University of Florida Surgery Internship Survival Guide 2006-2007 GENERAL PRINCIPLES: 1. Have a positive attitude. Always. 2. Communicate up the ladder. Always. If we do not communicate well within our teams and to the night team, our patients will get hurt. 3. Form your own system or routine that will allow you to optimize your efficiency. 4. Know your patients. 5. Remember that you are the first person to be called if a patient doesn t look right. Go see your patients when you are called! Then refer to #2. 6. Always perform a thorough sign-out with the on-call residents. The completeness of our sign-out is the ONLY continuity of our patient care. 7. Only consent patients for a procedure if you can explain the procedure and complications thoroughly. Alternatively, you can do the paperwork if you have witnessed an attending, chief, or junior resident discuss the procedure, risks, & benefits with the patient. 8. Dictate discharge summaries either the night before or the day a patient is discharged. At the end of your dictation, ask the transcription to send a copy of your dictation to the patient s referring physician (if one is listed on the chart). 9. Our nurse practitioners and physician assistants are great resources and very helpful. Do not abuse them. 10. Before you start a new service, contact the intern on that service for sign-out and call your chief. DAILY PRIORITIES: 1. Arrive 10-15 minutes before morning rounds and update The List. You can access your service s list by logging in at: http://www.surgery.ufl.edu/patientcensus If you are at the VA, each service keeps their lists on one computer in their team room (Microsoft Access program). Correct patient room numbers since your patients may be moved to different rooms overnight Make sure the antibiotics are correct Print out a short list for the chief and junior residents. Print out a long list for yourself. 2. During morning rounds, write every task down on your list with an empty check box next to it. You will be amazed at how many tasks you will forget if it is not written on your list. 3. After morning rounds, your top two priorities should be calling consults & calling to schedule radiology studies/procedures. Be considerate to our consultants. When they return your page, ask for a consult, and provide them with the patient s name, medical record number, and room number. Give them a concise patient history and specific question
that we would like them to answer. Write the order for radiology studies/procedures in your patient s chart AND call to make sure that your patient is on the schedule. Do not assume that if the order is written that it will automatically get done. Monday-Friday 8am-5pm: you need to call for fluoroscopy, interventional radiology, angiography, MRI, and nuclear medicine studies. For the most part, you will not need to call for routine x-rays, EKGs, CT scans, duplex scans and ultrasounds. On nights and weekends, you will need to call for everything except for x- rays and EKGs. After you have ordered a test, do not wait for the report to come up in the computer system. Call radiology and try to talk to a resident or attending to find out the results ASAP. As a general rule, remember that if your patient needs a test sooner than routine, a phone call never hurts. Everything is more efficient with a little love (i.e. person-to-person contact, follow-up phone call). 4. Discharge your patients that are going home. Patient discharges are MUCH more efficient if you complete them the night before. Check your patient s MAR (medical administration record) so that you can write prescriptions for their medications. With the exception of pain medications, your patient does not need to go home with PRN medications (or heparin SQ). Complete the 2 discharge sheets in front of the chart. Make sure that your patient has a follow-up appointment with your service and any other appropriate consulting services. Ask your chief resident when you should schedule your patient s follow-up appointment, then call for an appointment time. Dictate your discharge summaries the same day. Otherwise, you can count on a large pile of charts in medical records with your name on it. Remember that your discharge summary will be helpful to the next person who sees your patient at their follow-up appointment (another reason to complete your DC summaries in a timely fashion). 5. Check your patients morning labs. Alert your chief of any significant abnormal lab values so that they may be addressed early in the day. Replete electrolytes PRN. Order AM labs PRN. Remember that not every patient on your service will need morning labs, while others will. Ask your junior or chief resident. 6. At 11am, microbiology data will be updated. Check your patients cultures and sensitivities on a daily basis. 7. TPN orders are due at 1pm. If you have any questions regarding TPN, call Paula Johns (cell 258-2171). 8. Write your note and orders on one patient before moving on to the next patient. This routine will maximize your efficiency and prevent you from missing or forgetting anything. 2
9. Run the list multiple times throughout the day to make sure you do not miss anything. Update The List frequently. Check room numbers for patients that are transferred to SICU, IMC, or the floor. Add patients that are post-op admissions, and delete your discharged patients (after you have seen them physically leave Shands). 10. Prepare the pre-op notes and orders for the next day. Obtain the OR weekly schedule from each service secretary or the junior/chief residents. 11. Master the art of multi-tasking and efficiency. Find a computer with a phone next to it, and page your consults. As you are waiting for them to call you back, call radiology to schedule tests. At the same time, write down your patients labs on your list, write orders in the chart, and discharge patients. You will get used to it. 12. Make time to go the OR. Remember why you re here PREOPS: 1. All patients (inpatient and outpatient) need a pre-op note. This note is the only way to be sure that any abnormal tests are recognized the night before the operation. Alert your chief if you identify anything abnormal! Your chief and junior residents will not check these tests. They are depending on you to notify them. 2. Your pre-op orders will not be reviewed by your chief or junior resident. If you have a question regarding antibiotics or blood products, ask them. 3. Pre-op notes should include the following: Pre-operative diagnosis Planned Procedure Attending Anesthesia preferred Laboratory Data EKG (age > 40yrs or else indicated by history) CXR (age > 60yrs or else indicated by history) Blood products (if needed) Antibiotics Consent (Procedure consent AND blood consent) Verify H&P on chart 4. Antibiotics For skin operations (hernias, thyroids, parathyroids, breast, etc) use Kefzol one gram IV OCTOR. Kefzol has a short half-life so it must be given within 30 minutes prior to incision (usually given when pt is already in the OR). If your patient is allergic to penicillin, then use Clindamycin 900mg IV or Vancomycin one gram IV. Vancomycin needs to be infused over one hour, so if it is written for an inpatient, then the infusion needs to be started before the patient leaves the floor to go to pre-op holding. For GI operations, use Cefoxitin one gram IV or Cefotan one gram IV. Do not give Cefotan if the patient has any liver disease or liver metastases. If your patient is allergic to penicillin, then use Ciprofloxacin 400mg IV AND Flagyl 500mg IV. 3
For biliary operations (Whipple procedure, hepaticojejunostomy, liver resections) use Timentin 3.1 grams IV or if your patient is allergic to penicillin, then use Ciprofloxacin 400mg IV AND Flagyl 500mg IV 5. Write for SCD to BLE before pt goes into the OR 6. Peri-op beta-blockade (refer to additional print-out on this) In general, except for kids, healthy young adults w/o cardiac risk factors, and AV block or sick sinus syndrome, we should beta-block everyone before the OR. Metoprolol 5-10mg IV in pre-op, or Atenolol 50-100mg PO before the OR(unless pt has taken this already as part of home medications) 7. After your pre-operative paperwork is complete, drop them off at the OR front desk the day before the operations. 8. Bowel preps One gallon of Go-Lytely OR two bottles of Mag Citrate OR two bottles of Fleets Phospho-soda (Pt to drink all between 10am and 12pm) Neomycin one gram PO at 1pm, 2pm, and 8pm Erythromycin one gram PO at 1pm, 2pm, and 8pm Normal saline enema if patient s stool is not clear by 8pm History & Physicals/Consults 1. Always do a complete Review of Systems. Remember to specifically ask about weight loss, TIA symptoms, chest pain, shortness of breath, bleeding or clotting disorders, bloody stools, nausea, vomiting, buttock or calf claudication. 2. When you are meeting a new patient and performing an H&P, actively look for PMH reasons to cancel the patient s operation until a more complete pre-operative workup (cardiology or pulmonary clearance) can be completed. 3. Remember that your H&P will be the most detailed evaluation on the team. Your chief resident and attending are depending on you to pick up anything abnormal! 4. Dictate your H&Ps! 5. On some services, you will be the consult resident. As soon as you receive a consult, go and see your patient. Remember that you have been called because a patient might need to have an emergent operation, so evaluate them ASAP. After you have seen them, tell your chief or attending. The worst thing that you can do after you see a consult is to wait for hours before letting somebody know that the team got a new consult. Admission Orders: Admit: (Floor) / (Service) / (Attending Surgeon) ex: 64 / Surgical Oncology / Cance Contacts: (Intern or 1 st call s name) / (Service pager or 1 st call pager) & Night float pager Diagnosis: Condition: Vitals: Fresh post-ops or sick floor patients should be Q4h, others are routine Allergies: Activity: With a few exceptions, all post-ops are OOB on POD#1, ambulate on POD#2 Nursing: Call House Officer if temperature greater than 38.5 C, heart rate greater than 110 or less than 60, systolic BP greater than 160 or less than 90, diastolic blood pressure greater than 90 or less than 60 or urine output less than 30cc/hr. 4
Bilateral SCDs to lower extremities Strict I/O Chemsticks q6hr for diabetics and any patient on TPN or Tubefeeds. When pt is tolerating regular diet, change chemsticks to QAC&HS. NGT to LIWS, Foley to gravity, JP to bulb suction (if applicable) Orders for dressing changes (if applicable wet to dry BID, dry dressing QD and PRN, etc.) Respiratory: Incentive spirometer 10x/hr while awake If pt has epidural or a basal rate on PCA, then order continuous pulse oximetry Aggressive pulmonary toilet if needed Albuterol 2.5mg/Atrovent 0.5mg nebulizer treatments Q4h (if applicable) Chest physiotherapy Q4h or Q6h (if applicable) Diet: IVF: Meds: We usually use D5 ½ NS with KCl 20 meq Be cautious about fluids. If you have a patient whose rate of TPN or tube feeds is increasing, remember to decrease the rate of IVF so that the total fluids will equal maintenance. Be especially careful in patients with heart failure (don t fluid overload) or dialysis (don t fluid overload & leave the potassium out of their fluids). Ask your chief or junior if you are not sure. Pain meds (Morphine PCA 1/6/10 or Dilaudid PCA 0.1/6/1. If tolerating PO, use oxycodone 5-10mg PO q4-6hr PRN or percocet 1-2 tabs PO q4-6hr PRN) Morphine PCA 1/6/10 (Patients will receive 1mg every 6 mins for a maximum of 10mg an hr). Patients on regular floor should have pulse oximeter especially when you have a basal or continuous infusion as part of the PCA order. 1/1/6/11 (basal of 1 mg an hr infusion, 1 mg on demand every six minutes, for a max of 11mg an hr). Dilaudid PCA 0.1/6/1 (0.2 mg on demand every 6 minutes for a max 2mg hr). Try to avoid using continuous or basal rate morphine for floor patients. Do not use basal/continuous PCA for VA 5 th floor Surgery patients. If your patient has an epidural, write Page Acute Pain Service (APS) for pain control issues) Bowel regimen (Colace 100mg PO twice a day, Dulcolax suppository PRN) Tylenol 650mg PO q6hr PRN (not to exceed greater than 4 grams of acetaminophen per day from all sources) Benadryl 25-50mg IV/PO q6hr PRN pruritus or insomnia Zofran 4mg IV/PO q4hr PRN OR Promethazine 12.5mg IV q4hr PRN for nausea Insulin sliding scale & chemsticks (include how often to check chemsticks) Regular insulin SQ sliding scale: 0-75 one amp of D50 and call House Officer, 76-120 do nothing, 121-150 2 units, 151-200 4 units, 201-250 6 units, 251-300 8 units, greater than 301 10 units and call House Officer 5
You can also write a tighter sliding scale, above is only a guideline Check your patient s home medications too! Labs: Radiology: Consults: Prophylactic/Peri-operative agents Stress ulcer prophylaxis: Ranitidine 50mg IV q8hr or 150mg PO bid OR PPI (Lansoprazole 30mg dissolvable tab qd or bid). If pt has documented GI bleed, use Pantoprazole 40mg IV bid. Thromboprophylaxis: Lovenox 30mg SQ bid or Heparin 5000 Units SQ q8hr Beta-blockade/cardioprotection: Metoprolol 5mg IV q6hr scheduled AND 5-10mg IV q6hr prn HR > 90. Hold if SBP < 100. Anti-hypertensives: Labetalol 5-40mg IV q2hr prn SBP > 160. Hold if HR < 60 Hydralazine 10-20mg IV q2hr prn SBP > 160. AM BMP, Mg, Phos, CBC (and any other applicable labs) Order studies if appropriate Physical Therapy (reason: post-op deconditioning) 6