Introduction

For those of you starting this year, welcome.  For the rest of you, thank you for your hard work in making this residency what it is, and helping to update this gouge to our usual proud standard.  This gouge is intended as a, very, unofficial guide to the rotations you are about to undertake.  You need not feel compelled to read it.  That said, if you like to take pointless risks, go ahead and feel free to ignore the past experience of generations of residents who have gone before you. 

You will, no doubt hear, frequently, “For the juniors…”.  Well, this gouge is the exception.  It is for Juniors, Seniors and Chiefs alike, to remind us of where to go, how to get there and who to talk to once we do.  This is all very valuable information. 

One other thing.  There’s a few names and whatnot we’d like not to have bandied about with specifics on how we (or others) might feel about working with them, if you know what we mean.  So, please, keep these bits confidential within our ranks.

And remember, it’s us against them, not us against one another. 

Good luck to you, and confusion to the enemy; be it death, discomfort or sheer stupidity.

                                                                                                Very respectfully,

                                                                                                Tina F. Edwards, MD

                                                                                   2010’s Chief Gouger

PGY2

NMCSD ED Rotation

Get familiar with your new home for the next three years.

The ED is divided into two sides.  These may be referred to as the “high”(beds 9- 14 and G2) and “low” sides (beds 1-8 and G1) or the “blue” and “gold” side ( I can never remember which is which, but look at the clip boards and see what color clips they have to tell the difference).  There is also the “resus” room where resuscitations take place, and the “RTA” where initial evals are done, starter labs are drawn, sometimes patients are dispositioned directly from, etc. in order to keep up the ED flow.  Our Fast Track is run by nurse practioners and sees a high volume of the less acute patients each day.

As a resident, you will be in charge of one side.  Starting off as a junior you’ll be responsible for seeing 4 patients or so to start, but working up to supervising interns and knowing all the patients on your side.  We work 8 hour shifts, day (D), swing (S), and night (N).  D shift is from 0600-1400, S shift is from 1400-2200, N shift is from 2200-0600.  Try to be on the floor to relieve your fellow resident coming off shift at least 5 minutes prior to the start of your shift.

Each side will be covered by one attending.  Present your patients and your treatment plan to them as you go.

Nurses and corpsmen work 12 hour shifts and change shift at 0700 and 1900.  This is important to know because the execution of orders can cease for thirty minutes to an hour if you don’t mention that something is important and must be completed sooner rather than later.  Typically two nurses are assigned to each side of the ED, each covering half of one side (e.g. Nurse A has beds  1-4, Nurse B has beds 5-G1).  Know which nurses are working where so you can communicate with your team.

New patient charts will have a RED tag.  When a new RED tagged chart arrives, pick it up and evaluate the patient.  Circle or write down labs/studes or  you’d like to order on the ETR that is attached to the clipboard.  Pull the GREEN tag to let the nurses/corpsmen know that new orders have been written and place the chart back on the rack for orders to be executed.  Ultrasound and xray orders will be entered into CHCS by the clerks.  The resident (or intern) must order CT scans.  Remember to order them STAT or the order will not print out at radiology and the CT will never get done.  When discharging a patient, fill out the discharge instructions on Essentris, enter all medications into CHCS, talk to your patient and let them know what’s up, circle DISCHARGE on the ETR and pull the BLUE tag.

Become familiar with the airway cart and where supplies are for when you need them.  We have a glidescope for difficult intubations.  The “eye” cart is in the RTA and has a panoptic opthalmoscope and a tonopen for assessing intraocular pressures.  Fluoroscein is also in there.   There is a slit lamp in the RTA.  Alcaine is kept in the refrigerator in the fast track (the corpsmen know where).

Have fun!  Emergency Medicine is awesome. . .you’ve chosen well.

CCU

NOTICE: Beware of RRC violations. You will be remediated if you go over 30 hours. You cannot see new patients or perform procedures after 24 hours on call. You can finish paperwork for up to 6 hours afterwards, but hands off those patients. If you are asked to see a patient after 24 hours (in the ER for instance) you must say NO because of RRC violation. If they pressure you, please contact your ACR immediately to back you up. Under no circumstances are you to see a new patient after 24 hours.

 

Be prepared to take call on the first day. You may want to call the on call pager before you start to know when you will be on call.   Or you can email the Internal Medicine Chief Resident for a copy of CCU call schedule.  (Travis Harrell 2009-2010)  They usually have it available 2 weeks prior to calendar month.

Normal Start Times

Mon, Fri, Sat & Sun:  0800 ICU Xray board

Tues 0700 Cards Conf Rm – EKG lecture

Wed 0730 Cards Conf Rm – Lecture or Journal Club (usually breakfast)

Thu 0700 Cath Conf Rm – Cath Conf with Vasc Surg

Every other Tues – Morning Report with IM in Rads Conf Rm

 

The Run Down….

You are one of three residents on service.  You will be on call Q3.  There are anywhere from 4-5 interns on the service.  They are expected to do the most of the scut work.  There is a list that they prepare and update regularly which has, or should have, all pertinent patient info.  Everyone, including the attendings, depends on “the list” to get things done.  Your morning rounds (and the happiness of the attending, fellow, and in turn, you), depends on this list.  There is always some medication error or typo on the list, and then the whole cardiology team goes berserk and yells at the postcall intern which then slows down rounds.  The accuracy of this list will significantly shorten rounding time.

 

Show up 15-20 minutes before times noted above, and see if there is any last minute crap to do.  Check labs, see a patient the intern forgot, etc.  Then you will go to whatever conference.  Afterwards, you will round.  And round. And Round.  You will hear words like risk stratification, TIMI, beta-blockers, noncardiac chest pain, blah blah blah.  Then the patient will get cath’d.  Words words words cath.  You’ll see. 

 

You usually do bedside rounds with the interns presenting the patients and you fill in the blanks that are missing. 4W is the main cardiac floor with most of your patients. You rarely even present a patient on rounds unless you got so many admissions overnight that the intern capped (at five).  After rounds, gather your interns and make a plan of the day and ensure everything gets done.  You can help get some scut done, but really the interns have to do most of it.  It’s the way it’s set up.  You can be nice and help the intern you’re on call with, especially with proofreading the list, or helping the post call intern get out on time.   Post call you usually leave by noon.  Pre-call you can usually bolt by 1400 or earlier- just work it out with the on call resident, you scratch his back he will scratch yours.  On-call, the pre-call resident takes ER hits until noon Monday through Thursday.  Then you get the pagers (cards and code). 

 

The JOOD does all the admits until 1900 from the ED Monday through Friday. They will see them in the ED and admit, but you and the intern will have to write the orders and get the story again once they hit the floor.  But on the weekends and on holidays there is no JOOD and you will be seeing all the ER patients.  With this in mind try and spread load the pre-call interns with the new patients so that your on-call intern doesn’t cap early (maximum 5) and leave you having to write the HPs yourself. 

 

On Friday, Saturday and Sunday you are on your own on call because the pre-call resident is OFF.  This may result in missing all of rounds because you are in the ER evaluating new patients.  Normally, missing rounds is a good thing but on your call day it is a little tougher because you miss out getting to know the patients you will be responsible for all day/night.  Make sure your intern takes good notes if this happens.

 

When consulted to the ED you may want to stop by the cardiology clinic to make copies of the most recent Echo, cath and stress reports that the patient may have, this will help you, your fellow, and your team.  Before you even go to the ER to see someone call the EKG tech and have them fax all old EKGs/ECHOs/Cath Reports to the ER.  Ask the ER Resident/Intern to order the patients old chart and EKG from the MUSE system so that data can also meet you at the bedside. Then go to CHCSII and get the patients last clinic note/med and allergy list/problem list.  In this way you will already have an idea of the patients TIMI score and pretest probability before you even lay eyes on them. 

 

Go to the ER eval the patients and if you do not feel they will need admission write up a consult sheet and give the fellow a call with your presentation and plan. Let the ER team know your thoughts and put your consult on the chart. If you think the person will need admission than do a MRAN (medical resident admission note). This can be done on the intern’s H&P under resident’s comments. The interns caps at 5 admits a night so you may have to present and do the full H and P or do an MRAN and have a intern do the H and P the next day. Call your fellow with the plan and let the ER know.

 

An amazing portion of this rotation can be accomplished by chart and document review alone.  After you get the page from the ER call and see if it is the Resident or the Intern running the case.  If it is one of your fellow residents the case will likely require admission.  If it is the Intern, especially in the beginning of the yearly/monthly Intern cycle the case may or may not need admission.  Remember that the ER staff all have different thresholds for admitting versus discharging those patients with weak versus strong stories for chest pain and CHF.  You will rapidly get a flavor for the attendings in our department.

 

As a rule: do not give your fellow ER resident a hard time even if it is 0530 and you have already had 9 other “low probability”, very nebulous “bed-and-tread-type admits that day.  Be courteous as the consultant and get your data ready. The IM residents have a habit of trying to block ER admissions for God-only-knows-what-reasons but if you try and do that your name will be mud in the ER. And we know where you live…

 

 

Everyone needs a PT/PTT, CBC, P2, EKG, serial Cardiac Markers q6 hours until they trend down. Hold home po diabetic meds and put on SSI.  There are forms that you will need to use for the sliding scale. 

 

If you suspect an AM cath, NPO p MN, maint fluids, hold Lovenox AM dose.  If renal issues, they need Mucomyst or Bicarb drip or maybe both.  Dye allergy equals Benadryl and Prednisone.  Check all their pulses, especially DP and groins.  Post cath checks are looking for retroperitoneal bleeds.

 

If you think someone has true unstable angina, they will need plavix and lovenox. 

If patient is having NSTEMI (i.e. they ruled in), they will need to be transferred to CCU and started on integrilin. 

 

On discharge, almost everybody gets ASA, Plavix, Beta-blocker, ACE, statin, and occasionally nitro. 

 

You will have the system figured out in about a day and a half.  Call room is just off the former CCU in hallway.  Code is 12345. 

 

Bottomline: This is a good rotation in my opinion.  The hours are long, and depending on the strength of the intern, you call nights can be very, very long.  But you get to see what happens on the other side after you admit another chest painer.  It is humbling to hear Mr. So and So who you would have sent home last night, has a 90% LAD lesion with his atypical story.  You should be able to get some procedures as well including central lines and art lines.  You are there to learn as much as possible.  The interns are expected to do all the work.  You are expected to think and direct them.  Try to look like you have a clue.

Rady Children’s Hospital San Diego

General

Overall, this is considered a “low intensity” rotation.  Given the limited number of shifts that you are required to do, it’s often a rotation where you can take leave.  In the department, the attendings are good, and the tempo is modest (Unless you’re in during RSV season, in which case you’ll get to see a billion wheezers per shift).  You may be a little apprehensive at first, since most GMO’s (and IM/Transitional interns, now!) don’t see that many kids.  Regardless, once you get familiar with the “typical” pediatric complaints, you’ll get a lot more comfortable.

Check-In / Admin

Contact Gina Collier, 858-966-8036, for schedule requests and prerequisite paperwork prior to rotating there.  Fax forms to Shaela Parrott, GME coordinator, fax# 858-966-7477.  Call her to verify receipt at 858-576-1700 ext.6138.  These numbers may have changed; she is in the progress of converting to working from home.  You will need to bring or fax your orders to Gina Collier.

Check-in with Gina Collier at 7930 Frost St. Suite 300 prior to your first shift.  She will provide you with a Parking Pass/electronic door key (and validate your parking for that day).  If you have faxed Ms. Parrott your paperwork earlier, you can then go to the Badge Office to get your “badge”.  The badge is a laminated piece of paper designed to be worn with your NMCSD badge.

You can check the upcoming schedule at this website as well.  Click on the month and year to see the schedule.  Be careful, it‘s password protected to prevent unauthorized access.  The secret password is “emergency”. 

Computer Access

Ms. Parrott will arrange for the computer accounts that will be almost necessary to work, so get your paperwork in early. 

Reading

There is a list of suggest readings.  Try to accomplish as much as possible before your first shift.  Some of the general topics that can help you prepare are:

Pediatric fever (Newborn, Child<1yo, Child>1yo)

Asthma

RSV / Bronchiolitis

Fractures

Conscious sedation

Seizure

“Pediatric EM practice” has great 15 page summaries of each of these complaints (and more) which can be extremely helpful.

Shifts

You work 10 hr shifts during the week and 12 hr on the weekend. There may be a UCSD ER, PEDs or FP residents rotating at the same time.  NMCSD EM residents seem to see more patients than other residents per report from the attendings, other residents and nursing staff.  Remember that you are not running a side so you don’t have to see everyone.

There are several major areas where patients are seen.  The main area is when you first come into the ED.  The main area is fairly spread out, and there are several patient rooms near the nurses station, and additional patient rooms “around the corner” towards the check-in area (and the equivalent of the “Fast Track” area).  There are also 2 patient rooms on the opposite end of the main area, across the hall from the trauma bay.  Finally, there is a separate room off of the main ER where there are 4 beds separated by curtains.  This is the area where most conscious sedations are done for ortho reductions, sutures or other procedures.  The physician work area is a small room past the nurse’s station, on the way to the staff break room.  Past the trauma rooms is a second major area of the ER, called the “OBS” area.  There are 6 patient beds here. 

You “sign up” for patients on the computer system.  New patients will have a green highlight.  Once you sign up, you will enter your initials into one of the fields.  Patients are triaged into numbered categories 1-5.  Try to focus on 2’s and 3’s.  The staff often jump on the 1’s, but if there are many patients you’ll have a chance to see them.  They expect you to leave shortly after the end of your shift and often allow for dictation time during the shift.

Although you can see patients anywhere in the ED, it seems most convenient to work out of the Main area, or out of the OBS area.  That way you’re not running back and forth all night.  The main ED is where the procedures will be done, so if that’s your priority, staying in that area is probably best.

Trauma patients are brought into the trauma bay, and the resuscitation is generally run by the peds surgeons.  However, a peds staff will also be present, and if you ask to get involved, they will generally let you do so without a problem.

You will get a number of procedures:  lacerations, LP’s, I & D’s, procedural sedation, intubations, etc.  They use ketamine for their sedations, primarily, but they are trying to get Propofol.  Returning GMO’s will have far more experience with laceration repairs, I&D’s, and toe nail removals than most, if not all, of the other residents.  The staff may ask you to teach the pediatric residents how to do these procedures.

Dictations:

If you are not assigned your own dictation number, then use the dictation number for the staff who is supervising you.  There is a list of dictation codes on the bulletin board in the physician’s work room.

More Gouge

You can get all the critical information about the rotation at http://www.chsd.org/body.cfm?id=2022 

Mercy Trauma

Pre-Block Prep

It is tremendously useful to show up a day or two ahead of time and learn the SICU players, where the notes are, how to find vitals, use the computer, and look at CT/XR/MR.  Probably not essential, but definitely will not hurt. In the same vein, make sure you swing by the GME office, the one in the lower level (basement), and update your info.  You will need a computer password, ID badge (key to access free chow), and a dictation code (you dictate rarely  inter-facility transfer from the ICU and interim ICU summaries at block’s end).  You can get scrubs in the surgery lounge on the second deck.  Uniform of the day is dark blue scrubs.  I wore the fabulous ED greens sometimes and no one seemed to care.

Since your intern rotation…

The trauma service has taken over the 10th floor. Most floor patients will be located here. There is a telemetry unit which most ICU transfers to the floor should go to.  There is a 10th floor ICU which will take your more stable unit players. Call rooms for you, your intern, and staff are grouped together on the 9th floor with keys located in the trauma “work room” on the 10th floor, remember to return them in the morning for the next person. There is a locker room on 10 (access code 6019) to stow your valuables. You will be assigned a locker and combo lock on arrival.

Pre-Rounds

Show up at 0600, with the hour restrictions they do not want you there sooner.  The trauma conference room is on the 10th floor.  The interns will be in there getting their stuff together for rounds.  Have them print you a copy of the inpatients if not already done.  There should be “skeleton” notes ready for you, if the previous resident on call did them. These are electronic and pretty much “fill in the blank.”  Make sure the dates are all updated before you print them out.  You and the other resident, if present, are responsible for all of the Trauma ICU patients. These may be scattered across the SICU, 10th floor ICU [room 1012 on the list], MICU, and even PACU when unit beds are short.

Head down to the SICU (access code 234), on the second floor.  Start rounding. Almost all the info you need for rounds and notes is on the flow sheet and the bedside (this can be cumbersome to gather data but all the info is there). You should also check out all imaging on the Impax and get final reads for CT’s, etc.  Talk to the pt’s nurse, they have all the gauge.  Make sure you check chest tubes and record output (mark the pleurevac yourself), check for air leak.  Take down dressings and know what wounds look like.  Know all lines and have the day of the line (know what type of line).  The nurses will not have the I/O’s etc ready before 0600 and Dr. Sise doesn’t want you there earlier, because of RRC regs. Interns will pre-round with the Surgery chief resident or NP Barb at 0730 in the Dr.’s lounge on the 1st deck – optional, but an opportunity to get coffee/chow and gets you brownie points with the NP’s (who pretty much run the show and you definitely do not want to get on their bad side).

Rounds

Staff rounds begin at 0800 on the 10th floor in the trauma teaching room. The staff turns over the service to each other. It’s good to listen and interject when appropriate. Often you have more up to date info than the staff.  After staff rounds, you present the SICU players.  Every staff  likes to hear certain things when they write their notes.  Dr. Sise has his own format, which he will provide. It’s quite entertaining (you’ll see).  Typically you will go to the ICU and do staff rounds then back up to 10th floor to get the intern presentations of the floor patients.  Once they present, you will start gravity rounds, dropping off notes, seeing patients quickly through the floors.  You do not have to do walk rounds with the interns.  You do have to stay for the presentations before the gravity rounds though.

All this pain should be over by about noon but can go later. Because of RRC violations, if you are post call alert them you need to go and get out of the hospital, they are good at doing this. Make sure the interns D/C people early.  Barb and the other nurse practitioners are essentially in charge of the floor and you don’t really have to do much.  If you are transferring people out of the SICU you, your patient’s nurse will print out transfer orders – just check what you want, very easy.  Don’t forget to give the interns a heads up.  If the patient has been in the SICU for a long time, dictate and interim d/c summary.

Code Trauma

Anytime along the way you may hear “ATTENTION IN THE HOSPITAL, CODE TRAUMA, CODE TRAUMA, CODE TRAUMA” and get two pages, one is “code trauma” and the other is to call 8889-911 which is the number in the trauma bay – you don’t have to call it, just get there.  Drop what you’re doing and head to the trauma bay near the ED.  Put on the lead, gown, gloves, eye protection, etc. The interns will basically run the show, and you help along the way, stealing procedures at your convenience. Knock out the mini-H&P and admit orders during the resus and after in the CT scanner.  If there are no ER residents, the attending have been good about letting you “help” with the FAST exam and do the intubations.  Make friends with them early and ask.

If admitted to the unit, all pts need Mon/Thur BLE dopplers to screen for DVT and qMon prealbumins.  Head injured people get all the neuroprotective stuff.  Neurosurg will leave orders about HOB, mannitol, ICP, etc.

The nights you are on-call the intern will call you if there are any floor patient issues he/she can’t handle.  It’s usually easy to get fixed but if not you page the attending.  Error on the side of asking the attending (he/she is usually cool and likes to be in the loop).

You’ll get the hang of it really quickly.  It’s a lot of hours but a great rotation.  You should have another resident around to help, often one of the chiefs.  The surgery chiefs take call but don’t write notes routinely (you may not have a surgery chief).

Included are the important codes and numbers for Mercy at the bottom.  Many people have these on their palm pilots.  Just cut and paste yourself a memo.

System Access

Logon

a) SHMD, or b) shstaff, or

c) merlib

Password

a) Mercy, or  b) clinical, or

c) Mercury1

DOMINATOR IMAGING SYSTEM

USER: SHX001

PASSWORD: RESIDENT

Mercy NUMBERS

DOOR CODES

OUTSIDE DOOR: 4077

ER: 019

ER HEAD: 511

CT: 777

TRAUMA BAY: 019

TRAUMA OFFICE: 789

MALE LOCKER ROOM - OR: 355

FEMALE LOCKER ROOM - OR: 241

NURSES' LOCKER ROOM: 453

SICU: 0234

MICU: 234

10th FLR ICU: 234

10th FLR locker room: 6019  get locker and lock combo assignment during check-in

COMUPTER CODES – get these ahead of time

USER: likely your dictation number

PASSWORD:

**All #'s are pagers**

TRAUMA SURGEON: 290-2985

TRAUMA CHIEF RESIDENT: 290-3668

TRAUMA INTERN: 290-7842

ED RESIDENT1: 290-0114

ED RESIDENT2: 290-3780

DR. SISE: 619-968-1494

DR. YANG: 858-493-9663

DR. KAMINSKI: 888-219-0229

DR. KILL: 619-804-4787

DR. KROSNER: 619-641-8297

BARBARA LOME NP: 290-5151

TNTL: 290-5841/4800

BOB (CASE MANAGER) 290-4744

MARILYN (SOCIAL WORKER) 290-6468

RADIOLOGY NIGHT HAWK:

858-626-8106

BONGIOVANNI (Ortho): 619-299-5724

TONTZ (Ortho): 619-299-9090

VECCHIONE (Plast/Hand): 619-234-1674

ALTENAU (NSurg): 619-297-4481

MEYER (NSurg): 858-453-5444

V. TANTUWAYA (NSurg): 619-644-1877

NOWAK (NSurg) 858-205-2338

MIYA (ENT): 619-298-7109

AZUR (ENT) 619-294-1831

BALLON-LANDA (ID): 619-298-1443

** Hospital prefix is 619-260-****

5TH FLOOR: 7250

6TH FLOOR: 7260

7TH FLOOR: 7270

8TH FLOOR: 7280

9TH FLOOR: 7290

10TH FLOOR: 7316

11TH FLOOR: 7211

SICU: 7011

MICU: 7002

OR: 8263

ED: 3800

URGENT CARE: 7172

RADIO ROOM: 7067

L&D 5320

ER TRIAGE: 5424

TRAUMA BAY: 7182

TRAUMA OFFICE: 7019

TRAUMA CLINIC: 7022

PULMONARY: 2570

RADIOLOGY: 7036

CT: 8185

MRI: 5948

IR: 8812

NUC MED: 7034

LAB: 7030

ED LAB: 5757

PHARMACY: 7200

MICROBIOLOGY: 5012

MEDICAL RECORDS: 7190

MED PHOTO: 7034

SCRIPPS MERCY HOSPITAL TRAUMA DEPARTMENT

4077 FIFITH AVE

SAN DIEGO, CA 92103-2180

PHONE: 619-260-7285 

FAX: 619-298-3704

Remember!!!

All bolts get Ancef

DVT duplex qM/Th

qMon prealbumin

Floor

weekly DVT duplex qTues

VS Q4 on floor

NPO from trauma bay

GI proph for all

NS at maint and NPO

all pts get etoh and drug screen

all get IS and SCDs

C/S in most; +/- T/L

Daily CXRs for chest tubes

MERCY ANESTHESIA

First day, park in the visiting parking structure.  Mercy is located near Hillcrest, take Washington Street exit off 805 (or 5).  Cross street is 4th (or 5th).  You just sign your parking ticket name and write resident each day to get out for free.  Don't need to wear a uniform or anything.  Go to GME with your TAD orders (Barb puts them in your mailbox).  GME is downstairs walk in front and down the steps on immediate right.  They take your picture and you sign some stuff. Then get your ID in security (badge gets you into locker rooms – tell them you are working in the OR).  Now you are ready to work.

POC: Dr Brannigan (older female) – just find her during the first day and say hello.  Stick around with her and you will get some good education and good tubes.  Some folx say that she expects you to stay through cases, but she was fine with my drive-by intubations.

Arrive at 0700 each day to get the list of OR patients and then time your day to tube to your hearts content.  After the first round of intubations, I would go hangout near the pre-op desk and the nurses and clerks there would let me know who was good for the next tubes. Usually get out around 1330-1400. It's up to you how long you want to stay to get intubations. Some days can be slow and you may need to fight it out with some Mercy interns on service. No call or weekends. Good month to have some free time.

The OR is on the second floor.  For the guys:  When you face the automatic door to the main OR, the door on your left gets you to the locker room and lounge area - Code is 355.  Locker rooms require access via badge. Our locker is number is 87.  Combination is
30-12-6. R-L-R.  There are a couple articles in the locker. One is on RSI, good for dosing, side effects, Mallampati.  The other is a review article on anesthesia and bariatric surgery.)  For the gals:  the women’s locker room is a closet.  Get your scrubs from the anteroom to the guy’s locker room.  Take a few sets home and just wash and re-use. 

The trick is trying to figure out who wants to work with residents, what surgeons/cases where you are not wanted in the room and which cases require intubations.  This is where the nurses in the pre-op area can be great, they will steer you away from trouble, especially if you take them donuts.  Donuts are like nurse-crack:  use judiciously.

There are two OR’s, the main one and the ASC.  Each has their own schedule.  By hanging out at the pre-op area, you can get both types of cases as the pre-op area for ASC is right next to the main OR pre-op area.

There’s a doctor’s lounge you can go hang out in between cases to eat or whatever, but you’ll miss a lot of cases if you hang out there.  I recommend getting your chow and then going back to the pre-op area.  There’s a couple of consoles there you can use to surf the web, read articles, do your CORD tests and what all. 

Cases they don’t want you to go in on:  gastric bypasses or cervical spine cases.  Although some residents did anyway with certain cooperative attendings.  Try your luck, it won’t hurt.  But they definitely won’t want you to do laprascopic bypasses.  But, on the other hand, all other laprascopic cases are usually good for an ETT.

Anesthesiologists that don’t want to work with residents: WONG, ISLEY and some say PENTHEROUDAKIS although I found him easy to work with.

Surgeon’s that don’t want you in the room: ABITBOL

On alternate Wednesdays they do nasotracheal intubations on the special needs (developmentally disabled or brain damaged) folks that have to be intubated for dental procedures.  You can usually get 4-5 in one morning.

Get the morning CZAR list (anesthesiologists listed with cases/rooms) from the OR desk.  Mark off the gastric bypasses, cervical spine cases and rooms with the above listed anesthesiologists and surgeon.  Hopefully that leaves you some cases to pick from.  Look for cases that are laproscopic because you know they will be intubations.  When at all possible they use spinals, LMA’s and regional blocks so some days the intubations can be slim pickings or zero as I had one Monday.

Anesthesiologists that I worked with and would recommend:

KING, BRANNIGAN, NEFF, AUSTIN, KIM (Eung), DACANAY, MCHALE, GARAHAN, McHale, Costello, Dively, Nye.

There are many more to pick from, but you’ll probably find your faves and keep working with them.  Room 8 is the heart room.  If there’s no anesthesiology resident, or it is their conference day, you can usually get an art line or even a central line out of it.

Most don’t care if you pop in just for the intubation and then leave for another case.  I tried to meet the anesthesiologist before the patient was in the room and usually stuck around until they were starting the case.  GARAHAN expects you to follow the patient from pre-op to post-op but she teaches a lot.  She would be a good one to spend the day with if no other intubations were going on.

Ortho & O/B:

Ortho: You work in the Cast Room for 2 weeks and take no call and do not work on weekends. Try to reduce and splint any fractures you can, also perform hematoma blocks, digital block and go with resident to ER for consults. Get in good with the cast techs they will do a splinting class for you. You work with interns in the Cast Room and answer phone calls from outlining clinics on orthopedic issues, see cast room patients and respond to ER calls. I Showed up at 0800 but I think you’re supposed to be there at 0700, didn’t go to conference but they have one on Tues and Thurs morning which is rumored to be good. Ran all cases through PGY3 who taught a lot and was receptive to all questions so I pimped him on ortho/ED issues when it was slow. Grand rounds on Weds not worth going so stay and man cast room alone in the morning. Overall good rotation and easy.

OB:  This rotation takes place on 3W and your goal is to deliver 15 babies and become comfortable with the normal birthing process. Your POC is the "deck dog" who is the 3rd or 4th year OB resident who runs the OB delivery floor. Check in with them each day and let them know you are on board. You are technically supposed to work 5 days and 5 nights but you can pick your own days to work and at what time in my experience. Technically you are to work 12 hr shifts, either morning from 0500-1700 or nights from 1900- 0700 but I found this was not mandatory and I worked as long or as little as I wanted, no 12 hr shifts unless I felt I needed more deliveries that day.. As long as you get 15 deliveries it doesn’t really matter. I worked nights from about 2000 until I got tired or felt I had enough deliveries for that night. Do not see patients in the triage rooms, this is something the interns can do and is not the reason you are there. I would also recommend introducing yourself to the midwives and ask if you can watch their delivery technique and sometimes they will let you deliver. Most are pretty receptive and will help you out. This is a pretty easy 2 week rotation. Volunteer to suture the lacerations in the perineum this my be beneficial for complex laceration closures, also another procedure to log.

The Deck Dog was great and took my pager number so she could call me when a patient was near complete/complete so I could come and deliver.

1.PROCEDURES: Ortho rotation allowed me to perform reductions, hematoma blocks, casting, splinting.  Obstetrics had multiple deliveries, ultrasounds, scalp monitors, IUPCs, episiotomy repairs.

2.STAFF SUPERVISION & TEACHING: Almost exclusively supervised by residents.  Ortho cast room resident and OB deck dog.  Staff only involved rarely.  More so in OB for C sections and crash sections for example.

3.CLINICAL EXPOSURE: Saw a variety of ortho and OB patients.  Good experience for ED situations.

4.OVERALL EVALUATION & RECOMMENDATIONS: Ortho rotation is a good review.  Provides insight on when and what to consult ortho for.  Must be proactive to get most out of rotation.  Several interns on service at time.    OB was fun.  Great to get back and deliver babies again.  Can be difficult to get deliveries depending on time of year and number of interns and rotators on service.  Very beneficial 2 weeks.

PICU

CHOC Survival Guide

Two adjoining rooms, 24 total beds.  The population is divided between cardiology and non-cardiology patients.  You may have a week in the Cards side depending on scheduling.  My average census ranged between 2-9 patients, not counting days where you’re covering for other residents.  Turnover is high, however, and you’ll frequently find yourself transferring patients to other floor.  Procedures are done in the PICU like bronchs and usually don’t stay.

Our team consisted of two third year residents (including yourself), and a second year resident.  One of the team will be on the CICU side for a week, but takes call on the PICU side.  May also have a student rotating.  The calls are every 4th.  The CICU is covered qHS with NP’s.  On the weekends its just you and congenital heart diseases.

A Peds ICU fellow rotates every other month between the PICU and CICU.  The fellow doesn’t add much, but does steal procedures and order stuff on your patients that you’re unaware of.  They do not take patients.  There is one additional non-team resident “the mercenary” who will take the first two night of call that month with you to help with computer orientation.

Codes:  Hall to call room 1,2,3,4,5/call room 3299

A translator is available 24 hrs a day.  AT&T translator services are available for non-Spanish translation. 

Daily Schedule: Rounding

I generally arrived between 06:00 and 06:30 to start gathering numbers on my patients.  Depending on the previous night, you might have to take additional patients at that time.

Morning report begins at 08:00, but I didn’t make more than two my whole month.  The cardiology group rounds at approx 08:30.  If you have any cardiac patients, be prepared to give a brief summary of the patient’s current issues. 

Team rounds start at 0900-09:30.  They begin with a review of the morning’s films.  The team then rounds on the patients.  There may be multiple attendings, so you may not round with the whole team.

You’ll do a brief period of rounds again at roughly 12:00, and then again around 16:30.  A few sentences of update per patient suffices on these rounds. It’s redundant; I know.

As for 80-30 hours, it’s tough.  Your attendings will encourage you to leave post-call, but your leaving will be dependent on how efficient you and your team are.  Frankly, I felt that patient care demanded a little extra time from me, especially when the residents you’re signing out to are equally busy.  

Order Entry:

Progress notes are written; orders are placed into a computer system.  Pay attention during your computer orientation class.  The system is robust, but it has significant limitations if you have conflicting active orders.  You might have to phrase orders differently to find the right search item.  The nurses WILL come to you, frequently (q10-15 minutes), for clarification.  The most useful item in the ordering system at admission are the “Plans.”  Under the search menu for plans, simply type “PICU” and hit enter.  Multiple admission order sets, including those concerning vent management, will pop up for your selection.

Call Days:

If you’re on call, expect to take day admissions as well as admissions that night.  You can wear scrubs on the days you’re on call.  You’re given a pager for your month:  the operator will know to page you for outside admissions. 

Patients can come via different routes.  You take admissions from the adjoining St. Joseph’s Hospital ER, from surrounding hospitals, or floor transfers. 

Floor transfers are patients that were admitted to the general floor who are now deteriorating.  You will be asked to evaluate them prior to transfer in most cases.  My advice is to look at these patients prior to transfer:  some may not actually need to be transferred.  I found this out the hard way at least once. 

Admission H&Ps and Discharge Summaries should be dictated.  Transfer notes are not needed if the stay is less than 48 hours.  You will be given a dictation code at arrival.

When you’re on call, you’ll have one attending.  This attending covers both the PICU and the NICU.  Consequently, you might not be on call with a PICU attending at all.  Additionally, if an attending is dealing with a crashing child in the NICU, you may find yourself somewhat alone.  All in all, though, they were accessible and helpful if issues were truly problematic.  If you’re lucky, you’ll also be on with one of the fellows.

Keep in touch with the charge nurse.  They are the gatekeepers on room availability, so talk to them before you accept any admissions over the phone.

To be honest, most of your night will involve clarifying computer orders on the PICU patients.  This will really bug the heck out of you.  Honestly, if things are slow, don’t hesitate to go down to the resident’s lounge.  They have a computer there, and if something really needs clarification on a patient’s orders, they’ll page you.  If you sit in the PICU all night, you’ll be nickle-and-dimed to death.  Really. 

Food:

Free food all month long.  You’re given a $50 card for the CHOC cafeteria to start.  However, if you go to St. Joseph’s cafeteria, you’re not charged for your food.  This was my primary source of meals for the month.  If you make it to noon lectures, you’ll also find lunch provided.  Not a bad deal at all.

Parking:

There are two primary parking areas for your month.  When you’re on call, you can park in the CHOC clinic parking deck.  There are reserved “resident” parking areas on the 3rd level.  Off call, there’s a CHOC Associate parking garage just south of the hospital on Main Street.

My recommendation on your first day is to park in the main CHOC clinic parking deck.  You’ll get your stickers for your car that day. 

The Hotel:

You’ll be at the Extended Stay America on Katella Ave.  It has a refrigerator, microwave/kitchenette, and does have wireless internet access for $5/month.  An iron and ironing board will also be in your room.  There are coin washers/dryers on site, but there is no gym.

Books Needed:

None, really.  I brought my Harriet Lane, but there often was one in the PICU.  Drug formulations were found via book or Lexicomp via intranet.  MD Consult access is automatically provided via the network access.  You also have 24 hr access to pharmacists.  This was a big plus.

What to do:

Other than sleeping, which was my primary hobby that rotation, there are actually a lot of things to do in the area.  You live a few miles from Disneyland, and Angel’s Stadium is right next door to you.  If you like hockey and concerts, the Honda Center is directly next to you as well.  There are more than a few malls within 10 minutes of your location.  The chief residents provided me with a map of the local highlights.

PGY 3/4

La Jolla Trauma

POC: Katie Schaffer, trauma research associate, schaffer.kathryn@scrippshealth.org , office: 858-626-6822, pager: 858-494-2313, fax: 858-626-6354. Email her 1-2 weeks prior to start of rotation to complete paperwork and she will forward to GME office (most importantly is your computer password). Will need to stop by in person the week prior to pick up badge, keys, parking pass etc. You are supposed to have a meeting with Dr Simon (boss) prior to start, but that never happened in my case.  The earlier you work on getting access the better.  It came through for me on my last day there.

Four different trauma surgeons  Dr Simon, Dr Dan Dan, Dr Tominaga, Dr Schwendig.

Codes: Library and Drs Lounge  4242*

ICUs: 2468*

OR: 7420* (including OR staff locker rooms/scrubs, same hallway as Dr Lounge.)

Scripps La Jolla Trauma Reference

Trauma Docs

Codes

Fred Simon

Gary Schwendig

Library

4242*

pager: 619-998-0777

pager 619-223-9263

Doc Lounge

4242*

cell: 619-990-1344

Imad Dandan

ICUs

2468*

home: 619-437-0521

pager 619-989-4454 Scripps Trauma (La Jolla) Gouge

OR

7420*

#26534

Gail Tominaga

ER Lounge

6150*

TNTLs

858-684-8933

CCU

1236*

Christy Laflamme (night)

858-450-9665

ER

3000*

David Pedicini (day)

858-494-3842

shstaff

clinical

Debi Kosak (day)

760-602-9227

trauma bay

7*

Michael Amadeo (night)

619-200-5136

comp: 424861

nmcsd07

Nathan

Men’s lockeroom

532216*

Jonathan

TNTL cell

858-518-9050

Computer

TNTL Pager

858-494-3842

NPs

core clinical

424861/nmcsd07

Peter Schultz

760-293-0958

stentor

424861/scripps123

Kodimer, Henry

trauma 5381031

comp help

318-7500

Cheryl

Head

CT surg: 494-0833

Anne-Marie

ED Docs

Intensivists

Sean Evans

Sean Deitch

Wolcott

858-395-9525

Phil Brockel

Ian Riley

Corate

Martin Griglak

Dr. Smith

Boss ICU nurse

Amy Stack

Lisa “More-Ka-Doe”

Anthony Ferkich

Intensivist cell

858-614-2846

ER Phone Number: 858-626-6151

Katie’s Office

X 6822

Trauma Surgeon Sleep Room:  X 7125

Trauma Room X 7125

MISC-

Door-E

Phone: prefix 626

Jennifer

Lab

6016/6004

Anes

Frank Barrack

Jason Len-Hahn

Docwilder

Gary Plummer

Zeeman

A much different experience from Trauma at Mercy.  You make your own hours and that is both a blessing and a curse.  On the one hand, you don’t have to take 30 hr call and you get to pick when you do and do not want to be there. On the other hand, if you aren’t there when the trauma comes in you get to hear all about “the cool stuff you missed out on” because you were not there (and therefore must have been slacking off somewhere). On the bright side, the total absence of scut work, rounding and note writing is a nice break.  I usually got lucky around rush hour.  Friday and Saturday nights were not as trauma filled as I would have hoped.

There is a doctors lounge with snacks open round the clock.  It’s sometimes quiet enough to get some reading done.  Just bring your laptop to work on presentations, etc. There is open wireless access. I couldn’t get the pager to work in the library and there was only internet access for Medline/OVID searches. Ask for the parking lot key card the day you check in, so you don’t get stuck paying for parking.   Parking is nice and close and safe, even at night.

I have found the surgeons to be very different in terms of personality. Dandan is jolly and friendly. Schwendig is ex Navy and very personable.  Both are OK with you running the resuscitation by your self with them standing by if you need help (isn’t that the point of being a resident?). Simon is a wild card and interacts with everyone very differently. He hates Mercy Trauma and likes to talk a little smack about how they run their resuscitations. He likes you to be around when he’s on, but won’t probably remember you were supposed to be there if you don’t show up.  There is one more surgeon who we are not supposed to work with (can’t remember his name) but don’t do it.  They changed the schedule one day and I ended up being on when he was and it was just bizarre.  I never worked with Tominaga, she was away while I was there.

I had great luck with hanging out in the ED while waiting for traumas.  If you volunteer for lacs and LP’s the nurses will come find you for airways and central lines.  The staff docs were great teachers and, for as small as the place was, we saw some awesome cases.  One young guy had Stevens Johnson from starting tegretol.

MERCY ED

Check in with Tricia Frost at GME, about a week before your first shift. GME is located in basement of the main hospital building, down the hall from the auditorium. 

Just contact Trish by email at Frost.Tricia@scrippshealth.org or at (619) 260-7220

And set up a time to go sign your paperwork and get your badge. 

You will need: copy of your medical license, current TB test results, and TAD order

Please contact Dr. Jon Lee at jonylee123@gmail.com 6-8 weeks before the rotation starts with any scheduling requests.  If you don’t have any let him know that too.  He also asks that you remind him what day journal club is so he won’t schedule you.

You will work 14-15 shifts during the block (if no leave taken- 3 shift credits/wk)

The shifts are either DAY (11a-9p) or NIGHT (9p-7a).  Don’t be surprised if you work mostly night shifts.  You work in the main ED.  There are usually two staff docs which are divided in the ED into high and low sides.  You see patients on both sides and report to the respective staff. 

There is also a chest pain center off to the side of main ED which you aren’t expected to see patient’s in unless of course the staff asks you to.

There are also three rooms next to the trauma room called OR1, OR2 and OR3.  These patients are usually quick ones of lower acuity.

Respond to all the Code Trauma’s that you can.  One of the staff on in the ED will be designated to respond.  Once the primary survey is done jump in with the US for the FAST exam.  If it is a patient that may need intubation be ready as the ED resident you get to manage the airway with the ED staff.  You get first dibs before the ER resident on Trauma but of course can share if you like.

Respond to all code blue’s in the hospital.  A staff will grab the airway box with you and go to the room.  Good emergent airways in code situations.  Tube and leave.

DOCUMENTATION:  be prepared to do all the dictating because you’ll be pleasantly surprised that some of the staff will do much of it for you.  You will quickly learn who they are.  If you are busy doing procedures many staff will dictate the chart for you and let you dictate the procedure.  Some will even dictate the procedure note for you. Then there are others who have you dictate everything and even wait to go home for you to finish your dictation so they can tack on their addendum.  You will quickly learn who these are as well.  On code trauma’s some staff make you dictate everything including the entire H&P while others let you come in and do the FAST and intubate and will dictate everything for you.  Most staff will ask you to put the chart on hold with the phone and the chart so they can come in and add their addendum.  It seems acceptable to dictate your chart in two parts with an initial H&P after you see them and then the 2nd half prior to discharge/admission.  The take home point is to communicate with your staff so you know what is covered

Lots and lots of procedures.  Jump on them even if the staff was already seeing the patient first.  Most of the time they will come get you to do procedures especially central lines, LP’s, lacs and I&D’s because it saves them time.  Keep your ears open because you may miss an opportunity to run a code or intubate because you’re doing an I&D on the other side of the ED.

Be prepared for a chaotic system.

You can wear your own scrubs or acquire from the OR.

EMS

Good time to get EMS complete, work on research, observe SART exam and take vacation.

FYI, for 2007-2008…

-- No Fed Fire meetings were required

-- Mercy contact number is correct, but the contact name is outdated

Talk to Dr Sallee early before the rotation begins and let him know when you will be starting.  Do not sit back and wait to be told the dates of the upcoming required meetings (County Meetings, etc).  Again, track down Dr Matteucci early and find out when you can attend an intra-department meeting.  Keep in mind both jobs, department head and EMS director, may be yours in your post-graduation future!

911 Center observation, EMS ride along, and Mercy Radio Room can all be set up within the same week if you plan ahead early (see phone numbers below).  You can maximize your time off during this rotation if you plan it well.  Don’t be disappointed however if you’re scheduled 3 shifts during this month turn into more; you are the first to be pulled for back-up or resident disasters. 

Per Dr. Sallee:

“I have attached the EMS Rotation below. As part of this rotation, you need to contact me about when the monthly scheduled meetings are and well as other meetings of interest. Also, the San Diego Disaster Council meeting is not on the list. Yes, it is shorter, but it does not count for those of you that went. Some of you may not like EMS, but most of you will have to deal with it at some point in your Navy career, no matter how short you want or think that career may be.

This rotation is designed to give you an overview of what it is. I spend part of my time as Specialty Leader explaining to COs of hospitals why their ED physicians are wrong about certain aspects of EMS (my latest was yesterday). At least understand what is out there before you tell your next CO something.”

Resident EMS Rotation

The goal of this rotation is to gain an understanding of Emergency Medical Services (EMS) in general, and to become familiar with the unique features of a military EMS system. You will do this by participating in a focused didactic curriculum, and by gaining clinical and administrative experience with local EMS agencies. You will have the opportunity to meet with, learn from, and share ideas with some of the outstanding pre-hospital personnel who make up the EMS system in our community. At the end of this curriculum, you will have a better understanding of how you, as an emergency physician, fit into the EMS system.

Some specific goals and objectives include:

Understand the roles and responsibilities of the EMS physician. You will work with the NMCSD EMS Director during this time. Attend a total of 3 NMCSD and Federal Fire Department meetings and training sessions.

Review the treatment protocols under which pre-hospital care operates in the San Diego area. A Protocol test will need to be successfully completed. Contact Monica Norris at (619) 260-7176 at Mercy Hospital to pick up materials and to make arrangements for testing.

Recognize the role of communications and on-line medical control of pre-hospital care through observation and interaction with an MICN at Scripps Mercy Hospital and at the San Diego County 911 dispatch center. The resident will observe during one 4 hour periods, one period at each site. For Mercy Hospital, contact Monica Norris at (619) 260-7176. For San Diego County 911 Dispatch contact a supervisor at (858) 974-9891 to arrange a time.

Become familiar with the EMS quality assurance process. This will include attendance at local QA/QI Committee meetings and Physician Audit Committee. Contact the EMS Director for dates, times and locations. Attend a total of 3 meetings during your residency.

Become familiar with core concepts and contemporary research in EMS by reviewing key articles assigned by the EMS Director.

Participate in a minimum of one 8 hour ambulance ride-along. Contact Capt Saner at (619) 527-3438.

Gain familiarity with Incident Command System by reviewing the ICS 101 Level course enclosed.

Participating in at least one disaster drill at NMCSD. Contact the EMS Director.

Understanding the unique features of mass gathering medical care through participation in at least one MCAS Miramar Air Show during residency.

Participate in other ride alongs such as: helicopter, fixed wing, or water as your interest and logistics allow.

Meetings

EMS Meetings

EMS Director, Mercy Hospital, and Federal Fire Chief.

Variable times.

Contact NMCSD EMS Director

Base Hospital Physicians Committee

3rd Tuesday of each month from 1100 to 1300

Sharp Spectrum Conference Room

8695 Spectrum Center Court

Physician Audit Committee.

3rd Tuesday of each month from 1300 to 1500

Sharp Spectrum Conference Room

8695 Spectrum Center Court

Physician Supervisor Meetings

Accompany EMS Physician Supervisor to meetings and to training evolutions with paramedics in the field.

Tours

“Ride-Alongs” with San Diego Fire Department

Contact Capt Saner at (619) 527-3438.

San Diego County Communications/ 911 Center

For 911 Dispatch contact a supervisor

at (858) 974-9891 to arrange a time.

Mercy Radio Room

Contact Monica Norris at (619) 260-7176.

Reading Material

San Diego County EMS Protocols - Complete Self-Study

Prehospital Systems & Medical Oversight, 2nd Edition, Edited by Alexander E. Kuehl, 2003.

Chapter 1History

Chapter 10Response Phases

Chapter 11Levels of Providers

Chapter 17Medical Dispatch

Chapter 25Medical Oversight

Chapter 26Indirect Medical Oversight

Chapter 27Direct Medical Oversight

Chapter 31Risk Management

Chapter 32Legal Issues

Disaster Medicine by David Hogan, 2002.

Chapter 27Medical Care of Mass Gatherings

Incident Command System 100 Module

Relevant Navy Instructions

BUMED Instruction 6700.42

Ambulance Support, 1995

Additional Articles

Pepe P, et al. Effect of fulltime-time, specialized physician supervision

on the success of a large, urban emergency medical services system. Crit Care Med 1993; 1279-1286.

Alonso-Serra H, et al. Physician Medical Direction in EMS. NAEMSP Position Paper, 2000.

Post Rotation

DATE COMPLETED

Complete San Diego County Protocol Test            _____

Complete EMS Test. See EMS Director for test.

Open Book to be completed prior to successful             _____

completion of the rotation.

Complete Rotation Evaluation Form

To be completed and turned into Program Director            _____

Resident Evaluation Form completed and signed

by EMS Director and Program Director.            _____

The exact scheduling is left up to the resident (except for scheduled meetings). You are welcome to schedule in the morning, evening, or night, depending on what you want to see and do.  As always, Tuesday mornings are protected so that you can attend conference. The expected time commitment is 10 days during your residency. Make sure that you coordinate and communicate with the EMS Director.

Scripps Green ICU

Rotation is at Scripps Green Hospital in La Jolla next to Torrey Pines golf course. This is a small boutique hospital with a UCC but no ED. You will be handling patients that are admitted through the UCC, direct admits from outlying clinics and patients transferred from the ward floors to the ICU which are referred to as house staff patients. This is an important distinction as they will be followed on the weekend nights or days when there is no ICU resident by the Internal Medicine Resident on call.

The structure is set up thusly;:

There will be either an R2 and an R3 on during days during your first 2 weeks which are day shifts. You get there at 0600 and pre-round on your patients although the first day of the rotation just show up at 0630-0700 to get familiar and pick up 1-2 patients if you want to. 

After you pre-round you do a turnover with the night ICU staff to the day staff at the board.

Next is x-ray rounds where you go over all patients on the service, good teaching, you will be expected to read these and comment on lines, pertinent findings, etc.

Next you will do walk around rounds starting with the patients that are covered by the residents. The service consists of post-op patients which are taken care of by the surgical service who operated on them primarily with ICU serving as a consult service. Stay away from these, they are usually uninteresting. Other patients are direct admits from the outside and transfers from the ward (house staff patients). These are the patients you should pick up and follow. The ICU is primary on them and they usually have the more interesting diagnoses(sepsis, CHF and COPD, etc.).

For walk around rounds I usually print out the progress note from the day before and record my pre-rounding info on that for reference during walk around rounds.

After walk around rounds you will usually be excused to write notes, carry out orders, etc. On Monday and Thursday there are ICU attending teaching rounds that start around 1100-1115 in the ICU lounge area. These are pretty good and mandatory so be ready by 1100 on these days. Tuesday and Wednesday are ICU teaching rounds with the other IM interns in attendance. The first 2 weeks you will be expected to give a 15-30 minute teaching session on these days. It can be a case presentation with discussion or a formal presentation on ED stuff if you already have a canned presentation. NO PPT! Just low tech teaching. You can run a mock code if you want or get more in depth, it’s up to you and directed at teaching interns and the R2 if in attendance.

At noon there is usually a grand rounds or conference to go to with food that you are expected to go to. Sometimes worth it sometimes not. I suggest checking it out but if it’s lame just leave and get back to the unit in case there are procedures to be done. The staff more often than not will not make a huge effort to find you even if you are on the floor so make sure you put your pager number on the white boards on both sides each day and let the staff know you are available and interested. You should also call the hospital operator when you first start to let them know your schedule and pager number so you can be reached.

After noon conference come back to the floor and finish up your notes. If you didn’t get to someone in the morning and did not present him/her at morning walk around rounds you can finish them and present them at this time. You are expected to carry anywhere from 4-8 patients at a time but I suggest more like 4-6 at most. If you have a lot of patients and don’t feel like coming in at 0500 then pre-round on your sick patients first and do the stable rocks later in the afternoon. Just let the staff know during morning walk around rounds that you’ll get to these guys later and present them.

Sometimes you will be on with an R2 during days for the first 1-2 weeks and maybe a fellow as well. You will alternate accepting admission with the other resident if this is the case but if you’re alone then you accept all admits from the floor and UCC/outside clinics. DO NOT get involved with post-ops or pre-ops unless you are completely bored or the Staff beg you. There is no need and they are generally boring. You spend the rest of the day working on notes, taking care of your patients and waiting for admits. You do 1900 turnover at the board with the oncoming night staff and then you are outta there!

The schedule is M-S the first 2 weeks. You round on SAT until about 1200-1300. You are supposed to cover the other residents patients if you have an R2 on with you that week and he/she yours on SUN but I suggest you cover 1 or 2 just as a courtesy. Otherwise you are there all day writing notes.

You switch to night the 3rd week so you’ll have that Sunday off and start at 1900 the next Monday. You work M-S and on that SAT you will stay and do the rounding until 1200 with Sunday off. You have no teaching or note writing responsibilities except for any progress notes, admit notes or sig event notes so it’s much better than days.

As for note writing, there are templates available or you can just find a note written by another resident previously and cut and paste, same for admit notes. Procedure notes need to be typed and placed in chart as well as dictate, templates are available so as the Staff or Dr. Soghikian to hook you up. P-notes need to be printed out and placed in the chart daily as well as the first admit note.

Prior to your rotation contact the GME office, Barb should get you this info and it has not been included because this always changes. Also contact Dr. Soghikian about your upcoming rotation for resources like templates, policy and expectations and general gouge sheet. She is the resident/intern coordinator and very nice, loves to teach and wants you to enjoy the rotation. Dr. Serio is also an excellent teacher and you should try to work with him as much as possible.

A note on house staff patients. These are patients transferred from the ward to the ICU, not pre/post-ops. Try to remember which residents transferred them as they will go back to that resident when you tx them out.  When you leave  at night  and on Saturday you will be expected to sign these patients out to the IM resident on call. There is a fancy web-based sign out sheet for this so have one of the Scripps residents show you how to use it. When you are on nights you just turn over to the day R2/R3 at morning rounds. Not sure if there is ever a night resident to turn over to during your 1st  two weeks so you will most likely turn over to the IM resident on call. REMEMBER THESE ONLY HOUSE STAFF PTs you turn over to the IM resident on nights and weekends. But it’s all the house staff that are being followed by you and the other resident.

That’s’ all I can remember. I have included Dr. Serio’s handouts on sepsis, vents and Swan-Gans catheters. I highly suggest you read them prior to the rotation. You will look like a star on rounds and they are really simple and helpful. Dr. Soghikian’s info is below

Maida V. Soghikian, MD

pH (858)554-8860

FAX (858)554-8817

Soghikian.Maida@scrippshealth.org

Tox

Nice rotation to read and learn toxicology.  8 at home calls in the month, 2 of those are weekend calls.  Mondays are journal club and you will be expected to present one article that is assigned to you.  At the end of the month you will give a short 10-15 min handout (not powerpoint) presentation to the staff on a topic of your choosing.  The 1st and 3rd Mondays are CPC case reviews on the teleconference at 1200.  Tuesday you usually go to UCSD conference located at the 3rd floor conference room by the elevators.  Wed and Fri are call backs on poison control center cases that you find out what happens.  Things to do during the rotation include listening to PCC hotline at UCSD, attend Thurs conference, and receive at least one lecture from a staff or fellow each day you are there.  Days begin at 0930 on Monday, 0900 Wed and Thurs and 0730 on Tuesday.  Days end between 1400-1500.  You write long consult notes from the Olson text book (borrow a copy from the fellows for the rotation) on patients you are consulted on and these are good learning opportunities.

Daily rounds are held wherever the patients are – expect to drive or ride with someone to children’s or thornton UCSD or wherever…

Contact Cynthia Ona (619) 543-8254 the week prior to your rotation to schedule an appointment to do your paperwork.  She will email you a link to: http://meded.ucsd.edu/gme/housestaff/new_and_visiting_residents/ and go to “Rotating or Elective Residents” so you can fill out your paperwork ahead of time and fax it to her to expedite your visit.  The GME office is located right above the tox office in the same building.

Tri-City

Long commute to south Oceanside.  Work the B or C side with one staff for a 7 hour shift with the last hour or two for cleanup of patients.  Pick up new patient for 7 hours and then finish your work.  Steve Gabriel is contact, nice guy Stevengabriel@yahoo.com  858-699-5427   He’ll meet with you about ½ hour before first shift for orientation.  He’s very flexble with planning schedule but does it late.14-15 shifts with shift credit for vacations.  Elderly population and lots of nursing homes.   Whole system is computerized for discharge, orders, order sets and takes time to get used to but can create favorites and would recommend doing this as it makes things easier.  Some ex navy people work there.  Darin Garner is one and Dr. Tanen and French moonlight there. Try to use the glidescope they have for intubations to have experience with the device.  Everything moves very fast including radiology studies so be prepared to move patients quickly. 

For your third year, they only expect you to carry 4-5 patients at a time, at most.  During your chief year, they will expect you to carry a side.  If you are working the C side, you cover the resuc room, and you will tend to get resuscitations regularly.  If you haven’t’ done this already, I recommend having your own handy pocket resuc reference, with your favorite drugs and whatnot, because things move very quickly.  The system is set up for the physician there, and everyone is working to make you more productive.

Physicians do all procedures there, including NG tubes, for billing purposes.  There are PA’s who do these procedures as well, and they are happy to let you do whatever procedures you want to do.  You can get a lot of lines and tubes.   Also, the staff is probably not as experienced with ultrasound as you are, so you can show them new and interesting ways to use their machines. 

Tri-City has scribes.  This is a novel experience we think you will enjoy.  Primarily the scribes work for the attending, and some attending will have the scribes go with you and some attending will keep the scribes to themselves.  In any case, you can use the scribe’s note as a reminder to you when you dictate your own note.  For whatever reason, for now, they have the resident dictating a full note even though the scribe is also putting in a full note.  The advantage of the scribe note is that it has all the bells and whistles for billing.  If you have an interest in learning more about billing, I suggest paying attention to what the scribes are putting in their notes. This will tell you a lot about what you should be putting in your notes back at our ED to help us keep up the RVU’s—and of course, for the future when you are slaving away for you own lucre.