Intern Ward Survival Guide 2009
Intern Ward Survival Guide 2009
Code Blue
Calling Consults: With all consults, be sure you have a SPECIFIC 5. Heme-Onc: There is only one consult service. When calling for a
QUESTION that you would like the Consultant to answer. If a patient has possible transfer, never say “we’re consulting for a transfer.” Give the
outside records that are pertinent, be sure to have them in the chart before history and ask for recommendations and then you can ask if the pt may be
calling the consult. There are specifics for each service that will make better served on the HO ward team.
things run more smoothly, which are detailed below. 6. Pulmonary: This is the general consult team for non-acute consults,
which usually includes recommendations for pulmonary infections and
1. Cardiology: in general, you should always have a current ECG (and an possible need for a Bronchoscopy.
old one if possible) when calling a consult. If appropriate, have cardiac
enzymes sent before calling, and be able to tell the fellow/resident current 7. MRICU: For acute consults only. The assumed question when you call
labs and lab trends, what medicines you have given and pertinent history the MRICU Resident is “does this pt need to be in the MRICU.”
@MCV: 1. Gen Cardiology-for most non-urgent consults
2. EP: only if you’re sure it’s an EP question 8. Other Medicine Specialties: Endocrine, Rheum, Derm, Ophtho.
3. CCU: for acute consults page CCU Resident
4. Procedure Fellow: for midnight STAT procedures only 9. Surgery: Ortho, Neuro, General, ENT, Urology, CT Surg, Hand. In
@VA: 1. Gen Cardiology general, you should always have a recent CBC, coags and if appropriate a
2. EP type and screen before calling a surgery consult.
3. CCU Resident If you are calling Ortho, you can wait and let them tell you what
films to order, or make your best guess as to what they may want.
2. GI: for GI bleeds, be sure you can tell the fellow current CBC, coags, For general surgery, be sure to know what an acute abdomen is. If
pertinent history, stool appearance (black stool/BRBPR/trace heme someone has intractable abdominal pain, N/V, involuntary guarding,
positive), amount of blood vomited. Note that unstable GI bleeders are rigidity, and appears unstable, it’s probably an acute abdomen. You should
only acutely scoped in the MRICU. have at least a KUB, and if appropriate the patient should have an NG tube
@MCV: 1. General GI to suction, lactate level and other surgery labs.
2. Biliary
3. Hepatology 10. Psych
4. Nutrition Fellow (PEG Tubes, etc)
11. IR: have recent coags and labs available, let them know why the pt
3. Renal: There are only two renal services to consult. needs the procedure and how urgent is it (today or tomorrow)
1. General Renal
2. HD Fellow 12. Other Services:
-Substance Abuse
4. ID: when calling ID consults, be able to tell the fellow bacterial -PICC Team. If a pt is on Coumadin, be sure to ask what level they
sensitivities, current and previous antibiotics. It also helps to know what, if would like the INR to be in order to have a PICC line placed.
any, previous MDR infections a patient has had, and don’t forget to point -Virginia Smith: the consultant for Sickle Cell patients. She knows
out if the patient is immunosuppressed in any way. Also, whenever a pt them all well, and you would be well advised to follow her recs.
has fungemia, you will need to call an ophtho consult as well.
1. General ID
2. AMT: for antibiotics needing approval. This pager is covered by
the ID fellow at night and on weekends. They will typically expect
the same information as a general consult.
Electrolyte Repletion What to Do If You’re Called For…
Potassium (goal 4-4.5)-do not replete if pt is on HD -In general, whenever you’re called by a nurse for concerning symptoms,
In general 10mEq of potassium raises a pt’s serum K by 0.1mmol. If a pt always ask for a set of vitals to be given over the phone (and if they haven’t
has renal failure, then cut the dose you would give by ½. been done recently, ask for them to be done while you’re en route).
PO: tabs (big pills) vs. liquid (tastes gross, faster than tabs) -the recommendations below are meant to help you with the initial
IV: Can be painful through peripheral IVs. Slow! (takes an hour to management. When you’re starting out, it is always better to evaluate the
get in 10mEq) patients to help you learn when patients need to be seen immediately. If
If a patient is profoundly low (<3), the most you would typically give at you are asking yourself if the pt needs to be seen, then it usually means you
one time would be 40mEq PO now and 40mEq IV over 4 hours. should go see them. When in doubt, call your resident.
Magnesium (goal>2)-do not replete in HD 1. Insomnia: A very common call. Can give Ambien or Benadryl, but both
1 g of Mg will raise Mg level by 0.1. can cause AMS in the elderly. Trazodone is an alternative that doesn’t
PO: Mag Oxide cause as much AMS.
IV: 1-2g Mag Sulfate IV runs (slow but not painful like potassium)
2. Fever: If not done in the last 24 hrs, get a chest x-ray, UA/urine cx, and
Phosphate (goal 3-4.5, usually replete if <2.5)-do not replete in HD peripheral blood cultures. Can give Tylenol PRN. If the patient is
In a pt with chronically low Phos, be sure to check for Vit D Deficiency. neutropenic, then give cefepime empirically after drawing blood cultures
An acute drop in a pt that was NPO for days-weeks may indicate Refeeding (+/- vancomycin if there is concern for a line infection or h/o MRSA).
Syndrome.
PO: typically “2 packets of neutra-phos” 3. Nausea/Vomiting: Another common call, and can be due to meds,
IV: NaPO4 (4mEq Na and 3mmol PO4 in 1mL) chemo, underlying illness, reflux, etc. Evaluate a patient when they have
KPO4 (4.4 mEq K and 3mmol PO4 in 1mL) new-onset vomiting, persistent vomiting, or blood in their vomit. For
symptomatic control, you can give compazine or zofran. Phenergan is
Calcium (goal 8.5-10) –don’t replete in HD unless dangerously low and another option but is becoming less popular because of its association with
renal fellow is aware. Remember to correct for hypoalbuminemia! Can AMS.
send ionized calcium to avoid correction for albumin (but expensive). Be
careful repleting when the Calcium*Phos product is >55. 4. AMS: Always evaluate promptly and do a quick exam to determine if
PO: Tums, Calcium Carbonate (OsCal) the situation is acute (nonresponsive, blown pupil, acute decrease in
IV: Calcium Gluconate 1-2g IV runs (1st choice for peripheral IV) orientation in otherwise normal individual). Check the airway-if pt can’t
Calcium Chloride 1-2g IV runs (through central IV’s only!) maintain their airway, then call the MRICU. If they can maintain their
airway but appear short of breath, check an ABG (inc CO2 can cause
AMS). Stat labs that can be ordered: blood glucose, BMP, cultures, CBC,
LFTs (ammonia). Decide quickly whether or not the patient needs a
noncontrast head CT. Call your Resident early when you are called for
AMS!
5. Chest Pain: Always evaluate promptly. If the pt appears unstable, call 8. Hypotension: As with tachycardia, initial management depends largely
your Resident. ALWAYS get and ECG. If you are even slightly on whether the patient is symptomatic. If they are symptomatic or have
concerned for an MI, send cardiac enzymes. If the ECG is suggestive of had a significant drop in their BP, the pt should be seen immediately.
ischemia, give the pt aspirin 325mg, SL nitroglycerin (up to 3 doses in 15 Different causes include hemorrhage, CHF, sepsis, arrhythmia/tachycardia,
minutes), morphine, and be sure the pt is on oxygen. Your goal is to get PE, MI and medications just to list a few. Starting a fluid bolus is usually
the pt chest pain free. If the pt is not CP free after 3 doses of SLNG and safe, as long as they are not in a CHF exacerbation or have acute renal
morphine, and has suspicious ECG findings, then the CCU resident should failure. If the pt appears unstable, it’s always better to call your resident or
be notified. Be sure to notify your Resident before you decide to give the MRICU resident to come evaluate the pt. If the pt appears stable, take
heparin or lovenox, and call the CCU Resident to come evaluate the pt. the time to look at what meds they recently received. If they are septic,
Remember that time is muscle when it comes to cardiac ischemia/infarct. consider adding additional antibiotics coverage. Per the surviving sepsis
guidelines, if a pt is still hypotensive after 6 L of fluid boluses, then they
6. SOB/Hypoxia: Again, evaluate promptly. Since there are so many causes need to be started on pressors and the MRICU resident should be notified.
of SOB, you’re first question should be to ask for vitals. If their vitals
sound unstable (breathing 30x/minute, tachy, hypotensive, sats are <90) go 9. Hypertension: Efforts should be made to acutely lower a pt’s BP if they
immediately to the bedside. Assess the patient’s breathing (can they talk? are symptomatic or their BP is >160/100. If they are symptomatic (ie-
Are they maintaining their airway? Do they look like they’re getting tired- having CP, SOB, AMS, etc), then call your resident-symptom of end organ
ie using accessory muscles, diaphoretic, etc?). Get an ABG to see if damage is considered hypertensive emergency and should be handled
they’re truly hypoxic or hypercarbic. If they’re hypoxic, be sure they are on immediately. Medicines that can be used acutely include nitropaste (1 or 2
enough oxygen to keep their O2 sats above 90% (if they’re on a inches), IV diltiazem/metoprolol/labetolol, and IV hydralazine just to name
nonrebreather and still hypoxic, then call your resident). If they’re a few. If the patient is not symptomatic, check to see when their next
tachycardic get an ECG to r/o arrhythmia. If the pt is in impending antihypertensive medicine is scheduled to be given. If they are due for
respiratory failure, call your resident immediately. If you are concerned, it their next medicine in the next few hours, it’s ok to ask the nurse to give it
never hurts to ask the nurse to be sure the code cart is nearby. Lots of early.
things can cause SOB, including tachycardia/arrhythmia, pneumonia,
COPD exacerbation, sepsis, asthma, PE just to list a few. Your resident
will help you decide the best course of action.