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Pearls of Cross CoverJason 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.”