Dedicated to the Health of the Whole Community

Department of Medicine

Intern Survival Guide

2016-2017

Intern Expectations
Organize
Update your sign-out daily- include pertinent problems and be concise, what may happen to the patient overnight and what to
do if it happens
Run list often call resident with any big development/changes/family meetings/abnormal labs values/consultant
recommendations/etc. Remember that you are a member of a team.
Pre-rounds and work rounds (with your resident) - overnight events, vital signs, available labs, general plan, daily details e.g.
electrolyte repletion, bowel regimens, etc.
Attending rounding BIG PICTURE only. Be concise on presentations. If attendings want more details, they will ask for it.
Notes tell the patients story and the teams thoughts and plans. Always include meds, labs, physical exam including mental
status, complete assessment and plan with problem list. Beware of the copy forward feature often erroneous information
gets populated from the prior day.
RETURN PAGES UNTIL 5pm except on days off. Please carry your pager after youve signed out. You should not be paged
while you are in clinic. Do not sign out before your notes are completed to the day cross cover.
Avoid verbal orders.
Go over EKGs every time one is done.
Check the patients active medication list every day. Make sure to hit the Review button on the Orders Tab for long-term
patients because medications will fall off after 28 days.
Prioritize

Be on time. If your mornings are rushed try getting to work 15 minutes earlier. If you are struggling with efficiency check in with
a Chief for tips and advice.
Morning and noon conferences are mandatory - if you are held up by your resident or attending, tell them you have to go. If
this is an issue please let the chiefs know about it.
Always follow-up or sign-out pending lab work on-call e.g. cardiac enzymes, first dose antibiotics, electrolytes, etc.
Tell RN of any urgent/STAT orders in person or on phone; do not just place urgent orders.
Make sure to adjust the timing of lab draws with each lab draw order.
If at any time you feel in over your head, call for help. There is always at least one resident or an attending around, even at
night. There will be periodic huddles for the night float intern to meet with the ICU cross cover resident at night.

Tips for Efficiency & Success

Information management: Develop a tracking system (for example, cards or notebook) with basic elements of patients
H+P/significant hospital events/operations/studies/labs.
Prioritize tasks:
o
Morning sign-out: Get sign-out from the night float intern at 7:00 A.M. Be punctual so the night float intern can leave in
a timely fashion.
o
Discharges: Start prepping discharges early and aim for discharge order entry before 11am when possible. A key to
this is prepping for discharge the day before (reconciling medications, going over the plan with the attending, speaking
with the patient, etc.)
o
Consults: Call them early. Tell the consulting team what service you are, callback number, and pager number that they
can contact with recommendations. Be clear on exactly what question you are asking the consult service and put
together relevant clinical info before calling the consult. Be sure your team has done a reasonable work-up prior.
o
Scheduling diagnostic studies: Especially for complex patients, be clear on the clinical indication for the study.
Consider whether the patient needs to be NPO for the study.
o
Check labs/micro/imaging studies early in the day: Dont assume that anyone else other than you is following up
labs.
Always read up on your patients problems. You are expected to be an active learner and should present interesting facts and
articles to your team at least once a week. Remember that you are a teacher as well for the medical students and the entire
team.
Maintain communication with your patients and families, team members, consult services, and ancillary staff. Take ownership
of your patients they should identify YOU as their primary physician.
Calling for help: Try to figure out whats going on, and if youre confident about what to do, do it. Next, think about how soon
the info needs to be passed on to a senior member of the team. If you have questions, just ask.
Patients having procedures & transfusions: A consent form needs to be completed before all invasive procedures/blood
transfusions. Specialty teams usually do them for their own procedures. NEVER consent a surgery patient the surgical teams
are solely responsible.
Switch days: The first several days on a new service are often chaotic and unsettling. Try to get to know the patients and your
role. A good sign-out at the end of the month from the intern coming off service will make your job much easier. In your signout at the end of the month try to include 1) a brief summary of the patients and their active issues and 2) the logistics of the
service (i.e. conferences/clinic times/call schedule/etc). If the patient has been here for an extended period of time it is
courteous to start a discharge summary for the next intern.
Keep up non-medical interests/obligations and take care of yourself: family/friends/exercise/hobbies.
Look for role models in your seniors, chiefs, and attendings.

Reflect on the stories of your patients. Take advantage of the phenomenally intimate window into human experience
that medicine provides!
Medicine Wards at SCVMC

General: Medicine is probably where youll spend the majority of your time at SCVMC. Youll see extreme/bizarre presentations of
otherwise common problems as well as straight-forward bread-and-butter cases.
Location:
TCNU (Transitional Care Neurosurgery Observation Unit) & Step-down Unit Located on the 4th floor of the newer side of the
hospital above Radiology (on the 1st floor), cardiac cath lab & OR (on the 2nd floor), and Labor & Delivery (on the 3rd floor).
Continuous cardiac monitoring & lower nursing-to-patient ratios are available in this unit. This is the highest form of care outside of
the ICU. For all patients, not just Neurosurgery patients the majority of patients are your medicine patients.
3-Center/4-Center General med/surg beds located in the 3E/4E wing of the hospital. Depending on your ward team color, your
home base will be either 3-Center or 4-Center. Cardiac telemetry is available on these floor. More recently, the hospital has opened
up 3-Overflow and the previous Mother-Infant Care Center (MICC) to medicine patients. You may also have patients on 4-Surgical.
2-Medical (MSSU) Located on the 2nd floor this is where the Galen hospitalist group is based. This unit also has telemetry (may
serve as TCNU overflow) & admits the short stay/observation patients who are expected to go home within 24-48 hours.
Team Structure: Teams consist of 2 interns, 1 supervising resident (R2 or R3), the attending, & 1 Stanford MS3. Some teams may
also have Sub-Is who will admit their own patients with their supervising resident. Occasionally, a pharmacy student/resident will be
rotating as well; they can help with drug/pharmacy questions.
Call Structure: Call is Q4 days for the team (from 7am to 6pm), and the entire team goes home by 9 pm. There is an intern who
serves as night float cross-cover who will receive your sign-out and cover your patients overnight. Prior to signing out to the night
float cross-cover, you should run your list and to-dos with your own resident concerning your patients.
Team Caps: The admit cap is 10 patients per team (5 per intern). Time cap (applies if your team has not received their 10
admissions) is 6 pm. The absolute team cap is 20 patients (10 per intern). So if your team is going into call with 12 patients, none of
whom are being discharged that day, then your team can only admit 8 new patients. Once a discharged patient physically leaves the
hospital, this no longer qualifies as ongoing care and your absolute team cap opens for admissions again. In other words, if the
team has 14 patients when starting a call day your initial admission cap is 6. However if 2 patients are discharged before 6pm you
can admit 2 more patients for a new total admission cap of 8. If the intern lists are uneven (one has 7 while the other has 3), the
resident must redistribute (give each intern 5) so that the team can admit 10 patients.
What counts as an admission?
A patient you have evaluated counts as an admission in your cap if the following minimal criteria have been met:
1. The patient has been fully interviewed and examined
2. You have completed and signed a note in Epic
3. You have discussed the case with your attending (for patients being discharged from the ED) or the accepting physician
(for patients being transferred to a different service)
Bounce-backs & Transfers: Bounce-backs from another service count as half an admission on call days and count as one full
admission on short call days. ICU transfers count as one admission.
Code Blues: All members of the on-call teams should respond to Code Blues. You should go to all RRTs (rapid responses) on your
patients. Day cross cover intern is responsible for RRTs after sign out.
Teaching: Attendings, residents, interns, and medical students are expected to help teach each other and be active learners.
Mandatory Conferences:
Morning Report is from 8-9am in the department of medicine library
o Tuesday 8-9am - INTERN REPORT; attend unless you have a conflicting educational session. Your resident is
expected to hold your pager to facilitate your attendance. If this is not happening please let your Chief Resident
know.
o Monday, Wednesday, Thursday Resident Report, mandatory for all residents
o You are welcome and encouraged to attend resident reports as well. You will not be called on at Resident
report.
Noon conference: 12:15PM-1PM. Lunch is provided. The talk will begin promptly at 12:15. Arrive by Noon or shortly
thereafter to get food and settle in.
Grand rounds: Friday mornings 8AM 9AM (usually) in the Valley Specialty Center (VSC) basement
Rounds: Rounds begin at different times on different days, usually at the discretion of the attending. You are expected to pre-round
on your own and work-round with your resident prior to presenting to the attending. On short call and on call days, you should preround prior to 7:00 am so you will be ready to accept the new admissions from night float. Check-in with your resident to see when
they would like to meet up with you for work rounds.

Sign-out/Cross cover: Every weekday starting at 3PM and every weekend starting at 12 PM, either an intern or resident pulled
from an elective, will serve as cross-cover for RRTs for the wards patients until night cross cover arrives at 5pm.. If you are crosscover for the day, please pick up the cross-cover pagers (primary and secondary) in the resident room. Do not sign out to
crosscover until you have completed your notes/followed up on important labs/imaging/consults and answered questions
from patients and their families. Remember, you will be cross-cover soon. Respect intern karma! Until 5 P.M., you should keep
your pager on and return all pages unless you are in clinic or it is your day off. The cross-cover primary pager is 275-3212
and the cross-cover secondary pager is 820-1099. At 5PM the Night Float interns (primary and secondary) arrives to take over as
cross-cover for all patient issues until 7 AM.
Sign-Out

Interns with clinic in the afternoon sign out to their resident prior to leaving
On-call interns sign out starting 6pm but before 9pm to Night Float
HealthLink has a Handoff Tool which you will update for sign out
Update the key information including emergency contact, problem list, allergies and to-dos

I
P
A
S
S

Illness Severity

"Rock," Stable, Sick, Code Status

Patient Summary

"One-Liner," Brief Hospital Course, Plan

Action List

To-Do List

Situation Awareness & Plan Anticipate Events with Plan "If, Then..."
Synthesis by Receiver

Summary, Question, Confirm To-Dos

I-PASS Starmer AJ et al. I-PASS, a mnemonic to standardize verbal handoffs. Pediatrics 2012;129:201-204.

Common Anticipated Situations and Potential Plans/Questions (I-PASS)

o
Fevers cultures (blood x2, sputum, urine), which antibiotics to start, lactate
o
Shortness of Breath oxygen, nebulizers, chest x-ray, ABG, diuresis, BIPAP
o
Chest Pain troponin, CK, ECG, anti-coagulation
o
Bleeding IVF, type and cross, transfusion consent, CBC, INR, IV access, drips
o
Mental Status baseline (stroke, developmental delay, encephalopathy)
o
Pain PRN limits, pain-seeker, hospice, allergies, mental or respiratory status
o
Other baseline abnormal vitals, death, transfer from TCNU

Days off: You are guaranteed 4 days off a month. Youll work out days off with your resident at the beginning of the month.
Discharges: All patients being discharged home need discharge summaries of their hospital stay within 48 hours. We strongly
encourage you to complete the discharge summary on the day of discharge. If not, then the patient will need a progress note for that
day. Why write an unnecessary note? Prioritize a discharge summary on the day of discharge! Summaries must be completed
prior to transfer for the following patients: SNF, prison, or being transferred to another hospital.
Cross Cover: Cross-Cover consists of one intern or resident pulled from a subspecialty. You start taking sign out from other house
staff at 3 pm on a weekday and 12 pm on a weekend and stay until 5 pm when the night float interns comes in. You are expected
to attend any RRTs for the interns/resident that have already signed out. After receiving sign out, you are expected to return to
the regular duties of the elective from which you were pulled. You are not expected to answer basic pages before 5 pm this is the
responsibility of the primary team.
Night Float: All interns will be responsible for night float with each rotation between 1-2 weeks in duration. Each week three
interns will be on night float and all will have two nights off per week (N1 Thursday/Friday; N2 Saturday/Sunday; N3
Tuesday/Wednesday). Tuesday through Sunday one intern will cover primary cross cover (yellow, red, green, blue) and the other
intern will cover secondary cross cover (tan, orange, pink, grey). Night float for primary and secondary cross cover starts at 5 PM.
Sign out from the cross cover day intern/resident should occur prior to sign out from the call teams. Monday night all three interns
will work, but intern N1 (see below) will be responsible for aiding the ICU fellow with admissions and will come in at 7:30 PM (as
opposed to 5 PM). Every Sunday an intern will be pulled from the ED rotation to cover as primary cross cover at night. In addition to
the cross cover duties, primary and secondary cross cover interns will be expected to help their respective night float resident
(primary and secondary) with one admission including the H&P.

ICU
General: Many of the house staff find the ICU rotation to be the most fulfilling. The ICU faculty are outstanding teachers, and there
are many opportunities for procedures.
Location: Your home is Medical ICU (MICU) & Coronary Care Unit (CCU), both on the 4th floor in the new building. When the
census is high you may overflow into the Burn Unit on the 4th floor or the Surgical & Trauma ICUs (SICU/TICU) on the 2nd floor.
Team Structure: There are four ICU teams with one intern & one resident. You will admit MICU & CCU patients and staff them with
different attendings:
- For MICU patients, there are 2 attendings (each takes 2 ICU teams). There are ICU fellows who follow the MICU patients with you.
- For CCU patients, there is one CCU attending who staffs all CCU patients.
Call Structure: Call is Q4 days with admits beginning at 7AM and ending at 4 AM the next morning. The resident stays overnight
but as the intern, you will go home by 8PM. During your call day, you are expected to get signout from the other 3 teams and crosscover their patients, as well as perform any admissions to your team that day. There will be a night float resident who comes in at
7:30 PM to take over your cross cover duties. In the ICU, you do not take additional patients on the short call day of your call cycle.
There is no continuity clinic during your ICU month.
Cross-cover: The on-call intern cross-covers all the ICU patients on all 4 teams until the ICU night float resident comes in at
7:30PM.
Admissions: You are expected to admit patients with your resident. Your first priority is cross-covering, but whenever you can,
residents will want you to be part of the admission process from the beginning and have you see new admits with them.
X-ray rounds: All four ICU teams will meet in the ICU classroom at 7am to go over the daily films on each patient and hear about
new admissions from overnight. The on call intern reads the films to the rest of the group.
Morning Rounds: Rounds begin at different times on different days depending on where you are in the call cycle. In general, postcall teams round first.
Teaching Rounds: On weekdays, there may be 1 hour of formal didactics in the ICU classroom. House staff rotating through the
ICU are expected to give a brief talk during their ICU month on the topic of their choice.
Sign-out Rounds: On weekdays (M-F), bedside sign-out rounds begin at 2 PM in the MICU. The post-call resident is exempt from
these rounds, but everyone else must be present. On weekends, there are no sign-out rounds.
Days off: You are guaranteed 4 days off a month. Youll work out days off with your resident at the beginning of the month.
Stanford University Wards
General: There are 5 University Teams consisting of 1 Resident and 2 Interns. You will get sign out and pager from the previous
valley intern and will continue their call cycle. You can text page using the Stanford text service at http://smartpage.stanford.edu
(and use your SUNet ID to log-on).
Call: Stanford University wards operates on a five-day call-cycle. The team admits on days 1 and 4 of the call cycle from 7
am 7 pm, including short call.
Address: 300 Pasteur Drive, Palo Alto CA 94304. A one month parking permit is reimbursed by VMCsave your receipt
Page Operator: To speak to live person is: 650-723-6661 or ext 288. To page someone via phone, call 650-723-8222 or ext 222.
Give your ghost pager number to the nurses
Ghost Paging: Very important after getting sign out from night float intern or when you leave at the end of the day after
signing out. To forward your pager to the pager of the person covering you, dial 222 in house then * your pager number then #1, 1

and then the pager number you want to forward it to. To unforward pages dial 222 then * pager number then #1, 2. Note: you can
always call the page operator to forward or stop forwarding your pager for you.
Food: You'll get a meal card at the beginning of your month. Cafeteria is on the 1st floor and is open from 7 A.M. to 7 P.M.
Team Rooms: The medicine teams are on C3 and B3 (take stairs/escalator) to the 3rd floor.

Things to do BEFORE the rotation

Complete your Epic training - contact Debbie Valdez DValdez@stanfordmed.org in the GME office. For Epic training
support, contact CISLearningServices@stanfordmed.org. For all other IT support, contact the Service Desk at 650-7233333
See Debbie Valdez to sign papers and get your meal care/badge
Buy a 1 month parking permit at the Stanford Parking office: 340 Bonair Siding Road Stanford, CA 94305.
(Reimbursement is available for parking permit, save receipt).
Start the process to get reimbursed for driving miles (optional). Get a form for reimbursement from Emi Williams. You'll
need a county driving permit from HR. You will have watched the driving video during orientation. HR will give you a
packet to fill out. One of the forms needs the Chair of Medicine's signature - Emi Williams can help with this. The
Categorical interns permit will last you three years.
Palo Alto VA
General: There are 5 Medicine Teams consisting of 1 Resident and 2 Interns. You will get sign out and pager from the previous
valley intern and will continue their call cycle. If you have questions, please email Vivian Miller at vivian.miller@va.gov or the 2015
Stanford chiefs at chiefsmed@lists.stanford.edu. If you are going to be rotating through the VA and have not heard from them
about paperwork/fingerprinting by 6-8 weeks prior, please contact them.
Call: VA wards operates on a five-day call-cycle. The team admits on days 1 and 4 of the call cycle from 7 am 7 pm,
including short call.
Address: 3801 Miranda Avenue, Palo Alto CA 94304
ED
General: ED is a good rotation in which to learn and do a lot of procedures (pelvic exams, laceration repairs, lumbar punctures,
etc.). For categoricals and prelims, its a great chance to review basic peds, OB/gyn, and general surgery for Step 3. There is also
ED grand rounds scheduled on the 3rd Friday of the month at 9am in the AOB.
Rounds: It is your responsibility to take initiative and sign up for patients as they come in. Triage and see the sickest patients first.
After you see a patient, find the attending. This is the ED H&Ps can be brief and to the point. Labs, meds, any imaging are done
in HealthLink. You need to CALL radiology to protocol any contrast studies or ultrasound (x57625) or the studies won't get done.
Hours: Shifts are 10 hours. You will sign-out your patients to the attending, not the incoming intern. You dont cover patients from
previous shifts.
Structure: Each intern will be assigned to a template schedule with built in days on and off. If you require specific days off your first
step should be to swap templates with a co-intern and notify Dr. Erica Chiu Liang, the educational coordinator
(Erica.chiuliang@hhs.sccgov.org or EricaChiuLiang@cep.com) in addition to the Chief Residents. If you have multiple requests
which do not line up with the template, you are able to switch days with the other interns on ED as long as all required shifts are
covered. Lastly, you will be expected to cover a Sunday night cross on Medicine wards as part of your ED month.
Absences: If you are sick and will miss an ED shift you should immediately contact the ED admin physician (listed on AMION) in
addition to emailing the ED educational coordinator, Dr. Erica Chiu Liang (Erica.chiuliang@hhs.sccgov.org or
EricaChiuLiang@cep.com), and notifying and getting a response from the Chief Resident. In general, any missed shifts will need
to be made up prior to the end of the block. Prolonged absences will require replacing a week or more of future elective
time with ED shifts to ensure you meet ACGME requirements for the rotation. Please note the ED depends on your presence.
If you are sick the Chief Resident will first reach out to a co-intern on the ED rotation to see if they can cover your shift as one of
their 18 required shifts.
Breaks: Please work with you attending physician to determine the best time to break for meals. The ED flow is different from the
wards. Note also you are exempt from noon conference attendance during your ED rotation.
Subspeciality electives
Please check the SCVMC resident blog for rotation specific details: coordinator and attending information, schedules, where to
show up on day one, etc.:
https://scvmcmed.com/about/
Password: scvh

Sick Call/Jeopardy

If you are ill or have a family emergency, regardless of rotation, you must:
o Contact the Chief Resident and get a response (closed loop communication)
o Call your supervising attending through AMION (including your clinic attending if you will be missing
clinic) ASAP
Any absence not reported to the Chief Resident will be considered an unexcused absence and will have to be
made up.
Please make sure to check Amion to see if you are on sick call.
Sick call #1 and #2 must stay within 1 hour of the hospital.
While on sick call, keep your cell phone and pager on and with you at all times.
If you are on a night shift it is essential you let the Chief Resident know the moment you think you might call in sick to
allow adequate time for the sick call intern or resident to be notified to facilitate patient coverage while avoiding ACGME
work hour violations.
If the sick call pool has been used up, it will be up to the Chief Residents discretion in terms of pulling residents who are
not on call months.
Any missed continuity clinic will have to be made up to ensure you meet the minimum number of required clinics.
Any missed ED rotation will, in general, be made up before the end of rotation.
Switch Days

Residents switch rotations every 2-4 weeks; please check amion for switch days.
Interns switch rotations every 2-4 weeks, staggered one week ahead of residents. Check amion for switch days.
Switch days are on Mondays.
Continuity Clinic

All of the categorical interns are assigned to "medical homes" and preceptors. They will have a two-week "Ambulatory" introductory
block for your continuity clinics. This will give you a chance to meet your preceptors (categoricals work with for the entire three
years) and get familiar with how your clinic works. This block will be some time during your first 6 weeks prior to any ward block,
when your continuity clinic will start. The preliminary interns who have selected a continuity clinic also are assigned to an outpatient
clinic and preceptor but are not required to do the Ambulatory introductory two weeks.
Admission H&P Guidelines
If a patient is non-English speaking, try to see them ASAP in the ER as there are often interpreters there (esp. Spanish and
Vietnamese); otherwise must use phone interpreter.
1. See patient
2. Write Admission Orders through the Admission navigator tab immediately. To ensure patients receive timely care in the
correct location, admission orders in the ED are prioritized. The ED physician or your resident may place holding or
skeleton orders. This is not intended to subvert your learning or autonomy but to ensure smooth flow for the patient.
3. Must reconcile outpatient medications on admission. This is a crucial and mandated part of all admissions. If you need
assistance please ask your resident. A reconciled admission medication list ensures a smooth and safe discharge. Do
your best.
4. Complete H&P
5. Order/Verify Code Status every time.
6. Check ER records for initial and current vitals, meds given, studies done, big events
7. Check labs for those that are current/pending. Check ClinWeb screen for prior records of labs, pathology, imaging,
transcribed reports, cardiovascular reports, old ED reports, discharge summaries. Gather previous values on all current
abnormal values (e.g. Cr, Hct, etc.).
8. Check EKG & compare with prior EKG (in chart & computer), make copy for presentation to resident and attending, and
show resident ASAP if detect abnormality, pt having chest pain, or cardiac enzymes abnormal in any way immediately
page resident, get EKG if not done and physically see the patient
9. Check IMPAX for radiology (scan all studies done, will give hints to PMHx). Try to look at current studies that have been
done in the ER: CXRs, CTs, U/S even if there is no official radiology read. Show resident if there is abnormality.
10. Besides ClinWeb, can also check for outpatient notes in ELMR (PCP), physical chart (specialist visits)
11. Check Healthlink Encounters for scheduled appointments & current PCP.
12. REQUIRED admission order sets - Stroke
13. Try to avoid restraints (can try redirecting patient, ordering a sitter, meds for agitation). But if need them, restraint form
needs to be co-signed by someone with a license (ie. your resident or attending).
CALL RESIDENT to discuss within 2 hours of getting patient review orders
KEEP ORGANIZED! ALWAYS CHECK LABS, EKGS, STUDIES OF PTS ALREADY ADMITTED before leaving the hospital.

Troubleshooting Common Medical Problems

1.

Altered Mental Status

Differential Diagnosis:
A. Infection: meningitis, encephalitis, systemic infections
B. Drugs: benzodiazepines, opiates, anti-cholinergics (Benadryl/Phenergan), steroids
C. Metabolic: hypoxia, EtOH withdrawal, hepatic encephalopathy, uremia, electrolyte imbalance, hypoglycemia,
seizure, hypotension
D. CNS: intracranial bleed, tumor, stroke
E. Other: sundowning, ICU psychosis, TTP, cerebritis, vasculitis, fall/trauma
History: Age of patient, baseline MS, acuity of MS change, recent medications
PE: Vital signs, pulse oximetry, Basic physical exam, neuro exam, pain stimulus, check brainstem reflexes
Tests/Treatments:
A. CBC (infection), P7, iCa, Mg, PO4, ABG (hypoxia), EKG, LFTs (liver failure), U/A (UTI), Fingerstick (check for
hypoglycemia)
B. Consider Head CT (eval for ischemic, hemorrhagic stroke)
C. LP (for meningitis) get opening pressure, send CSF for cell count, diff, glucose, protein, culture, gram stain, VDRL,
India ink, crypto Ag, fungal Cx, AFB
D. Treat possible underlying cause: Consider Narcan, antibiotics, oxygen, hold all sedating drugs
E. Consider transfer to Neuro Obs/ICU, soft restraints, posey vest if necessary

2.

Hypertension
Definition: SBP > 160, DBP > 90
Key points: Mild HTN can wait until AM, treat if SBP >180, if CAD/CHF treat SBP> 140
History: Does patient have CHF/CAD? Renal Insufficiency?
Any signs or symptoms of malignant hypertension? (chest pain, headache, visual changes, mental status
changes, weakness, numbness, hematuria, nausea)
Treatment possibilities:
A. Clonidine 0.1mg PO Q4hrs prn; safe with CHF or low EF; can cause reflex tachycardia
B. Metoprolol 25-50mg PO Q6hrs prn or 5mg IV q5min max 3 doses; avoid in patients with decompensated CHF,
bradycardia (HR<60), heart block, prolonged PR interval; good for CAD
C. Hydralazine: 25-50mg PO q4 hrs or 10-20mg IV Q2 hours; safe with CHF or pregnancy
D. Others: Short Acting ACE inhibitors: Captopril/Enalapril at low doses
Other comments:
Always check for allergies/contraindications for any of these meds
If BP remains elevated after 30 minutes, repeat any of these meds x 1
If you cannot get SBP <200 and there are signs of hypertensive emergency, patient may need to be transferred to
the ICU for a drip

3.

Chest Pain
Differential Diagnosis:
A. Cardiovascular: MI (pressure like pain), PE (dyspnea, hypoxia, pleuritic pain), pericarditis, aortic dissection
(tearing pain radiating to back, unequal pulses)
B. Pulmonary: Pneumonia, pneumothorax (decreased breath sounds, deviation of trachea)
C. GI: Esophageal reflux/spasm, gastritis
D. Other: Musculoskeletal, anxiety
General Rules: Assume this is ISCHEMIC CHEST PAIN until proven otherwise
History: Ask patient about pain, onset, place, quality, radiation, severity, time, SOB/N/V/diaphoresis
PE: Check vitals (HTN, tachycardia), overall appearance, check JVD, cardiac murmurs, S3, pulm edema
Tests/Treatments (MONA)
1. Get STAT EKG, give 0.4mg NTG SL q5min x 3 doses (beware if BP drops <90)
2. Give ASA 325mg beware for h/o of PUD
3. Oxygen 2L/min to keep O2 sats >92%
4. COMPARE NEW EKG TO OLD EKG FOR SIGNIFICANT CHANGES (T wave inversions, ST depression, ST
elevation) if any of these -> CALL RESIDENT
5. If still in pain after NTG, give Morphine 1-4mg IVP (check if has renal failure)
6.
B-Blocker if HTN/tachycardic, can give Metoprolol 5mg IV q5 min x 3 doses or give 50mg PO x 1
7. If need to start Lovenox, do a rectal exam to check for blood!!!!
8. If you really think it is GI: give a GI cocktail: 10cc Donnatal, 10cc viscous lidocaine, 30cc Maalox
9. Get CXR or STAT CT scan if you think its aortic dissection
10. Write a cross cover note detailing your assessment/plan/treatments

4.

Shortness of Breath
Differential Diagnosis:
A. Pulmonary: Asthma/COPD, pneumonia (cough/fever), pneumothorax (acute onset pleuritic CP), pleural
effusion, atelectasis, PE (pleuritic CP, hypoxia, clear CXR)
B. CV: Ischemia, CHF, tamponade, arrhythmias
C. Miscellaneous: Anxiety, upper airway obstruction, anaphylaxis, massive ascites, OSA, anemia, sepsis
Phone Questions
1. What are the patients vital signs, including pulse ox?
2. How acute is this onset of dyspnea? (Acute SOB bronchospasm, PE, MI, ARDS, anxiety)
3. Any associated symptoms? (cough, chest pain, palpitations, fever)
4. Any new events/medications given around the time of onset?
Physical Exam:
Does the patient look comfortable, or sick? Can you increase O2 or are they CO2 retainers!!!!!
Check Vitals: RR >20/min: hypoxia, pain, anxiety, <12 central depression, stroke, drug OD. Heart rate consider
arrhythmia. Temp: infection with fever. BP: if hypotension, sepsis, PE, CHF, PULSE OX
Listen to the lungs: clear, wheezes, rhonchi, crackles, good air movement, dullness
Check JVD, edema, S3, signs of fluid overload
Check extremities for edema (?DVT) and perfusion
Stridor indicates upper airway obstruction:
Assess mental status, gives an idea of cerebral oxygen delivery
Tests
ABG (check for hypoxia, hypercapnia), STAT CXR, EKG (ischemia, PE), CBC
Treatments ok to give Oxygen if not CO2 retainer, goal is to get O2 sats >92%
If asthma Albuterol/Atrovent breathing treatments, beware for tachycardia, consider steroids
If CHF/pulm edema Lasix 20-40mg IVP x1, NTG SL, Morphine 2-4 mg IVP, BiPAP, intubation
If worsening pneumonia consider broadening antibiotic coverage
If you feel the patient is crashing, call ICU resident to intubate patient (Always better to call the resident earlier rather
than later)

5.

Hypotension
Definition: SBP <90 (usually)
Differential Diagnosis:
A. Hypovolemia: GI bleed, N/V/diarrhea, overdiuresis, retroperitoneal bleed
B. Cardiogenic: ischemia, MI, CHF, arrhythmia, valvular disease, tamponade, tension PTX
C. Sepsis!!!!!!
D. Overmedication Vasodilators, Morphine
E. Endocrine: Addisons, myxedema, thyroid storm
F. Miscellaneous: Massive PE, aortic dissection, liver failure, anaphylaxis, neurogenic shock
History: Does patient usually have a low BP? If yes, worry less. Is the patient symptomatic?
Physical Exam: Check pulse (if bradycardic <55 and symptomatic: call resident), do a full PE
Tests/Treatments
Trendelenberg position, ensure adequate airway
At least 1, preferably 2 large bore IVs (antecubital)
Bolus with NS wide open (500cc to 1L to start with) use less if pt old/CHF/JVD/edema
Consider STAT EKG to eval for MI/tachyarrythmia
Consider panculturing if sepsis a consideration consider starting empiric antibiotics
Hold any BP meds, nitrates, opiates, benzodiazepines
If no response to 1-2 liters of NS, call ICU resident, may need to start pressors
Consider transfer to TCU for closer monitoring
NEED TO FIGURE OUT WHY PATIENT IS HYPOTENSIVE

6.

Tachycardia
Phone Questions:
1. Vital signs? (i.e. hypotensive), Is the patient symptomatic or unstable? Get 12 lead EKG
2. What is patients baseline HR?

Differential
A. Sinus tachycardia: Causes: pain, fever, anemia, hypoxemia, hemorrhage, MI, meds
B. SVT (Aflutter, AFib, MAT, etc), does pt have hx of irregular rhythms
Treatment
A. If normo-or hypertensive, try Metoprolol 5mg IVP x 1, may repeat x2 at 5 min intervals total 15mg
B. Call resident if you are uncomfortable, if Vtach -> call CODE BLUE

7.

GI Bleed
Differential Diagnosis:
A. UGIB Esophageal varices, Mallory Weiss tear, esophagitis, PUD, cancer, AVM
B. LGIB angiodysplasia, cancer, diverticulosis, ischemic colitis, IBD (UC/Crohns)
History: History of bleeds? Alcoholic? Is patient on ASA, Coumadin, Heparin?
PE: Check vitals (increasing HR, decreasing BP indicate ongoing blood loss, orthostatics, do RECTAL exam -> heme+
brown stool (slower bleed), melena (significant UGIB), maroon BRBPR (massive bleed)
Tests/Treatments
STAT CBC, PT/PTT/INR, Type and cross 2units PRBC and keep 2 units ahead
2 large bore IVs, bolus with NS if hypotensive or tachycardic
Transfuse PRBC as needed, usually 2 units, Transfuse platelets if <20-30,000
NGT lavage if patients with emesis (hematemesis suggests active bleeding)
If active bleeding, IV Protonix 80mg bolus, then 8mg/hour drip
Give FFP/SQ Vit K if patient coagulopathic, give protamine if on heparin
NPO
Octreotide drip for esophageal varices
HCT Q2-4 hours, transfer to TCNU or ICU based on rate of blood loss
May need to call GI if significant bleed, call ICU resident first!

8.

Decreased Urine Output (This will happen more than you thought!)
Definition: Less than 30cc/hour
Differential Diagnosis
A. Pre-renal: low perfusion of kidneys results in low urine production. (overdiuresis, hypotension, N/V/diarrhea,
bleeding) Clues: dry mucous membranes, poor skin turgor, tachycardia, I<<O for days, overaggressive diuresis,
BUN/Cr ratio >20, tachycardia, hypotension, orthostasis)
B. Renal: Intrinsic kidney disease Clues: chronic renal disease, recent severe hypotension, meds
C. Post-renal: kidney makes urine, but its blocked from coming out (Foley obstruction, BPH, prostatitis, renal
stones, tumor compressing), Clues: painful, distended bladder
PE: Check BP, pulse, check mucous membranes, JVD, check bladder, review BUN/Cr, review I/O
Tests/Treatments
If patient has a foley catheter, flush it in case it is plugged, if no foley -> consider straight cathing patient if >400cc. If
no urine with straight cath, consider acute renal insufficiency
If patient appears to be dry, fluid challenge with NS 250-500cc bolus and see if UOP increases
If still no UOP, re-eval fluid status of patient with exam and repeat bolus if pt still seems dry
If patients seems wet or euvolemic, try Lasix (IV is twice as strong as PO), start with 20mg IV if patient is Lasix nave.
Start at double the patients usual dose if they are already getting Lasix. Max Lasix dose is 160mg IVP
Get Renal U/S to check for obstruction
Send off urine Na/Cr to calculate FENa before you give the Lasix. (If pt already on lasix, get urine urea, urine
creatinine)

9.

Hyperkalemia
Definition: K>5.5 without hemolysis
Signs/symptoms:
arrhythmias, muscle weakness, paresthesias
EKG changes, first peaked T waves, prolonged PR interval (>0.20), wide QRS, absent P, ventricular arrhythmias
Tests/Treatments
STAT EKG, P7; stop any potassium in IVF or PO
If K>5.5-6.0 and no EKG changes, give Kayexalate 30grams PO x1
If K >6.0 or with EKG changes
o
Give 1amp Calcium Gluconate
o
Give 25g D50 IVP and 10units regular insulin IVP
o
Give 30g Kayexalate
o
Can also give 1amp Bicarbonate
o
Repeat P7 after above treatments; if still high or EKG changes, call resident and renal and consider
emergent dialysis
10. Hypokalemia
Definition K < 3.4
General Rules
Keep K>4.0 in cardiac patients and in those on Lasix
Be very careful if repleting a renal failure patient!!!! (see Electrolyte section)
KCL PO: 40-60mEq PO, can repeat Q2 hours, difficult to swallow, poor taste
KCL IV: 10-40mEq, can only run at 10mEq per hour; if running through peripheral IV, need to give 1% Lidocaine 1cc
per bag
If phos is also low, you can give KPhos to replete both at once
11. Hyperglycemia
Treatment:
A. Stop Glucose from IVF; place on ADA diet, Insulin Sliding Scale
B. If BS >400, consider checking UA for ketones, Chem 7 to r/o DKA
C. If patient with elevated anion gap and serum ketones, may need to transfer to TCU or ICU for insulin drip (make
sure you have IV fluids running)

12. Hypoglycemia
Definition: Glucose <60
Treatment:
A. If taking POs, give orange juice
B. If NPO, give 25g IVP D50
C. Hold insulin, diabetic medications
D. Recheck Glucose in 30 minutes/1hour
E. If still hypoglycemic, may need to start D5, D10 drip, increase frequency of checks to Q2/4hr
13. Fever
Phone Question: 1. What are the patients other vital signs (hypotensive/tachycardic)?
H&P, PE: Look for immunosuppressed states. Does the patient have any indwelling catheters/lines? Signs of meningitis?
What meds is patient on?
Differential Diagnosis:
A. Infection: (Lung, Heart, Brain, Urine, Sinuses, Prostate, Abdomen, Skin, Lines)
B. Inflammation: (Collagen Vascular Diseases, Neoplastic disease)
C. Atelectasis
D. Blood product reaction
E. Drug Fever (B-lactam antibiotics, amphotericin)
F. PE/DVT
Tests/Treatments
G. Blood Cultures X 2, U/A + Cx, CXR, Culture any other lines
H. Consider starting Abx depending on clinical scenario (Consider broad coverage e.g. Zosyn/Vanco if pt
decompensating give one time doses to hold pt overnight)
14. Insomnia
Look through patients chart to check for allergies and other meds for potential interactions
Think about patients underlying medical conditions (does patient have renal or hepatic dysfunction that is going to
affect the clearance of whats being given), go see the patient
Treatment options
Ambien 5mg PO or Trazodone 25-50mg po
Low dose Benadryl 25mg po, but be careful for anti-cholinergic side effects in ELDERLY patients
15. Combative patient
Phone Questions: Does patient have altered MS, has patient been agitated before?
If concerned about physical injury, call security, restraints
Look at chart for possible causes of this behavior: h/o etoh, drug abuse, dementia, meds, DM, lung disease, head
injury
Is this patient delirious? If you suspect an underlying reason for the agitation (pain, sundowning, hypoxia,
medication, withdrawal, electrolyte disturbances), try to treat the underlying reason
Chemical restraints: Haldol 5mg SQ/PO (make sure QT is not prolonged on EKG), ativan 0.5-1mg po or IV (low dose
for elderly!)

LYTE REPLETION BASICS with any very abnormal value, recheck the labs later in the day. Replete more aggressively in
cardiac patients (K to 4.0, Mg to 1.0, Ca to normal range)
Serum K+
(mmol/L)

Std Scale
KCl Replacement

Aggressive Scale
KCl Replacement

4-4.5

10 mEq IV

20 mEq IV

3.5-3.9

40 mEq PO or 20 mEq IV

40 mEq IV

< 3.5

40 mEq IV

40 mEq IV and 20mEq PO

Check K*+* level periodically especially if using aggressive scale

Arterial pH affects K+ level
Check Mg++ level if having difficulty repleting K+
Each 10mEq KCl will inc. serum K+ by ~0.2 if given IV & ~0.1 if given PO
**Use caution with renal insufficiency**
KCl can be infused at 10mEq/hr via peripheral IV (burns add lidocaine) & 20mEq/hr via central
line (doesnt need lidocaine)
If given via peripheral IV write as KCl 10mEq IV w/ 1% lidocaine 1cc/bag x number of doses
Use PO when possible. K-Dur (PO) = sustained release (less stomach upset), K-lor (PO) = fast
acting powder (more stomach upset). Only replete a max total PO of ~60mEq at a time as K can
cause severe diarrhea/upset stomach

Serum Mg++
(mmol/L)

Magnesium Sulfate
Replacement

0.7-0.8

1 gm

0.6-0.7

2 gm

< 0.6

3-4 gm

Ionized Ca++
(mmol/L)
1.00-1.12
0.9-0.99
0.80-0.89

Remember Mg is essential for most other lytes to be

utilized properly. Replete aggressively to at least 1.0 if
having trouble keeping other lytes normal. Use caution
with renal insufficiency
Check pts K+ & Ca++ levels
Give initial 2g followed by 1g/hr to avoid excess renal
loss
Can take 36-48 hrs to re-equilibrate serum Mg++ levels

Calcium Gluconate
Replacement
1-2 gm IV
2 gm IV
3 gm IV

CaCl2 contains 3x Ca++ as Ca Gluconate

Serum PO4Serum PO4IV Sodium/Potassium Replacement

Oral/NGT Phosphate Replacement
(m/dL)
(m/dL)
2.3-3
10 mmol IV
2.3-3
1 packet Neutraphos Q8hr x 2
1.6-2.2
20 mmol IV
2-2.2
2 packets q8 hours x 3
< 1.6
20 mmol x 2
<2
USE IV REPLACEMENT
Use KPO4 if K+ < 3.5. Use NaPO4 if K+ > 4 or renal insufficiency. Use po when possible
Each 3 mmol KPO4 contains 4.4 meq K+
Check Ca++ as PO4- may decrease Ca++
Neutraphos contains 8 mmol/packet

Misc:
Give iron sulfate 325mg PO daily with food (consider Colace too)
For alcoholics banana bag = IV 1L NS with 10cc MVI, 1mg Folate & 100mg Thiamine (write for rate of administration)
Transfusions:
Type and Screen gets pt blood type IDd only (Doesnt waste blood products, expires in 48 hr)
Type and Cross preps blood to be transfused ASAP (blood product discarded if not used)
Consent patient explain risks and benefits, provide info sheet to pt, place signed consent in chart. Order:
-transfuse 1 unit PRBCs, 6 pack platelets, and/or 1 unit FFP
-dont need to routinely premedicate with Tylenol 650mg po/pr x1, Benadryl 25mg (12.5 for old/small) po/iv x1
-lasix 10mg between each unit if >2units/at risk for fluid overload in CHF

DEATH NOTE (adapted from UCDMC Intern survival guide)

It can be quite stressful to pronounce someone whom youve never met, in front of their family whom youve also never met. When
you are called by the nurse for a patients death, take a moment to pull yourself out of whatever you were previously doing writing
notes, calling consults, etc. You will be interacting with family members in one of the most important times of their lives, and they
deserve your full attention. They will remember you and this moment for years.
Enlist the help of your resident if you feel uncomfortable or want support.
When you arrive at the nurses station, a death packet will likely be ready for you; you will have to fill out the Death Notice in the
packet and write a death note in HealthLink. You should first pronounce the patient. Then, find out if anyone has been notified and if
not, notify next of kin. You will develop your own style. It is often helpful to enlist the nursing staff who have had contact with the
patients family over the previous days, to help determine the best approach with individual families.
Please offer the family an autopsy as well. Recent studies show that autopsy rates have declined precipitously over recent years,
but when done, the rates of significant difference between the clinical and autopsy diagnoses are as high as 24%. Families often
react strongly to this offer. Emphasize that autopsies are not for experimentation or research. Explain that if the patients death was
not expected, an autopsy may help the family understand what happened, or may help physicians better care for similar patients in
the future, and that open viewing of the body will still be possible. Document this discussion in your note.
Page the primary teams attending for all unexpected deaths.
Death Packet: You should fill out the death certificate template with the cause of death. Do NOT write on the actual death
certificate. A licensed physician must sign the actual death certificate (your attending the following day)
Coroner: If a death was unexpected, occurred <24 hours after admission, (+)tox screen on admission, or was due to injury or
hospital procedure, the coroner needs to be notified. The coroner must also be called for any death that could potentially be related
to a crime (even if the crime occurred years ago). If you are unsure, you can call the coroner 793-1900 to see if it qualifies as a
coroners case. If not, they will give you a release number. It is better to err on the side of calling.
Example death note: Called by RN to pronounce Mr. X. Patient examined, unresponsive to verbal or tactile stimuli, no
spontaneous respirations seen or auscultated, heart sounds not audible, pulses absent, pupils unreactive to light. Patient
pronounced at 20:00. Attending, Dr. X was/was not notified. Next of kin, Ms. X, notified. Autopsy discussed and
declined/requested by physician/requested by family.

PATIENT LEAVING AMA (Against Medical Advice)

You may be called to talk to a patient who wants to leave against medical advice. Try to talk to the patient to find out why; most of
the time, it is easy to convince them to stay. Ask, Is there anything I can do that would make it easier for you to stay/
If a patient does want to leave and is competent, please document in the chart that you spoke to the patient about the risks of
leaving against medical advice. Have the patient sign the AMA form. You should provide the patient with discharge medications
and a follow up clinic visit even if he/she is leaving AMA (let the PCP know). You must notify the primary team in the morning if this
occurs.
AMION
-http://amion.com password = scvh
-Click on Int Med Resident Misc
-Click on Block to access 20-16-2017 monthly block schedule
-Click on Clinic to view when you are assigned to clinic for the month
-Click on pager icon
to select individuals/groups to text page
-Click on actual names/pager #s to text page directly

SCHEDULE REQUESTS
Schedule requests for ICU or ward months
You can submit your requests for days to not be on call. Requests will be solicited by the chief residents, generally 2-3 months
ahead of time. A deadline for requests will be given. After schedules are done, switches can be made but only after consultation with
the chief residents and four weeks advance notice.
Requests are to be submitted via Google calendar through the link emailed to you. Right click on the date you wish to request next
to your name, and leave a comment. The chief residents will try to accommodate requests to maximize happiness, but many
requests will not be possible based on the complex scheduling involved.
Schedule requests for Elective or ED months
Residents/Interns are to contact the subspecialty schedulers (listed below) for requests regarding the home call/weekend duty
schedule. Any requests for additional time off (i.e. M-F 8-5) must go through the chief residents first by means of the schedule
request form; if the request is reasonable, the resident/intern will be directed to the attending on service to ask for permission.

Education Coordinators and Administrative Assistants

Rotation
Cardiology
Dermatology
ED
Endocrinology
Geriatrics
GI
Heme/Onc

ID
Medicine Consult
Nephrology
Neurology
OB

PACE
Palliative Care
Pediatrics

Psychiatry
Pulmonary
Rheumatology
Social Medicine

Stanford/VA

Surgery
TB/Refugee Clinic

Administrator
Sherry Hamamjy
Meenakshi Aggarwal MD
Reza Kafi MD
Erica Chiu Liang MD
Cheryl ONeill
Patty Salmon MD
Nirmala Gopalan
Louise Leprohon
Elizabeth Hwang MD
Christine Ollila
Sangeeta Agarwal MD
Nam Cho MD
Norma Desepte
Supriya Narasimhan MD
Michelle Wilson MD
Mary Jane Monroe
Amul Jobalia MD
Brajesh Agrawal MD
Debbie Garcia
Jennifer Domingo, MD
Miel Vallejo-Brooks, MD
Nancy Nguyen
Jennifer Lin MD
Thuy Pham MD
Stanford Peds Chiefs
Celia Radcliffe
Ashna Khurana MD
Jennifer Foreman MD
Harriet Roeder MD
Amy Bodine
Eric Hsiao MD
Lupe Ibanez
Tom Bush MD
Cheryl Ho MD
Sara Doorley MD
Robin Tittle MD
Stanford Chiefs
Karina Delgado
Debbie Valdez
Vivian Miller (VA only)
Tanya Johnson
Ron Jou, MD
Andrea Polesky MD

Attending Contact
Sherry.Hamamjy@hhs.sccgov.org
Meenakshi.Aggarwal@hhs.sccgov.org
Reza.Kafi@hhs.sccgov.org
Erica.ChiuLiang@hhs.sccgov.org
EricaChiuLiang@cep.com
Cheryl.Neil@hhs.sccgov.org
Patricia.Salmon@hhs.sccgov.org
Nirmala.Gopalan@hhs.sccgov.org
Louise.Leprohon@hhs.sccgov.org
Elizabeth.Hwang@hhs.sccgov.org
Christine.Ollilia@hhs.sccgov.org
Sangeeta.Aggarwal@hhs.sccgov.org
Nam.Cho@hhs.sccgov.org
Norma.Desepte@hhs.sccgov.org
Supriya.Narasimhan@hhs.sccgov.org
Michelle.Wilson@hhs.sccgov.org
Mary.Monroe@hhs.sccgov.org
Amul.Jobalia@hhs.sccgov.org
Brajesh.Agrawal@hhs.sccgov.org
Debbie.Garcia@hhs.sccgov.org
Jennifer.Domingo@hhs.sccgov.org
Miel.Vallejo@hhs.sccgov.org
NancyT.Nguyen@hhs.sccgov.org
Jennifer.Lin@hhs.sccgov.org
Thuy.Pham@hhs.sccgov.org
lpchchiefs@gmail.com
Celia.Radcliffe@hhs.sccgov.org
Ashna.khurana@hhs.sccgov.org,
Jennifer.Foreman@hhs.sccgov.org
Harriet.Roeder@hhs.sccgov.org
Amy.Bodine@hhs.sccgov.org
Eric.Hsiao@hhs.sccgov.org
Lupe.Ibanez@hhs.sccgov.org
Thomas.Bush@hhs.sccgov.org
Cheryl.Ho@hhs.sccgov.org
sara.doorley@hhs.sccgov.org
Robin.Tittle@hhs.sccgov.org
chiefsmed@lists.stanford.edu
karinad@stanford.edu
DValdez@stanfordhealthcare.org
Vivian.miller@va.gov (VA)
Tanya.Johnson@hhs.sccgov.org
Ronald.Jou@hhs.sccgov.org
Andrea.Polesky@hhs.sccgov.org

For ANY schedule changes or issues, all people listed need to be notified in addition to current attending on service.

PROCEDURES
The New England Journal of Medicine website (accessible through lane.stanford.edu with your SUNet ID/password) has
handouts/videos on common procedures including central line placement, lumbar puncture, paracentesis, thoracentesis and arterial
line placement.
Dont forget to get informed consent from the patient/patient representative prior to performing the procedure. There is also a one
page standardized procedure note form that you should use to document each procedure and log it on New Innovations- see below.
Lumbar puncture: Check opening pressure & note color of fluid. Send CSF for cell count with differential, glucose, protein, gram
stain & culture. Send additional studies as indicated india ink, cryptococal Ag, fungal stain & culture, VDRL, AFB, toxo Ag. Write
order to save remaining CSF for future studies.

Paracentesis: Inoculate blood cultures bottles at bedside. Send peritoneal fluid for cell count with differential, gram stain & cultures,
albumin, total protein, LDH, amylase. Dont forget to check serum albumin to calculate the SAAG (serum ascites albumin gradient)

Thoracentesis: Note color/appearance of fluid. Check pleural fluid LDH, protein along with serum LDH & protein to utilize the
Lights criteria in distinguishing a exudate (TP >0.5x serum protein, LDH >0.6x serum LDH or LDH >2/3 upper limits of normal LDH
for lab) from transudate. Send cell count with differential, gram stain & culture, pH (must go in ABG syringe on ice), glucose. Can
also send AFB, fungal culture, cholesterol, triglycerides, amylase, cytology (need large amount of fluid) as indicated.

PAIN MANAGEMENT GUIDELINES

24 HOUR OPIOID DRUG EQUIVALENCIES
DRUG EQUIVALENCIES NOTES
Oral
Morphine Sulfate
180mg
Codeine
1200mg
Hydromorphone
45mg

(adapted from NEJM, 335(15),1996)

IV/SC/IM
60mg
Morphine IV:PO = 1:3 Ratio
720mg
Max dose 360mg/day (no IV VMC)
9mg
Dilaudid IV:PO = 1:5 Ratio
Dilaudid PO:Morphine PO = 1:4
Fentanyl Patch
100mcg/h
--Fentanyl (mcg):Morphine (mg) PO
1:2 Ratio; change q3 days.
Oxycodone
180mg
--Oxycodone PO:Morphine PO = 1:1
Meperidine
500mg
Do not use. Has neuropathic metabolites.
Methadone
40-60mg --See Methadone Chart. Good for neuropathic pn
METHADONE CONVERSION RATIO (Methadone Treatment for Pain States, AFP, 4/1/05, Table 3)
Daily oral morphine equivalent dose
Conversion ratio (morphine:methadone)
100 mg
3:1
101 to 300 mg
5:1
301 to 600 mg
10:1
601 to 800 mg
12:1
801 to 1000 mg
15:1
1001 mg
20:1

LOGGING PROCEDURES: Logging procedures is important for all housestaff.. Use New Innovations to log procedures.
1) Go to https://www.new-innov.com/Login/Login.aspx?Hospital=scvmc
2) At the top left go to the Main Menu. From the drop down menu select Procedure Logger Then click on Add Procedure Logs
3) Fill in the appropriate information (those with the red asterisk are required)
4) When you are done click on Save and Retain if you have multiple procedures with the same attending, or click on Save and Clear
to start a new log.
5) An email will be sent to that supervisor to sign off on that procedure.
7) You can view what procedures you are credentialed for by going to Reports, then Reports for Student/Physician Reports, then
Credentials by Physician. Search for your name and it will list the procedures you are credentialed for.
Guide to the USMLE Step 3
Scheduling:
Start thinking about when you want to take the exam early during the intern year. Good months to take the exam are during your
vacation and during emergency medicine where you will have about 10-11 days off during the month. You MAY NOT take off 2
days of an elective to take your exam.
Registration:
The entire application process takes between 1-1.5 months.
Go to the main website: http://www.fsmb.org/m_usmlestep3.html. Click register online.
Read the USMLE Bulletin of Information (http://www.fsmb.org/pdf/USMLEStep3_bulletin.pdf)
Follow the instructions after clicking the state of choice. You can register under any state. It does not matter if you are going to
another program in a different state after intern year.
After reviewing the info, you will be taken to a generic application form. You will be required to mail a form that requires a notary
public's signature and seal. Categoricals get reimbursed for the registration fees. Prelims and transitionals do not. You cannot use
your educational stipend to pay for the cost of applying. You can however use it to pay for the cost of educational tools like
registration for USMLEworld/Qbank or books.
Study materials:
USMLE world, Kaplan Qbank, First Aid. The former seems to be the most popular since it has MCQ questions and also about 50
cases. The cases are not presented in the format you will interact with on the day of the exam. They are however helpful to go
through to get a sense of the kind of case scenarios and the basic tests that you can order in the case scenario section. Also review
the questions on the CD you will get after registering. There a few practice questions books available in the Chiefs Office.
The Exam:
Broken up into 2 days. First day is all MCQ. The second day starts off with a couple more MCQ sections and then on to the case
scenarios (CS). The CS are quite interesting and actually fun. But you need to familiarize yourself with the screen layout and how
the case works. The online sample program which you can download is sufficient to orient you to the format for this part of the
exam.
RESIDENT WELLNESS
Dr. Singh (outpatient psychiatry), Dr, Bernette Tsai (outpatient medicine), and Dr. Gary Lee (Palliative Care) are available to you for
Physician Wellness issues. These individuals are great resources to get help if you feel in over your head as are your resident,
attending, chiefs and program directors. In addition, your House Mentors (for Scarlet, Teal, and Gold) are designated as resources
for you as well. Remember that you must take care of yourself to take care of your patients!
Doctoring to Heal
Doctoring to Heal is a monthly gathering of interns, residents, and attending physicians designed to support each other's wellbeing through sharing of personal experiences and stories. It is driven by the residents. The meetings are informal and the time
is spent in reflection and sharing with each other the impact that our patient interactions have on us. In the past, many
participants have found the experience to be very healing, encouraging, and empowering. We encourage all of you to come. It
will definitely enrich your residency experience here at the Valley.
Additional Wellness Resources

VMC Employee Health in the VSC Building on the 1st floor, (408) 793-2658
Employee Assistance Program - 1885 The Alameda Suite#211, (408) 241-7772
Burnout Assessment and Solutions http://www.mindtools.com/pages/article/newTCS_08.htm

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