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Here are a few pearls of wisdom from orientation for internship.

JHH specific stuff

  • CICU is surgical cardio ward
  • CCU is medical cardio ward
  • Most referrals are via general request form
  • Contact Pall care nurse for assistance with end of life discussions
  • Dial 63 if a phone is engaged. You will automatically be called back when they're off the phone again. Pick up --> you will be connected
  • Pager number: 13955
  • Between CT area and ED is the MRI area
  • VBG/ABG machines
    • ED resus bay
    • Theatres - left hand side
    • ICU
  • Do VBG (green tube) on all sick patients: pH or lactate

Typical day on med term

  1. Come in early
  2. Be fast, don't hold up the round
  3. Bring request forms with you on the round in a folder, fill them in as you go:
  4. After ward round - consults for sick people
  5. Write discharges if there's time
  6. Check bloods at lunch time
  7. Do imaging requests
  8. Write in notes
  9. Paperwork, discharges/discharge planning
  10. New blood orders for next day

General tips

  • Learn from other peoples' mistakes
  • Meds on discharge list
    • Add ** for stopped/changed meds
    • Add a "CEASED" list and a "NEW" list -- so people don't get confused
  • Copy and paste from last discharge list, and edit (be careful with this as you may accidentally copy old information)
  • Past medical history
    • Can earn brownie points by including specialty-specific info
      • Eg in resp: last Spiro, whether their COPD was mild/moderate/severe, previous ICU, whether home O2, and meds. For a diabetic, include microvascular and macrovascular complications
  • If you fax something, write that you faxed it
  • For an ultrasound or CT, include heaps of clinical details on the form if you want it to actually get done
  • Vascular sonography has its own form, they are usually easier to get done
  • If on after hours, run everything by the after hours Med Reg until you're confident
  • Never ask someone else about fluids though
    • Care: if someone's fluid restricted don't Rx their oliguria with fluid bolus. Angry surgeon

Bloods

  • First few weeks, run through bloods with your reg
  • Sick people - bloods daily
  • Kinda sick - every 2nd day
  • The rest: PRN
  • Not sure: check frequency with reg
  • Milestones to take bloods
    • ACEI (UECs 48hrs)
    • Diuretics
    • Vanc, Tobra levels
    • Gent usually not given as a targeted therapy (except 1st dose for urosepsis in the elderly, could kill all the bugs in one go)
      • Gent charting protocol: kidneys, weight. Only empirical, not targeted
      • >72 hours gent = levels
  • Check your protocols for vanc vs gent


Detecting the deteriorating patient

  • Every hour delayed in diagnosing sepsis is associated with 8% increase mortality
  • Sepsis pathway
  • Our "Track and Trigger" system is stipulated by the Between the Flags project [1]
    • SAGO = standard adult general obs chart
    • SPOC = standard paeds general obs chart - by age category
    • "Triage" ranking: 1. Clinical review 2. Rapid response 3. ALS pathway
    • Lecture notes on this topic, including what to do in each zone
    • Interns should err on the side of safety - if unsure whether to do a rapid response call, just do it (you won't get in trouble for being too careful early on)
  • NSW Health Protocol for deteriorating patients [2]
  • HETI online module for detecting the deteriorating patient using DETECT acronym [3]
  • SOCCER criteria (p13) [4]
    • Early
      • Base deficit -5 to -8mmol/L
      • Partial airway obstruction (excluding snoring)
      • Poor peripheral circulation
      • Greater than expected drain fluid loss
      • pH 7.2-7.3
      • PaCO2 51-60mmHg
      • Urine output < 200ml over 8 hrs
      • Noted decreased urine output
      • GCS < 9-11 or fall in GCS by > 2
      • Any seizure
      • Respiratory rate 5-9 or 31-40
      • New pain
      • SpO2 90-95%
      • Other
      • Systolic BP 80-100mmHg
      • Alteration in mentation
      • PaO2 50-60mmHg
      • Uncontrolled pain
      • Pulse rate 40-49 or 121-140/min
      • BSL 1-2.9mmol/L
      • Systolic BP 181-240mmHg
      • Complaining of chest pain
    • Late
      • Cardiac arrest
      • Urine output < 200mL / 24hrs
      • pH< 7.2
      • Unresponsive to verbal commands
      • Other
      • Anuric
      • Base deficit < -8.0mmol/L
      • GCS ≤ 8
      • PaO2 < 50mmHg
      • Pulse rate > 140 or < 40
      • Respiratory rate > 40 or < 5b/min
      • PaCO2 > 60 mmHg
      • Failure to reverse variable < 1 hr
      • SpO2 < 90%
      • Systolic BP < 80mmHg
      • Airway obstructed / stridor
  • LITFL Registrar's lecture on the topic

DETECT Course

  • Detect, Evaluate, Treat, Escalate, Communicate to Team
  • Anaemia hides cyanosis
  • Cyanosis >50 g/L deoxyHb
  • Ventilation: drugs that affect pre-Botzinger complex
    • Resp rate falling = tired. Late stage sign --> respiratory arrest
  • Alveolar gas equation higher CO2 = lower PaO2 in blood
    • NP 2-4L
    • Hudson mask: 6-10L
    • HiFlo nasal: 40-50L
    • Non rebreather: 15L
    • Venturi mask: look at litres requirement for percentage target
    • VBG: add 5 for CO2 approximate for ABG
    • Asthma protocol: see asthma handbook
  • Asthma COPD emergency: consider pneumothorax and do CXR
  • Don't intubate asthmatic or you can cause pneumothorax
    • CXR mobile is very slow.
    • Check trachea. Percuss. Thing PTX
    • Call a rapid response or ICU --> pass on management

Oliguria

  • <200mL/24 hours or base excess -8 = anuria
  • decreased urine postop = surgical stress response (just bolus 500mL)
    • normal 12 hours oliguria postop
  • Oliguria = 100-400 mL/24hr. Anuria <100mL/24hr.
  • Decreased renal blood flow activates sympathetic nervous system --> aldosterone and ADH production
  • Causes of oliguria
    • Prerenal
      • hypovolaemia: bleed, N/V and diarrhoea, NG tube, diuretic, APO
      • decreased vascular resistance: sepsis, antihypertensives
      • decreased cardiac output
    • Renal
      • glomerular + tubular
      • intrinsic renal autoimmune
      • drugs: aminoglycosides, NSAIDs, frusemide, contrast
    • Postrenal
      • oliguria/anuria
      • check catheter
      • BPH
      • ascending calculi
      • bladder neck obstruction mass
  • Fluid challenge: for prerenal give 500mL see if it increases urine output
    • Improve MAP eg 3rd spacing postoperative
    • care in CCF, ESRF (don't pee or don't pump)
  • Fluid loss: low BP from fluid loss = 20ml?kg lost
    • ECF 10% loss = tongue, skin, mucus (clinical), sunken eyes
  • Look at specific gravity --> dipstick
  • Urine goal: 0.5 mL/kg/hour
  • HyperK
    • VBG
    • ECG
      • peaked T, flat P, wide QRS, calcium gluconate for only 20 min cardioprotective (Ca gluconate can't be given twice)
      • rehydrate, rezonium, salbutamol etc. K will also respond to fluids
  • Don't give diuretics unless blatant APO
  • Polyuria: T2DM or diabetes insipidus or postobstructive. Electrolyte abnormality

Confusion

  • Delirium: high mortality
  • ABCs, GCS<8 = escalate.
  • GCS: E4M6V5
  • Check for blown out pupils (the D of ABC's): escalate
  • neurological exam
  • Note early or late warning Sx
  • Note observations can change due to brain injury
  • WHIMPS: Withdrawal, Wernickes, Hypoxia, Hypercapnia, Hypotension, Hyper/o glucose, T, thyroid Na, infection, etc
  • G: Can try antidotes for induced CNS depression (Naloxone)
  • Drug: midazolam
  • Seizure: diazepam (10-20mg), midaz (5-10mg), clonaz
  • Delirium: haloperidol (0.5-1mg in old, 2.5-5mg in young). Nowadays we'd use olanzapine
    • Our job is to Rx the cause.
    • Do not prescribe sedatives as a JMO
  • Investigations of confusion: ABG, BGL, FBC, UEC, LFT, Coags and TFT, blood cultures, CT brain (care confusion and falls)
  • Need to check GCS when asleep - wake em up!
  • If saturations decrease after fluid bolus, then they're APO (+clinical)
  • NG suction: decreased K+ and paroxysmal AF, fix the electrolyte/hydration

ALS

Calling criteria

  • From the policy[5]:

The colour coded zones on the Standard Observation Charts indicate when a patient is showing early and late warning signs of clinical deterioration and outline the appropriate escalation of care to a Clinical Review or Rapid Response. For example in the charts:

  • The Blue Zones (where applicable) represent criteria for which increasing the frequency of observations is required
  • The Yellow Zones represent early warning signs of deterioration and the criteria for which a Clinical Review (or other CERS) call may be required
  • The Red Zones represent late warning signs of deterioration and the criteria for which a Rapid Response Call is required.

NB: these may be altered for the individual patient, as may the obs frequency

Clinical reviews

  • Calling criteria
    • discretionary zone
    • Activation of the facility’s CERS based on Yellow
    • Zone observations or additional criteria is discretionary and based on your Clinical Judgement of the patient’s condition.
    • Decision to escalate or not to escalate MUST be done in consultation with the NURSE IN CHARGE.
    • With nurse, consider: what is usual for this patient, are there documented alterations to calling criteria, does the trend reflect deterioration, >1 yellow zone obs or additional criteria, or are you concerned?

Pathway:

  • First check if escalation is required or not. If not, continue:
  • Initiate appropriate clinical care
  • Repeat your patient’s observations
  • Increase the frequency of observations as indicated by the patient’s condition
  • Document an A-G assessment, reason for escalation, treatment and outcome in the Health Care Record
  • Inform the AMO as soon as practicable
  • Big DDx's for causes of deterioration (roughly similar to 4H's and 4T's)
    • Sepsis
    • Arrhythmia
    • Hypovolaemia/haemorrhage
    • Pulmonary embolus/dvt
    • Pneumonia/Atelectasis
    • AMI
    • Stroke
    • Overdose/sedation

Rapid response

  • Calling criteria
    • Any red zone observation
    • Deterioration in CR not reversed within 1 hour of review
    • Serious concern - you or nurse
  • Red zone obs
    • Call a rapid response
    • Initiate appropriate care
    • Inform the nurse in charge you have called for a rapid response
    • Repeat and increase frequency of observations
    • Stay with and own the patient as a priority
    • Get more people involved - if a ship is sinking, load it up
    • Document an A-G assessment, treatment, escalation process and outcome in health care record
    • Inform the AMO as soon as possible eg 7am if on nights

MEWS score

  • use it on MDCalc app
  • The Modified Early Warning System (MEWS) is a tool designed to identify patients with declining conditions.
  • It has been shown to be superior to clinical judgement for this purpose.
  • It was originally designed for nurses but can be used by any healthcare professional with adequate training.
  • MEWS is based on the principle that clinical deterioration can be seen through subtle changes in a number of parameters as well as large changes within a single variable.

ResidentGuide

  • Use the app
  • Rovers for different specialties
  • Overall guide on the bottom part of the app written by a bunch of residents

End of life discussion

Discharge summaries

  • Do discharges and meds and scripts the day before the patient leaves hospital
  • Explain the meds to them
  • Highlight the meds and the plan - these are the most important components for pt
  • Double check with the boss about followup
  • Organise websterpacks
  • Scripts
    • Only drugs to give supply of = new ones from hospital
    • Include dose change. Dose strngth, frequency, route etc
      • Throw out old ones
      • Hospital pharmacy supplies 1wk. Then GP
    • Supply whole course of Abx
    • Warfarin: initiation pack for a range of tablets (bunch of each size)
    • No prescriber number needed, write "Hospital prescriber"
    • No stickers for schedule 8 scripts - all must be hand written (eg narcotics)
      • Quantity: based on time to GP. In letters and words. No repeats.


After hours

  • This is not your patient
    • Just give stat and PRN doses
  • Never forget the CXR: simple test

ECGs

Blood gases

Fluids

Analgesia

  • See intern app
    • WHO guidelines: Panadol --> P+Codeine --> Endone (Old people: 2.5-5 q4hrly max15; review in an hour)(Young people: 5-10mg) --> Morphine
  • Only use panadeine forte/Tramadol if can't take endone
    • Tramadol care: serotonin syndrome
  • Codeine: 30-60mg q4-6hrly
  • Morphine/endone contraindicated in low GFR: ALWAYS check GFR before charting
    • In this case use hydromorph (1mg) or fentanyl
      • Fentanyl 25-50mcg subcut is a good starting point
  • Long term analgesia for people on lots of PRNs
    • Targin (lasts 12 hours) = oxycodone slow release + naloxone
    • Panadol QID or TDS
    • Starting fresh on Targin: 2.5-5mg
  • Ordine is good in dyspnoea.
    • No more than 2-3mg q2hrs
  • Can't give ibuprofen in pregnancy --> stops ductus closing

Constipation

  • Coloxyl/senna tablet
    • Prophylactic coloxyl: 2bd tablets
  • Movicol sachet
    • PRN
    • BNO 2 days: 2bd movicol + coloxyl + senna
    • Still BNO: 6 Movicol in 1L
  • Check the ED constipation pathway

N+V

  • Ondansetron wafer 4-8mg q8hrs
  • Metoclopramide 10mg q8hr
    • O+G only use this

VTE risk

  • look up framework
    • identify patient risk
    • assess and documen vte risk and whether they need pharmacological vs mechanical prophylaxis
    • prescribe: heparin or lmw and why. Do we need mechanical prevention
    • engage the patient and need to mobilise early
    • its their responsibility as well
    • reassess every day
    • monitor practice
  • IMS to report pulmonary embolism
  • assess risk on discharge - will need vte prophylaxis at home-injections
  • risk factors: age obesity previous history pregnancy thrombophlebitis varicose veins
    • reduced mobility, cancer, use of HRT or oral contraception, surgical intervention, active infection, inflammatory bowel disease
  • HNE vte risk chart is in the office. This assists your risk stratification
  • UFH-preferred in patients with renal impairment. Ccr <30. 6hr halflife. Reversible
  • LMWH- need dosage adjustment in renal impairment
  • factor Xa inhibitors
  • direct thrombin inhibitors
  • heparinoid
  • contraindications: bleeding, thrombocytopenia, end stage liver disease, treatment with therapeutic anticoagulation, cns trauma
  • weigh risk vs benefit
  • Mechanical prophylaxis
    • graduated stockings
    • internittent compression device
    • foot compression device
  • contraindications:ulcers, trauma, fat, oedema, stroke patients
  • dedicated section of vte on the MED chart
  • use the heparin tool
  • report adverse incidents on IIMS
  • links
    • cec vte prevention on health nsw gov
    • vte prevention resource centre - safety and quality gov

Book recommendations and pdf sources

  • The Washington Manual Internship Survival Guide
  • On Call by Marshall + Ruedy
  • Titles available here, searchable pdfs and epubs

Handy apps

  • ListRunner - for patient lists and jobs. Negative: look at phone during rounds
  • ResidentGuide - most hnehealth stuff you need. Negative: look at phone during rounds
  • Uptodate - get subscription via CIAP

References

  1. http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/between-the-flags/standard-calling-criteria
  2. http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_049.pdf
  3. https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/deteriorating-patients
  4. https://www.safetyandquality.gov.au/wp-content/uploads/2012/02/UsingObservationCharts-20091.pdf
  5. http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_049.pdf