory – enteritis, appendix, retroperit-abscess/hematoma, pancreatitisIschemiaDrugs w/ GI effect (CCB, antipsychotics, narc, anticholinergics

IleusMechanical obstruction-LBO, SBO, gastric

Nausea

15

i. 10mg qhsii. 5mg in elderly

d. What I do and what works:i. Turn the lights off, turn the TV off, tell everyone to be quiet around the room

ii. Tuck the patient in with a blanket and pet them a littleiii. Calm their fears if they’re worried

4. Acute Anxiety a. Go to the bedside EVERYTIMEb. Etiologies:

i. Pulmonary – dyspnea, PE, pneumothorax, laryngeal spasm, allergic reaction, asthma, worsening infection

ii. Neuro/Psych – baseline?, anxiolytics as part of home meds, sundowning, ICU delirium, reaction to meds, ETOH/drug withdrawal (DTs – increased HR) CIWA scale.

iii. Cardio – impending doom, MI, Afibiv. Infectiousv. Metabolic – hyperkalemia, hypermag, liver failure (encephalopathy)

vi. Idiopathicc. Altered Mental Status …think…

i. 1. Hypoxiaii. 2. Shock (hemorrhagic)

iii. 3. ETOH/drug withdrawald. Check: O2 sat, ABG, labse. Treat: RARELY do you treat with anxiolytics. Do NOT order sedatives without speaking with

an upper level. Do NOT give ativan or benzos to the elderly.f. Lorazepam (Ativan)

i. 1-2mg PO/IV q4-6hrs prng. Alprazolam (Xanax)

i. 0.5-1mg PO TID prnii. Do not use in patients with liver disease

5. Agitation a. Haldol

i. 2mg-5mg PO/IVii. In the elderly, use 0.5-1mg PO/IV

iii. Watch for dystonic reactions (extrapyramidal symptoms – give benztropine 1mg to counteract)

b. Ativani. 2mg PO/IV

ii. Avoid in elderly patients.c. May need higher dose if patient chronically uses this medication

6. Constipation a. MoM (milk of mag)

i. 30ml POb. Magnesium Citrate

i. 8oz (240ml) bottle POc. Fleets enemad. Almost all patients on pain medication should also be on a bowel regimen consisting of at

least Docusate and Colace.e. Bisacodyl (dulcolax)

i. 10mg PO/per rectumii. can cause cramping

f. Avoid the following in dialysis patients for risk of hyperMg/hyperPhosi. Milk of mag, mag citrate, fleets enema


g. Lactulosei. 30mL PO

ii. Can cause bloating/gash. Can use combinations

7. Heartburn a. MgOH/AlOH (Maalox)

i. 30ml POii. Avoid in dialysis patients

b. CaCO3 (tums)i. 2 tabs PO

ii. Safe in dialysis patientsc. Rantidine (Zantac)

i. 150mg PO BID prnii. Dose once daily in dialysis patients

d. Do not give PPI alone for acute heartburni. Onset of action is delayed for several hours

8. Pruritus a. Benadryl

i. 25-50mg PO/IV q4hrsii. Avoid or reduce dose in elderly

b. Hydroxyzine (Atarax, Vistaril)i. 25-100mg PO/IM q6hrs

ii. Avoid in the elderyiii. CANNOT be given IV

9. Chest Pain a. Tell then nurse to get vitals before you hang up the phone so when you arrive at the bedside,

there will be a new set of vitals. Evaluate the need for ACLS. Pain (character, location, chronology, origin, radiation, intensity, events, duration, alleviating/exacerbating factors.

b. Classify the chest paini. Definite angina, probable angina, not angina

c. Assess the risk factors – history of CAD, age, gender, DM, HTN, etcd. PE palpate the radial pulse. Tachycardia, tachypnea, and desats should increase your

suspicion for a PE. Get an ABG and check for low pCO2 2/2 hyperventilating from tachypnea.e. EKG – get this within 5 min and compare it to previous EKGs in the chart. This must be a 12-

lead. i. Repeat EKG in 30min if needed

f. Cardiac Workup (do this in a vascular patient even if they just have nausea without chest pain since most have a significant cardiac history and are known vasculopaths)

i. Lytes, divalents, cardiac enzymes (CK, CK-MB, trop cycled q8 hrs x3), CXR, EKG (as mentioned above), possibly CBC if you think there is a component of demand ischemia 2/2 blood loss/hypotension which may require transfusion.

ii. If you’re thinking about transfusing, make sure you’ve also ordered a type and screen and coagulation factors.

iii. Get a BNP if you suspect CHF.g. As you are working the patient up, you should’ve already notified your upper level. Also call

cards if you are suspecting cardiac etiology. There is also a STEMI pager.i. MONA

1. Morhpine2. Oxygen3. Nitroglycerine

a. 0.4mg sublingual q5min. watch responseb. response does not predict cardiac source, but may give the patient


reliefc. If no response, to NTG x3 and EKG is negative, try MAALOX.

4. ASA 325mg chewed (unless hemorrhage/allergy)ii. Beta Blocker (don’t give if patient is bradycardic or hypotensive)

iii. Heparin and clopidogrel (Plavix) – leave this up to the upper level/cardsh. DDx: 7 lethal causes of chest pain

i. Acute MI – usually occurs POD31. Diabetic patients present with SOB and weird discomfort

ii. PE – get ABGiii. Pericarditis with tamponadeiv. Tension pneumothoraxv. Aortic dissection

vi. Boerhaave’s syndrome (esophageal rupture)vii. Severe pneumonia

i. STEMI 1mm ST segment elevation in 2+ leads or inverted T waves >1mmi. ASA (+clopidogrel if PCI), IV heparin or LMWH, IV/PO beta blocker, Primary PCI or

thrombolytics, ACE inhibitor (12-24hrs), Statin (first 24hrs)j. NSTEMI ASA (+clopidogrel), IV heparin or LMWH, IV/PO beta blocker, GP IIb, IIIa blocker,

ACE inhibitor (12-24hrs), Statin (first 24hrs)

10. Hypotension

Created by Saiqa Khan

Neurogenic

Bld/Urine/Wound CxAntibiotics

Isotonic fluidsSource of infection

Isotonic fluids (LR or NS)Source of hemorrhage

Surgical intervention vs PCI

SepsisHypovolemiaCardiogenic

Decreased JVPDecreased UOP

Tachycardia

Elevated JVP – distended neck veinsCrackles, Chest pain, Dyspnea

Widened pulse pressureGood cap refill

Fever or hypothermiaLeukocytosis/leukopenia

(look @ WBC trends)

Decreased pulse pressurePoor capillary refill

Cool extremities

Systolic BP < 100mmHg

18

a. Look at the trend of patients vitals and H/H. Check vitals again once you arrive at the bedside. Evaluate patient (SOB?, Chest pain?, cyanotic?, cold?, altered mental status?)

b. Check: insicions, drain output, fistula output, NGT output, ostomy output. Check O2 sat (if low, patient may be oversedated. If GCS is 8, intubate). Check recent meds for possible beta blocker overdose.

c. Patient who just got a central line and became hypotensive – tension peumo until proven otherwise

d. Postop Hypotension – hemorrhage until proven otherwisee. Intervene place foley with urometer to monitor UOP, EKG, ABG (lactic acidosis due to

hypovolemia), CXR, consider sending pt to ICU before decompensates furtherf. Steps:

i. Examineii. O2 sat (give O2, intubate if needed, protect airway)

iii. Fluid resuscitate (2 large bore IVs, isotonic fluid LR/NS, give 1L and stay and watch it go in and watch the patient improve. While waiting, get blood ready)

iv. Investigate causes while working on the above: EKG (acute intra/post-op MI), CBC (compare to preop, may not have a big Hct change as it takes three days for Hct to represent blood loss)

v. Physical examvi. If no improvement after 1Lbolus (or after you’ve adequately replaced fluids), might

have to go back to the ORg. Fluid replacement

i. EBL: give 3ml for every 1ml blood lossii. Insensible: 10ml/kg/hr for every 1hr the abdomen is open

iii. Bolus Pedi: fluid 20ml/kg, blood 10-15cc/kgiv. Maintenance IVFs: 40, 20, 10 rule 40ml for the first 10kg, 20ml for the second 10,

and 10ml for the next 10mg, and 1ml/kg onwards.h. Key clinical signs of circulatory volume

Volume depletion Sepsis Euvolemia Fluid overload

Hands Cold Warm Normal Cold

Cap Refill Delayed Delayed Normal Delayed

Skin Turgor Poor +/- Normal Normal Normal

Tongue Dry +/- Moist Moist Moist

JVP Low Low Normal Raised

Crackles No No No Yes

Peripheral edema No No No Yes

In sepsis, you have 1hr (the golden hour) to start appropriate antibiotics until mortality is significantly decreased.


11. Oliguria (<30ml/hr (adult), 1ml/kg/hr (peds). Check urine creatinine and Na to calculate FENA)a. Prerenal check ins/outs

i. Hypovolemia, poor intraop IVF management, vomiting, NGT, high ostomy output, diarrhea, burns, diuretics

ii. Hemorrhageiii. Sepsis (requires more volume due to third spacing)iv. Acute CHF due to MIv. Abdominal compartment syndrome (swollen bowel postop)

b. Renal check baseline BUN/Cr, is patient on dialysis?i. Intraop hypotension

ii. Nephrotoxic drugsiii. Rhabdomyolysis (trauma, hypothermia)iv. Suprarenal clamping (during vascular surgery)

c. Postrenal make sure foley is working – flush if there is hematuria. Check a bladder scan to make sure foley is adequately draining bladder.

i. Obstructed foleyii. BPH

iii. Tumor compressioniv. Ureteral/urethral injury

d. Treatment for postop oliguria is RARELY lasix. It is almost ALWAYS fluids. Lasix increases UOP but does not fix the underlying derangement. Same with metoprolol for tachycardia, and pressors for hypotension. You must figure out the cause/etiology instead of just treating the abnormal number.


Types of Shock CVP PCWP CO SVR SV02 (marker of perfusion)Hypovolemic Cardiogenic:-LV MI Nl or -RV MI Nl or

Obstructive:-Tamponade-Massive PE

Nl or

or

Distributive:-Early-Late

Nl or Nl

NlNl

or Nl or

Nl or or

12. Electrolytes – check BUN/Cr, glucose, albumin (these affect Mg, and Ca). Low Mg can prevent correction of low K, and low phos can prevent correction of low mg.

a. Sodium (135-145)i. Hyponatremia (<130)

1. Signs/symptoms – N/V, confusion, HA, convulsions, coma2. Treat: fluid restriction, limit free water, then give NS. Hypertonic saline only

used for extreme (<120) – controversial.3. Correct slowly (no more than 0.5mEq/L/hr). Too rapid correction central

pontine myelinolysisii. Hypernatremia (>150) must calculate free water deficit and replete this amount

over 48hrs1. Signs/symptoms – lethargy, MS changes, edema, coma2. Treat: free water (either IV or oral). If IV, give as D5W. Rate depends on free

water deficit but usually 50-70cc/hr. If tolerating PO, give tap water boluses of 20-50cc/hr.

3. Correct slowly (no more than 0.5 mEq/L/hr). Too rapid = cerebral edemab. Potassium (4-4.8)

i. Hypokalemia (<3.5, in surgery <4 is too low)1. Signs/symptoms: arrhythmia, EKG changes (large P, narrowed QRS, small T)2. Treat: (po is safer than IV)

a. IV KCl 40mEq in 500cc, infused over 4hrs (rate should not exceed 10mEq/hr in PIV, 20/hr in CVL)

b. PO K (potassium tab) or potassium powderc. 10mEq for every 0.1mEq above 3.0d. 20mEq for every 0.1mEq below 3.0

i. K2.8 in ordered to correct to 4.0, give (20x2)+(10x10) = 140mEq

e. For urgent replacement, give PO liquid or IV, do not give PO tablets/capsules

f. IV ratesi. As mentioned above:

1. 10mEq/hr through peripheral2. 20mEq/hr through CVL

g. If pt has central line, a more concentrated dose can be given, but don’t exceed 10mEq/L/hr

h. Use caution when replacing patients with chronic kidney diseasei. Do NOT replace in dialysis patients unless absolutely neededj. If patient has concurrently hypo-phos, give IV K-Phos 20mmol or

30mmolii. Hyperkalemia (>5.2) MCC is lysis of sample REDRAW the sample since it may be

hemolyzed. 1. Signs/symptoms: arrhythmias, EKG changes, (peaked T, widened QRS,

blunted P)2. Treat mild: see below. Diuresis (loop diuretics, if patient has normal

kidneys). Lasix 20-40mg IV or bumex 1mg IV3. Treat severe: (>6)

a. Calcium – cardioprotective, antagonizes depolarization effects of K, effect is short, so only give in severe hyperK when all 3 EKG changes are seen

b. Calcium Gluconate 500-1000mg (5-10mL of 10% solution) infused slowly over 2-3min (2amps)

4. Temporary Treatments:a. Insulin+glucose – drives K into cells (activates Na/K pump in

skeletal muscle), effect begins in 15min, peaks at 1hr, lasts several hours.


i. 10units Insulin IV + 1amp (50cc) D50b. Bicarb – increases pH, causes H movement from cell to serum with K

moving into cells through H/K pump.i. Sodium Bicarb 45mEq (50ml of 7.5% solution), infuse over

5min (50mEq)c. Beta-2 adrenergic agonists – increase Na/K pump, drives K into cells

i. Albuterol 10-20mg in 4mL saline by nebulization, over 10min (effect seen in 90min)

ii. Or epinephrine 0.05mcg/kg/min by IV (effect seen in 30min)

d. Permanent Treatments -> Almost always treat initially with kayexelate (po or per rectum if vomiting)

i. Kayexelate – cation exchange resin, takes up K, releases Na.1. Kayexelate oral 15-30g in 60-120ml of 20%

Sorbitol (30-60g)2. Kayexelate enema 50g mixed in 150ml tap water

(not sorbitol)ii. Dialysis (most effective) – use HD rather than PD. Can

remove 25-50mEq/hre. If patient is in renal failure or on TPN stop K in IVFs

c. Magnesium (4mg/dL): HYPO-mag is more common than hyper-mag. HyperMg is rare. Replace 1mg for every 0.1 increment in Mg level you are hoping to achieve.

i. Signs/symptoms: usually asymptomatic until Mg <1. Most worrisome is ventricular arrhythmias, hypokalemia, tetany

ii. As mentioned above, hypoMg can affect other lytes, as can hyperglycemiaiii. Treatment: Mag sulfate 2gm (16mEq)IV. Or mag oxide 400mg tab PO (but PO will not

correct quickly)1. Safe to give in large amounts. Can be given quickly.2. Give 2-4 MgSO4 IV (always give 4grams if Mg is <1.4)3. Only replace if absolutely necessary in dialysis patients

d. Calcium (8mg/dL)i. Hypocalcemia

1. Signs/symptoms: trousseau sign of latent tetany (carpal spasm with inflation of BP cuff above systolic BP), Chvostek’s sign (tap inferior portion of zygoma, facial spasms), laryngospasms, arrhythmias

2. If low, first check serum albumina. Measured Ca + [4.0-albumin) x 0.8] = corrected Ca

3. Treat: PO calcium carbonate 500mg, or IV Calcium gluconate 1g (4.65 mEq) or 2g (9.3mEq)

a. Ca gluconate 1amp (10m of 10%solution) = 1gmb. 1g Ca gluconate = 4.65mEqc. usual replacement is with 1-2 Ca gluconate IV

ii. Hypercalcemia1. Signs/symptoms: “stones, bones, moans, psychic overtones.” (renal stones,

bone pain, pancreatitis, N/V, MS changes)2. Treat: don’t treat unless symptomatic

a. Increase fluid intake, loop diuretics, rarely bisphosphonatese. Phosphorus (3mg/dL). Usually will see Hypo-Phos

i. Signs/symptoms: muscle weakness, MS changes, WBC dysfunctionii. If mildly low (>1.5), replace PO

1. Phos powder, 2packets, BID-TID with mealsiii. NaPhos 15 or 30mMol IV, over 2-4hrs (if Na deficit too)iv. KPhos 20 or 30mMol IV over 4-6hrs (if K deficit too) 30mmol Kphos gives you

45mEq K.v. If very low or symptomatic, pt needs IV as well.


1. Ask for help2. Do NOT replace in dialysis patients unless absolutely necessary

13. Fever a. Obtain blood cultures BEFORE starting antibioticsb. Causes in hospitalized patients

i. Wind – POD 1,2. Atelectasis, PNA (CXR)ii. Water – POD 2. UTI, foley (UA/Urine Culture)

iii. Wound – POD 2,3. Cellulitis, thrombophlebitis, decubitus ulcers (go look at the wound)

1. The culprits that cause high fevers on POD 0 that must be ruled out are clostridium and Grp B strep. Take down the dressings and look at the wounds esp for POD 0 fevers. Look for dishwater drainage.

iv. Walk – DVT, PE (although DVT rarely presents as a fever. However if you’ve done a full fever workup and everything is negative and the patient is still spiking temps, get a duplex u/s to r/o DVT. This is not part of your routine fever workup.)

v. Plastic (IVs, Central lines, drainage catheters, etc.) – go look at the line insertion site and rule out erythema. (Blood cultures X2)

1. Ask cultures to be drawn from central line as well as peripheral IVvi. C.Diff colitis (if diarrhea is present and WBC is through the roof.) (CBC w. diff)

1. The only things that cause a tremendously elevated WBC are steroids and C.Diff

vii. Sinusitis (if NGT has been used)viii. Prostatitis – do a rectal exam and look for perirectal abscess, sacral decubitus

ulcers/abscess (especially in ICU patients)c. Timeline

i. 1st 24hrs = atelectasis (pt has a fever but feels fine)ii. 1day = wound (clostridia, step) as mentioned above

iii. 2-3days = thrombophlebitisiv. 3-5days = wound (staph aureus, gram neg). Staph epidermidis 1month.v. 5-7 days = UTI

d. Exami. History of patient, preop abx, prior infection, appropriate pain control

ii. Lungs (atelectasis, PNA)iii. Heartiv. Incision (strep – red, edematous. Clostridia – not red, dusky, pain out of proportion,

dishwater drainage, edematous). Always mark inflammation/area of erythema with a marking pen and label with date and initials so that erythema can be evaluated (getting better or worse over the next few days with or without intervention)

v. Lines (thrombophlebitis, suppurative phlebitis). Discuss with team about removing unnecessary lines. Push on vein to look for pus coming out of line. Can send central line tips for culture.

e. Pan-culture: take cultures while fever is present (decide which of the following are indicated for your patient. Don’t be a cowboy order shotgun labs. Try to be a sharp shooter like a true


Texan or order what’s indicated based on your overall assessment and order tests where you know you will do something about the results – think about 1. What you are looking to find, 2. What the test will tell you, and 3. What you will do with that result).

i. UA, urine cultureii. Blood x2 (2 different sites 15min apart)

iii. Sputum (bronchoscopy, deep suctioning) culture – BAL vs. mini BAL (especially on ICU, ventilated patients)

iv. Wound culturev. Stool – C. Diff, fecal WBC, ova and parasites, stool studies

f. Treat: Don’t have to treat fever unless its 104F. Body fights infection best at 38.5-39.5C. Not always necessary to give Tylenol. Don’t start Abx unless sick looking (confused, tachypneic, unstable BP. If UOP is low = sepsis)

i. Golden hour to start appropriate abx until mortality is significantly affected.ii. Encourage IS (incentive spirometer, 10x every hour. Every commercial break)

iii. Respiratory therapyiv. Chest physical therapyv. Treating thrombophlebitis – remove line, if no improvement treat with abx (cover

gram positives 2nd generation cephalosporin), cover MRSAvi. Treat suppurative phlebitis with OR, surgical removal of vein

g. Intraabdominal infection – not tolerating diet (unresolved ileus), not mobilizing 3rd space (continued low UOP), smoldering WBC (not really high but above normal)

h. When to order CT – rule out other causes, POD 5 will start to see abscess. Order if patient is decompensating and you suspect intraabdominal process, if there’s peritonitis, and patient is stable enough to go down to CT. Do not move an unstable patient from a stable environment (OR, floor, trauma bay) to an unstable environment (transport, CT, etc.) unless you are emergently wheeling the patient to the OR for an emergent operation.

i. Tachycardic s/p new anastomosis – if anastomosis is going to breakdown, it usually happens POD7. Patient will be tachycardic, abdomen will be distended, and pt may also have respiratory symptoms. This is an emergency and will require OR intervention.

1. Rectal stump leaks or blow-outs will also present similarly.

14. Altered Mental Status a. Primary Survey – ABCs, vitals, neuro exam (GCS <8 = intubate), C-spine precautions (trauma

patient, missed occult C-spine fracture)b. Tests – ABG, EKG, full labs, drug screen, radiographic studiesc. Look through meds ordered and ensure this is not a drug reaction from meds we are giving

the patient or sedation from pain meds. Especially in the elderly.d. Immediate intervention – Oxygen (NC/intubate), IV access, glucose check, cardiac monitor,

pulse-oxi. If ABG returns and CO2 is elevated, make sure patient is not a chronic retainer

(history of COPD, look back in CIS at past CO2 and see what baseline is). If patient is not a chronic retainer, start BiPAP

1. Contraindications to BiPAPa. Anastomosis (BiPAP could put anastomosis under tension and blow

it)b. Inability to remove the mask (poor neuro status)

i. This is so patient can remove mask if he feels like he’s about to vomit

ii. Therefore, do not restrain patients who are on BiPAP and make sure the nurse is aware of this

c. Chronic retainersd. Intracranial bleeds

2. When ordering BiPAP, place patient on low settings and write a note for respiratory therapy to titrate. (it doesn’t matter what settings you order


since respiratory therapy will tweak)3. Make sure to order repeat ABGs while the patient is on BiPAP so respiratory

therapy has a marker to use to titrate and so you can see if your intervention is working and when the patient will be ready to come off of BiPAP.

e. DDx – hypoxia, infection, brain (CVA, seizure), metabolic, cardiac, lungs, toxins/drugs. Treat the underlying cause

f. Get a Head CT to rule out stroke if you’ve completed your full mental status workup with no results. Stroke/ICH must be ruled out if suspicion is present. Discuss with team.

15. Shortness of Breath a. DDx – PE, COPD, volume overload, PNA, tamponade, pneumo/hemothorax, pleural effusions,

anxietyb. Get vitals, O2 sat, CXR, ABG (on RA is more accurate)c. Call respiratory therapy if needed and give oxygen (increase L of NC for example)d. If suspicious for PE, notify team and get a CTA. e. Treat cause – heparin, albuterol/atrovent, Lasix, abx

i. Chest physical therapyii. IR drainage for pleural effusions

iii. Chest tube

16. Hypertension a. Consider cause – pain, withdrawal, haven’t restarted home antihypertensivesb. Symptoms – HA, chest pain, hematuria. Look up patients baseline BP and antiHTN medsc. Give next dose early, increase dose, or use new agent (discuss with team)d. 10mg Hydralazine for SBP >160 and HR <100 as side effect is tachycardiae. Labetalol 20mg for SBP >160 and HR >100 since HR can be decreased as well. (Only given in

the ICU and when patient is on a monitor/tele)

17. Lab Ordering a. Dx Acute Hepatitis: hepatitis panel (HAV, HCV, HBsAg, HBc Ig) b. Cardiac enzymes

i. Troponin/CK total/CKMBii. Make sure to cycle the cardiac enzymes q8hrs x3 and watch the trend

iii. Tropinemia may exist in renal patients, which is why trend is important.c. Pre-procedure workup

i. H&Pii. EKG for age >55 or significant cardiac history, CXR if there’s history of pulmonary

disease/symptoms or age >55iii. Coags if known history of liver disease or recent history of bleeding diathesis, or if

patient takes Coumadin for known afib/stent/etc.iv. Type and screen if patient may need blood in ORv. CBC (esp with known history of anemia)

vi. Lytes (esp if pt takes diuretics)d. Blood cultures

i. Community acquired PNAii. Cellulitis

iii. Febrile patients


Pearls for Answering Pages:

Goals of answering a page 1. Take care of the patient!

a. Identify life-threatening problemsb. Temporize less acute problems until they can be addressed properlyc. Address problems that can be resolved fully over the phone

2. Always respond to pages in a timely fashion, even if it’s just to call back to say that you are busy and will call back later. Nurses want to feel heard, acknowledged, and respected.

3. Make the nurse your friend4. Avoid the appearance of neglecting the patient or the family

Questions to ask yourself when answering a page 1. Is this a life-threatening problem? What could I miss that would kill the patient?2. Is this a life-threatening problem masquerading as a simple problem?3. Can I resolve the problem or temporize the problem over the phone?4. Do I need to go see this patient? When?5. What information will help me decipher the acuity of the problem?6. What is a reasonable solution to the problem?7. Is there any follow-up necessary?

Tips for staying out of trouble 1. Your first goal is to take care of the patient – not yourself

a. You’ll never be sorry you went to the bedside to see a patient, but you might be sorry you didn’t go to the bedside to examine a patient.

2. Ask yourself, “what is it that I cannot afford to miss in this case?” If you rule that out, it’s almost impossible to make a serious mistake.

3. It’s okay to say “I don’t know” or to ask for help from your senior resident, attending, or nursing colleagues

4. Its okay to ask the nurse, “what would you like to do?”5. As an intern you are never truly responsible for a patient, BUT you are truly responsible for letting

others (ie. Senior residents and attendings) know that there is a problem or a potential problem.a. The only unforgivable mistake as an intern is not informing your senior resident or attending

of a patient who is not doing well or has a problem.b. Load your boat


Surgical Cricothyroidotomy:

With a 10-blade, make a vertical incision in the neck (don’t extend it so far down you hit the innominate). Identify the cricothyroid membrane and immobilize it between the thumb and middle finger of your nondominant hand with the index finger placed on the thyroid notch. Never move this hand so that the cricothyroid membrane is always visualized.Make an incision down to the cricothyroid membrane using a scalpel with the dominant hand. Hemostasis is a secondary concern, as the focus of the procedure is to rapidly secure an airway.Placing the scalpel handle through the membrane and turning the scalpel 90 decrees can open the cricothyroid membrane further. A 6-0 endotracheal tube, or a No. 4 or No.6 tracheostomy tube is then inserted.

Leg Compartments:


Arm Compartments:


CPIS <6 and low suspicion: not treated nor further evaluatedCPIS >6 or high suspicion: BAL and initiate therapyBAL specimens with greater than or equal to 10^4 CFU are considered positive.


THORACIC SURGERY

There is one amazing life-saver incredible PA – Amy Zajac. She is so helpful. She sometimes gets instructions regarding patient plans directly from the attendings. Stick close next to her so you can stay up to date. There would be no thoracic service without AMY. She is amazing and a true gift.If you are covering thoracic, it will most likely be on the weekend. But this will be very rare. Page your senior for EVERYTHING and page the attending for pretty much EVERYTHING after you’ve spoken with your senior resident. The thoracic patients can be very sick and complicated and as an intern, you are just not ready to manage these patients alone. When it comes time for you to scrub a thoracic case, when you’re a PGY2, prepare for the case as much as you can – know the anatomy, the patient, the indications, complications, etc. The more you demonstrate your knowledge, interest, and preparation, the more likely you will be to actually do something and not just watch the case from a distance or just drive camera. You’ll learn a lot from clinic. The attendings will teach you a ton if you take time to ask questions and join their discussions, especially in clinic in between patients.

Topics:Lung cancerEsophageal CACMEMIEWedge resectionsTracheostomies BronchsEGDsPNAChest tubesHiatal hernias


TRANSPLANT SURGERY

Melissa is the PA, and she is incredible!If you’re lucky enough to be on call when a transplant comes in, try to go down and pop your head in and see how it’s done. This is a great rotation to master your vascular anastomosis skills. You’ll be making fistulas, doing thrombectomies, balloon angioplasties, etc. Once in awhile you’ll get an open nephrectomy or an actual transplant. Teaching conferences are excellent.Review transplant drugs for immunosuppression.Watch UOP closely on fresh transplants. Keep the attendings and your senior updated on any changes with fresh transplants

Topics:Nephrotoxic immunosuppressive drugsImmunosuppression – tacrolimus, etc. and mechanismsDifferent types of AVFsWhen a thrill turns to just pulsatile flow, there is most likely a proximal obstructionHyperparathyroidism in kidney failure


PLASTIC SURGERY

This is one of my favorite rotations, but I am biased. The beautiful thing about this rotation is you get reminded of the honor and privilege it is to be a physician. You gain access into a person’s entire life – what motivates them, what scares them, what their goals are, etc. And they grant you access to their world and give you full control. You can listen to what they’re not saying, counsel them in the right direction, and change their life just with a conversation. You listen to what their goals are, and through one operation, you can help them change their outlook on life and their future. This is the most invasive surgery – you not only operate on their body but you “operate” on their mind.

Spend as much time with Dr. Parikh as possible. He will teach you not only about plastic surgery, but about the world, humanity, and yourself believe it or not. Demonstrate your work ethic, interest, and preparation, and Dr. Parikh will reward you by letting you do awesome parts of the case. Draw out the anatomy on the white board in the OR before the case starts and discuss it ahead of time with Dr. Parikh. Have your plan in mind before the case starts. Think of yourself as an attending and think of how you would approach the case and then discuss it with Dr. Parikh to see if you’re right.Dr. Refermat is excellent as well and will trust you to do entire cases. He is also an incredible mentor. The PAs are exceptional Luanne McCloskey and Nicole Leone. They function at the level of an attending and will help you and teach you whenever you want.

Prepare as much as you can for the OR, take good care of your floor patients, maintain your enthusiasm. Passion will take you far on this rotation.

Topics:Breast reductionBreast recon s/p cancer resectionAbdominal wall reconPanniculectomyKnow the extensor tendons and flexor tendonsVascular supply to flapsYou can never know enough about blood supply. For whatever case you’re doing, know the relevant blood supply and important nerves. BrachioplastyBack cutV-Y advancement flapsFree flaps – ALTs, DIEPs, etc.

Remember, plastic surgery is based on principles. These principles are used to approach problems we are consulted for. Learn the basic principles and apply these. Watch these operations on Youtube ahead of time. Bust out your netters. And use Grabb and Smith.


RED SURGERY

There is no PA. This is a great time to work on your laparoscopic skills. You can learn so much just by watching these attendings operate. You might cover these patients on call, but interns are usually not on this service.Once of the best rotations at Baystate as a result of getting to work with Dr. Alexander and Dr. Haag.

Topics:Lap bandsGastric sleevesLap hernia repairsTAPPTEPLap choleDeflating lap band via port (you’ll get to fill and unfill bands in the office, and will have no problem deflating them in the ED when they coming in vomiting and intolerant of any PO after a fill)


RESEARCH FELLOWSHIPI was fortunate enough to spend two years in the lab. I applied for the position around October/November of 2nd year. The attendings are very supportive and will help you in whatever you set out to accomplish. If you leave for research, you must come back. Research years are not a guarantee. If you think you might be interested in this, communicate that clearly to the administration as soon as you decide, even if its July 1st intern year. Never put yourself in a box. Innovation starts by having an open mind and not limiting yourself. Baystate gives us the skills, knowledge, and mentoring we need to become irreplaceable and essential. You will see how well trained you are once you leave. This is the best program in the country in my opinion because of how involved our attendings are with making us the absolute best we can possibly become. They help us gain confidence in ourselves and our skills and help us believe we can accomplish everything and anything. But its up to you to practice and to read and develop yourself.Be prepared to work harder than you have every worked. Research fellowship is not the time to relax and “take a break.” Hustle and make things happen for yourself.

Carmen Mora, Katie Wong (PhD), Erica Kane, Katie Bittner – Research at Baystate


SURGICAL MISSION TRIPSMany attendings serve abroad, including Dr. Alouidor, Dr. Parikh, and Dr. Seymour. I also have connections abroad and have spent a few past vacations on surgical mission trips. You would have to use your vacation for this endeavor but it is worth it in my opinion. “Gifts from the Poor,” by Dr. Glenn Geelhoed explains a bit of the transformation that happens.

INTERVIEWSComing soon

_______________________________________________________________________________________________________________________________THE END

Hopefully this guide to the lands will help yall avoid lookin’ rode hard and put up wet.Regardless, always remember to Cowboy Up!

Final Quotes from Dr. Parikh:“ABCs – Assume nothing, Believe no one, Check everything.”“You can compromise in love, but not when it comes to (surgical) exposure.”“Sell low, deliver high.”“Surgery without heart is assault.”

Textbooks – Sabistons, Camerons, SCORE portal. Read Sabistons now and Carmerons when youre older. ICU bue book (Marino). We have a lot of sources in PDF format on google drive which will be shared with you.

Recommended reading for self-actualization (a few of these should be read multiple times):The Four Agreements by Don Miguel Ruiz

Toltec wisdom. Must Read. – Be impeccable with your word, don’t take things personally, don’t make assumptions, and always do your best

Extreme Ownership by Jocko Willink, Leif Babin. How the US NAVY leads and wins.Written by navy seals, this will explain true leadership and how to coordinate a successful team and inspire greatness

Resilience by Eric GreitensFascinating stories of resilience as a virtue from the perspective of navy seals

Mindet by Carol DweckAre you of the fixed mindset or the growth mindset – this determines everything

Linchpin by Seth GodinBecome essential. Be a linchpin not a cogwheel

Big Magic by Elizabeth GilbertWe are all artists. Perhaps surgery is our art. Whatever it is, be creative

Brave Enough by Cheryl StrayedCollection of amazing quotes

The Alchemist by Paulo CoehloMust Read

Mastery of Love by Don Miguel RuizGame changer in every way

I am always available for questions, issues, etc.Cell: 713 398 2355Email: [email protected]@gmail.com

Be true to yourself. Set aside time for yourself once per week to relax and regroup. Work hard. Study hard. Play hard with your classmates. Find what feeds your soul. It’ll never feel like you’re actually working once you’ve figured it out and time will fly. Do your absolute best always especially when no one is looking, and push yourself to be great.


mailto:[email protected]

mailto:[email protected]

hands - web viewnight float – includes sign out and how to think through common issues/pages

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