Transcription
Tips & Tricks forIntern tobe)R2s
QuickRunDown llHelpIsOntheWayYourTurn!!
Top10InternPages&HowtoRespond
1.Nausea MedicaTons– Zofran(odansetron) TypicalDose:4mgIVPq8hprn Max32mg/24hours– Reglan(metoclopramide) Typicaldose:10mgq6hprn AvoidinallpaTentwithnewbowelanastomoses– Compazine(prochlorperazine) OnlyavailablePOandPRmakingitsomewhatuseless– Phenergan(promethazine) despiteitbeinganopTon) Startwithsingledoses(6hapart) Notafirstlineagent Contraindicatedinchildren 2y(respiratorydepression) VomiTng?– aballoon”?– MakepaTentNPO– ConsiderNGTandKUB,talktochief
2.PainTypicalUCLApainregimens– PCEA ManagedbyAcutePainServiceonly etc.)theRNshouldcontacttheacutepainteamdirectly mnolence,itching—letpainteamknow– IV by0.1upto0.4forunrelievedpain Dilaudidslidingscale:0.2/0.4/(0.6)mgdilaudidq2- ‐4hprn Morphine(2- ‐4mgq2- ‐4hprn) lyeither1xdoseorATCforupto72hours Tylenol:PACU,ICUonly
HowtoWriteforaPCA
2.PainCont.– PO Oxycodone5/10/15mgq4hprnmild/mod/severepain– Elixirformavailable Norco/Percocet1- ‐2tabsq6h– Maxtylenoldose3g/24h Tylenol650mgq6(prnorATC)– Elixirformavailable Motrin600mgq6(prnorATC)– Elixirformavailable Tramadol50- ‐100mgq6prn
3.LowUOP Isitlow?– UOPgoal:0.5- ‐1cc/kg/hr– BaselinekidneyfuncTon?HD?Meds? VerifyI/Os Assessoverallpicture:pre- ‐renal(“dry”),renal,vspost- ‐renal(foley) Foley?– Isitworking?Flushit Aretheyretaining?– Bladderscan le?Howold?Weretheystartedontheirhomeflomax? S
wanttoremoveitatnight heckwillbefirstthinginthemorning
4.H&PsandSCIPs ntmusthave:ü H&Pwithin30days Ifthereisn’tone,doonethedayoftheprocedure vantinfoü SCIPPre- ‐OpNote nseen/isinpre- ‐op)ü ProcedureConsent Validfor1year ,mediatab)ü BloodConsent urgCenter r
SCIP
Consents
Don’tStopYourPa.entfromGe3ngtotheOR H&P– Within30days– Include:HPI,PMH,PSxH,SocHistory,ROS,PE,A/P SCIPnote– Mustbesignedthedayofsurgery,AFTERpaTentarrives OperaTonConsent–––– switnessBloodConsent– RequirenewbloodconsentforeveryvisittoOR MarkedforlateralityForin- ‐house/consultpaTents:– T&Swithin24hours– Completesetoflabs– )
&
5.UnreconciledOrders TransferOrdersfromOR DischargeOrders
ReconcilingOrders
6.HypertensionGeneralPearls:- ‐WhatistheeTology?(pain,anxiety,hypoxia )- ‐Doesitmakesense?(havethelast4beennormal)- ‐Wasitre- ‐checked?Ontheoppositearm?Manually?Chronic– WhatarepaTent’shomemeds?Haveyourestartedthem?– Osendon’ttreatunlessSBP 160– HxaorTcstenosis?Don’tgivehydralazineorACEi
HTNAcute– Neurostatus?CP/SOB/anxiety?– Meds: l,labetalol,hydralazine,nitroprusside,nitropaste
7.Hypotension Sepsis– SIRS:tachycardia,febrile,leukocytosis,tachypnea– Hypotensionà res(blood–alllines,urine),CXR Hypovolemia– Bleeding–tachycardic?LowUOP?LatestCBC coags?– Post- R? PCEA– Hypotensionwithouttachycardia– 1stbolus500NSà noresponseà callPaintodecrPCEA– Veryconcernedabouthypotensionà turnoffPCEA
8.ChestPain Thingstothinkabout– Natureofsymptoms:onset,locaTon,quality– Cardiachistory,cardiacmeds riTs Heartburn– Tums– Pantoprazole!– Pepcid MI– EKG,Troponin– ALWAYSLOOKFORPRIOREKGFORCOMPARISON Incisionalpain– Pressonit
9.AFib Hemodynamicallystable?SymptomaTc?– Fullsetofvitals– FormalEKG,BMP/Mg/Ca,TSH;considertroponins– GOSEETHEPATIENT HDUnstable&SymptomaTcà ACLS HDStable– Metoprolol IVP5mgq15mintomaxof15mg OnfloorpaTents- ‐MDmustpushmedsandconfirmdosepriortoinjecTon GreatereffectonBPvsdilt– DilTazem IVP5mgq5mintomaxof25mg– Amiodarone,Digoxin Service/aHendingspecific angesareprobablybeHerservedintheICU
10.DesaturaTon 92%à GoseepaTent PD,HomeO2,Fluidoverload ,listentolungs HasO2beenTtrated?Crankitup(seebelow) STATportableCXR ConsiderABG(donebyMDonfloor) w1- ‐6L,FiO228- ‐44%Facemask:Flow6- ‐15L,FiO228- ‐44%Non- ‐rebreather:Flow10- ‐15L,FiO2100%AnyaddiTonalneedsà CallRT
AFewHorrorStoriestoMakeaPoint . Strokecode– one– WhilewaiTngforneurology WillthepaTentbeabletogointheMRI?– Dotheyhaveanymetalintheirbody?– DotheyhaveaPCEA? GetahistoryforpossibletPA? STEMI– OrderEKG,troponin,fullsetoflabs,CXR– PainmedicaTon,O2,nitroglycerin,aspirin– ult(coveredbyanaHending)– NoTfyyoursenior
PhoneNumbersx66766(310)206- ‐6766Andyournisyphonecards
HowtomanageyournewbestFrienemy Se{ngupyourownpager– MosthelpfulifpasswordisyourpagerID# ServicesPagers– Listedonphonecard– Alwaysgiveyourservicepager# LoggingontoaPager– Login&PWareboththepagernumber Callingtochangepagercoverage– Pageoperatorx66766 BaHeriesavailableinsupplyroomoneveryfloor
UCLAWebsite hHps://amcomwbsm.ad.medctr.ucla.edu/smartweb/
PagingETqueHe- ‐ Alwaysinclude:- ‐- ‐- ‐- ‐- ‐- ‐CallbackextensionPagernumber(Service lofurgency- ‐ ALWAYSreturnpagespromptly
ADayintheLife PrepforRounds– Getsign- ‐outfromovernight/NFintern– Printthelist– Chartpre- ‐round– resentpaTentsAssistwithpre- !– Enterorderstheytoldyouto andtheonestheydidn’t Lytes,ModifyIVFs DVTppx–shoulditbeheld?conTnued? Dressingchangeorders PT/OT,Ambulate,IS Checkhomemeds** ut
ADayintheLife PrepforRounds–––– Getsign- ‐outfromovernight/NFinternPrintthelistChartpre- nroundsPresentpaTentsAssistwithpre- !–Enterorderstheytoldyouto andtheonestheydidn’t OutCreateasystemthatworksforyou rogressnotes)
ADayintheLife Canyo!tluuscovernocweNcase?this PrepforRounds–––– Getsign- ‐outfromovernight/NFinternPrintthelistChartpre- nroundsPresentpaTentsAssistwithpre- !–Enterorderstheytoldyouto andtheonestheydidn’t ksforyou sing FollowupwithConsultants,?deosufrngoe rthroughout Keepseniorsupdatedthedaycae KeepyourpaTentsupdatedtshroughouts thedayCa nORyoudis PMRoundschargeMr .RPrepforSignOuteady?
PresenTngonGSRounds �� xVitalsI&OLabsRadiologyCulturesLines/Tubes
RepletethoseLytes! Potassium(Goal 4)– IV/PO:10mEQforevery0.1increase– CanaddtoIVfluidsifpersistentlylow Calcium(iCa 1.1,Ca 8.7)–––– 1.05 Ca 1.09:1gcalciumgluconateIV/calciumcarbonatePO1.00 Ca 1.04:2g0.85 Ca 0.99:3g 0.84:4gMagnesium(Goal 2)– IV:1gforevery0.1increase– diarrhea) Phosphorus(Goal 3)– IV:KphosorNaphos– PO:sodium/potassiumphosphatetabletsorpackets
DroppingaSlip EssenTalitems/infofordroppingaslip– 2PaTentLabelSTckers– AHendingName– Diagnosis– OperaTon&CPTCode– SpecialEquipment– CONTACTINFO GotoORFrontDeskon2ndFloortodropitoff SlipscanalsobeprintedfromFormsPortal
Equipment–yellowfins,bronch,etc.8. TimeRequested9. ContactPerson3456789
HowtofindCPTcodes CPTs– Codebinderbyschedulingforms– CodebookatORdesk– GOOGLE– ORSchedulingFormsforprevioussurgeries
FormsPortal hHp://www.mednet.ucla.edu/
LoggingCases KEEPthepaTentlabels garecorrect Don’tlosethelabels – Youalsoshouldlogcentrallines,CTs,etc. OR” Onlylogcasesunder“MajorCodes” MakeafavoriteslistintheACGMELog
Mobilelogging
Computerlogging
nyou’reoncall– hisschedule
HowDoesCallWork?
HowtoSignOut PrintoutlistofpaTents – ryProblem,AHending GiveOnCallResident’sName,PhoneNumber,Pager Giveaquickone- ‐lineroneachpaTentandwhatneedstobedone– PODs/p– F/UonCTA/Pwithcontrast&getread findingsLabs/Imagingtofollow- waboutthem– s– dia,hypotension––––
Helpyourcrosscoverinternout Youwillhavealreadyworkedfrom5a- ering5servicesand40paTents . TheulTmategoalshouldbetosignoutnothing– PMrounds!!– � RemovefoleysintheAMsonovoidchecks– IfyouwantPMlabs,checkthemat2- ‐3p– CleanupordersforyourpaTents: ssarynursingcommunicaTonorders?
HelpfulLinks Res.mednet.ucla.edu– AnTbioTcsguide– Internalmedicineà internsurvivalguide hHps://atyourserviceonline.ucop.edu/ayso/login.do
Thereisalwayssomeoneinhouse! TraumaJunior:x76454,p95550 TraumaSenior:x76455,p95551
QuickThings �� Step3:GS/VascVA,Peds,OP,SMH,CT/VA– ABSITE:EarlyJanuary– Research:LeveyawarddueendofMay Loupes– EndoftheR1Year
Ques%ons!?!?!
Tips & Tricks for Intern Year KentGarb
