Jacobi Medical Center

Medicine ServiceMedicine Service

New Building (Building #6)New Building (Building #6)4A: 4A: General Medicine/SurgeryGeneral Medicine/Surgery MSOU (Special Observation Unit)MSOU (Special Observation Unit)4B:4B: ICUICU5A:5A: General Medicine – TelemetryGeneral Medicine – Telemetry5B:5B: CCUCCU5D:5D: OncologyOncology6A:6A: General MedicineGeneral Medicine

Old Building (Building #1)Old Building (Building #1)3 North – Medicine Department and Library.3 North – Medicine Department and Library.5 South: General Medicine5 South: General Medicine

Welcome to Jacobi WardsWelcome to Jacobi Wards

Day StructureDay Structure--Interns arrive ~6:30-7:00 AMInterns arrive ~6:30-7:00 AM-Retrieve Sign-out from Night Float -Retrieve Sign-out from Night Float

(4A Conference Room, New Building)(4A Conference Room, New Building)

-General medicine residents report (PGY2-3) -General medicine residents report (PGY2-3) to intake rounds 7:15 AM in the 3 North, Medicineto intake rounds 7:15 AM in the 3 North, Medicine

Library (old building).Library (old building).-Pre-Round on all pts 7-8 AM -Pre-Round on all pts 7-8 AM (Vital signs, Exam)(Vital signs, Exam)

-Work Rounds with Resident 8-9:15 AM-Work Rounds with Resident 8-9:15 AM(you must SEE all the new patients and the sickest)(you must SEE all the new patients and the sickest)

--Attending Rounds 9:00-11 AMAttending Rounds 9:00-11 AM(Will discuss all new admits, old patients, radiology rounds, (Will discuss all new admits, old patients, radiology rounds, SWSW

roundsrounds, didactics, presentations, discuss chart documentation.), didactics, presentations, discuss chart documentation.)

Jacobi WardsJacobi Wards

Intern Work Completion 11-12:30Intern Work Completion 11-12:30Learn how to prioritize work to be done. (This is a critical time period)Learn how to prioritize work to be done. (This is a critical time period) -call consults early!-call consults early! -review morning labs -review morning labs -order and arrange all diagnostic tests-order and arrange all diagnostic tests -discharge pts scheduled to go home-discharge pts scheduled to go home -start daily progress notes if not started already!-start daily progress notes if not started already!

Resident Report (PGY2-3)11:00-12:00Resident Report (PGY2-3)11:00-12:00(3 North Medicine Library, Old Building)(3 North Medicine Library, Old Building)

All medicine All medicine residentsresidents must attend! must attend!

Noon ConferenceNoon Conference 12:30--1:0012:30--1:00

3 North Medicine Library, Old Building3 North Medicine Library, Old Building

Your attendance at Noon Conference is MANDATORY, unless Your attendance at Noon Conference is MANDATORY, unless you have an emergency or are scheduled for clinic.you have an emergency or are scheduled for clinic.

Attendance will be taken. Program directors will be officially Attendance will be taken. Program directors will be officially notified if anyone is routinely absentnotified if anyone is routinely absent from conference. from conference.

Jacobi WardsJacobi Wards

Complete all work 1:30-5:00 PMComplete all work 1:30-5:00 PM*Finish all work for the day*Finish all work for the day

*Make sure you see your pts at least one more time *Make sure you see your pts at least one more time

prior to leaving for the dayprior to leaving for the day

**Attend ClinicAttend Clinic (your responsible for knowing your clinic day) (your responsible for knowing your clinic day)

*Follow-up to make certain all procedures are completed*Follow-up to make certain all procedures are completed

*Check the chart for notes from attendings, consults*Check the chart for notes from attendings, consults

*Complete progress notes, print, and place in chart.*Complete progress notes, print, and place in chart.

*Order labs and other test for the next day.*Order labs and other test for the next day.

*Admit if you are on call*Admit if you are on call

Sign-out 5 pm Sign-out 5 pm (when done)(when done)

* On holidays and weekends not earlier* On holidays and weekends not earlier

than 3 pm (when not on call)than 3 pm (when not on call)

Jacobi WardsJacobi Wards

Resident Responsibilities (PGY2-3)Resident Responsibilities (PGY2-3) The “SUB-Intern”The “SUB-Intern” Work Rounds – see and examine all ptsWork Rounds – see and examine all pts Attend Morning ReportAttend Morning Report Facilitate and help organize the interns dayFacilitate and help organize the interns day Answer all questionsAnswer all questions Help call consults, CT scan, MRIHelp call consults, CT scan, MRI Have a general working knowledge of what is going onHave a general working knowledge of what is going on with all the ptswith all the pts Replete lytes, optimize BP, blood glucose, review medsReplete lytes, optimize BP, blood glucose, review meds Take the initiative to manage pts when necessaryTake the initiative to manage pts when necessary

Jacobi WardsJacobi Wards

Additional Intern ResponsibilitiesAdditional Intern Responsibilities

Perform Complete Work-upsPerform Complete Work-ups

--Include old info/”baselines”Include old info/”baselines”

-Formulate a complete differential-Formulate a complete differential

-Explain all abnormal data and-Explain all abnormal data and construct a planconstruct a plan

““Be the Doctor”Be the Doctor” -Constantly review meds-Constantly review meds

-Know what is going “into” and-Know what is going “into” and coming “out of” your ptcoming “out of” your pt

-Be proactive, attempt to predict-Be proactive, attempt to predict

adverse situations and have aadverse situations and have a

plan to combat themplan to combat them

Jacobi WardsJacobi Wards

Additional Intern Responsibilities cont’dAdditional Intern Responsibilities cont’d-Case-based reading-Case-based reading

-Consult the literature when questions arise-Consult the literature when questions arise

-Primary goal – to recognize “sick” or unstable pts.-Primary goal – to recognize “sick” or unstable pts.

When uncertain about something, When uncertain about something, Ask!!!!!!!Ask!!!!!!!

(There are no stupid questions. Period.)(There are no stupid questions. Period.)

Jacobi WardsJacobi Wards

MS III Medical StudentsMS III Medical Students

Read! Read! ReadRead! Read! Read

Study for Shelf ExamStudy for Shelf Exam

Follow 2-3 ptsFollow 2-3 pts

Shadow your internShadow your intern

Help as much as possibleHelp as much as possible

Write daily notesWrite daily notes

Your note does not replace interns noteYour note does not replace interns note

PresentationsPresentations

Bring in pertinent articles to share with the teamBring in pertinent articles to share with the team

We are “hands on” at Jacobi – learn your procedures here!!!We are “hands on” at Jacobi – learn your procedures here!!!

CallCall

-Once the ER decides to admit a patient to the -Once the ER decides to admit a patient to the medical service, they contact the SMR medical service, they contact the SMR (Senior Medical Resident [i.e. MAR]).(Senior Medical Resident [i.e. MAR]).

-SMR contacts both the admitting resident -SMR contacts both the admitting resident andand intern/sub-I.intern/sub-I.

General Medical Service CallGeneral Medical Service Call- Residents, Interns, Sub-Is are on-call every 4Residents, Interns, Sub-Is are on-call every 4 thth day. Sabbath day. Sabbath

observers (Residents, Interns, Sub-Is) will occasionally have Q2 call observers (Residents, Interns, Sub-Is) will occasionally have Q2 call alternating with Q6 call. They are not on call on Friday nights and/or alternating with Q6 call. They are not on call on Friday nights and/or Saturday.Saturday.

- ““Short HitsShort Hits”: These are additional admissions given on the second ”: These are additional admissions given on the second day after call (middle-day). Usually worked up by resident only. You day after call (middle-day). Usually worked up by resident only. You can get up to 2 pts. can get up to 2 pts.

- ““Pick-upsPick-ups”: Occur on call day. Usually, these are patients admitted ”: Occur on call day. Usually, these are patients admitted overnight that have already been worked up by overnight residents overnight that have already been worked up by overnight residents and interns. These count as admissions for the day. and interns. These count as admissions for the day.

CallCallVery Important:Very Important:

““Back Admissions”Back Admissions” Occurs occasionally on Occurs occasionally on weekends and rarely during the week. If weekends and rarely during the week. If interns/sub-Is do not “max” by the end of their call, interns/sub-Is do not “max” by the end of their call, they may receive the remainder of their admission they may receive the remainder of their admission the next morning. the next morning.

These pts are worked up by residents and an These pts are worked up by residents and an overnight intern. overnight intern.

Call TimesCall Times

--General Medicine and Specialty Service ResidentsGeneral Medicine and Specialty Service Residents: 8 AM – 8 PM (last : 8 AM – 8 PM (last admission 7 PM). admission 7 PM). Must stay until 8 PM even if finished with admissions before 7 Must stay until 8 PM even if finished with admissions before 7 PM.PM.

--General Medicine Interns and Sub-internsGeneral Medicine Interns and Sub-interns: 7 AM – 9:30 PM (last admission 8 : 7 AM – 9:30 PM (last admission 8 PM). Sign-out 9:30 PM – 10 PM.PM). Sign-out 9:30 PM – 10 PM.

- - Night Float ResidentsNight Float Residents: 8 PM – 8 AM (last admission at 5:30 AM).: 8 PM – 8 AM (last admission at 5:30 AM).

--Night Float InternsNight Float Interns: 9:30 PM -11 AM (last admission at 5:30 AM).: 9:30 PM -11 AM (last admission at 5:30 AM).

Call Times

Subspecialty teamsSubspecialty teams: : On call every other day. Between short-call and long callOn call every other day. Between short-call and long call

--ACS/Onc Shot-call (Q4)ACS/Onc Shot-call (Q4) Intern: 7 AM – 5 PM (7 days a week). Intern: 7 AM – 5 PM (7 days a week).Last admission 4 PM and must stay until 5 PM.Last admission 4 PM and must stay until 5 PM.

- - ACS/Onc Long call Intern (Q4ACS/Onc Long call Intern (Q4): 7 AM – 9:30 PM. Admissions for both ACS and Onc ): 7 AM – 9:30 PM. Admissions for both ACS and Onc starting at 4 PM. Last admission at 7 PM. Cover until 9:30 – 10 PM. starting at 4 PM. Last admission at 7 PM. Cover until 9:30 – 10 PM.

--Pulmonary ServicePulmonary Service (Q2): 7 AM – 8 PM. Last admission at 7 PM. Sign-out to (Q2): 7 AM – 8 PM. Last admission at 7 PM. Sign-out to ACS/Onc Intern at 8 PM. ACS/Onc Intern at 8 PM.

Note: 1) Onc admissions need to be approved by the on-call fellowNote: 1) Onc admissions need to be approved by the on-call fellow2) Pulmonary service do not admit from 8 AM Saturday until 8 AM Sunday2) Pulmonary service do not admit from 8 AM Saturday until 8 AM Sunday3) ACS sometimes admits every day and requires attending approval 3) ACS sometimes admits every day and requires attending approval

(check (check with the attending on service)with the attending on service)

Call: How many admissions?Call: How many admissions?

General Medicine Interns (including pick-ups):General Medicine Interns (including pick-ups):

* If on-call with sub-I: 4 but up to 6 if the last are unit transfers. * If on-call with sub-I: 4 but up to 6 if the last are unit transfers.

* If alone: 5 but up to 7 if the last are unit transfers.* If alone: 5 but up to 7 if the last are unit transfers.

Sub-interns:Sub-interns: 3 admissions 3 admissions

Pulmonary InternsPulmonary Interns: total of 4 admissions in a 24 hrs if 2 interns on team. : total of 4 admissions in a 24 hrs if 2 interns on team.

ACS/Onc:ACS/Onc: as per SMR/Attending as per SMR/Attending..

Intern CoverageIntern Coverage

-Long call intern covers their team and “sister team” from 5 PM until 9:30 – 10 -Long call intern covers their team and “sister team” from 5 PM until 9:30 – 10 PM. At that time, day intern will sign-out to the designated night float intern PM. At that time, day intern will sign-out to the designated night float intern (see intern coverage grid).(see intern coverage grid).

-Sub-interns cover themselves when on call.-Sub-interns cover themselves when on call.

Resident CoverageResident Coverage

--Residents job is to assist in coverage!Residents job is to assist in coverage!

-Residents must discuss cases with interns/sub-Is.-Residents must discuss cases with interns/sub-Is.

-On weekends, pick ups are presented to the intern by the admitting resident.-On weekends, pick ups are presented to the intern by the admitting resident.

-It is both the admitting resident and on-call intern responsibility to discuss new -It is both the admitting resident and on-call intern responsibility to discuss new admissions. admissions.

WeekendsWeekends

-Residents have one weekend day off per week. No gold -Residents have one weekend day off per week. No gold weekends.weekends.

-Floor interns are usually scheduled for one “gold-weekend” per -Floor interns are usually scheduled for one “gold-weekend” per month. Specialty team interns are not scheduled for “gold month. Specialty team interns are not scheduled for “gold weekends” a/p the official schedule. However, team interns may weekends” a/p the official schedule. However, team interns may decide to cover each other for a weekend in order to allow for a decide to cover each other for a weekend in order to allow for a weekend off. This is allowed only if: 1.) the interns formally weekend off. This is allowed only if: 1.) the interns formally request this in advance by emailing the chiefs 2.) It occurs no request this in advance by emailing the chiefs 2.) It occurs no more then once per month per intern.more then once per month per intern.

-If a resident was on-call Saturday he does not come in on Sunday. -If a resident was on-call Saturday he does not come in on Sunday. The SMR will present the case during intake rounds on Sunday The SMR will present the case during intake rounds on Sunday AM. AM.

-Interns are to come to intake rounds (7:30 AM, 3 North Medicine -Interns are to come to intake rounds (7:30 AM, 3 North Medicine Library) on the weekends. This is so the interns can hear about Library) on the weekends. This is so the interns can hear about their new admission and discuss the case management with the their new admission and discuss the case management with the covering day resident.covering day resident.

Intern/Sub-intern LimitsIntern/Sub-intern Limits

Interns: 12 patientsInterns: 12 patients

Sub-interns: 7 patientsSub-interns: 7 patients

Residents are encourage to re-distribute Residents are encourage to re-distribute patients if approaching maximum. patients if approaching maximum.

General PolicyGeneral Policy

-Bounce back: 7 days-Bounce back: 7 days-Unit transfers: 48 hrs-Unit transfers: 48 hrs-SMR should be notified of any specialty team direct -SMR should be notified of any specialty team direct admissions. admissions. -All transfers require both an intern and resident note.-All transfers require both an intern and resident note.-Document everything. Use event note function in Mysis.-Document everything. Use event note function in Mysis.-Use Nextels -Use Nextels (when available).(when available). No excuses. No excuses.-Problem with the computers:-Problem with the computers: Call the help desk (3-HELP)Call the help desk (3-HELP)-Intern/Sub-Is must review sign out with team resident.-Intern/Sub-Is must review sign out with team resident.-Intern/Subintern -Intern/Subintern Team/Covering Resident Team/Covering Resident SMR SMR 405 Attending or Service Attending. 405 Attending or Service Attending.

General PolicyGeneral Policy

Code “CAC”Code “CAC” – During the day, code team and – During the day, code team and anyone in the vicinity. At night, anyone in the vicinity. At night, everyoneeveryone should should respond. Dial the operator.respond. Dial the operator.

““RRTRRT” – ” – RRapid apid RResponse esponse TTeam: A team of eam: A team of clinicians (SMR, Critical Care Nurse, Resp. clinicians (SMR, Critical Care Nurse, Resp. Therapist) who respond to critically ill patients on the Therapist) who respond to critically ill patients on the floor (i.e. The “CRASHING PATIENT”) floor (i.e. The “CRASHING PATIENT”)

Dial 3-5110Dial 3-5110

WeeklyWeekly Medicine Conference Schedule: Medicine Conference Schedule:

Resident Report (Medical Residents)…Every weekdayResident Report (Medical Residents)…Every weekdayat 11:00 AM, except Thursday in the Medicine at 11:00 AM, except Thursday in the Medicine

Library Library (3N, old building).(3N, old building).

Clinical Question/Journal Club (Monday’s Resident Clinical Question/Journal Club (Monday’s Resident Report)……11:00 AM, Mondays in the Medicine Library,Report)……11:00 AM, Mondays in the Medicine Library,

(3N, old building).(3N, old building).

Noon Conference…..……Every weekday at 12:30 PM in Noon Conference…..……Every weekday at 12:30 PM in the the Medicine Library (3N, old building).Medicine Library (3N, old building).

Intern Report (Sub-Is and MSIII too)………. Wednesdays at Intern Report (Sub-Is and MSIII too)………. Wednesdays at 12:30 PM in the Medicine Library (3N, old building).12:30 PM in the Medicine Library (3N, old building).

Weekly Medicine Conference Weekly Medicine Conference ScheduleSchedule (cont’d): (cont’d):

Chief-of-Service Rounds (Noon conference)…..Every Chief-of-Service Rounds (Noon conference)…..Every Thursday at 12:30 PM in the Medicine Library (3N, old Thursday at 12:30 PM in the Medicine Library (3N, old building).building).

Medicine Grand Rounds (All medical house staff)….Medicine Grand Rounds (All medical house staff)…. Fridays at 12:30 PM in the 4Fridays at 12:30 PM in the 4thth floor Auditorium, floor Auditorium,

Building Building 1 (old building). 1 (old building).

Renal Grand Rounds…Tuesdays, 12:30 PM in the 4th Floor Renal Grand Rounds…Tuesdays, 12:30 PM in the 4th Floor Auditorium, Building 1 (old building).Auditorium, Building 1 (old building).

Cardiology Imaging Conference……Tuesdays, 4 PM, Cardiology Imaging Conference……Tuesdays, 4 PM, Building 1(old building), RM 1N-48.Building 1(old building), RM 1N-48.

Tumor Board…… Thursdays, 12 PM, Building 1 (old Tumor Board…… Thursdays, 12 PM, Building 1 (old building), RM 1N-48.building), RM 1N-48.

Jacobi WardsJacobi Wards

Eric Barna, M.D. 917-Eric Barna, M.D. 917-

Manuela Calvo, M.D. 917-Manuela Calvo, M.D. 917-

Michael Grushko, M.D. 917-Michael Grushko, M.D. 917-

Dave Sohal, M.D. 917-Dave Sohal, M.D. 917-