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Internal Medicine Resident

Handbook
- Inpatient First Edition
2013-2014
Editors:
Alejandro Moreno M.D.
Celina G. Mankey M.D.

Authors:
Payas Vasanth M.D.
Gayathri Nanja M.D.
Benjamin Salgado M.D.
Karthik Mekala M.D.

Table of Contents

14

Quality Improvement ...................................................... 16

Admission ............................................................................. 3

15

Language of Caring and Positive Intern .................... 16

Call Schedule ...................................................................... 4

16

Phone Dictation Instructions ......................................... 16

17

Contact Information ........................................................ 17

18

Seton Emergency Codes ................................................. 18

2.1

Q6 Call Schedule ................................................................ 4

2.2

Amion ..................................................................................... 5

2.3

Geo-Loco ............................................................................... 5

2.4

Sample of Progress Note ................................................. 6

2.5

Intern Responsibilities ...................................................... 7

Transfer from IMC/ICU to Floor: ................................. 8

Discharge .............................................................................. 8
4.1

Outline DC Summary ........................................................ 9

4.2

Transfer to LTAC, Inpatient Rehab, SNF. ................. 9

Core Measures .................................................................. 10

X-Cover .............................................................................. 11
6.1

X-cover Responsibilities................................................ 11

6.2

X-Cover Note .................................................................... 14

6.3

Code Blue Issues.............................................................. 14

Emergency Room Rotation ........................................... 14

Specialty Rotations .......................................................... 15


8.1

Hematology and Oncology .......................................... 15

8.2

Gastroenterology and Hepatology ............................ 15

ICU Rotation..................................................................... 15

10

Psychiatry Rotation ......................................................... 15

11

Emergency Coverage ...................................................... 16

12

Access to Pathways .......................................................... 16

13

Death Records .................................................................. 16

Admission

Admit Orders:
When you are called to see a patient, head down to
locate them in the ED (Crash, Treatment or Chest
Pain). Add them to the list by MRN if not already
done.
Note the admit to location entered by the ED
physician. If you agree with that location, all is well.
If you do not on assessment of the patient, please
contact the ED charge nurse and alert him/ her to the
change of location.
Be aware that the ED fills up fast, and you will need
to enter your orders in a timely fashion, otherwise
the patient cannot move upstairs.
Look at the upper right hand corner to ascertain
whether the patient has been placed in a virtual bed,
only then the orders may be entered. You can plan
your orders and wait to initiate in the interim.
Powerplans:
When you are on a medicine service, whether you
are admitting to ICU, IMC, Telemetry II, use the
Hospitalist Admit powerplan. Under your admit to
orders, make sure you mention the appropriate level
of care, floor based on geo-loco, and reason for care
(admission diagnosis).
There are powerplans for different diagnoses, E. g.
DKA/HHS, A. Fib, UGI bleed, that are at your
disposal. Use these plans as you see fit but make
sure you use your clinical judgment as well.
You must state appropriate reasons for using or not
using VTE or GI prophylaxis.
If you do need to initiate a patient on a heparin drip,
insulin infusion or cardizem drip these orders can be
found in the power plans for heparin infusion plan,
DKA/HHS plan, and atrial fibrillation power plan
respectively.
Admission Medication Reconciliation:
Make sure you always enter physician team
assignment.
Once you have seen the patient enter pertinent
orders, and verify med reconciliation with the
patient.
As soon as you have completed your admission
orders, always complete the Admission Med Rec.
We are penalized every time we do not reconcile
medications.
Consults:
Calling consults: Call early. Start with the reason for
consult. Provide important information on the
patients past medical history, and current medical
problems. Be concise. Include the patients location,

MRN, name, and date of admission. Always be


aware of the name of the consultant and document it
in the chart, and be in a position to answer follow up
questions the consultant may have for you (meaning
in front of a computer/chart.)
Special situations: For IR consultations, such as
cerebral angiograms and other special procedures,
you must place a computer order for the consult and
physically call the IR attending on call and obtain
information.

DISCHARGE PLANNING BEGINS AT


ADMISSION!!! This means thinking about what
services are available on the weekdays vs. the weekend,
and putting in consults early:
1. DM education
2. Outpatient PT WC
3. PT/OT/ST referrals for all stroke patients (especially
crucial for those going to rehab facilities.
4. Palliative care for patients with multiple co
morbidities or terminal diagnoses to establish goals
of care, MPOA only if it is beyond your capability
Also consider catheters, mobility, follow ups and the
patients insurance status.
Monitoring:
Address patients potential needs overnight, e.g.
antipyretics, pain meds, antiemetics, diet, electrolyte
needs, as the nurses cant proceed without specific
orders. Beware of using unnecessary PRNS, such as
electrolyte sliding scales, or milk of magnesia in
patients with CKD/AKI.
Beware the levels of monitoring on different floors:
1. ICU- q1hr
2. IMC q2hr
3. TELE/FLOOR- q4hr
In some instances you can order a more frequent
level of monitoring for a limited period of time (e.g.
Med/Surg- q1hr CBGS for the first 4 hours, and then
q4hr checks).
When ordering insulin, make sure your accucheck
and sliding scale orders are synced up, e.g. tidAC,
vs.qidACHS
When you have a patient on TPN, order
hypoglycemia protocol in the event patients feeds
are unexpectedly stopped.
Category Status
It is important to clarify category status with all
patients once they enter the hospital, and to reassess
as the need arises.
- CAT 1: Full code

CAT 2 : Limited resuscitation (a variation of


NO INTUBATION< NO PRESSORS< NO
COMPRESSIONS)
- CAT 3-:DNR/ DNI (not one of the above
measures, but full treatment, antibiotics, etc.)
- COMFORT CARE ONLY- usually only pain
management, motility drugs, nebulizations etc.
If you do have a patient who is Cat 2 or Cat 3 or
Comfort Care, enter a separate communication order
stating Pre arrest orders stating explicitly what life
saving interventions the patient does or doesnt
want.
Laboratory:
When ordering labs on a patient that has already
received preliminary labs in the ED, be aware that
under Collect Instructions you can order in lab,
which helps avoid unnecessary blood draws, and
gives quicker results. If you do require stat labs on a
patient, even if you order STAT, call the RN/RT and
let them know. Consider the need for labs; be a
steward of limited health resources.
Readmissions:
In the bar at the top right corner, you can make note
of whether the patient is High Alert 3, which
means they have over utilized the health care
system, whether it is in terms of aggressive
behavior, drug seeking behavior, or frequent
readmissions for a chronic condition. If that is the
case you can contact the CM, SW or RN to obtain
the Care Plan that may have been made for them.
If a patient is discharged and is readmitted while the
same resident is still on service, it is considered a
bounce back. Bounce backs are unfortunate as
they do not count towards the daily cap of patient
you may receive, and may indicate some sort of
failure of the discharge process. This should be
reviewed with the team to determine what went
wrong, and whether or not the admission was
preventable.

2 Call Schedule
2.1 Q6 Call Schedule
Long Call:
Rounds start at 9.00 A.M.
Mandatory morning report /noon-conference 11.40-1
P.M.
Admit 4 patients from 4-7 P.M.
Resident, interns and medical student have to be
present.
Resident may get one handoff.
Mandatory checkout to cross-cover before leaving
the hospital.
Day 1:
Resident picks up 1-2 handoffs from night float team
and interns get checkout from cross-cover team at 7
A.M. in the doctors lounge.
Finish pre-rounding at 8.45 A.M.
Rounds start at 9.00 A.M.
Mandatory morning report/noon-conference 11.40
A.M-1 P.M.
Admit a maximum of 5 patients till 4 P.M.
Mandatory checkout to cross-cover before leaving
the hospital.
Resident, interns and medical student have to be
present.
Day 2:
Resident picks up 1-2 handoffs from nigh float team
and interns get checkout from cross-cover team at 7
A.M. in the doctors lounge.
Finish pre-rounding at 8.45 A.M.
Rounds start at 9.00 A.M.
Mandatory morning report /noon-conference 11.40
A.M-1 P.M.
Admit a maximum of 5 patients till 4 P.M.
Mandatory checkout to cross-cover before leaving
the hospital.
Only one intern can take the day off.
Day 3:
Resident picks up 1-2 handoffs from night float team
and interns get checkout from cross-cover team at 7
A.M. in the doctors lounge.
Finish pre-rounding at 8.45 A.M.
Rounds start at 9:00 A.M.
Mandatory morning report/noon-conference 11.40
A.M-1 P.M.
Admit a maximum of 5 patients till 4 P.M.
4

Mandatory checkout to cross-cover before leaving


the hospital.
Only one intern can take the day off.

Day 4:
Resident picks up 1-2 handoffs from night float team
and interns get checkout from cross-cover team at 7
A.M. in the doctors lounge.
Finish pre-rounding at 8:45 A.M.
Rounds start at 9:00 A.M.
Mandatory morning/noon-conference 11:40 A.M-1
P.M.
Admit a maximum of 5 patients till 4 P.M.
Mandatory checkout to cross-cover before leaving
the hospital.
Only one intern can take the day off.

2.3 Geo-Loco
Floor
4thFloor :Tele, Cardiac Step
Down Unit
7th Floor: Tele, Non tele
8th Floor: Non tele
9th Floor: Non Tele, EMU,
Hem/Onc, NeuroSurgery
ICU 1st and 6th , IMC 6th

Teams
Silver, Blue
Gold, Green, Red,
Orange
Gold, Silver, Ortho,
Surgery, Plastics
Tan, Surgery, Neuro,
EMU, Neurosurgery
All medicine teams and
ICU service

Day 5:
Interns pick 1-2 handoffs and get checkout from
cross-cover team at 7 A.M. in the doctors lounge
Finish pre-rounding at 8:45 A.M.
Rounds start at 9:00 A.M.
Mandatory morning/noon-conference 11:40 A.M-1
P.M.
Admit a maximum of 5 patients till 4 P.M.
Mandatory checkout to cross-cover before leaving
the hospital.
Resident and medical student can take the day off.
Weekends:
No morning report and noon conference will be held on
weekends. Rounds usually finish earlier.
Cap/Team: 16 patients
Cap/Intern: 8 patients
Cap/Medical Student: 4patients

2.2 Amion
Amion is used to text/page residents and faculty www.amion.com
Groups
Internal Medicine
On call consult services
Neuro
Family
Surgery

UserName
austinim
Seton 3tak
utmbneuro
Amepfp
Traumall

It is recommended that you check Amion everyday to


know your call cycle, and to find out if you have been
assigned emergency coverage while on clinic or elective
rotations.
5

2.4 Sample of Progress Note


Patient ID. (at least 3: NAME, DOB, MRN#):
Date/
Time
Meds List:
A. Name
B. Dose
C. Frequency

Abx Day#

R1 Team Name
Subjective:

Events in the last 24 hours (include BMs, sleep, mental well being)

Objective:
1. Vitals:
Tm/Tc BP
2. Physical Exam:
General
HEENT
Neck
CVS

PR

RR

OSat I/O

Resp.
Abdomen.
Ext.
CNS

3. Labs

Alb|TP|AlkP|ALT|AST|TB
PRNs

4. Micro:
5. Imaging:
EKG:

A. Pain Meds
B. BZs

IVF

FOLEY
LINES

6. Assessment:

Begin with brief description of patient.


Example: 40 year old . Hispanic male with history of COPD and DM type
2
admitted for community acquired pneumonia
1. Admission diagnosis always first in the list
CAP:
Symptomatically better
On Azithromycin and Ceftriaxone
Micro showed negative BC times 2, CXR
improving.
2. COPD:
Stable. Continue albuterol, atrovent nebs and wean O2 as tolerated.
3. Tobacco abuse: counselled to quit
4. PPx:
DVT: Lovenox, hepatin, SCDs.
GI:Protonix, pepcid.
Plan: Discharge home with Azithromycin to complete 5 days

Signature/Printed name/ Date/ Time

Dr. Moreno

2.5 Intern Responsibilities


1. Pre Rounds
Allow yourself lots of time in the beginning.
Pre-write your notes the night before (write
neatly and your colleagues will love you).
Never come to rounds without a note.
Talk to the overnight nurse, if you can.
Make copies of your notes for rounds. Do not
leave your notes lying around; this is a violation
of HIPPA. All notes must be shredded in a
Cintas bin, which can be found throughout the
hospital. Do NOT take pictures of your notes on
your phone or iPad.
- 9th floor the copy machine is a room
labeled COPY MACHINE on the East
side, combination to the room = 47090.
- 8th floor there are copy machines in break
room, copy your notes using the fax
machine.
- 7th floor there are copiers on both sides.
- 4th floor copier is in the nurses' station.
2. Finish your notes by 8:45 AM, pre-round with your
senior resident.
3. Rounds.
Every attending is different LEARN YOUR
ATTENDING.
Learn how to summarize your patient.
Speak loudly and clearly.
Be ready to answer: So whats your plan".
4. Ward Attending Pearls
Dr. Williams

Dr. Corak

Dr. Salib

Physical exam wizard.


Know your physical exam well.
Prepare for drawings.
Former hematologist/oncologist.
Impress him with your hematology
and oncology knowledge.
Rounds are quick and concentrate on
presenting complaints only.
You and your upper level manage the
chronic issues.
Make sure you document everything.
Make sure you have read your
consultant note.
PT/OT/WC/Palliative/SW note every
day.
Present well.

Dr. Maxwell

He has done his home work before


rounds.
Embrace the Socratic method.
Keep your presentations short and
sweet.
Be ready to justify DVT prophylaxis,
GI prophylaxis, telemetry.
Stairs are good exercise.

Be ready to answer the golden


question: So whats the plan?
Keep your presentations short and
sweet.

Dr. Miller

Just relax.
Expand your differentials.

Dr. Huth

Infectious disease specialist.


Know your antibiotics.
Follow up sensitivities.
Presentation and physical exam is the
key to impress him.

5. After rounds and noon conference.


Change medications.
Follow-up on consultant notes.
Talk with social workers.
Discharge patients.
Plan upcoming discharges.
Follow-up on imaging or talk to radiology.
Update families.
Be ready to admit 1-2 patients.
6. Feed yourself.
Don't skip breakfast.
Eat your lunch during noon conference if you
are running late.
Cafeteria stops serving dinner at 6:45 pm(set an
alarm to remind yourself).
7. Check Out.
CORES (in Compass):Fill out the DRAW
format for every patient:
- D- Diagnosis (admission diagnosis, and
comorbidities).
- R- Recent events (e.g. changes in status,
recent procedures).
- A-Anticipated events (e.g. pain, SOB, neuro
status change).
- W- What to do? (e.g. escalate medications,
call consultants, evaluate the patient, etc) .
The CORES is of great assistance to cross cover
because they are taking care of a hundred
7

patients they are not familiar with. Please


include the patients pain medication status,
cardiac status, renal status, and respiratory status
if these are of note.
Note on pain meds, BZs, Fluid status, renal
status, cardiac status, BP status, Rs status.

8. Recommended readings.
Pocket Medicine.
Washington Manuel Dr. Millers favorite.
ICU Book Dr. Perrets favorite.
Marinis Critical Care Dr. Morrisons favorite.
Felsons Principles of Chest Roentgenology.
Learningradiology.org.
Harrisons and Cecil textbooks of medicine.
MKSAP 16.
MedStudy.
9. Dress Code
Clothes must be clean, neat and in good
condition with no obvious stains or tears. This
includes your WHITE LAB COAT.
Physicians must maintain clean personal
hygiene.
Physicians are NOT allowed to wear scrubs
unless they are on call for ICU or are on night
float rotation.
All physicians on consult services, wards,
hospitalist, elective and clinics are expected to
be in formal clothing.
Formal clothing DOES NOT include BLUE
JEANS.
Formal clothing DOES NOT mean fancy or
revealing clothes (just normal/daily wear
clothing is considered appropriate). Please
consider that you are acting as a healer and
health mentor in the eyes of your patients and
therefore you should try to dress accordingly.
No sandals or open toe shoes.

Transfer from IMC/ICU to Floor:

In order to transfer a patient from ICU/IMC to the floor


(Med Surg or Tele II):
Type "transfer to".

Click Admit/Observe/Transfer and fill in where


you want to transfer the patient.
Click Reason to Care and fill in with the most
relevant diagnosis of patient.
- (In order to geolocalize you may type in
comments of transfer to transfer patient to a

designated floor depending in the floor your


team is suppose to work on. e.g.:Please
transfer patient to 7th floor)

Every patient transferred to floor should have a


transfer med rec.
- Click reconciliation and proceed to continue or
discontinue every medication and infusion.

Make sure to review all orders on the patient, and DC


orders that are inappropriate or too frequent for the floor
to which they are being moved. Once this is complete,
select the order Orders reconciliation complete which
confirms this.

To finish the transfer click Add and add the order


Orders Reconciliation Complete

If the patient is admitted to medicine team from


ICU team, go through the orders, ICU bundle be
discontinued and should be done by ICU team You
must write an acceptance note. This note should be a
brief summary of why this patient was admitted,
how ICU Team managed the patient and the future
plan. Subjective and objective findings will be
crucial for your team to assess and resolve.

Every time a patient is transferred to a higher level


of care like IMC or ICU, they should have a transfer
note explaining the reason for transfer.

Discharge

Brief note on DC process:


Plan discharges with time. Enter these orders 12-24
hours prior to discharge if possible. Planning
discharge the day before or even before helps to
understand what needs to be done before the patient
is discharged or why the patient is still in the
hospital. e.g. oxygen requirements, IV antibiotics,
placement, etc.

Click Depart and fill Problems and Diagnosis. Fill


first Problems and Diagnoses addressed in this
visit and then in problems fill in chronic
problems.

Click orders and add discharge orders. Fill in


activity, diet and specific recommendations on
discharge here, sign.

Click medication reconciliation and fill as


discussed by the team.
8

In order to discharge a patient you should fill in


the discharge medication reconciliation.
The discharge medication reconciliation
contains all the medications the patient has been
exposed during the hospital stay and also the
outpatient medications.

these medications, ensure well in advance that


you will have a prescriber and the physical
prescriptions for them.

Initiate discharge.

Follow up date. Fill in when you and the team


recommend following up. It is really important to
know who the primary care physician is. If not, and
patient is from Travis county with no insurance or
MAP, you may be able to set up a follow up
appointment in Paul Bass Clinic. Patients with MAP,
Medicare and Medicaid can be seen at Paul Bass
Clinic.

4.1 Outline DC Summary

Paul Bass clinic: Seton Healthcare Network - Paul


Bass Clinic
1400 N. I-35 Lower Level Suite CL-400.
University Medical Center at Brackenridge.
Austin, Texas 78701.
Telephone number - (512) 324-8070. Dial for
clinic hours or to make an appointment.

Click Patient Education and add education


documents available in order for patients to read and
increase insight of the diseases.

Sign and close Depart template.

Talk with the patients about the final


recommendations and symptoms or signs for which
they should come to the ER.

Printing prescriptions:
Print scripts for all the new or changed medications
you are prescribing and ask the patient if they need
any new prescriptions for their chronic medications.
Click Medication History and Right click on
the medication you want to print.
Click Resend
A list of printers will appear, select the printer of
the floor you want the prescription get printed.
Prescriptions are printed in a special prescription
paper; most of the nursing stations have a printer
for that paper. Your prescription will come out
from one of them.
Review your prescription, sign it and leave in
the chart. RN of the patient will give the
prescription on discharge.
If the patient requires a controlled substance,
such as MS Contin, Dilaudid, etc. on discharge,
you will require a triplicate, which only certain
attendings carry. When you have patient on

Patient Identification: Name, DOB, MRN.

Team, attending, resident, intern, consultants.


Dates of admission and discharge.
Reason for hospitalization.
Discharge diagnosis.
Discharge medications and reasons for any changes
from admission medications.
Post discharge follow up.
Significant findings from admission work-up:
- History and physical examination.
- Laboratory studies.
- Imaging studies.
- Other tests.
Procedures performed.
Results of procedures and significant testing.
Condition at discharge.

We strongly recommend working on the discharge


summary at the time of discharge when the chart is in
front of you and patients hospital course is fresh in your
mind. Per program policy all discharge summaries
should be completed within 48hrs of discharge. You will
receive fines and site suspensions if you do not complete
your summaries in a timely fashion.

4.2 Transfer to LTAC, Inpatient Rehab,


SNF.

For patients who cannot live independently at home,


either following a hospitalization or as a result of
progressive decline, various care options may be
available.
Post acute care options following hospitalization
include inpatient rehabilitation (for patients with
stable medical issues able to participate in 3
hours/d of therapy); skilled nursing facilities, for
patients requiring care that must be administered by
trained nursing personnel or needing rehabilitation
services but are unable to participate in at least 3
hours/day of therapy.
Long-term acute care hospitals (LTACHs), which
provide long-term complex care following hospital
discharge, including ventilator care and weaning;
advanced health care services provided in the home
(home health care); and hospice or palliative care.
9


Transfer Med Rec (in compass and paper):
In order to discharge a patient to a health care facility,
you must decide what medications you would like them
to continue.
Complete the on screen discharge med rec, as you
would for a patient being discharged home, as this
will be important for documentation.
- Health care facilities require a physical
medication reconciliation on paper and do not
require prescriptions.
- Click Task and select Med Rec to Outside
Care Venue and select Print.
- Once printed you must fill the boxes of which
medicines you want to continue, discontinue or
modify. If you have antibiotics, or steroids that
need to be tapered, include stop dates and taper
instructions. Initial each page, and sign the last
sheet.

Core Measures

Core Measures (AMI, CHF, Pneumonia, SCIP, Stroke,


& VTE) are publicly-reported, evidence-based indicators
that affect reimbursement.
AMI
Order aspirin (oral or rectal) w/in 24hrs of arrival to
hospital or document reason why not ordered.
Prescribe aspirin at discharge or document reason
why not prescribed.
Prescribe beta blocker at discharge or document
reason why not prescribed.
Prescribe statin at discharge or document reason
why not prescribed.
If EF <40%, prescribe ACE I or ARB at discharge
or document reason why not prescribed.
Make referral to cardiac rehabilitation, Phase I Inpatient
and outpatient cardiac rehabilitation according to
standards.
CHF
Document EF or document reason why not
evaluated.
If EF <40%, prescribe ACE I or ARB at discharge
or document reason why not prescribed.
Order CHF education.
If patient NYHA Functional Class III or IV, refer to
Seton Heart Failure Clinic if indicated, or recommend to
PCP to make referral.

If blood cultures done, collect specimen prior to


antibiotic administration.
Initial antibiotic selection made for CAP see our
antimicrobial website on intranet

SCIP
Order prophylactic antibiotics to be administered
within one hr of surgery start time, complete w/in 24
hrs of surgery end time.
Control 6am blood glucose on POD 1 and POD 2
(blood glucose < 200 mg/dL) for cardiac surgery
patients
Remove urinary catheter by POD 2 or document
reason not removed.
For patients on BB, order BB during perioperative
period or document reason not ordered.
Order VTE/DVT prophylaxis w/in 24 hrs prior to,
through 24 hrs after surgery.
Stroke
Order VTE/DVT prophylaxis on admission see our
guidelines. TEDS alone does not count as VTE
prophy for stroke patients neither does ambulation.
If antithrombotic therapy not started by hospital day
2, a reason must be documented.
Patients that arrive within6 hours of symptoms
should be considered candidates for acute stroke
interventions (IV-tPA, IA-tPA, or thrombectomy). If
patient is not a candidate an exclusion statement
should be documented.
Nursing bedside swallow screen should be
performed before anything PO including
medications. Patients with a failed swallow screen
should have a ST swallow eval.
Order fasting LDL and prescribe statin on discharge
or document reason not prescribed.
Order PT/OT evaluation for rehabilitation potential,
or reason must be documented why PT/OT eval not
done-if patient at baseline, document patient at
baseline does not need rehab eval.
Patients with Afib discharged home on
anticoagulation or reason must be documented
why patient was not discharged home on
anticoagulation.
VTE
All patients - Order VTE prophylaxis on admission or if
no risk document No VTE prophylaxis needed
Patients with DVT/PE - Overlap therapy for AT LEAST
5 days and with an INR >2 prior to discontinuation of
overlap therapy. Note: If discharged sooner than 5
days, either discharge on overlap therapy or document
reason otherwise.

Pneumonia
10

Warfarin Discharge Instructions: Add follow-up app


for warfarin or INR monitoring to depart

X-Cover

6.1 X-cover Responsibilities


There will be 2 shifts-Early X cover (4 pm-2am) and late
X cover (9pm-7 am).
Early X-Cover Roles:
Pick up Code Blue/Heart and X cover pagers from
the long call interns of the day.
Make sure they are working!!!
Early X-cover intern will get checkout from all the
teams verbally or they should update the cores
every day on every patient on their list. They also
should call to give checkout on critical patients.
Early X cover intern will take calls for all the
internal medicine team patients. Calls about newly
admitted patients by the third year residents should
be referred back to the third years as they know the
patient better than you do.
Late X- Cover Roles:
Roles can vary depending on the patients that need
to be admitted from the ER. The admitting
hospitalist can page you to admit new patients or
you should be helping with the pagers if the other X
cover intern is busy.
Get a check out from the outgoing early X cover
intern on all the teams as you will be the one who
will be reporting the nights events the following
morning.
Be in the doctor's lounge at 7 am SHARP for
checkout unless you are attending to a critical
patient. All teams will be coming and getting
checkout. If any team is not available for check out
or does not get check out by other means, call the
chiefs.
Finally these are the characteristic qualities that are
expected in all interns while on the phone or
approaching any person in the hospital: be polite, use
effective and clear means of communication, always
keep in mind that this is a teaching hospital not only for
residents but also for all ancillary support staff including
nurses, patient care assistants. They are like you in early
stages of their career. Be professional and try to educate
nurses in patient care and with appropriate medical
knowledge. Every time a nurse pages you for your help
in caring for a patient nurses in the hospital follow
SBAR report to physician about a critical situation.
This form is available on Seton Intranet. SBAR includes

SITUATION, BACKGROUND, ASSESSMENT,


RECOMMENDATION.
What Kind of Questions will I get as an intern?
Calls can be as simple as pain management, nausea,
vomiting, lack of sleep, or complex as sudden onset
fever, chest pain, stroke, acute SOB, or sepsis. IF
YOU ARE UNCOMFORTABLE ANSWERING A
QUESTION PLEASE DO NOT HESISTATE TO
TELL THE NURSES, LET ME CALL YOU BACK
WITH A GOOD ANSWER. CALL THE
ADMITING 3rd YEAR RESIDENT IN THE ER,
HOSPITALIST OR THE PATIENTS
ATTENDING.
Most of the calls are from nurses, RT, and
sometimes from radiology to report new findings for
patients.
If there are any instances where you are unable to
reach the upper level on call, chiefs or hospitalist,
you may call Dr. Miller at 512-694-3328 or Dr.
Moreno at 512-715-3100 or Dr. Maxwell at 512574-6081. They have graciously given their personal
phone numbers for questions or for incidents with
hospital personnel which require serious attention.
If there are more than 2 calls from a nurse for a
single patient during any call night, always go assess
the patient personally.
ORGANIZATION OF INFORMATION ABOUT
THE PATIENTS WILL BE THE KEY
Following are the most common problems you will see
as an X-cover Intern:
1. Chest Pain: Code heart might already been called.
Go assess the patient. An EKG will be available by
the time you are there. Hospitalist and CRT will also
attend the call as well.
Key things on EKG: ST waves for depression or
elevation>1mm, new heart block, new LBBBCALL CARDS STAT. Transfer patient to
ICU/IMC.
Stat vitals. You can start with ASA,
nitroglycerin X3, morphine, oxygen, B-Blocker,
ACEI, LMWH or heparin drip at therapeutic
dose.
Cardiac Enzymes 3 sets (1 set every 6 hours).
X cover note: Document on the chart with time and
date and indicate cardiac causes such MI, stable or
unstable angina, pericarditis, or non cardiac causes
PE, pneumonia, pneumothorax, GERD, PUD,
esophageal spasm, costochondritis.

11

2. Abdominal Pain: Could be ischemia, inflammation,


obstruction, or bleed. Ask the nurse for
hemodynamics, severity, new vs. old pain.
Go find H&P. You dont want to miss an AAA,
acute abdomen, bowel rupture, perforation,
ischemia, appendicitis, retroperitoneal
hematoma.
Physical Exam: Acute Abdomen!!! Look for
guarding, rigidity.
Get labs: CBC, CMP, ABG with lactate,
amylase, lipase, UA, KUB, CXR, EKG based on
your assessment.
3. AMS: GO SEE STAT
Get STAT vitals, glucose, BMP, Ammonia, too
much pain meds (try nalaxone).
Delirium is one of the common causes. Look
for:
- Drugs: ETOH, BDZ, Narco, DKA, HHS,
DT.
- Emotional: anxiety, pain.
- Low PO2: MI, PE, anemia or high PCO2 in
COPD.
- Infection: Elderly-UTIs, sepsis, meningitis,
increased ICP.
- Retention of urine or feces.
- Post-ictal.
- Undernutrition/Underhydration.
o Metabolic: electrolytes, glucose, TSH,
ammonia, kidney.
o CNS: Epidural, subdural, CVA, TIA.
Labs: CBC, CMP, ABG, TSH, UA, EKG, CXR,
CT
Transfer to ICU or IMC: Start with primary
survey ABCs
4. Headache:
Hemodynamic stability, vitals.
Alarming Signs: LOC, neurologic deficits,
fever, nausea, vomiting.
H&P: MM IT ACHES.
M: Meningitis.
M: Migraine.
I: Inc ICP (tumor, hemorrhage).
T: Trauma, Trigeminal neuralgia, Temporal
arteritis, Tension headache.
A: Autoimmune (vasculitis).
C: Cluster.
HTN: Urgency vs. emergency.
E: Emotions.
S: SAH, SDH, Sinusitis.

5. Urine Output:
< 50 cc in 8 hrs is ok i.e., 20-30 cc/hr is ok but if
<20 intervene.
Oliguria: <400 in 24 hrs, anuria <100/24 hrs.
Vitals, urine output, I/O, volume status: check
lytes, K+, Hco3, BUN/CR, UA
For RN to check: Foley-volume status a.
Hypovolemia, give fluids b. hypervolemia, i.e.,
CHF, Cirrhosis, renal failure-try lasix. If none of
the above get bladder scan > 2000-2500 ml do in
and out cath.
Causes of Oliguria:
a. Pre renal: volume depletion, CHF, cirrhosis,
nephrotic, hepatorenal.
b. Renal: glomerulonephritis, ATN (Drugs,
Toxins).
c. Post renal: obstruction (BPH), stones,
clogged foley.
Check FeNa: <1% prerenal. >1% renal
FeUrea: In case of diuretic use if <35% then pre
renal.
6. Alcohol Withdrawal: Watch for hyperautonomic
dysfunction (Confusion, HTN, Tachycardia, dilated
pupils, diaphoresis. Try IV Ativan PRN if not
controlled then DT protocol with antipsychotics
such Zyprexa (check QT interval). Make patients
NPO.
7. Constipation:
Try Miralax, Colace, Senokot, Dulcolax, Fleet or tap
water enema, if patient on opiates, can try Relistor.
NEVER GIVE MAGNESIUM CITRATE IN
ESRD/AKI/OLIGURIA.
8. Diarrhea: HYDRATE, Check stool for WBC, ova
and parasites. If on antibiotics get c diff stool toxin.
DONT MISS ISCHEMIC COLITIS.
9. Arrhythmias: Is it too fast, too slow, irregular
A. fib: EKG stat, No p waves, irregular, RVR, check
vitals, cardiac enzymes.
STABLE: If RVR, cardizem 10-15 mg IV X 1, start
the cardizem drip if rate not controlled at 5-15 mg
and titrate to keep HR<110. If the HR is consistently
less then start titrating to PO cardizem 30, 60, q 6
hrs.
- Get ECHO, TSH, CXR, cardiac enzymes
- Calculate CHADs score, if 0-1 start aspirin or if
2 then warfarin.
UNSTABLE: Cardiovert
12

SVT: Narrow complex. Try Adenosine 6 mg IV, if


not controlled try another 6 mg or 12 mg I. Then
start verapamil or cardizem. If unstable cardiovert.
10. Blood Pressure: GO SEE THE PATIENT IF IT IS
TOO LOW OR TOO HIGH
HYPOTENSION:
a. BP trend, reason for admit, is pt conscious,
confused, or disoriented?
b. Use of any BP meds
c. H&P Cause: SEPTIC SHOCK/CARDIOGENIC
SHOCK/HYPOVOLEMIC?ANAPHYLAXIS.
Look for hypoperfusion, cold and clammy
hands, decreased urine output, mental status
change, Chest Pain.
d. Check the size of BP cuff
LABS: CBC, CMP, CXR, ABG with lactate. Get
EKG to rule out A fib, V tach, SVT, MI, Heart
block.
Treatment:
a. Fluids, fluids, and more fluids. Except
cardiogenic decreased preload, decreased
afterload, consider ionotropes. Call ICU. With
hypovolemic, septic , anaphylactic shock try at
least 4-5 L NS.
b. Epinephrine- 0.3 mg IV, repeat every 10 mins,
for steroids, benadryl for anaphylactic shock.
c. Septic: IVF, cultures, antibiotics, Call ICU for
pressors if not fluid responsive.
d. Never miss: Other causes including
Pneumothorax, PE, cardiac tamponade
(Hypotension, pulsusparadoxus, increased JVD,
distant S 1 and S2 with or without rubs).
SIGNS OF SEVERE SEPSIS:
Fever, AMS, decreased BP, increased HR or RR,
decreased UOP, decreased perfusion (mottling,
pallor), serium lactate>4mmol/L:
Initiate Emergency Pre-Arrest Protcol for Suspected
Sepsis, Call MD and CRT.
Neutropenic fever is an oncologic emergency, blood
and urine cultures, +CXR should be done and broad
spectrum antibiotics initiated within 1 hour of arrival
on unit.
ANC =WBC x [(segs 100) + (bands 100)]
ANC 1000-1500/mm3 moderate neutropenia
ANC<500/mm3 severe neutropenia
Prevent infection in your neutropenic patient
1. Meticulous CVC care

2. Meticulous hygiene-daily shower, hand


washing, focus on oral/peri care
3. Prevent constipation and diarrhea
4. Patient/family education-avoid exposure to
pathogens

HYPERTENSION:
a. HTN emergency: BP>180/110 with signs of
end organ damage (encephalopathy, ICH, CVA,
MI, angina, pulm edema, aortic dissection, renal
insufficiency.
b. HTN Urgency: BP>180/110.
LABS: CBC, BMP, EKG, troponin. Look for
precipitants cocaine, amphetamines, MAOI.
Treatment:
HTN emergency: Goal MAP<25% in 2 hours with
IV agents.
- IV Labetol (SE: Hypotension, especially
elderly).
- IV Hydralazine (SE: reflex tachycardia, long
life 10 hr, proteinuria).
- IV Nitroprusside (Cyanide toxicity, AMS< lactic
acidosis, death).
- IV Nitroglycerin (MI, pulm edema).
11. SOB: Get CXR, ABG, O2 sat, RT STAT
H&P: Causes include PULM (COPD, asthma, PE,
pneumothorax, pneumonia, mucus plugging), CVS
(CHF, MI, tamponade), RS depression (opiate
induced, try naloxone)
Oxygen Deliver: O2 via NC flow 1-6 L/min FiO2:
24-44% next try Simple mask with Flow 5-8 L min
with FiO2 40-60%.
If SaO2 still low with tachypnea try high flow
Venturi mask with flow 4-12 L/min and FiO2 2440%, or escalate to NRB with reservoir 6-10 L/min
FiO2 70%.
If still SOB try BiPAP titrate to keep SaO2 >88%.
Try CPAP for OSA/OHS EPAP 5.
12. GI Bleed: Check hemodynamics, hypotension,
tachycardia.
STAT H&H, BUN, Coags, type and screen.
Upper GI bleed (hemetemesis, coffee ground
emesis, melena).
Lower GI Bleed (hematochezia, BRBPR).
- Hgb/Hct>8/25, if not transfuse, give IVF.
Protonix bolus and drip with 8 mg/hr and
octeotride bolus and drip with 50 mcg/hr
Consult GI.
13

13. Fever: Check Hemodynamics


CXR, UA, Blood culture, Urine Culture, sputum
culture
Dont miss: septic shock, meningitis
H&P: - Infection (CNS, Sinuses, UTI, Abd, IV lines,
immune status)
- Drug Induced (Zyprexa, Anesthesia, Psych
meds)
- Post-Op.
- DVT/PE.
Neutropenic Fever: Fever>38.3, ANC<500.
- Start Cefepime 1 gm IV q 8, if PCN allergy
Aztreonam 2 g IV q 8hrs.
- Vanc 1 gm IV q 12.
- Of course pan culture.
ACLS: ALWAYS HAVE ALGORITHM FOR AHA for
your course. If not there is one on crash cart.

6.2 X-Cover Note


In the interest of time and practicality document all the
calls for every team for yourself and check out on a sheet
of paper but when you go to assess patients with a
serious conditions such as listed above always document
on the chart reason for call, presenting history and
physical, your ddx, and finally your intervention. Sign,
date and time every note. If you have an EKG sign it and
document your findings on it as well.

6.3 Code Blue Issues


Assess the patient STAT. Attend all code blues. Always
document the reason for code blue, presenting history
and physical, your ddx, and finally your intervention.
Sign, date and time your note. An ED physician will be
arriving shortly however; sometimes it might be you
who will be running the show. SO BE PREPARED
WITH ACLS ALGORITHMS. Patient is more important
than reading the chart, assess the patient and get
information from the nurses and CRT

Emergency Room Rotation

SCHEDULE:
You will have 4 weeks of emergency medicine, during
which you will have 17 9-hour shifts. Dr. Berger will ask
for your preferred 4 days off in the month 6 weeks in
advance, which he will try to accommodate. Your final
schedule will be posted on New Innovations. There is
usually also a schedule hung up in the ER Physicians
section of treatment. The schedule will specify whether
you are working in Crash or Treatment, and also
morning, afternoon or night shift.
SHIFTS:
You may be assigned to work the 7 am to 4 pm, 3 pm to
12 am, or 11 pm to 8 am shifts in ER. You are expected
to show up promptly and be present for teaching rounds,
which may occur in Treatment or Crash. The rounds
occur when there is overlap between the oncoming shift
and the outgoing shift. Usually the residents who are
outgoing will present mini discussions on interesting
cases or teaching points.
RESPONSIBILITIES:
Access the tracking list through FirstNet. Pick up
patients according to your interest, or the time of arrival.
When you pick up a chart you may fill out all the
documentation in terms of history and physical. ER
charts are designed as templates according to the chief
complaint, and pertinent negatives and positives can be
filled in with check marks and circles.
14

Initially present the patient to the attending before


ordering any labs or diagnostic studies. Once you
work with an attending, over time he/she may be
comfortable with you proceeding forward with
management.

Specialty Rotations

8.1 Hematology and Oncology


In this rotation you will round with different UMCB
hematologist oncologist.
You will be paged for new admissions. Admissions
should be dictated. Dictations need to include the
demographic information of the patient, team and
attending requesting the consultation and the question
asked by the team.
Frequent consultations include management of
neutropenic patient with fever, thrombocytopenia,
suspicion of cancer, recent diagnosis of cancer or
management of cancer, need to establish care in Shivers
cancer center, VTE and need for ruling out
hypercoagulable states.

8.2 Gastroenterology and Hepatology


In this rotation you will round with different UMCB
gastroenterologists.
You will be paged for new admissions. Admissions
should be dictated. Dictations need to include the
demographic information of the patient, team and
attending requesting the consultation and the question
asked by the team.
Frequent consultations include upper GI bleed, lower GI
bleed, management of cirrhotic patient, chronic diarrhea,
and abdominal pain.

ICU Rotation

The attendings for this rotation are Drs. Perret,


Morrison, Shah, Hayden, Shapiro, Deaton, Clark.
Rounds start between 8 and 8:30 am (check with your
upper level). Progress notes in ICU are different from
the progress notes used in wards. Templates of the
progress notes can be found in the nursing station. Put
emphasis on drips, rate of drips, IV meds, PRN
requirements, lines, tubes, Ins/Outs, fluid balance,
antibiotics, cultures, procedures, etc. The assessment and
plan should be written in a comprehensive fashion.

ICU patients are sick and complicated; never hesitate to


ask for help! Talk to your senior resident and your
attending about what they expect to be called for. Take
advantage of the expertise and experience of the nurse,
RT, and pharmacist. A hallmark of ICU care is the
multi-disciplinary approach.
During your call as intern be prepared to receive new
admissions. You will be paged for new admissions. As
soon as this happens, page your upper level and let him
know about the patient. Upper levels are responsible for
calling the attending.
Read every day about the problems of your patients. ICU
attendings will ask about your plan for the patient. If any
doubts pre-round with your upper level.

10 Psychiatry Rotation
The attendings for this rotation are Dr. McRoberts and
Dr. Garapedian.
The schedule during your psychiatry rotation will be
from Monday to Friday, and usually form 8 am to 5 pm,
depending in how many patients you have assigned.
Rounds are twice a day; at 9 am and 2 pm. You will be
working with a second year resident of family medicine,
psychiatry residents, medical students and psychiatry
social worker.
As an intern you will be responsible for admissions and
progress notes of patients. Admission notes have to be
dictated and you must put emphasis in psychiatric
symptoms, mental examination and nuerological
examination. Assessment should include DSM-IV five
dimension diagnosis.
The DSM-IV organizes each psychiatric diagnosis into
five dimensions (axes) relating to different aspects of
disorder or disability:
Axis I: All diagnostic categories except mental
retardation and personality disorder
Axis II: Personality disorders and mental retardation
Axis III: General medical condition; acute medical
conditions and physical disorders
Axis IV: Psychosocial and environmental factors
contributing to the disorder
Axis V: Global Assessment of Functioning or
Children's Global Assessment Scale for children and
teens under the age of 18

15

11 Emergency Coverage
In order to have coverage of interns/residents that may
have unexpected leaves, 2 interns will be assigned for a
certain period of days to be emergency coverage 1 or 2.
There is no preference in which one can be called first.
Chiefs do reserve the right to call either one in order to
cover for interns/residents that may have an unexpected
leave.
If you are in emergency coverage it is recommended to
stay within 1 hour UMCB just in case you get called in.

15 Language of Caring and Positive


Intern
Greeting: Be fully present; knock first & wait for
answer; know pt name; introduce self and role; shake
hands if appropriate.
Maintain eye contact, especially if using interpreter.
Sit down when possible, gives perception of time and
interest in patient.
Engage the patient: Inquire from patient..How are
you feeling today?

12 Access to Pathways
Log on to Seton Intranet, go under Clinical resources,
Clinical Practices, You may access Antimicrobial
Management and Anticoagulation Guidelines.

13 Death Records
Once a patient passes away, you are expected to right a
brief death note with course in the hospital, and cause of
death, dictate a Death Summary, and record the patient
on the CTMF Census Deceased Patients Log on the G
drive. You will eventually be forwarded the Death
Certificate for signature, just follow the given steps.

Push for all concerns: How can I help you today?,


How can I help you feel better today? "State your
ideas/concerns for the visit".
Use exhaustive what else: What else is worrying
you? Anything else? Agree on priority for the
dayaddress issue B and indicate any other concerns
expressed. Not sure can cover all concerns today but
give suggestions on how to proceed.
Positive intent: This is what I can do for you.
Reduce anxietyconnect all the dots for patient and
family.
Explain and check for understanding before leaving
the room.

14 Quality Improvement

Quality improvement is a two week long rotation


that will occur during one of your ward months. This
month was designed to allocate you time for
simulations (such as sepsis, A.Fib, angry patient), as
well as time to complete the Institution for
Healthcare Improvement online modules.
The IHI modules are tutorials that teach you how to
design and carry out your own quality improvement
project, which is a requirement for graduation. Once
you complete the modules, print out all your
certificates of completion and submit to Darleen, as
they are required by UT Southwestern for
graduation.
When you are on QI, you will be emailed your
schedule beforehand, and it is your responsibility to
be present at all the scheduled simulations. It is also
a time where you can practice simulation procedures
(e.g. central lines, pap smears). You will also be
expected to attend morning report and noon
conference. This may also be a time for you to
complete work on your QI project.

Indicate when you will return and how to reach if you


have questions.
Answering beeper and phone: excuse
yourselfmeeting with patient is important.

16 Phone Dictation Instructions


1. Call into system.
UMCB: 324-3621.
2. Enter your 4 digit ID#.
3. Enter the 2 digit work type:
01 History and physical.
02 Consultation report.
05 Discharge summary.
4. Enter the account/finance number as indicated by the
prompt and begin dictating.
16

To dictate another report, press 5 and enter the next


medical account/finance number.
Press:
1: Listen.
2: Dictate.
3: Short rewind.
4: Pause.
4: Next report.
6: Go to end.
7: Fast forward.
8: Go to beginning.
9: Disconnect.

International Dc Planner
(Oscar)

77825,77824
47047 (W), 47041 (E)
47003
47110
47022
49731 (ER), 78957 (Floor)
49810

1st Floor ICU


Front Desk
Charge RN
Pharmacy
Case Manager ( Janet)
Social Worker (Maggie)

47007
49838
73021
78962
78847

4th Floor Telemetry, Cardiac Step down


47330
Front Desk
49804
Charge
Social Worker (Cynthia) 78972
78963
Case Manager
6th Floor IMC and ICU
Front Desk
Charge
Pharmacy
Case Manager
(Diane)
Social Worker
(Leslie)
7th Floor Tele and Non Tele
Front Desk

49757
78964
78970(W),
78844(E)
589-8802 (Cell)

8th Floor (Surgery, Ortho, Plastics, Non Tele)


47085 (W), 47080 (E)
Front Desk
49794 (W), 49732 (E)
Charge Nurse
Blair (78975), Debbie
Case Managers
(78959)
78973
Social Worker
(Shelly)

17 Contact Information
Emergency Room
ER resident room
Crash
Treatment
Chest Pain Unit
Step Unit
Spanish Interpreter
Charge RN

Charge RN
Case Manager (Monica)
Social Workers (Jessicas)

47065( IMC), 47650


(ICU)
78886 (IMC), 49708
(ICU)
49748
78965

9th Floor (Non Tele, Oncology, Neurology, EMU,


Neurosurgery)
47987 (W), 47090 (E)
Front Desk
Charge Nurse 49811
47982
Pharmacy
Case Manager 78958 (Suzette), 78959 (Debbie)
Social Worker 78971 (Jamie)
Radiology Phone Numbers
ARA
Radiology front desk
Neuro-radilologist
Interventionalist
Float
CT Scan
Ultrasound
MRI
Nuclear medicine
Special procedures

795-5100
77750 or 324-7111
73947
73943
73771
47758
47759
88018
47797
48589 - press option
number 2

Internal Medicine Coordinators


Tommie Starkey 512-324-7863
77563
Mike
77563
Darleen
Chief Residents
Amrew AlAhmed

78921
Payas
Vasanth

Cell-phone: 803-295-0155
Email: amrew84@yahoo.com,
aalahmad@seton.org
Cell-phone: 703-577-8706
Email: payas.vasanth@gmail.com,
pvasanth@seton.org

47075 (W) and


(E)
17

18 Seton Emergency Codes


Emergency Number - dial 66666
Code Amber/Adam - kidnapped female/male child
Code Black - utility system failure
Code Blue - cardiac/respiratory arrest
Code Down - medical assistance needed
Code Fire Watch - fire hazard
Code Gray - abusive assaultive behavior
Code Ice - ice storm
Code Key Security - lockdown
Code Orange - Hazardous material
Code Pink - possible infant kidnap
Code Purple - missing patient
Code Red - fire
Code Silver - person with a weapon
Code Stork - emergency baby delivery
Code Triage (1-4) - disaster alert
Code Twist - tornado
Code Yellow - bomb threat
Code Zero - evacuation

18