CCU cheat sheet
Code to most doors 2154
Code to IM workroom in ED 2040
Code to CCU call room 5051
Every day, you arrive at 7am, pre-round on your patients then update your seniors around 8:30. Dr. Ahsan and Dr. Wesley join you for formal rounds at 9am. You meet them in the CVCU (3rd floor)
How to access the CCU list:
Log into any computer with your windows log in.
Start my computer Q drive interdepartment UNSOM medicine CCU list.doc
You can edit this list and save it. Always print out copies for your senior and attending.
How to print out daily notes and H&P:
Start my computer Q drive interdepartment UNSOM medicine TEMPLATES IM progress note or INTERNAL MEDICINE 2 page H&P. (the only 2 forms I have ever printed).
Things to know for rounds:
Every morning, ask if the patient has any of the following?
Chest pain? Shortness of breath? Fevers overnight? Palpitations?
Ask the tele person if the patient had
Overnight bradycardia or atrial fibrillation or PVCs or PACs, etc
Ask the nurse if the patient is on pressors, if so, which ones and what dose?
On physical exam, mention if patient has:
chest tube? If so how much did it drain and when will it be removed?
Foley? If so, how much did it drain?
Lasix? If so, what are the I/O?
Intubated? If so, what are the vent settings and sedation settings? When will patient be weaned off?
From the chart:
Always ALWAYS ALWAYS have the EKG. I usually made copies. You cant just say your findings to the attending. They always want to physically see it. Make a copy of the most recent EKG and make copies of old EKGs to compare it to.
Find out if the patient ever had a cardiac workup here at UMC or somewhere else. This includes Cath, echo and stress test. Go through dictations and pull up old records. You should always know the dates of these tests and what the results were. You should have these numbers memorized. They will ask you about EJECTION FRACTION for every patient you ever see. Know that number or else.
Always calculate the TIMI score
Always know what type of anticoagulation the patient is on.
Lab values: can be found using clinical suite
Every patient gets CBC, renal panel, mag and phos in the morning. They should also get an EKG.
Troponins and CPK are always ordered x3 and should show a downward trend. If they stay high, keep trending them out.
Get BNP for patients with CHF
ABG for anyone with breathing issues
CXR for anyone with breathing issues (hard to be faulted for getting CXR)
Every intubated pt should get daily ABG and CXR
It is usually the intern’s job to order daily morning labs.
If patient develops fever:
UA
CXR
Pan culture (urine, blood, sputum)
Start Vanc and Cefepime
For admissions:
STEMI patients usually go to cath lab within 90 mins.
NSTEMI are usually admitted and you order the following:
CBC w diff
Renal panel
PT/INR/PTT
EKG x3 q 6hrs
CXR
CPK and Troponins x3 q6hrs
Nitroglycerin sublingual 0.4mg q5mins x3 PRN pain
ASA 81mg PO qday
Coreg 3.125mg PO BID (hold for SBP <90 or HR<60)
Lisinopril 20mg PO, hold for SBP<110
BNP
Simvastatin 40mg qday
Plavix 75mg
If diabetic, get Ha1c, lipid panel, urine microalbumin, order ISS
If anemic, do serum iron, TSI, transferring, ferritin, retic count
For discharges:
You must do a “discharge order” and prescriptions:
Write the following on an order sheet
-DC patient home
-DC all IV lines
-DC diagnosis 1) Chest pain NSTEMI
2) history of asthma
3) hypertension
4) GERD
5) atrial fibrillation
6) you get the idea, list all their diagnosis here
-condition: stable
-activity: as tolerated
-diet: cardiac 1800kcal AHA diet
-hospital course: see dictation or H&P
-DC medication: as per prescription
-DC advise: F/u in XXX clinic in XX days/weeks
Take all medications as prescribed
Abstain from smoking, drugs, alcohol
Return to ER immediately if you have any chest pain, shortness of breath, palpitations etc.
OPTHO/ENT
EYE:
Dr. Abrams
702-304-9494
call his office Thursday afternoon, tell them who you are and when you're starting. they'll do the rest. wear a tie and white coat. He is super nice and so is the office staff. As long as you are friendly and interactive you'll do great. Learn the slit lamp, and tono pen, other than that you will just be shadowing. Dr. Abrams will also do your eye exam for you if you ask nicely!! Enjoy its a super chill rotation.
ENT:
Angie Gage
702 671-2298
702 384-7506 Fax
2040 building ste 601
call angie a few days before you start, tell her your coming next week and she'll direct you to either dr Wang (wong) or dr Ng (ing) or o'lee. wear business casual and a white coat. Dr. Wang is neck and throat guy (know your neck and throat anatomy), Dr. Ng is ears and nose so know that anatomy before you have office hours with him. Dr. O'Lee works with Dr. Tran (anesthesiologist) try to get in on his OR cases to have fun intubating pediatric patients. Tell Angie this so she schedules you accordingly. Basically u just shadow this rotation, Dr. Wang will have you do new patient H&P. Also a chill rotation! There are many sites so remind Angie to email you the locations of the clinics.
MICU
Code to most doors 2154
Code to IM workroom in ED 2040
Code to MICU call room 5051
Every day, you arrive at 7am or before, pre-round on your patients then update your seniors around 8:30. Dr. Singh likes to round around 9pm-9:30. Dr. Prahbu likes to around 9:30. You meet them in the SICU (Floor above the ED) The new attendings usually round earlier so ask your senior what times rounds will start.
How to access the ICU list:
Log into any computer with your windows log in.
Start my computer Q drive interdepartment UNSOM medicine ICU list.doc
You can edit this list and save it. Check to see which patients have your name under it so you know who to round on.
How to print out daily notes and H&P:
Start my computer Q drive interdepartment UNSOM medicine TEMPLATES IM progress note or INTERNAL MEDICINE 2 page H&P. ICU/CCU Transfer list.
To print general admit orders: Open a web browser and go to the home page. Click “Physician Orders” on the left hand column. Scroll down to “General” and print “NPHY 55(29)(220) GENERAL ADMIT 11-12.pdf”
Things to know for rounds:
Every morning, ask if the patient has any of the following? (talk to the nurse)
Changes in pulmonary status, vent settings, fevers, pressors, etc...
On physical exam, mention if patient has:
Been intubated, secretions, changes in lung exam, sedation/mental status changes, etc...
From the chart:
If the patient is intubated, always have vent settings, ABG, and CXR results. (look at your own x-ray as the attendings will ask if you looked at it yourself)Always write down labs, cultures, etc..
Things to order everyday for almost all patients: AM CBC w/diff, Renal Panel, Mg.
Things to order everyday for intubated patients: AM CXR, ABG
It’s best to put these orders in while you are pre rounding so you don’t forget… or else you won’t have these labs for the next day’s progress notes.
Lab values: can be found using clinical suite
Nurses won’t always print this out so I typically start my prerounds writing down all the labs from clinical suite. Its annoying though because some things are only “printed” so you have to check the physical chart anyways.
For admissions:
Print out: Internal Medicine 2 page H&P and General admit orders
Look through old records. Make a copy of the H&P when you’re done for your senior to dictate.
For transfers to the ICU service (from medicine):
You do not need to fill out a full H&P form but you basically need to do the same work. Get a green blank progress note and write a Transfer Acceptance note. Write down info like: A brief history, why the patient was transferred to ICU, physical exam, PMHx, SHx, Social Hx, Meds, Labs, A/P, etc…
When you are transferring a patient to another service (HMG, Medicine)
Print out “ICU/CCU transfer note” and fill it out. Try to know beforehand who will need this type of note so you don’t waste your time writing a progress note as well. Also transfers to private attending do not need this note.
Random things to know:
Extubation criteria in awake patient (must meet all 3): RVR <105, NiF <-24, + cuff leak
Initial vent settings: TV 8ml/kg, FI02 1%/kg, Rate 12, PEEP 5-7.
DKA patients you need to fill out the DKA protocol (same sheet as in ER) but you also need to fill out the “transition to SQ insulin” form. You can find this on the “physician orders” website.
On Rounds: If you aren’t presenting, grab the chart/order sheet and write down the orders that are called out. It will save you time and less things get missed.
TRAUMA
I think you meet in the trauma room at 7?? Please make sure correct time.
for trauma activations, you'll be at the head of the bed. check your intubation stuff. ask a history: allergies, meds, pmhx, etc... do airway, breathing, HEENT. when the patient goes to CT scan, this is a good time to fill out this huge packet (H&P). put stickers on everything.
Take a green blank progress note sheet and write "RTAS" on top. All the radiology reads will be written on this. Leave it by the radiology computer so anyone could fill it in.
While waiting for reads to come back this is a good time to fill out the orders sheet.
After all the reads are back and you have an a/p. DICTATE the H&P. basically reading off the entire packet.
Then add the patient to the list. (my computer, interdepartment, unsom, residents, trauma list)
If the patient's going to TICU add it to their list not your list.
Day shift: primarily responsible for discharging patients on the service
Night shift: primarily respnosible for writing progress notes on everyone. Don't do this until after 12am. some ppl will just start writing notes at 4am some will start at 12am. if it doesn't get done because of activations dont' sweat the day team will finish.
Most patients you will just fill out the trauma progress note template. for certain attendings (ozobia) you will fill out the note on a blank green sheet.
jump on procedures. i actually liked this rotation because i got to do so much. don't really need to go to the OR unless you want to. i think i scrubbed in only once.
On the computer at the nursing station there is a word document saying welcome explaining stuff to do. Same way that u get to the list my computer..q drive..unsom..residents..surg lists...welcome to trauma
OB/Gyn
Day 1, meet on 7th floor labor and delivery.
On weekdays, hand off is at 6am, on weekends, 7am (arrive at that time)
Doctor’s lounge door code is 7205*
Supply room code is 2154 (where you can get gowns and gloves for deliveries)
The OB residents will tell you that you are not allowed to do private patient deliveries. Don’t listen to them. Introduce yourself to the private attendings and ask them if you can help with the delivery. You will be alone with them and will probably do most/all of the work. You should hang around the nurses station or the room where the delivery is taking place to find them.
Look at the white board in the nurse’s station every morning to see how many patients are in labor, if they are going to be vaginal, which attending is doing the case, who the nurse is and how far they are into labor. Several days, I cherry picked a few “ripe” patients and got deliveries at the beginning of my shift.
Keep a very close eye on the FHT monitors and tell the nurses to call the resident room when the patient starts pushing. If you don’t pay attention, you will miss deliveries.
The old white lady in scrubs could be a janitor, nurse or your attending. Don’t assume anything.
Don’t enter the OR without hat, booties and mask. Someone will yell at you if you do.
Take stickers from every delivery you do or else it didn’t happen. (log them on new innovations)
Bring study material everyday because there is a lot of downtime (like 5 hrs a day!)
For an H&P, you must ask the following:
Very detailed OB history. List every pregnancy, year, date, gender of baby, method of delivery (if CS, then why) how many weeks was the baby confined, weight of the baby, any complications like UTI etc. Ask about STD history, last pap smear, age of menarche, Measure fundal height (pubic symphisis to top of uterus) if you cant do it, just say its xx centimeters (xx being the fetal age in weeks). You will often see three numbers (ex: 6/80%/-1). The 6 is dilation of the cervix, 80% is percent effacement of the cervix and -1 is the position of the baby relative to the tubercles. Ask the nurse for these values because they check the patient with a vaginal exam every hour.
Ask about fetal kick counts, contractions (every how often). Always ask about if the water has been broken. Then ask your typical ob questions. Vag bleed, discharge, pain or burning on urination, preeclampsia questions (headache, dizziness, vision changes etc).
Order a UA, GC/Chlamydia, wet prep on everybody. Look for pooling, do a nitrazene and ferning test on everyone.
These are the things I told the OB residents:
We need 10 deliveries
We don’t carry pagers (ever)
We don’t write daily progress notes (or do floor work)
We have conference ALL DAY Wednesday and cant come in before or after.
Random stuff:
There will be a ton of downtime so bring study material.
They should let you use their meal cards
Anesthesia
Hey here is a guide for anesthesia, aka the best 2 weeks of any "rotation":
The night before you start call the Anesthesia T1 number (702-503-0302) which is one of the anesthesiologists who has the schedule for the next day and can tell you where to start the morning. Show up to the OR whenever you decide to, look for the main scheduling room once you walk in and grab some OR scrubs in a cabinet. They will have a big board with all the cases and surgeons posted so you can plan out what cases you can go to. All doors have the same code (2154 and if that doesn't work it is 2154*). Then go change into your OR scrubs and find the pre-op area.
Find the anesthesiologist before they take the pt back to the OR to make sure you can tube them then help take the patient back and prepare to intubate. Some of the attendings are cool and will let you show up and put the tube between the cords then leave, others will pimp a little before and after, you can ask to experiment with different blades/glidescope/bougie/any new techniques you always wanted to try. Some will be standoff-ish though and might not let you intubate unless you know about the pt and evaluated their airway prior to showing up in the OR, I tended to avoid those docs. Some will place central lines and art lines so definitely try to get in on those if you want.
The better docs I remembered were Dr Tran, Dr Flores, Dr Volk. You will just find out who you mesh with along the way and tend to do more cases with them. After you intubate/line-up the pt in the OR del free to bounce around and bug as many of the docs as you can find. Nobody keeps track of you and you can leave WHENEVER you feel satisfied with the day (0-6 tubes per day in my case). Just be prepared to answer airway and RSI med questions especially when doing the peds cases. In my opinion the most valuable part of knowing your shit in anesthesia is knowing how to bag valve mask ventilate a patient effectively. Practice this and get this down. This is waaaaay more important than being able to put a ET tube between cords usually because when it gets real in the ED and you have a difficult airway you can't get immediately, it comes down to being able to bag the patient and if you can't you now have to cut their neck. I was always impressed with how my technique on bagging was improved by every one of the anesthesiologists. Also practice with the LMA if you don't already know how to, this can be a temporary airway that is pure money on some patients.
And by the way there is NO radiology rotation at the same time as this, DO NOT show up to radiology in the afternoons because they won't be expecting you to and Dr Epter and Ketan both told me that we don't do that anymore. You should be home by noon at the latest everyday you show up on this rotation, no weekends, no call. Hope this helps, call/e-mail me with any questions.
Neurosurg
I didnt ever actually talk to the secretary, Valerie. It might be smart to give her a heads up a week ahead of time to find out if Dr. Smith is out of town (apparently it happens a lot), but if you dont, no big deal. Just go to the clinic on Maryland on Monday morning about 830 and they will point you in the direction. Dr. Smith will have you see pts then present to him. You will not have to dictate, like it says in the off service guide. Dont put in too much effort, as he generally already has the MRI's and doesnt really listen to your assessment.