Sub-I Medicine

Discussion in 'Clinical Rotations' started by Voxel, Feb 27, 2002.

  1. Voxel

    Moderator Emeritus

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    Just wondering if someone can give me a heads up on some common things that come-up when one is cross-covering during sub-I? Also, have you had a problem with interns dumping stuff during sign out they should have been able to get done during the day and how have you handled this situation?
     
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  3. dbiddy

    dbiddy Member

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    You should not be cross-covering during a sub-I. The intern on your team should be doing that. How can you cross cover if you can't write orders without someone cosigning?
     
  4. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by dbiddy:
    <strong>How can you cross cover if you can't write orders without someone cosigning?</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Messy signature?
     
  5. Voxel,

    I'm not really sure that interns can dump that much stuff during sign out to you (even if you are doing a sub-i).

    Speaking from the point of view of an intern, there's nothing more annoying than interns who dump stuff to you during sign out. It is absolutely amazing to me how many labs get ordered at 6 P.M. instead of at 2 P.M. or 4 P.M. Granted, sometimes they are necessary at a specific time, but often they are not. Anyhow, I'm not really sure you can question an intern as a medical student, but as an intern, I often grill the intern so they at least feel guilty if they are dumping on me.

    If there is lab work, CT scans, etc. that are ordered after sign out, I'll ask them why the lab work wasn't ordered earlier and what they are worried about. If you are worried about a low HCT, CHF, PNA, MI, etc., ask them what they want you to do with the information (especially since you are a medical student still). Yes, you can figure out how to treat a standard MI, CHF, etc., but sometimes attending have specific things they want done or the patient may have other co-morbidities that prevent you from giving the standard treatment. When you are cross-covering, you really don't have time to sit there and figure all this stuff out. Have them write down exactly what they want done for what they are worried about. Personally, I never sign out CXRs, CT Scans, EKGs, etc. I sign out very little lab work as well and anything that can wait until the morning should wait until the morning. Unfortunately, many interns make diagnoses by CXR and lab work rather than relying on clinical judgement. We have interns that will order daily CXRs on patients with CHF or PNA.

    Also, be aware of how much you sign out as well. Do you dump on other interns? Often, the ones who complain the most about getting dumped on are also the ones that dump a lot on their sign out. This often becomes a vicious cycle. Make sure you don't sign out too much stuff before you give another intern a hard time. On several occassions, I've refused to let an intern sign out an unstable patient or some BS lab work in the middle of the night. I've actually told them to cancel that order and either order it in the AM or earlier that night.

    I actually have a really good relationship with most of the interns because they know that I do my work and don't dump on them. Also, I follow up on almost everything the sign out as long as the tests were warranted. Many of the annoying calls in the middle of the night can be avoided by giving parameters. Personally (depending on the patient), I have parameters for potassium, HCT, fevers, urine output, etc. including when to call H.O. Unless contraindicated, almost all patient get prn or qhs orders for sleep, pain, nausea, no BM, etc. The night float loves me and many of the interns have copied some of these standing orders. Obviously, you have to use your clinical judgement as to which patients you can't do this for. Often, however, you will find that you get called with silly things in the middle of the night and all too often, you are just baby-sitting nursing home residents or patients looking for placement.

    Things that you will often get called about and you should learn how to manage are:

    1. Fever
    2. Chest Pain
    3. SOB
    4. Pt. fell out of bed
    5. Low urine output
    6. Mental Status changes
    7. HCT of &lt; 27
    8. Bleeding
    9. Abdominal Pain
    10. Increased or decreased HR, BP, and Glucose.
     
  6. Voxel

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    Any books you know of that has an algorithms for management of these TOP 10 encountered problems? Any specific recommendation for standing orders on your patients (baring any contraindications of course).
     
  7. jdaasbo

    jdaasbo Senior Member

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    I had cross coverage on my sub I, 20 to 30 patients. My Senior was the person I contacted when I needed orders "co-signed."
     
  8. dbiddy

    dbiddy Member

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    That sucks for you and your patients.
     
  9. Goofy

    Goofy Senior Member

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    Vox,

    Check out Interns survival guide. There is a palm format for this as well. This small book will get you through about 85% of late night pages.
     
  10. jdaasbo

    jdaasbo Senior Member

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    A little bit self righteous bdiddy?
     
  11. dbiddy

    dbiddy Member

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    Maybe so. I call em as I see em.
     
  12. Voxel,

    Check your private messages.
     
  13. Voxel

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    Thanks ST. Check your PM
     
  14. Pinky

    Pinky and the Brain

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    I've heard stories about one intern who used to give everyone he was cross-covering tylenol as "prophylaxis" for fevers so as not to be called as often. The story goes that his actions were eventually discovered and he was disciplined (dismissed from the program). I don't know if this is a real story or just another one of the many medical urban legends out there.
     
  15. denise

    denise Member

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    I will have to say as an intern, I think it is kind of risky to write for too many prn meds. The only one I write for is Restoril (that is what my hospital uses). I usually do not even write for tylenol for temps, only if the pt came in with one and I have already evaluated them. Actually, the way I look at it is I am staying the night at this place, so why not just get up and go see the pt! Just this year, I have seen haldol given (by the intern) for "agitation" reported by the nurse, one guy had acute CHF (low O2 can make anyone funny) and the other guy perforated his tic and was septic (it is amazing what sepsis can do). See, as soon as that nurse calls you, he/she writes in the little chart, Dr. X notified. So, now it is your butt on the line. Actually, I just had a case this week, the nuclear med tech calls to tell me the pt (whom has Downs and a major VSD) will not lay down for his HIDA scan. So, I said "I'll be there in a minute" Well, I go there, and sure enough Buddy does not want to lay down. Remember, he has Downs, so I start asking him questions. I look down at his O2 tank, and it is empty!! I was upset, and did a little talking to the tech. His pulse Ox was 80% on rm. air. He came down on 6L n/c. So, another reason. . .We are interns and residents, it is our job to evaluate as much as possible; just get up and go look for yourself!!
     
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  17. ghostcow

    ghostcow Member

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    fine point but...6L NC is very uncomfortable, try it, anything above around 4L NC and should move on to a diff. O2 delivery system.
    PEACE
     

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