Intro to Intern Year

1. Always Remember

Don’t worry, you’re not alone!

Hierarchy exists for a reason.

See the patient, assess the situation...
    ...then call your senior or your chief!

If your seniors and chiefs are scrubbed, you can still go to the OR and update them. If the ship is going down, load up the ship! Update the team and make sure everyone is aware of situation.

  • Surgery consult resident
  • Surgery residents on other teams - peek in the team rooms
  • The in-house senior surgery resident overnight
  • Anesthesia for patients in respiratory distress
  • The Rapid Response Team (p:1RRT)
  • The on-call code team (Team 7000)
  • The medical teaching resident for any medical questions

ALWAYS DO YOUR BEST... AND NEVER LIE.

(“I don’t know” is better than a lie!)

2. What is SBAR?

S-B-A-R is Mount Sinai’s Hand-Off Communication Policy.

Situation is used to identify a caregiver and patient (MRN, name, age, sex, DOB, diagnosis, etc) and a brief statement of the patient’s condition.

“I am concerned about Mr X as he is POD#4 s/p colectomy and...”

Background is for the patient’s most up-to-date and accurate condition with information such as medications, vital signs, pre-op mental status, etc. as appropriate to the situation

“Mr X is currently febrile to 38.7 and tachycardic to 110s, though his pressures, mental status and abdominal exam are stable”

Assessment is for the caregiver to convey his/her professional opinion of the situation

“I think Mr X may be septic from a leak, though pneumonia is also possible...”

Recommendation is for the caregiver to state his/her request or recommendation. The caregiver may request a specific test or that another provider see the patient immediately. The caregiver should include a state of what to anticipate.

“I’d like to know what antibiotics you think we should start Mr X on. When do you think you will be able to see him? I’ve already ordered a stat CXR, blood and urine cultures, is there anything else we need in the meantime?”

3. The Surgical Note

Note that all surgical notes are completed in EPIC. It is not acceptable to simply copy/paste notes from the previous day. Notes should be filed as early in the day as possible, but no later than 10 AM.

Subjective
New events or complaints overnight
Bowel function – flatus? BM?
Diet – tolerating PO? N/V?
Pain control – using PCA? asking for meds?
Ambulating?
Other complaints – chest pain? SOB?

Objective (type .vitals for smart text input in EPIC) Vitals: Tmax/24h, Tcurr, BP, HR, RR, Sat
Ins: IVF at rate and type of IVF? + boluses?
Outs: Urine/shift + voiding vs Foley
Drains/shift + quality
Ostomy/shift

Exam: General
Heart
Lungs
Abd
Wound
Extremities Labs: (type .24 for last 24 hour labs smart text)

Assessment and Plan (copy signout info / update it!)
[ ] Advance diet?
[ ] IVF or medication changes? Pain ctrl?
[ ] Studies, labs to check?
[ ] Ambulate, OOB, Venodynes, SQH? GI PPX? IS?
[ ] D/C Planning – VNS for wound or drain care? PT consult?

4. The On-Call Checklist

Remember: Unstable patients take priority over all else!

  • Arrive before rounds for signout from overnight NP/PA
  • Make sure list is ready: vitals, I/Os, and any labs back
  • AM rounds with chief (or senior)
  • Run list with other juniors and PA and assign tasks
  • Place orders
  • Call radiology early and as often as needed to get imaging studies done or read
  • Call consults early
  • Write notes (separate from med student notes)
  • Check AM labs, call chief/senior re: abnormal labs
  • Discharges: Rx, follow up appointments, medication reconciliation, social work needs, discharge orders
  • Round with social work (10AM for 10E)
  • Check prelim OR schedule for tomorrow (ie – preops?)
  • Pre-ops for tomorrow (see pre-op checklist)
  • Keep chief posted about any new patients on the service from consult resident, direct admits, and review plans
  • Check Sign-Out to watch for new post-op patients on list
  • Prepare for PM rounds: chart check, get vitals, see patients, follow up studies
  • PM rounds: know what labs need to be ordered for tomorrow, know what final studies/consults need to take place tonight vs. those that can be deferred
  • Post-op checks in order of OR time and case complexity
  • Check final OR schedule after 4pm
  • Update sign out
  • Sign-out to NP/PA if on short-call using SBAR: stress priority of tasks and what chief needs to know about

5. The Pre-Op Checklist

  • Confirm exact procedure with chief/attg
  • Elective/scheduled? Or needs a pink slip?
  • If pink slip, is it category 1 (OR within 1 hr) or category 2 (OR within 6 hrs, sometimes more)
  • Labs: CBC, BMP, Coags with date; AM K+ in HD pts
  • T&S: need active T&S within last 72h before OR
    • 2 T&S needed for all pts new to hospital!
  • Products on hold: 2 units pRBCs, FFP if elevated PTT or INR, platelets if low plts
  • Beta HCG or urine pregnancy test within 24h for all women w/ period in last yr (same tube as BMP for bHCG)
  • EKG if indicated
  • CXR for pts > 60, smokers, pts with pulmonary disease
  • Call film library if attg wants films in OR (ie. angiograms)
  • Medical clearance: POMA for ASA 3+ or BMI 40+
  • Renal clearance for ESRD pts – HD patients need dialysis day before surgery, arrange with ESRD fellow
  • Medication review
    • Anticoagulation: SQH, heparin gtt, coumadin, aspirin, Plavix → ask chief/attg if should be held
    • Long acting insulin (i.e Lantus, NPH). If Type 2 diabetic and pt NPO, halve the dose. Never stop long-acting insulin in Type 1diabetics; call endocrine.
  • NPO-past-midnight except meds, hold tube feeds
  • IVF after midnight at maintenance; gentle for cardiac/CHF pts, none for ESRD/severe CHF pts
  • Bowel prep/colon bundle: ask attg, colon bundle order set
  • Consent: full procedure including side, no abbreviations
    • Needs witness: RN, phone interpreter with ID# - If no capacity, call health care proxy (HCP) if documented or next of kin, write down telephone #, RN must witness phone consent
    • Place in “consents” section of chart with copy in team room; if ED consent keep in team room and hand to nurse in OR holding.
    • At Elmhurst telephone consent requires AOD to be present. Also you must do “case request” order and notify Anesthesia and the Holding desk.

6. The OR Checklist

  • Show up 15 min before start of case in holding area
  • If not 1st case, call holding area or core desk for updates - Room updates found on: ORwatch.mountsinai.org
  • If OR ready but patient missing, find them! Call GP2 for outpatients, floor for inpatients, or go to investigate delay
  • Complete paperwork
    1. Consent
    2. H&P or update form if H&P within 30 days
    3. OR Preop Checklist surgical section and signature
  • Pathology form if needed
  • Ask the patient’s correct pharmacy if ambulatory case
  • Ensure attg has co-signed the consent, H&P, POMA
  • Make sure attg marks patient on side and site of surgery
  • Make sure circulating RN has seen patient
  • Make sure anesthesia has seen patient
  • Check if room is ready
  • Bring patient & chart into room
  • Check safety strap, venodynes
  • Antibiotics / Foley / shave / position as needed
  • Prep if ok with attending

After the case:

  • Ask attg what Rx’s & f/u appointments are needed
  • Help get patient to the stretcher and into the PACU
  • Write the operative note or help student to write it
  • Write discharge orders in EPIC using Post-op D/C tab
    • D/C & PACU orders, ie CXR or void check
    • D/C instructions & send e-prescriptions
  • If patient is being admitted, put in orders & add to list, update sign out, tell your team, sign out the postop check
  • Save a sticker and log your case at acgme.org
  • Dictate if applicable

7. The Brief Op Note

Template is available in EPIC. Search “Brief Op”

Pre-op diagnosis
Post-op diagnosis
Indications
Procedure
Surgeons
Anesthesia
Antibiotics
Wound classification
Findings
EBL
Drains
IVF and urine output
Specimens
Cultures
Complications
Condition

  • Brief op notes are to be completed IMMEDIATELY (within 30 minutes of arrival to PACU); this is a JCAHO regulation.
  • Full operative dictations must be completed within 24 hours.

8. Wound Classifications

Clean: Uninfected operative site with no inflammation. Respiratory, GI, or GU tracts not entered.

Ex: mastectomy, vascular bypass, hernia repair, thyroidectomy

Clean/Contaminated: Biliary, GI, or GU tract is entered without inflammation or unusual contamination.

Ex: colectomy or appy without inflammation, roux-en-Y, small bowel resection, Whipple, cholecystectomy of lithiasis, fistulas

Contaminated: Op site with acute, nonpurulent inflammation (incl ischemic/necrotic tissue); Open, accidental wounds; break in sterile technique or unusual spillage from GI tract. Must be documented in op note.

Ex: acute appy, acutely inflamed diverticulitis/IBD, ostomy closure with stool drainage, cholecystectomy for acute cholecystitis, dry gangrene, necrosis, or open wounds returning to OR

Dirty/Infected: Wounds with pus, abscess, existing infection or infections from perforated viscera. Must be documented in op note, (+) intra-op cultures are not sufficient evidence of infection.

Ex: I&D of abscess, perforated bowel, feculent peritonitis, ruptured suppurative appendix, gangrenous gallbladder

9. The Post-Op Order Set

  • Use the appropriate surgical post-op order set on EPIC 1) Ambulatory 2) Post op abdominal surgery 3) Bariatric Post op
  • SIGN OUT your case to your on-call colleague or the primary service taking care of the patient immediately!
  • Include what case you did, what time the post-op check should be, and what post-op orders you want

General principles:

  • Admit to [Floor/Service]
  • Diagnosis
  • Condition
  • Vitals’ frequency
  • Allergies
  • Nursing orders:
    • Strict I&Os qshift
    • Tubes & drain care
    • Venodynes in bed
    • Notify MD conditions
  • Diet * Activity
  • Labs: post-op, next AM (alert PACU RN to post-op labs)
  • IV Fluids
  • Special imaging: ie. CXR or next day upper GI
  • Medications:
    • Antibiotics with d/c date or number of doses if peri-op
    • Anti-hyperglycemics if DM (‘Diabetic Agent’ order set)
    • Anti-hypertensives PRN always with ‘hold’ parameters
    • Anti-emetics PRN (Zofran 4mg q6-8h if no long QTc)
    • Bowel regimen if po (Colace 100 TID)
    • DVT prophylaxis (SQH BID, TID in IBD; and bariatrics; Lovenox 40mg qD if cancer, unless otherwise specified by chief/attg)
    • GI prophylaxis (famotidine 20mg qD or BID or PPI qd)
    • Pain control (Tylenol linked w/ 1-2 Percocet q4h vs PCA)
  • If the patient has a new stoma, put in an “IP consult to enterostomal therapy” order for the ostomy nurse

10. The Signout

Signout Format:

Age/Gender with PMH (including relevant meds), PSH (including dates) presenting with chief complaint / indication for surgery
Date: Name of procedure
Orders: Diet / fluids / pain / antibiotics / anticoag or antiplatelets / misc / home meds / PPX / tubes / drains
[ ] To Do 1
[ ] To Do 2
* Language spoken *

  • For consult (“outside”) list signouts, the first line should be the attending’s name in all-caps.


Signout Example:

66M with DM, HTN, CAD s/p CABG 2015 (on ASA/Plavix) who presented with perforated diverticulitis
1/15: Ex lap, Hartmann’s
NPO/IVF125/dPCA/Zosyn/ASA/PPI/SQH/Foley/JPx2 (1 in pelvis, 1 in left paracolic gutter)

[ ] TOV POD2
[ ] OR cultures: NGTD
[ ] F/u AM labs
* Spanish speaking *

11. The Post-Op Check

  • Should be done 4-6 hrs after the end of surgery.
  • This is a crucial assessment as many post-op patients have just undergone huge volume shifts and need to be monitored closely.
  • This is the time to catch post-op bleeding early.

  • Ask the patient about chest pain, shortness of breath, and pain control at the surgical site
  • Check PACU and recent floor vitals and fluid trends – look at trends, watch for tachycardia and hypotension
  • Check urine output – minimum of 0.5cc/kg/hr since OR
  • Check drain (JPs, NGT, G-tube, etc.) outputs
  • Examine the patient
    • Is the pt alert or overly sedated?
    • Are tubes connected properly and working?
    • Flush NGT
    • Check the dressing: alert senior/chief if saturated
    • Check quantity and quality of drain outputs: can send fluid for hematocrit if very sanguineous
    • For vascular pts: check pulses and compare to immediate post-op exam, should be marked
    • Venodynes working?
    • Incentive spirometer at bedside? Educate pt on use
  • Check post-op labs and order new ones if necessary
  • Check post-op CXR if indicated
  • Review post op orders and make sure appropriate drugs are continued or discontinued
  • Document your encounter with date and time!
  • If the patient has a new stoma, make sure that they know about the stoma self-care self-education video

Basic Management

12. Diets

  • Clear liquid: anything you can see through, ie. Jello or coffee without milk
  • Full liquids: all liquids, including dairy
  • Low Fiber diet (aka GI Soft): regular food but no hard-to-digest fiber/veggies/nuts/seeds; for anyone with GI anastomosis/ostomy
  • Heart healthy: low fat, low cholesterol
  • Carb controlled, AKA diabetic. 1800 kcal ADA: for diabetics, low sugar
  • Special diets: Bariatric Stage I and II, post gastrectomy, post whipple, dysphagia diets, renal/dialysis diet, enteral feeds, etc

13. GI Prophylaxis

  • H2 blocker or PPI for all abdominal surgery patients (prophylaxis is not indicated for thyroid/parathyroid patients generally)
  • Indicated for anyone with an NGT (PPI)
  • Indicated for anyone with a suspected GI bleed (PPI)
  • Continue PPI if patient already on at home
  • IV Nexium requires pharmacy approval – only for patients with suspected active GI bleed. Call the pharmacy to order it; they need to order it for you through EPIC.
  • For TPN patients, H2 blocker is typically mixed into TPN – thus, if you d/c TPN, check and remember to start GI prophylaxis again.

14. Bowel Regimen

  • All patients except strict NPO or with an ostomy should be on a bowel regimen
  • If the patient has a colon and are not having diarrhea then they should be on Colace 100mg PO TID
  • May possibly add Senna, suppositories, or enemas as directed by chief/attg

15. Total Parenteral Nutrition

Indications for artificial nutritional support include pre- existing nutritional deprivation (ie, in Crohn’s or short-gut patients), anticipated or actual inadequate energy intake by mouth (ie, in an elderly patient s/p colectomy whom you anticipate won’t be taking PO for >7 days), or significant multiorgan system disease.

TPN consists of predetermined amounts of carbs, amino acids, fats, vitamins, minerals. The formula needs to be re- written and ordered daily by 1PM and submitted to the TPN pharmacy. At Mount Sinai, surgical patients who need TPN can have TPN ordered and managed either by the Surgical Nutrition Support Service (SNSS = same team as line service based in SICU) or by an attending endocrinologist. TPN for SICU patients is managed exclusively by SNSS.

To start TPN:

  1. Your patient must have a central line. Arrange by placing Vascular Access Service Consult and making sure CBC and Coags ordered.
  2. You must consult SNSS (p1872) or the endocrine attending directly (check with chief to ask whom who should contact). Certain GI attendings also write TPN orders.
  3. You should have Chem-10, LFTs including albumin, and triglycerides drawn, initially daily then 3-4x/week
  4. Same day TPN orders are due by 11am in TPN pharmacy (46601)
  5. The service managing the TPN will order the relevant surveillance labs and place the actual TPN order

16. IV Fluids

For virtually all large operations in non-cirrhotic patients, post-op fluids should be isotonic (i.e. NS, LR, Plasmalyte). Post-op patients are in a high catecholamine, high ADH state, so resuscitative fluids are indicated for volume expansion. Re-assess fluid status in 2-3 days and if resuscitation not needed, convert to “maintenance” (D5 ½NS w/ 20mEq K at hourly rate based on 4:2:1 rule). Don’t forget ostomy and NGT losses—ask chief if they want 1:1 or 1:2 repletion. NEVER bolus patients with ½NS or fluids containing sugar.

On Surg Onc, cirrhotic patients post-hepatectomy are on strict albumin drip protocols. NEVER bolus cirrhotic pts with crystalloids without clearing with chief or attending first

17. Repleting Electrolytes

Always recheck values after repleting electrolytes. It may be ok to wait until next day AM labs, but if a patient is symptomatic or risk of inadequate repletion is high, recheck immediately. If you don’t know the dosing, call pharmacy.


Potassium:

  • Goal >3.5, if CAD >4.0, for all <5.2

Hypokalemia

  • Replete in all patients EXCEPT ESRD patients. Their K will continue to rise until next HD. If post-dialysis labs show hypokalemia, recheck in a few hours. If their potassium is still really low (i.e. after SEVERAL hours or next day), then ask on-call ESRD fellow if OK to replete.
  • 10mEq of IV KCl raises serum K+ by 0.1
  • If K <3, give 3 runs of 10mEq KCl IV at 1 run per hour and give 40mEq PO stat if taking PO. 10mEq/h only through IV, 20 mEQ/h only through central line.
  • Can give K orally in patients tolerating diet. Klor-con (powder) vs K-Dur (very large pill). Oral potassium causes diarrhea
  • If K <3.5, give 10mEq packets of KCl, as many as needed for appropriate rise. If more than 40mEq is needed, divide doses by at least 2 hours.
  • Low Mag can make K difficult to replete, replete Mg first

Hyperkalemia

  • Send stat plasma K to confirm, also check EKG, ask if patient is symptomatic (i.e. chest pain).
  • If the patient is asymptomatic and no EKG changes, give kayexelate 15-30mg PO stat (only if pt has bowel function)
  • If the patient is symptomatic or if there are EKG changes, give Ca gluconate or CaCl (only if coding or if have central line), 1 amp dextrose (D50) THEN regular insulin IV (10 units), kayexalate, consider albuterol. Recheck K! Patient may need HD. Calcium gluconate is cardioprotective, it does not lower blood K. (see “Hyperkalemia” order set)


Magnesium:

  • goal >1.5, if CAD >2
  • 1g MgSO4 raises serum Mg 0.1-0.2
  • If Mg <1.2, give 1g over 1 hour x2 and recheck - If Mg>1.2, give 500mg Calcium gluconate PO or 1g IV over 1 hour


Calcium:

  • Always correct for albumin: Serum calcium falls 0.8mg/dl per 1g/dl drop in albumin <4. Check ionized calcium level.
  • Blood txf precipitates Ca out as CaCitrate. Needs repletion
  • Low Mg can make Ca difficult to replete, replete Mg first.
  • If mild and asymptomatic, give 1g PO qd
  • If <7 and symptomatic, give 1-2g calcium gluconate over 10-15 minutes and 0.5-1.5mg/kg/hr


Phosphorus:

  • More relevant for critically ill, malnourished, and severely debilitated patients, liver resections.
  • New hypophosphatemia after starting TPN or feeds in malnourished patient may be sign of re-feeding syndrome. May replete with IV/PO regimens
  • If 2-2.5, give 20 mmol KPhos or NaPhos or 2 tabs KPhos tablets
  • If 1.6-1.9, give 30 mmol KPhos or NaPhos
  • Use KPhos if K <4 and NaPhos if K ≥4

18. DVT Prophylaxis

  • Early ambulation: You can write a nursing order for this (OOB or ambulate today)
  • Venodynes: All post-op patients unless contraindicated (i.e. known DVT in that leg or PAD in b/l lower extremities)
  • SQ Heparin: Usually fine to start right after surgery but this can be attending dependent, so check with your chief or the attending directly. Dose is 5000U SQ q12 hours. IBD and bariatric patients get SQH 5000U TID.
  • SQ Enoxaparin: As directed by chief/attg. Enoxaparin is also generally used for DVT prophylaxis in trauma, cancer, and sometimes bariatric patients. 40mg daily SQ.

19. Anticoagulation

Heparin drip (IV)

  • For patients who are pre-op or fresh post-ops as effect can be reversed over ~6h by stopping the drip
  • Must know goal PTT (usually 60-80, sometimes 50-70)
  • EPIC contains an order set for ‘heparin drip by protocol’ which automatically instructs the nurses to draw PTTs and adjust the drip as indicated. This may be ordered and a goal ptt selected (low or high range). Check with your chief. In general DO NOT bolus to start (you may see this only on vascular). The PTT orders and amounts to adjust by are automatically sent but you must follow up with nurses to confirm adjustment and ensure the PTT is being drawn q6h.
  • EPIC contains ‘heparin non-protocol’ order set as well.

Coumadin (PO)

  • Needs to be ordered daily based on that day's INR until therapeutic
  • Target INR is 2-3 for DVT, PE, a-fib; 2.5-3.5 for mechanical heart valves (depends on type of valve)
  • Typically start with 5-10mg at bedtime, but ask chief
  • Reversed by vitamin K (PO, subQ or IV, long time to work), FFP (keep in mind FFP has INR of 1.6), or PCC.

Enoxaparin / lovenox (SQ)

  • Used as bridge to coumadin for patients nearing d/c date
  • Therapeutic: use 1mg/kg q12h SQ OR 1.5mg/kg qD ASK chief, for renal patients: 1mg/kg daily SQ
  • If patient/family member cannot be taught, VNS must be set up for day 1 after d/c (talk to SW)

20. Diabetes Management

For help with management, can always page 917GLUCOSE

First, know if your patient is Type 1 (autoimmune disorder, insulin dependent) or Type 2 (may be on oral regimen +/- insulin). NEVER STOP insulin in Type 1 diabetics.

Insulin at Sinai

  • Lispro (Very short acting): Given with meals TID or as part of sliding scale (LISS).
  • Regular (Short acting): Not used often on floors, can be used in sliding scale (RISS).
  • NPH (Intermediate acting: peaks 6 hours, lasts about 12): Favored in ICU at Sinai, dosed q6h to q8h
  • Lantus (Long acting: 24 hours, does not spike): Favored on floors, dosed q24h, sometimes q12h

Post-op glucose management in Type 2 diabetics

  • If patient has Type 2 DM and takes long-acting insulin (Lantus/NPH) at home, CONTINUE the insulin post-op at half the dose (even if they are NPO and EVEN if their glucose levels are normal).

  • If patient was a Type 2 diabetic on oral hypoglycemics only, use a sliding scale for 24 hours and monitor insulin requirements, then...

    • If persistent hyperglycemia, begin low-dose Lantus dosed 0.1 units/kg daily (i.e. 7 units for 70kg patient) usually given at night - Adjust Lantus daily by 20% based on AM FS.
    • If patient was hyperglycemic pre-op or immediately post-op, or required several hypoglycemic agents pre- op, then starting low-dose Lantus immediately post- op is appropriate.

  • When patient resumes diet, additional insulin may be necessary. If this is the case, start Lispro to be given immediately after each meal (hold parameter if patient eats <50%). Generally, you may start Lispro at 2-3 units per meal and adjust. The nurses should continue giving sliding scale adjustment doses before the meal. Immediate post meal finger sticks are not indicated.

  • For dosing when patient eating: For breakfast dose, see pre-lunch finger stick and titrate up/down. For lunch dose, see pre-dinner finger stick and so-on. Generally, you should aim to have patients on equal doses of meal time and basal (i.e. Lantus) dosing. For example, if a patient is on 18U Lantus QHS, then mealtime dosing should be 6U with each meal. It is unsafe to have a much higher long- acting dosage in patients who are eating.

Glucose Management Pearls

  • Patient being “NPO” is not a contraindication to long-acting insulin. This is a widespread misconception.
  • Never increase insulin by more than 20% daily.
  • Type 2 patients on long-acting insulin made NPO should have their insulin dose halved (but not discontinued).
  • New hyperglycemia in a non-diabetic or borderline diabetic sometimes signals early sepsis.
  • Always D/C metformin for any inpatient. If NPO, also d/c other oral-hypoglycemic agents.
  • Keeping a patient on a “sliding scale” for more than a day or two with persistent hyperglycemia (daily glucose levels >180) is inappropriate!
  • Diabetes is often diagnosed post op, so make sure these patients are aware and have appropriate follow up. Order an HbA1C.
  • Remember that steroids make glucose management difficult, and therefore insulin needs may change with steroid tapers.

How to calculate Total Insulin Dose

  • Weight (in kg) times 0.3U/kg equals total insulin, use 0.5U/kg in insulin resistant patients
  • Divide the total in half. One half is the basal (Lantus) insulin nightly. The other half is divided in 3 and given with each meal as Lispro.
  • Lispro Insulin Sliding Scale (LISS) then used for any additional correction.

21. Pain Management

Take your patient’s pain seriously!! It needs to be thoroughly investigated and adequately controlled.

Oral options

  • Tylenol +/- codeine or Ibuprofen PRN mild pain
  • Percocet 1-2 tab q4h PRN moderate-severe pain
  • Dilaudid 2mg q3h PRN moderate pain
  • Link Tylenol to Percocet to limit Tylenol amount daily

IV options (for NPO pts or without adequate GI function)

  • Morphine 2-4mg IV q4h PRN severe pain
  • Dilaudid 0.2-1.0mg IV q3h PRN severe pain (1mg dilaudid is about equal to 7.5 morphine. So go slow starting out)
  • Always include hold parameters for low RR or BP
  • Toradol 15-30mg q6h x 5 DAYS (always check with chief or attending first given reported risk of bleeding from platelet inhibition, increased risk of anastomotic leak (?) AND precipitation of hepatorenal syndrome in cirrhotics!)
  • IV Tylenol from pain service if NPO or avoiding opiates

Patient Controlled Analgesia (PCA)

  • AVOID basal rates as they can lead to respiratory depression (can only be prescribed by pain service)
  • AVOID prescribing oral and IV opioids on top of PCA
  • Morphine, fentanyl, or dilaudid PCAs, with opioid-naive, opioid-standard, or opioid-tolerant settings
  • In a patient completely new to opioids can start with opioid-naive PCA and increase as needed. Otherwise use opioid-standard for most patients.
  • If patient has PCA and still in pain → are they ACTUALLY using it? Interrogating PCA history is easy (ask anesthesia/pain fellow or senior to show you how)
  • If adjustments necessary, increase their dose or switch to another narcotic. If still no success, call pain-service after checking with chief/attg.
  • Patients with BMI of 40+ require a pain service consult for a PCA. Either use IV push only or obtain a pain consult (check with chief and attending).

22. Antibiotics

ID consults are common at Sinai. However, just because a consulting physician/team is following a patient doesn't mean you stop following cultures and the clinical status of a patient's infection. You can look in EPIC to investigate your patients' previous infections. You can also login with “test” temporarily. Be familiar with bug susceptibility trends at main Sinai website → Medical-services → antibiogram to review bug susceptibility trends

Prophylaxis: Peri-operative antibiotics are prescribed as prophylaxis against surgical site infections, or less commonly for prophylaxis against endocarditis in patients with artificial heart valves. Almost always should only be for ONLY 24 hours peri-op, usually one dose pre-op and two doses post- op. Make sure this is not extended otherwise you risk complications like c-diff, diarrhea, resistance, etc.

Empiric therapy: The fundamental principle of antimicrobial therapy for intra-abdominal infections is to utilize agents effective against aerobic, facultative anaerobic (i.e Enterobacteriacae like e-coli), and anaerobic organisms (particularly Bacteroides fragilis). Start broad, then narrow. Different hospitals and even different ID doctors use different cocktails. Below are the Sinai trends.

Cholecystitis/Appendicitis/Diverticulitis regimens

  • Kefzol/Flagyl
    Cipro/Flagyl
    Unasyn* (covers enterococcus)
    Zosyn* (covers pseudomonas)
    Third generation cephlosporin + Flagyl
    Ertapenem* (doesn’t cover pseudomonas /acinetobacter)
    * Needs ID approval

If true penicillin allergy:**
Cipro/Flagyl
Clinda/Aztreonam (Clinda for the gram positives and aneorobes, and aztreonam for the gram negatives)
** Allergy: The great majority of patients with penicillin “allergy” aren't really allergic. Before you label them, investigate and document the previous drugs they have tolerated. A reasonable approach is that cephalosporins can safely be given even to penicillin-allergic patients if they did not experience ANAPHYLAXIS. (For further reading, see Pichichero ME. Cephalosporins can be prescribed safely for penicillin-allergic patients. J Fam Pract 2006;55(2):106-12.)


Surgical Site Infections

Superficial SSI (above fascia) can usually be treated with open drainage (ie, remove a few staples). If marked erythema/ cellulitis/fever then add antibiotics. Kefzol usually fine (unless patient has already been on Kefzol for several days).

Deep SSI needs drainage (IR or surgery) plus antibiotics.


Antibiotics Pearls

  • Pseudomonas is only empirically treated with a few antibiotics choices: Cefepime, Ceftazidime, Piperacillin/Tazobactam (Zosyn, but at higher dose), Cipro/Levofloxacin.

BIG ID guns: Imipenem, Amikacin

  • If using Zosyn or Unaysn, avoid adding Flagyl for anaerobic coverage. Only use Flagyl for treating C-diff, or in addition to an antibiotic (i.e. Kefzol or Cipro) that doesn't cover anaerobes.
  • Many antibiotics have to be renally dosed. Check with Pharmacy if you have a question.

23. Tubes & Drains

Nasogastric or Salem sump tube. Device used to suction gastric contents for patients with obstruction/ileus, proximal GI anastomosis, upper or lower GI bleed. 14-18 Fr.

  • ALL NGT require CXR to confirm placement before use per Sinai policy GPP-248. May use NGT for emergency decompression before CXR.
  • Salem sump NGT has 2 lumens: 1 sucks stomach contents into external canister, 1 sucks external air (via the blue air- port) into stomach then immediately suctioned back into wall canister, thus preventing the internal tip from getting stuck to the gastric mucosa. Cork with white side facing out.
  • Typically placed on low continuous suction (80-100 mmHg)
  • If not draining, need to first flush the tube by disconnecting from wall suction, injecting ~20cc saline via catheter tip syringe into tube. You should see gastric contents coming back via NGT on suction. If not, next step is to flush air lumen with ONLY AIR. If still doesn’t work then notify a senior. You may need to take off nasal tape and manipulate NGT until gastric contents are returned. May need to check the CXR for positioning.
  • NG feeding tubes can only be placed in SICU, NSICU, CTICU, ENT and Peds units. 8-12 Fr with metal stylet, single lumen. Also requires CXR before use. Do NOT remove stylet before CXR done and position confirmed.

OGT: oropharyngeal tube is preferred over NGT for patients who need a tube long-term.

JP: Jackson Pratt. Closed suction device with flat, white internal portion with multiple holes, generally considered for removal after output < 30cc/day

Blake drain: similar to JP but internal portion is same size as rest of the drain and has four longitudinal channels

Penrose: open rubber tube allowing free drainage

G-tube: gastrostomy tube placed in OR in open fashion (vs. PEG: percutaneous endoscopic gastrostomy placed by GI), for long-term feeds in patients who can't take sufficient PO

J-tube: jejunostomy tube placed in OR for patients whose gastric outlet / duodenum / biliary tree must be bypassed

24. Central Lines

TLC: Triple lumen catheter. Short-term central venous catheter for TPN, IV antibiotics or poor peripheral access; needs to be changed every 7-10 days, cannot send patients home with these

Hickmann / Broviac: long-term tunneled central venous catheter for TPN, long term IV antibiotics, poor access

Shiley: short-term large-bore catheter for dialysis or plasmapheresis; used as bridge to permcath or AV fistula (Do not confuse with Shiley trach)

Permcath: long-term large-bore catheter for dialysis or plasmapheresis; used as bridge to AV fistula

Portacath: long-term catheter with subcutaneous reservoir used for chemotherapy/poor access in need of very long term, intermittent IV meds/transfusions

PICC: Peripherally inserted central catheter. Long-term small-bore catheter for TPN, antibiotics; should not be used for blood-draws.


To get your patient a line...

  • Call Vascular Access Service for midline, TLC, Shiley, PICC
  • Vascular or IR for permcath
  • General Surgery for portacath
  • Vascular Access Service is busy so call ASAP! (p:2827)
  • Have the following information available:
    • Patient name, MRN, patient location
    • Why and when is the line needed,
    • What are the most recent coags and platelets
    • What the most recent creatinine is. If elevated, will need renal clearance before getting a PICC.
    • Patient hemodynamically stable and DNR/DNI status.
    • Whether the patient is consentable & English-speaking. (If not, you have to obtain consent and place in chart.)

25. Post-Op Problems: Fever

  • Fever = Temp > 38°C or 100.4°F
  • Get a history and examine patient for obvious signs of infection (i.e. look at wound, look at peripheral IV sites for phlebitis)
  • Check CBC, send blood cx, UA, check CXR (if stable, can go to radiology for AP/Lat films), consider wound cx.
  • Remember the Ws and rough timeline
    • Worst (POD0: necrotizing fasciitis, early anastomotic leak if very high fevers)
    • Wind (POD1: atelectasis... debatable)
    • Water (POD3: UTI - almost never in surgical patients, anastomotic leak)
    • Walk (POD5: DVT/PE)
    • Wound (POD7: surgical site infection, abscess)
    • Wonder drugs
  • Fever on POD0 and POD1-2 most likely due to stress/tissue-inflammation related to surgery, not usually worked up. However, very high fevers should be taken seriously.
  • Fever in the setting of rising WBC, tachypnea, and/or tachycardia may be indicative of early sepsis. Notify a senior immediately.

26. Post-Op Problems: Hypoxia/Dyspnea

  • Ask the nurse to recheck all the vitals while you are on your way. Put on supplemental oxygen. Then go see the patient...right away!
  • Stable or unstable? If unstable, call someone for help while you start to address the problem
  • Check the vitals. Get a portable O2 sat machine in room.
  • Interview and examine the patient, focusing on cardiopulmonary system
    • Cardiac: HF, MI
    • Pulmonary: PE, COPD, asthma, aspiration, pneumothorax
    • Sudden onset or subacute or chronic?
    • JVD, accessory muscles, lung sounds, heart sounds
  • Diagnostic actions to consider
    • ABG -> calculate A-A gradient, EKG, stat portable CXR (follow up and call radiology to look at it with you)
    • Nebulizer treatments/albuterol
    • Empiric lasix if lungs are congested and CXR wet (ask chief) * Empiric heparin bolus if clinical suspicion of PE is extremely high (ask chief)
    • Consider calling anesthesia/respiratory for elective intubation if patient is really in distress (if you call, start setting things up like suction, ambu-bag)
    • Consider transferring the patient: 10E step-down or SICU, ask RRT to see the patient

Pain Management Pearls

  • For post-op patients who are difficult to manage, consult acute pain service after OK from chief. For patients with terminal or chronic pain-inducing illness, consult palliative care (p9399).
  • If your patient is receiving opioids and found to be in respiratory depression, stop all opioids immediately and have naloxone (Narcan) ready. Mix 0.4mg in 10cc normal saline and give 2-3cc every few minutes until reversal achieved. Repeat as needed. Consider narcan drip afterwards as narcotic half-life longer than narcan (0.1mg/kg/hr).
  • Don't forget senna/colace for patients on several days or more of narcotics and without diarrhea

27. Post-Op Problems: Chest Pain

  • Stable or unstable? Think about recent events: OR, line or chest tube pulled, new medication, etc.
  • Check vitals, EKG, order stat portable CXR
  • Interview and examine the patient! Is pain reproducible with palpation of chest?
  • Things to think about: MI, PE, angina, pneumothorax, esophageal spasm/inflammation/rupture, reflux, aortic dissection
  • If you suspect MI: “MONABS” (morphine, oxygen if needed, nitrates - if BP allows, ASA 325 chewed, beta-blocker, statin)
  • If you suspect PE, get an ABG
  • Labs: CBC, CMP, Coags, Troponins q6h x 3 sets, CK
  • TR or cardiology consult? Start heparin drip? CTPA?
  • Should the patient be in a more monitored setting? (Step- down, ICU)
  • Call someone else (senior, chief, attending, teaching resident, cardiology fellow, etc), but have an assessment and a basic plan first
  • Anxiety/musculoskeletal pain do cause chest pain, but don't assume they are the cause!

28. Post-Op Problems: Tachycardia

  • Stable or unstable? If unstable → ACLS algorithm.
  • Check BP, urine output, JP outputs, O2 sat
  • Get a CBC, ABG, EKG, consider troponins
  • Interview and examine the patient
    • Does patient have history of a-fib?
    • Shortness of breath or chest pain?
    • New abdominal pain or worse abdominal exam?
    • Blood soaked dressing or fresh blood in the JP?
  • Possible etiologies / treatments:
    • Hypovolemia: Low UOP, low BP, high JP output → fluid bolus, +/- blood transfusion if Hct low
    • Pain: Patient also hypertensive → adequate pain control
    • Medication withdrawal: If patient was on pre-op beta blocker
    • Rapid A-fib
      • If BP ok, metoprolol 5mg push. May repeat twice every 3-10 minutes.
      • If borderline or low blood pressure, call TR or cardiology consult for input re: cardioversion, and consider diltiazem 10mg slow push (may repeat) or 150mg amiodarone load over 10 min
      • Sepsis/anastomotic leak? New a-fib may be an omen.
    • Pulmonary embolism
      • If no other obvious etiology and renal function ok, PE may be ruled out with CT Angio

29. Post-Op Problems: Hypotension

  • Recheck the vitals manually. Look for associated abnormalities.
  • Examine patient: evidence of bleeding? If JP drain looks sanguineous consider JP crit, foley draining? low urine output? dry mucous membranes?
  • Is the patient stable or unstable?
  • Review intra-operative fluid losses and replacement: is the patient behind on fluids?
  • Review medications: hold BP meds and narcotics (turn down epidural?)
  • Check labs. An unexpectedly high creatinine or hematocrit might reveal hemoconcentration; a very low hematocrit may signal bleeding
  • Start with a 1L normal saline/plasmalyte/LR bolus (as fast as possible in healthy patients)
  • Alert senior if you think it is a significant problem or patient not responding to boluses
  • Consider steroid withdrawal in patients refractory to bolus IVF who have been on steroids

30. Post-Op Problems: Hypertension

  • Stable or unstable? If unstable, call for help while starting to address the problem
  • Recheck and get a full set of vitals
  • Ask and examine patients for signs of end-organ affects: vision changes, HAs, AMS, focal neurologic deficits, ↓UOP.
  • Possible etiologies:
    • pain/anxiety
    • changes in medication/anti-hypertensives held* (missing home meds are notorious)
    • withdrawal (missing clonidine causes rebound HTN)
  • Treatments:
    • is pt on home BP medications? Restart those.
    • go slow, if blood pressure is extremely elevated
    • treat underlying issue (pain medication, anxiolytics)
    • metoprolol 5mg IV push stat if not bradycardic
    • labetalol 10mg IV push stat if not bradycardic
    • hydralazine 10mg IV stat if not tachycardic (can cause rebound HTN)
    • all of these can be given multiple times, but give them time to work otherwise the patient will “bottom out”
  • Consider calling medical teaching resident on call for help with management
  • If AMS or focal neurologic deficits present, consider getting non-contrast CT Head and calling stroke team
  • Does someone else need to know immediately or in AM?

31. Post-Op Problems: Altered Mental Status

  • A for Airway! If the patient cannot protect their airway page Anesthesia stat – you can always decide not to intubate but better to have help on the way.
  • Postop delirium often has an ORGANIC cause – find it!
  • Check vitals, O2 Sat, fingerstick glucose
  • Hold narcotics and psych meds—if opioid overdose is a possibility, have naloxone ready.
  • Check pupils, check for focal neurologic deficits—did the patient have a stroke? Consider CT head and call stroke team (p 3886).
  • Check EKG—is the patient having an MI or PE?
  • Check abdominal exam—AMS may be first sign of sepsis from anastomotic leak or perforated stress ulcer! Consider a portable upright CXR or lateral decubitus film to rule out free air.
  • If any concern for low saturation check ABG—PE may present with AMS! Can draw ABG and add vacutainer to draw remainder of labs.
  • Send basic labs: CBC, Chemistry, Troponin if elderly or with other cardiac risk factors, Type & Screen if expired
  • If fever/high WBC also present, send blood cultures.
  • Notify your chief!

Specifics

32. I Think My Patient is Coding...

  • If your patient is poorly responsive or unresponsive,
    ASK FOR HELP!

  • Confirm DNR/DNI status
  • Call/ask nurse or someone else to call RRT and/or Team 7000 (47000) and Anesthesia Airway Team stat. During the day have a team member notify the chief resident immediately. Overnight the senior surgical resident on call should be notified immediately.
  • Call for the ambu-bag and crash cart to be brought into room
  • If you are the first one there and CPR is indicated, do it!

  • Airway → Start with chin-lift, jaw-thrust, ventilate the patient with the ambu-bag and be sure you are getting adequate chest rise, have oral airway in place, suction as needed
  • Breathing → You may have an RN bag the patient if you know the airway is patent
  • Circulation → If no pulse then immediately begin compressions, make sure patient has good IV access and bolus NS, get patient hooked up to a defibrillator.

  • Send full set of labs including troponin and T&S
  • Code team will help you with medication administration

33. Patient Deaths/D.A.V.E. application

Learning to cope with patient deaths and families of the deceased patients is one of most difficult tasks of residency. If they happen when you are on call, there are several things that must be taken care of.

  1. Notify your chief resident. He or she may call the attending, or have you call the attending directly. Either way, the attending must be notified immediately. (If it is not your primary patient, alert the primary team!)
  2. Clarify who will be calling the family to notify them about the death and ask for permission for autopsy.
  3. Complete a note in the chart with the death exam, the next of kin notified, and whether an autopsy request was granted. There is a template for this note in EPIC.
  4. All deaths within 30 days after surgery must be then referred to the Medical Examiner (212-447-2030). If the ME accepts the case, they will complete the death certificate. Make sure to record the ME case number.
  5. If the medical examiner rejects the case, or the death has not occurred within 30 days after surgery, you must complete the online death certificate. You can get help completing this online form by paging the nurse manager on call or going to medical records. You must know the cause of death—if you need help, call the ME and present the case and they will recommend an “official” cause of death.

So you have to do the D.A.V.E......

  1. Go to designated D.A.V.E. computer (marked on monitor, there is at least one on each floor)
  2. Go to original screen (not Citrix) try hitting windows key. Press the D.A.V.E button.
  3. Initial login/password: mtsinai/Mtsinai1
  4. Then use personal login/password for EVERS on left hand side.
  5. Fill out the “Death Start/Edit New Case”. License for Sinai is 42360.

34. Autopsy

  • Autopsy should be requested for all patients and should be discussed with the family in an appropriate manner.
  • Autopsies are performed either by the Dept. of Pathology at Mount Sinai or by the NYC Medical Examiner (ME).
  • Clarify with your chief who should ask the next of kin for autopsy consent.
  • Autopsy consent forms are available on Patient Works.
  • Be clear about the benefits of autopsy:
    1. providing family & medical team knowledge about all the factors that may have contributed to patient's death
    2. sense of closure for the family
    3. potential knowledge about illnesses that may affect other family members.
  • Autopsies can generally be performed within 24-48h and do not typically delay funeral arrangements. They also do not significantly alter the external appearance of the patient.
  • Overnight, a completed autopsy consent form goes in the chart which goes to Medical Records the next morning.
  • You should page pathology on-call to alert them to an expected autopsy.
  • Funeral home and hospital morgue communicate re: transfer of the deceased.

35. Discharge Planning/E-Prescriptions

  • Talk to patient and family on admission to assess living situation, mobility prior to surgery/ hospitalization
  • Clarify with chief resident and attending anticipated discharge dates and patient needs so you can pass on information to SW
  • Round with social work every day and follow up throughout the day to make sure paperwork is completed

Visiting Nurse Services

  • If a patient needs wound care, drain care, IV antibiotics, TPN, Lovenox injections, etc. they will need VNS
  • Home Health Aid: Patients have to qualify for this if they need assistance at home. HHAs help with things like cleaning, cooking, etc. They do not perform medical tasks.


Physical Therapy

  • Place an inpatient PT consult through EPIC and then call PT to insure they received the consult. They check messages twice a day so call early. You can also call the BA and ask them to alert PT when they see them on the floor.
  • Follow up to see what PT recommends re: no needs vs home PT vs acute rehab vs subacute rehab


Forms to know about and fill out early:

  • Inter-institutional Transfer Form (ITT): for patients going to rehab/nursing facility after discharge
  • Briggs Form: for patients who need VNS or home PT
  • KCI form: for patients who need home wound VAC, takes ~2 days to arrive

E-PRESCRIPTIONS:

  • NY State requires prescriptions to be done electronically
  • Confirm patient’s pharmacy, let them know you are sending prescriptions electronically there
  • If prescribing Dilaudid, call pharmacy to confirm they have tab dose you want (2mg vs 4mg)
  • Some pharmacies will not take general DEA that covers residents. Ask them to use the corresponding attending DEA. If they can’t, ask PA to e-prescribe.

Paper Prescriptions: If you do have to print a paper prescription then go to one of the computers on the floor that is designated to print on prescription paper and enter the order “Lab Rad” during discharge orders and make sure to designate ‘normal’ to print. This should cause the printer with prescription paper to print out a blank prescription to allow you to fill it out.

36. Leaving Against Medical Advice

If you are called that a patient wants to leave AMA, IMMEDIATELY go and assess the patient. Determine why they want to leave. Determine current clinical status (eg. Are they recently septic, are they currently delirious, etc). Next, quickly assess their capacity to make the decision to leave the hospital against medical advice.

Capacity consists of:

  1. Comprehension by the patient of their current clinical status. Do they understand what is currently happening with their medical course?
  2. Understanding of the risks of leaving against medical advice. Can the patient understand the potential risks of leaving the hospital before medically discharged?
  3. Free Choice. Determine if the patient is free from coercion or being forced to make the decision to leave AMA.
  4. Consistent over time. Does the patient’s decision and thought process remain stable over time?


After you have quickly assessed capacity IMMEDIATELY go and notify your chief with the update on their current clinical status and the results of your Capacity evaluation. The chief will direct you from there regarding speaking with the attending and whether a formal Psychiatry Capacity Consult should be called 4STAT.


If the patient is deemed competent to leave AMA then have the patient sign the ‘Unauthorized Departure Release Consent Form’ found in Patient Works. Then discharge the patient as normal with a discharge summary (noting the AMA status), discharge medical reconciliation (noting the AMA status again) with all correct prescriptions, and set up follow up appointments.

  • If a patient leaves AMA you are still to provide them medications and follow up appointments as usual. Ref: Institutional Policy ‘Discharge Against Medical Advice (AMA)’ number GPP-206.

37. Consult and Paging Etiquette

Paging at Sinai: 41300 / Paging at Elmhurst: 41908

  • Enter the extension you are at followed by () and your pager number (i.e. 455333602). When you page someone who may not be in the hospital, only page to an extension starting with 4 so that they can call you back directly.

  • You can text page on www.amion.com BUT the text pages will not be forwarded. To forward your pager when in the OR or unavailable dial: 41200, your pager ID, 1, 7, covering pager number, #.

  • DO NOT text-page important information. Remember, if you don’t hear back after a text page, do not assume the person got the message!! (Conversely, always text “ok” to acknowledge that you received a message.) If your question requires a response, speak to the person directly. If nurses text page you about patients, call them back to discuss the issue and remind them that you do not always get text messages immediately (i.e. if you are scrubbed). The same goes for other services following your patients. Do not accept consults via text page! Call the team back and ask them to tell you about the patient over the phone. Alert your chief if this happens.

  • When calling a consult, ALWAYS CLARIFY with your chief/attending who exactly is to be called. Sometimes you will be directed to call the teaching service for that specialty (i.e. the pulmonary service); other times you will have to directly page a specific private attending, or their covering partner, in that specialty for the consult.

CALLING A CONSULT/ RECEIVING A CONSULT

  1. Call/Page/Answer the desired consult person/service.
  2. Speak politely
  3. Give/Acquire patient information in the following order:
    a. MRN
    b. Last name, First name
    c. Patient current location
    d. Specific reason for Consult
    e. Callback number or pager
    f. Patient story/background
  4. Thank the consultant for seeing the patient and find out when they expect to see the patient or follow up with you/team or let them know when you expect to see the patient.

38. Websites

Attending license numbers → http://www.health.state.ny.us/ professionals/doctors/conduct/license_lookup.htm

Call schedule for all services → http://www.amion.com

mssurg2018 for surgery
mssm for most non-surgical specialties
msmed for medicine residents
ehc for Elmhurst rotators

Case logs → https://apps.acgme.org/connect/login

Evaluations and work hour logs → http://www.new-innov.com

Levy Library, access to online textbooks, UpToDate → http://icahn.mssm.edu/about-us/services-and- resources/levy-library

MSH intranet page → http://intranet1.mountsinai.org

OR web schedule → http://intranet2.mountsinai.org/ms_schedule

ORWatch → http://www.orwatch.mountsinai.org

Resident homepage → http://www.mssurg.com
→ http://www.mssurg.com/current

SCORE curriculum → http://portal.surgicalcore.org

Shuttle schedule → http://www.mshsshuttle.org

39. Computer Programs

EPIC: Used to view patient data, enter orders, update the list, write daily progress notes. Used at both Sinai and Elmhurst

OR Web Schedule: OR schedule (Access through “Applications-Web-Based” link on main intranet page, use “Future date” function for updated schedules). Use your EPIC ID and password

  • The OR schedule can also be accessed on orwatch.mountsinai.org with your Epic login and then from the dropdown menu in the top right, choose “schedule”
  • The OR schedule can also be accessed via the Status Board in Epic

PACS: Radiology images. login: ‘GILLEM03’, password: GREENDAY

Patient Works: Used to print forms like consents, progress notes, pre-op checklist. Only prints on specific printers.

40. Dictation Procedures

To dictate a report at Sinai:
From in-house phone: 89889 or if outside: 212.659.9889
Enter facility ID: 89#
Enter your 5-digit dictation code (ie 11111#)
Enter patient's 7-digit medical record number
Enter work type: 1=inpatient, 2=ambulatory Begin dictating at the tone
1=Pause
2=Record
3=Rewind & Play
4=End of file & Record
5=Play
6=Next dictation
7=Beginning of file & Play
8=Insert
9=Long rewind
0=Help
*=End call

At Elmhurst:
Dictation: 45061 in house or outside: 718.334.5061

  • Soarian ID followed by # sign (from Glen)
  • Work Type = 32 followed by #
  • Patient CSN (next to MRN in EPIC)
  • At the tone begin recording
  • To note the job #, press 6 at the end. Document the job # in a brief EPIC note, as it may take a week for dictation to appear in the chart
  • Press 8 between reports if multiple dictations

Operative dictations must be completed with 24 hours.

41. Shuttle Schedules

Shuttle schedule → http://www.mshsshuttle.org

42. The Glossary

AMA: against medical advice

ALC: Alternate level of care, only at Elmhurst. This means the patient does not need to be seen every day by the team. Used primarily for social admits or completely stable patients awaiting placement.

AOD: Administrator on duty, at Elmhurst. This is person available 24/7 who helps take care of disputes & delays in patient care and must witness telephone consents.

Blue-slip: Call the ER and ask them to notify you when the patient arrives in the ER.

CCU: Cardiac care unit (5E)

CTICU: Cardiothoracic intensive care unit (5C)

FPA: Faculty Practice Associates. All full-time faculty have their clinic/offices in the “FPA” located at 5 E. 98th Street.

HMP: Hospital Medical Practice. The non-teaching medicine services, run by attendings/hospitalists/NPs.

IDP: Implement discharge plan. An order in EPIC that should be written the day before a patient is/may be discharged. Allows patients the chance to appeal their discharge.

IMA: Internal Medicine Associates

LTM: liver transplant monitor, includes chem10 + LFTs

MAR: medicine admitting resident

ME: medical examiner

MICU: Medical intensive care unit (5E)

NSICU: Neurosurgical ICU (Ann8)

PACU: Post anesthesia care unit, where patients go post-op and stay overnight if waiting for a stepdown or ICU bed.

Phase II: Where ambulatory patients at Sinai go after PACU and prior to discharge home. Located on GP2.

Pink-slip: Go to OR/call OR desk to book for an emergency/add on case at Sinai or Elmhurst. As in, “pink slip the appy.” Actual pink piece of paper. At Elmhurst you have to order a ‘case request’ for the procedure.

POMA: PreOp Medical Assessment Form: required for all ASA 3+ nonemergent inpt cases. Page (POMA aka 7662) to complete.

PT: physical therapy

RRT: rapid response team; a critical care attg, fellow, and NP

SAR: Sub-acute rehab (a recommendation from PT)

Social Pool: The medicine service at Elmhurst can distribute patients to other services who are medically ready for discharge but cannot leave for social/placement reasons.

SICU: Surgical ICU (6E)

SNSS: Surgical Nutrition Support Service (Line service/TPN)

SQH: Subcutaneous heparin

Step-down: A 4 bed room with 2 nurses. Level of care between ICU and regular floor beds. Surgical stepdown is on 10E.

Team7000: A code

TCC: Terrance Cardinal Cooke, a nursing home that accepts many otherwise difficult to place patients (dialysis, wound vacs, TPN, etc)

TR: Teaching resident, PGY3 medicine resident on-call for curbsides or consults re: any medical issues, including general medical clearance.

VAT: Vascular Access Team for difficult IVs and long term IV access. p:2827

VNS: Visiting Nurse Service. Patient who are discharged home and need nursing care at home (i.e. wound care, dressings, ostomies, etc).