Intern Survival Guide Part 1

CARDIAC SURGERY
Intern "Survival" Guide

Kirk J. Fleischer, M.D.
 

1. Meet with fellow between 5:15AM and 5:45AM (Monday through Saturday)
   6:00AM and 6:30AM (Sunday) » Depending on fellow and patient census
2. Preround for:
   vital signs and fluid balance (from data board) 
   Rhythms (from telemetry at RN station)
3. CSICU rounds begin at 6:15AM (Mon through Sat) and 8:00AM (Sun)
4. CSICU rounds end between 6:45 and 7:10AM
5. Fellow expected in O.R. by 7:30AM
6. Teaching conference is held in the Cardiac Surgery office (Blalock 618) at 8:00AM on M, T, W, and F.
7. Pre-CPB time » Routine questions can be answered by fellow in O.R. during this time
8. Avoid disturbing case once on CPB (see below)

AM ROUNDS

1. Usually late afternoon/early evening
2. "Card rounds" (day's events, labs, CXRs, etc.) with examination of selected patients

PM ROUNDS

Due to the demand for focused precision in cardiac surgery and the great importance of aortic cross-clamp/CPB duration, interruptions of cases must be kept to an absolute minimum. Here are some recommendations of how to deal with the spectrum of problems on the wards.

1. Page fellow
2. If fellow not immediately available (unable to leave O.R., etc.), call CSICU for assistance from the senior resident in the unit or attending

Emergent problems on floor:

Problems that need to be addressed before fellow out of O.R. (cardiopulmonary instability, discharges/rehab transfers, etc.):

Call O.R. and ask to speak with the circulating RN » ask if you can interrupt surgeons for a question or when you should call back/come by O.R (Note: A visit to the O.R. is always preferred).

Problems that need to be addressed before evening rounds (i.e. between cases):

Making a list of questions that the fellow can think about and/or discuss with attendings in the brief break is extremely helpful. Please leave this list attached to the fellow's pager in the O.R. (In between cases, the fellow often has less than 30 minutes to transport the first case patient to CSICU, see the next patient's films, speak with attendings about ongoing ward/CSICU problems, and get a quick bite to eat)

Your best first resource if a fellow is not available are the nursing case managers who have considerable experience in the management of the cardiac surgery patient. They can also assist in evaluating the acuity of the problem.

1. Preop information
   
   1. Medications
   2. Arrhythmia history
   3. Weight
2. Current medication record from the pharmacy
3. Laboratories including cultures
4. CXR results

At the minimum, the "Book" should contain the following for each patient

1. VS and heart rhythm
2. Problem-oriented physical exam
3. Reason why patient requires in-hospital care (anticoagulation, IV antibiotics, O₂ requirements, arrhythmias [esp. atrial fibrillation], infection, etc.)
4. Plan

DAILY PROGRESS NOTE

May be brief, but should include:

Remember to date and time all notes.

EVENT NOTE
Critical for cross-cover. Include a brief description of event and what interventions were performed (both successful and unsuccessful).

POD 1

Transfer from CSICU to "step-down" unit monitoring (Q2 - 4hr VS, I/O's and nursing assessments; telemetry +/- O₂ saturation monitor in room; intermediate care unit). If aggressive diuresis necessary, central line and foley catheter left in place.

POD 2

Down-grade to standardpostop cardiac surgery ward monitoring (Q4hr VS and I/O's for 1st 24 hours then Q8hr; Q8hr nursing assessments, no monitor in room, remote telemetry). Ambulation in halls. (Note: At this time, there is no Level 2 or 3.)

POD 3

Routine CXR and EKG. +/- Removal of pacing wires. Continue PT and diuresis.

POD 4 - 7

Discharge home. General requirements for discharge include:

1. Minimal diuresis remaining (Lasix PO QD for 2 - 4 days)
2. No supplemental oxygen requirements
3. Clearance by PT (or arrangements for home PT)
4. Afebrile for approximately 24 hours
5. No arrhythmia for approximately 24 hours

Staples may be removed prior to discharge

1. The "OR Board" in Cardiac Surgery office has the most up-to-date operative schedule. During the day, the secretaries usually notify the on-call intern with changes in the schedule, but checking the board every few hours is the safest practice. After 4:30PM, the fellow will call the intern with new pre-ops; unfortunately, it is the rule rather than the exception that the schedule changes every evening.
2. All patients should have a preop note the night prior to surgery. If a note has been completed previously (case cancelled,etc.), a brief updated note is necessary with new lab, UA and CXR information.
3. Call dental consult early if there is any concern about dentition in valve patients
4. Setup carotid duplex* if:
   
   1. Bruit
   2. Radiation of any murmur to neck (except in young patients)
   3. History of TIA/CVA
   4. Elderly patient with known significant PVD

   * If before 4:30PM, vascular laboratory (955-1425) is best for carotid studies. Otherwise, call the radiology department (daytime: 955-6800; evening and nights require calling the censor in the ER at 283-RADS ).

5. If > 10 mm Hg difference in brachial SBP, confirm with Doppler at bedside. (Why? The LIMA may not be used if left brachial BP is significantly less than the right » concern for steal phenomenon after bypass.)
6. Have patient stand or at least hang legs over side of bed to rule out significant varicose veins (Important part of physical exam! If veins are varicosed, a plan for alternative conduits must be made prior to surgery.)
7. Document if distal pedal pulses (PT and DP) are palpable or dopplerable. This information is crucial for the early postop evaluation of the patient (especially if an IABP in place) » Pedal pulses provide important clinical evaluation of peripheral perfusion; furthermore, if pulses are not obtainable postop, one must decide whether to urgently consult vascular surgery.
8. See preops early in day for initial evaluation:
   Are labs, T&C, UA, CXR, and EKG current? 
   Is dental consult needed? 
   Is carotid duplex indicated?
   (See Role of the Thoracic Surgery Intern)
9. Notify fellow if:
   
   1. Poor dentition (in valve patient)
   2. Concern about carotid A. disease
   3. BP discrepancy
   4. Varicose veins
   5. Called by cardiology HO about chest pain or fevers during the night prior to surgery
   6. No consent in chart
10. Standard preop orders:
    
    1. NPO after MN except meds with sips. No maintence IVF.
       (Exception: Pediatric cases may have a different time for NPO and may receive IVF » check with the on-call fellow)
    2. Heparin drips should be continued to the O.R.
    3. Ancef (or Vancomycin if allergic) 5 gm taped to front of chart
    4. Hibiclens scrub x3 to chest, abdomen, and legs
    5. Nitroglycerin tabs 0.4 mg taped to front of chart
    6. D/C Aspirin
    7. Note: No SCDs/TEDs necessary for cardiac surgery patients
11. Type and cross
    
    1. Number of units of PRBCs:
       

       	Adult	4 U
       	Redo adult	6 U
       	Pediatric	Check with fellow

    2. Have blood sample drawn early » some patients have antibodies that require up to 12 hours to cross-match for blood
12. *Transfers from outside hospitals:
    
    1. Coordinated by the Hopkins Access Line ("HAL").
    2. If patient has not arrived by 11AM, call HAL (5-9444) and ask what is delaying the transfer. Repeat calls approximately every 2 hours until arrival.
13. See sample "Preop Checklist" sheet

1. Patient cross-cover:
   Patient sign-out should very briefly summarize the status/recent course of each patient. (Taking a few extra minutes to give a complete problem-oriented sign-out not only can save the covering intern hours of guessing what the best therapy might be, but it also may save a patient's life.
2. "Scut work":
   
   1. The fellows should be aware of tasks that are being signed out to the cross-covering intern.
      
      1. Routine labs (coags,etare the most common studies to be checked at night. Others include following up on a therapeutic plan initiated by the fellow (diuresis, respiratory therapy, etc.)
      2. CXRs should rarely be signed out to the on-call intern at night. Results of routine films should be found during the day and those for active problems cannot wait for the cross-covering intern to locate and have read by the E.R. censor. Finding films at night may be time-consuming and difficult due to staffing.
   2. Labs/CXR whose results might potentially prompt a more than routine intervention (i.e. transfusions, chest tube, transfer the CSICU for observation, etc.) should be dealt with prior to sign-out.
      
      1. The on-call intern is responsible for 30 - 40 patients, completion of preops, and all CSICU transports »any of these may distract him/her for hours from an ongoing problem.

1. Progress notes
2. AM census sheet: Include patients admitted to CSICU from OR that day
3. Anticoagulation plans for on-call intern
4. Prescriptions for patients to be discharged in AM
5. Have all pacing wires & chest tubes been removed? (Must be done before 3PM » If later, call fellow)
6. +/- Write for daily MgSO4 (check with fellow for the current protocol)
7. Are there any evolving "problem patients" ?

AFTER RECEIVING SIGN-OUT, THE ON-CALL INTERN SHOULD HAVE SPECIFIC INSTRUCTIONS FOR:

1. Anticoagulation » Specific parameters for beginning/changing heparin drips, etc.
2. Plan/algorithm for cross-coverage of "problem patients"
   
   1. A clear plan must be passed on to the covering intern » treatment algorithm established by the primary fellow prior to leaving
   2. Obviously, the patient's attending and the covering fellow should be aware of these patients

DAILY "TO DO" LIST PRIOR TO SIGNING OUT

 

***Unlike some other services whose patients are relatively healthy from a cardiopulmonary standpoint and thus will tolerate significant delays in appropriate management of arrhythmias, etc., cardiac surgery patients often have little reserve. Be proactive (not reactive) in your management of their problems!

THURSDAY
7:30 AM to 8:30 AM: CMSC 906 (Garrett Room) or Ross 703.

DAILY (M, T, W, and F)
8 AM to 8:30 AM: Blalock 618 Conference Room.

Cardiac surgery attendings meet for small group teaching sessions with housestaff and students. A tremendous learning experience and a unique opportunity to ask any question about cardiac surgery. Please make every effort to attend.

 

Cardiac Surgery Grand Rounds. A variety of speakers from cardiac surgery, cardiology, cardiac anesthesia, perfusion services, etc.

1. Decisions regarding changing a patients monitoring status should be approved by fellow.
2. Do not routinely leave tasks for the on-call person that could be completed prior to your departure.
3. Sign-outs between interns are critical » you should be comfortable managing the cross-cover problems before your partner leaves. If not, please ask the red/blue fellow to assist in developing a management plan for the night.
4. If you oversleep (and it happens to everyone), do not speed but you should be in hospital in less than one hour after you awaken. » You are an integral component of the ward team.
5. Do not tell transplant candidates (i.e. Novacor patients) about potential transplantation until informed directly by fellow to preop patient.

Role of the Thoracic Surgery Intern

The thoracic surgery intern has the following duties:

Coverage of thoracic surgery patients (service and consults) [this includes dictation of all discharge summaries.], preop all in-house thoracic surgery patients (Qday)*, admit (write H&P) all same day admissions thoracic surgery patients (QAM)*, assist in thoracic surgery cases (either first or second assistant depending on the number of cases), cross-coverage of cardiac surgery service Q 3 days, preop in- house cardiac surgery patients Q 3 days**

* Regardless of intern "on-call status"

** Often, the thoracic intern is available during the day to begin the cardiac preops before lunch. However, in the event that he/she is in the O.R. for part/all of the day, several aspects of the preop must be initiated early by the "off-call" cardiac surgery interns. It will be the responsibility of the thoracic intern to contact the cardiac surgery intern(s) and notify them of his/her O.R. status so that the following can be performed:

1. Order preop labs (including T&C/UA) and CXR
2. Evaluate all patients for possible carotid duplex study Performing this early is important so that:
   
   1. "Better" quality study might be performed by the Vascular Lab (Osl 6)
   2. Vascular surgery can be consulted
   3. OR schedule can be changed to accommodate the addition of a CEA
3. Evaluate all valve patients for dental consultation Performing this early is important so that:
   
   1. Dental consultation may be performed while their clinic is still open during the day
   2. Permit the case to be canceled (if extraction necessary) and another case awaiting a time slot can to be added to the schedule in a timely fashion

Ultimately, the "on-call" thoracic intern is responsible for completion of the preop notes. There are rare situations where the intern may be assisting in the O.R. until late into the evening. On these occasions, the "off-call" cardiac intern may be asked to assist in the completion of the preop notes while waiting for the thoracic intern.