Download VA Morning Report December 12, 2005

Pearls of Cross Cover
Jason B. Martin
What is cross cover?
• Covering for your partners
• other interns who are off
• teams signed out to you at night
• You are the patient’s primary physician after hours
• labs, consult recs, consent (blood)
• family concerns
• ALL medical and nursing issues
• The sign out sheet
• BRIEF explanation of why patient is here
• Just the facts! Don’t editorialize.
• Pertinent demographics (name, age, MR, room #)
• allergies
• CODE STATUS (and keep this up to date)
What NOT to sign out:
• Routine daily responsibilities
• get your notes done before rounds
• Subjective comments
• Results that won’t affect patient care
• Non-specific plans
• RESTRAINT RENEWALS
Responding to pages
• Be prompt, especially with tagged pages
• Your tone
• Irritated? Hurried? Rebuking?
• Be polite
• What does the nurse REALLY want?
• Reassurance? Appease patient or family?
• Empower the nursing staff
• What do they think is going on?
• What should WE do about this issue?
• Come to a decision and ask for read-back
• Leave tracks in the chart, sign-out sheet
Giving Medications
• Do I really need to give a medication?
• Does the patient have a medication on his/her list that I can use,
or dose early?
• Review allergies
• Consider renal and hepatic function
• General principles
• shorter-acting agents are better in the middle of the night
• PO > IV
• lowest dose to achieve
• think about patient comfort and nursing care
• Use phenergan and ativan with caution in older patients
You are not alone
• Use your resources  nurses and techs, residents, fellows,
attendings
• ALWAYS call your resident if something’s not right
• ALWAYS call early
• Trust your instincts
Common Questions
on Call
Disclaimer:
This list in NOT
comprehensive. Even
seasoned veterans can be
surprised on call
Common Questions
on Call
• Insomnia
• Constipation
• Diarrhea
• N/V
• Electrolyte problems
• Fever
• Loss of IV
• Decreased UOP
• Confusion
• EtOH withdrawl
• Dyspnea
• HTN
• Hypotension
Insomnia
• Probably the most common call
• Consider prn orders at admission
• Why can’t they sleep?
• pain
• anxiety
• noise
• sundowning
• What normally works for the patient?
Insomnia
• Antihistamines
• Diphenhydramine (Benadryl)
• 12.5, 25, or 50 mg (IV or PO)
• Benzos
• Temazepam (Restoril) 15-30 mg
PO  great for older pts
• Lorazepam (Ativan)  0.5 mg PO,
IV
• Avoid alprazolam and valium
• Zolpidem (Ambien) 5-10 mg po qhs
prn
Constipation
• Review medication list  review with AM team
• Iron
• CCB
• Laxatives
• Bisacodyl (Dulcolax)
• 5 or 10 mg pr
• Docusate Sodium (Colace)
• 100 mg po BID
• Milk of Magnesia
• 30-60 mL PO
• Metamucil
Constipation
• Lactulose 10-20 grams (15-30 mL)
• Go easy
• Tastes bad
• Dramatic results
• The Green Bomb: Magnesium Citrate (300 cc bottle)
• Fleet’s Enema
• Don’t order it
• Just use soap suds
• Avoid Mg-containing compounds in renal failure
Constipation
Attention Interns:
The patient may need manual disimpaction.
“Diarrhea – Cha! Cha! Cha!”
• Is it diarrhea or just loose stools?
• Associated with fever or leukocytosis?
• c.diff? Start empiric flagyl?
• hemorrhagic colitis?
• Leakage around an impaction?
• Avoid anti-diarrheals acutely
• Immodium or lomotil if needed
Nausea and Vomiting
• Promethazine (Phenergan)
• 12.5 – 25 mg PO/IV q 4-6 hours prn
• Caution in elderly
• Metoclopramide (Reglan)
• 5-10 mg PO
• Lorazepam (Ativan) 0.5 – 1 mg PO
• Serotonin antagonists (Anzemet, Kytril, Zofran) are available
• generally second-line ($)
• oncology patients
• refractory cases
Hypokalemia
• Hypokalemia
• normal range is 3.5 – 5.0
• replace PO/per tube when possible (immediate and SR
forms)
• can replace IV if necessart
• be aware of patient’s renal function
• be aware of any standing K orders
• conisder empiric Mg replacement if refractory
Hypokalemia
• KCL immediate release  orally 40-60 meq is a standard dose
• powder/elixir  rapidly absorbed
• tastes terrible; patients with nause may not tolerate
• Kdur tablets
• slower onset, longer-acting
• IV KCl  it hurts
• slow replacement (10 meq/hour peripherally)
• takes the IV port
Hyperkalemia
• Hyperkalemia can kill a patient (arrhythmia)
• Order EKG (and call your resident)
• Does it fit the clinical setting? Hemolysis?
• Swift action may be required
Hyperkalemia
• Calcium gluconate  rapidly stabalizes the cardiac muscle
membranes; effect is transient
• Insulin (10 units IV) with 1 amp D50
• drive K into cells
• onset 15-30 minutes
• Bicarbonate
• transient cellular shift
• Beta agonists
• Dialysis
Fever
• ALWAYS EXAMINE THE PATIENT
• Draw cultures prior to abx
• You will rarely be faulted for choosing broad abx; just think about
the possible sources
• Don’t forget about allergies
• Renally dose medications  Use Sanford Guide
Loss of IV
• Does the patient need an IV?
• Any meds scheduled for tonight?
• Ask for IV therapy to assist (at VU)
• Attempt yourself?
• Can you convert to PO?
• What about a central line?
Low UOP
• Is the Foley placed properly?
• Flush the Foley
• Reposition it
• Assess patient’s volume status and read the history
• volume overloaded  Lasix
• crackles, elevated JVP, S3, edema
• volume depleted  NS
• orthostasis
• hypotension
• tachycardia
• Get your resident involved if unsure
Chest Pain
• Huge differential diagnosis  from annoying to life-threatening
• Always evaluate CP in person  get out of bed
• Have the nurse get EKG while you are on your way
• Think about GERD, PE, MI, dissection, anxiety
• Assess vital signs, careful physical exam
• diaphoretic?
• dyspnea?
• acutely ill-appearing?
• pleuritic?
Chest Pain
• EKG changes? Call for help  Time is myocardium
• Cardiac enzymes
• CXR
• Transfer to another unit?
• If you think it’s cardiac:
• ASA
• nitro spray or SLNG  in new pts, ask about sildenafil use
• O2
• morphine
• βBs
Dyspnea
• Always examine these patients in person
• Vitals (RR and sats)
•
Huge differential
• failure, edema
• bronchospasm
• PE
• ptx
• MI
• pneumonia
• bronchospasm
• acidosis
• anemia
Hypertension
• Urgency, emergency, or no big deal?
• Physical exam
• BP in both arms
• funduscopic exam
• rales?
• neuro exam
• Labs / Imaging
• BMP
• EKG
• UA
• CXR
• AMS or focal neuro deficits  CT head without contrast
Hypertension
• Is the patient in pain? Anxious?
• Use current medications
• early dosing
• increase doses
• Clonidine  it works, but no style points
• 0.1 mg to 0.3 mg po
• Nitro paste
• IV push (with consultation): labetalol
• IV gtt (with consultation): cardene, nitroprusside
EtOH Withdrawl
• Can be life threatening
• Be suspicious: agitation, tremor, hypertension, tachycardia in a
drinker
• Treat with IV benzos
• Start low, titrate rapidly to achieve effect (Protocol in place?)
• Ativan IV: 2 mg  4 mg  6 mg  10 mg
• MVI, thiamine, folate
• Consider transfer to a monitored unit
Confusion / Delerium
• Check VS, sats, glucose, consider ABG
• Discuss with nursing staff, family  what’s the baseline? How
acute is the change?
• Why?
• hypoglycemia
• recent fall? CT head?
• infection?
• medications?
• ICU or hospital-induced delerium
• EtOH withdrawl
• iatrogenic (phenergan is a common offender)
Confusion / Delerium
• Sundowning
• very upsetting to families
• can worsen with ativan
• best therapy  family and reassurance
• restrain for patient / staff safety
• try some haldol
AVOID
• Demerol
• Major changes in plan without consultation
• Treating patients without examining them
• Short temper with nurses
• Calling for help too late
Intern Companions
• Hemoccult cards, developer (and a gentle touch)
• Opthalmoscopes and tropicamide (Mydriacyl)
• Motivated medical students
• A supportive resident:
“ If the horse dies, the cowboy walks.”