Common on Call Complaints...Tried Again

[OveractiveBrain]

What are some of the most common on call complaints and how do you deal with them?

Fever
Pruritis
Hypertension
Pain
Shortness of Breath
Chest Pain
Altered Mental Status
Hypoglycemia
Hyperglycemia

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[squareknot]

Dude, go on amazon and type in "on call medicine" or "on call surgery" and you will get a slew of books. pretty standard stuff.

 

[jdh71]

What are some of the most common on call complaints and how do you deal with them?

Fever
Pruritis
Hypertension
Pain
Shortness of Breath
Chest Pain
Altered Mental Status
Hypoglycemia
Hyperglycemia

Go see the patient and decide . . . doctor

Any doc that can be replaced by an "on call" list of ailments and treatments, should be

 

[Doctor4Life1769]

Go see the patient and decide . . . doctor

Any doc that can be replaced by an "on call" list of ailments and treatments, should be

Props, that sounds very much like Dr. Cox; but nonetheless, the message is clear and very true.

 

[DD214_DOC]

Go see the patient and decide . . . doctor

Any doc that can be replaced by an "on call" list of ailments and treatments, should be

Don't pretend that we have done anything more than memorize information and algorithms from a book. That's essentially all it is.

 

[jdh71]

Don't pretend that we have done anything more than memorize information and algorithms from a book. That's essentially all it is.

I'm not pretending anything. While we generally treat certain things a certain general way, but there is nuance given the clinic picture and scenario every single time. Things change the game all the time. Benedryl for an octogenarian? Ha! Why don'y you just give him a bottle of wild turkey. There is no "always do it this way sleep algorithm", you need to think about it doctor.

Any doctor who can be replaced by a computer algorithm . . . should be.

EDIT: There will be a certain time of the year when interns know enough about medicine and their patients that they do not need to get out of bed on every call, but sending and intern into their first few months of call with simple algorithms is irresponsible and hurts their education.

 

[PMPMD]

What are some of the most common on call complaints and how do you deal with them?

Agree with above. SEE THE PATIENT. But here are some things to consider when you're on your way. This is not meant to be complete, just the basic LIMITED DDX's to get your gears turning at 0300.

I strongly recommend coming up with your own ddx lists, these are from my own that I put together for oral board prep.

Again, this is not meant to be comprehensive, use at your own peril. I'm an anesthesia resident, so some of these are more geared to OR, PACU, SICU.

Fever - If postop, consider 4 Ws (recent data shows atelectasis is NOT a true cause of postop fever.) Also think about thyroid, MH, NMS, transfusion rxn if likely. Consider infectious w/u if appropriate: panCx, etc.

Pruritis - Again, depends on pt. Common if receiving opioids (esp neuraxial route). Also BUN, NH3, bili.

Hypertension - why is pt HTNsive:
baseline,
pain, anxiety,
ICP,
autonomic hyperreflexia,
hypervolemia,
hypercarbia,
hypoglycemia,
hypothermia,
pheo,
thyroid,
drugs (vasopressors, MAOIs, TCAs, cocaine), etc.
Investigate for signs of end organ damage. Don't overtreat (20% of baseline acutely.) If pheo or AH, alpha block before beta to avoid unopposed alpha stim.

Pain - Ummm be more specific here as to location, severity, acuity.

Shortness of Breath - SEE THE PATIENT. Tx depends, consider ddx:
Intrapulmonary problems (COPD, RLD, Asthma, Atelectasis, ARDS, PE, PTX, Pulm edema)
Systemic dz: sepsis, acidosis, hypoxia, shock, fever
Heart failure (CHF, CM)
Diseases of chest wall (MG, polio)
Airway obstruction (intra- or extrathoracic)
Anxiety/pain

Chest Pain - MUST SEE PT, can ask for EKG/troponins on your way if suspicious for ACS. Consider ddx.
·CV
o MI/UA
o Pericarditis
o AS
o Aortic aneurysm
·Pulmonary
o Pleuritis
o PNA
o PE
o PTX
o Lung CA
·GI
o GERD
o PUD
o Cholecystitis
·MSK
o Costochondritis
·Other
o Zoster
o Anxiety

Altered Mental Status - clarify whether delirium, dementia, decreased level of consciousness, etc *Compare to baseline. Ask for full set of VS, +\- ABG. SEE PT.
·Hypoxia, hypercarbia
o Mechanical, surgical, patient
·Pain
o Surgical, full bladder
·Meds
o Inhaled anesthetics, NMBs, opiods
o Ketamine
o Scopolamine
o Droperidol
o Steroids
·Metabolic
o Hypoglycemia
o Hyponatremia
o Uremia
o Hypercalcemia
o Thyroid storm
o MH
·Infection
o Meningitis
o Sepsis
·Neuro
o CVA, TIA, aneurysm rupture

Tired of typing on my iPad so I'll let someone else do the last 2.

Hypoglycemia

Hyperglycemia

 

[jdh71]

You forgot "alien baby". I've seen the movies and that's some chest pain right there.

 

[PMPMD]

You forgot "alien baby". I've seen the movies and that's some chest pain right there.

Yeah i have a separate list for deep space mining expeditions.

 

[PMPMD]

You forgot "alien baby". I've seen the movies and that's some chest pain right there.

this is why you have to SEE THE PATIENT:

 

[OveractiveBrain]

You forgot "alien baby". I've seen the movies and that's some chest pain right there.

I guess the usefulness of SDN's helpfulness terminates when people reach MD status. I know how to handle common on call complaints. I was trying to create a thread where people actually contributed their method for handling typical call complaints. Since the first one failed, and became a ranting session for useless posters, I thought I'd try to reopen the topic. I guess only ONE person cares about sharing their ideas. Everyone else has something useless to contribute, like "DONT FOLLOW ALGORITHMS!" or "READ A BOOK!" Which of course translates into "crap, i don't actually know how to handle these complaints... I'm worried my method wont stand up to SDN ridicule."


I wasn't looking for a diagram, was looking for people's feedback, what they thought, what they'd learned, some pitfalls they've encountered and lessons learned. Amazing that a useful thread like this has failed twice...

I suppose it would have been more beneficial to open ANOTHER thread about how to do well on Step 3...

Awesome guys. Awesome.

 

[Smurfette]

The responses may have been more useful had the original "common on-call complaints and what to do" thread was not still a few threads down on the page. Trying within the original thread (and a link from the sticky thread in this forum) to get it back on-topic to what you would like to discuss may have worked better than having people see what looks like another redundant thread, IMO. It is very common on SDN for people to repeatedly ask the same questions instead of doing a search first, and the responses to these threads are often less-than-helpful as a result. And insulting other posters generally only makes the situation worse.

And, if "you know" how to handle on call complaints, why did you post a new thread asking for, instead of a useful post in the original thread sharing this knowledge that could become a useful tool for up and coming interns? You could instead have posted *your* algorithms and others may have responded in kind or asked questions about them. There are multiple posters in the other "front page" thread who are likely to respond in a positive manner to such a post. Obviously it's frustrating when a thread doesn't get the responses you would like, but sometimes a different approach may work, or an in-thread non-ranting attempt to get it back on track.

Will stop contributing as I am not useful....I have MD status.

 

[jdh71]

I guess the usefulness of SDN's helpfulness terminates when people reach MD status. I know how to handle common on call complaints. I was trying to create a thread where people actually contributed their method for handling typical call complaints. Since the first one failed, and became a ranting session for useless posters, I thought I'd try to reopen the topic. I guess only ONE person cares about sharing their ideas. Everyone else has something useless to contribute, like "DONT FOLLOW ALGORITHMS!" or "READ A BOOK!" Which of course translates into "crap, i don't actually know how to handle these complaints... I'm worried my method wont stand up to SDN ridicule."


I wasn't looking for a diagram, was looking for people's feedback, what they thought, what they'd learned, some pitfalls they've encountered and lessons learned. Amazing that a useful thread like this has failed twice...

I suppose it would have been more beneficial to open ANOTHER thread about how to do well on Step 3...

Awesome guys. Awesome.

Kid, first let me say, good luck and congrats starting residency. This is a big step and finishing medical school is a big accomplishment.

Now, my method for handling "common on call problems" is to go see the patient. I'm done with residency in 6 weeks. I'm not worried about my method and ridicule. There is nothing on your "common on call" list I can't deal with standing on my head. And perhaps some of this is my fault for lack of effective communication but there is NO magic list. Look at the "chest pain" list above? You NEED to go figure it out, and an exhaustive list of what you need to ask, exam, labs to look at, other tests to order is something you will have to learn, if you do not already know it. That's why you do residency in the first place. If I give you a thoughtless list, then you don't learn, and if you don't learn, it is MHO, that you are not a physician but rather a technician. Did you go to medical school or PA school?

Doctor . . . go see your patient and decide.

 

[PMPMD]

Kid, first let me say, good luck and congrats starting residency. This is a big step and finishing medical school is a big accomplishment.

Now, my method for handling "common on call problems" is to go see the patient. I'm done with residency in 6 weeks. I'm not worried about my method and ridicule. There is nothing on your "common on call" list I can't deal with standing on my head. And perhaps some of this is my fault for lack of effective communication but there is NO magic list. Look at the "chest pain" list above? You NEED to go figure it out, and an exhaustive list of what you need to ask, exam, labs to look at, other tests to order is something you will have to learn, if you do not already know it. That's why you do residency in the first place. If I give you a thoughtless list, then you don't learn, and if you don't learn, it is MHO, that you are not a physician but rather a technician. Did you go to medical school or PA school?

Doctor . . . go see your patient and decide.

 

[OveractiveBrain]

Kid, first let me say, good luck and congrats starting residency. This is a big step and finishing medical school is a big accomplishment.

Now, my method for handling "common on call problems" is to go see the patient. I'm done with residency in 6 weeks. I'm not worried about my method and ridicule. There is nothing on your "common on call" list I can't deal with standing on my head. And perhaps some of this is my fault for lack of effective communication but there is NO magic list. Look at the "chest pain" list above? You NEED to go figure it out, and an exhaustive list of what you need to ask, exam, labs to look at, other tests to order is something you will have to learn, if you do not already know it. That's why you do residency in the first place. If I give you a thoughtless list, then you don't learn, and if you don't learn, it is MHO, that you are not a physician but rather a technician. Did you go to medical school or PA school?

Doctor . . . go see your patient and decide.

Explains why you're also so curt and generally useless in the Medical Student forums. You must have enjoyed residency... going private I hope...

Again you missed the point of the thread. Thanks though.

 

[Doctor4Life1769]

Explains why you're also so curt and generally useless in the Medical Student forums. You must have enjoyed residency... going private I hope...

Again you missed the point of the thread. Thanks though.

Dude's an excellent clinician and will be starting a fellowship. You should take what he says to heart. He's been there and knows how it is. You're acting like a pre-med here. I definitely plan to see every patient I'm called about, regardless of how "minor" it may be.

 

[smq123]

Explains why you're also so curt and generally useless in the Medical Student forums. You must have enjoyed residency... going private I hope...

Again you missed the point of the thread. Thanks though.

No need to call jdh "useless," or to make this personal.

There's no substitute for learning how to find your own way. I can tell you how to handle all of those complaints until I'm blue in the face - but the only way that you'll KNOW how to handle them is by experience. And that comes from looking at the patient, at least in the beginning.

There is no "method." And my method that works for me may not work for you. And the possibilities for what is causing each of those things (fever, chest pain, cough, pruritis) are so vast that you can't even begin to discuss those things on an internet forum.

My question to you is why you're asking the question in the first place. Are you trying to prepare for internship? Trying to alleviate your worries about having so much responsibility? What exactly is the motivation for this thread? If it's because you're trying to prepare for internship, you've already forgotten the first rule of residency, which is - learn from those who already went through it. Instead of insulting JDH for not giving you the answer you wanted, perhaps you should read his response and take it to heart?

Good luck.

 

[Mattchiavelli]

this is why you have to SEE THE PATIENT:

You can just give PRN tylenol for this, right? I mean no aspirin b/c of bleeding risk, obvs

 

[jdh71]

Explains why you're also so curt and generally useless in the Medical Student forums. You must have enjoyed residency... going private I hope...

Again you missed the point of the thread. Thanks though.

I don't think I'm overly curt generally, though occasionally I do make a quick comment for effect. I don't post often in the medical student forums but when I do, I am being helpful. I did like residency, will be going onto fellowship and will most likely stay in academics. I also don't think I'm the one that missed the point here, and I think if you calmed down, took a few deep breaths, and got over your initial offense at my comment, you might see that not only am I responding to the OP, but that I've got a good point.

So you may simply write me off as a guy who all bitter, doesn't know anything, and hurt your feelings, or you could swallow some of that pride and try to learn a little from someone who has been there, done that, and has the t-shirt. Ball's in your court.

 

[Reductio]

Everyone did or will graduate med school.
Everyone knows how to treat the basics.
Everyone knows they need to see the patient.
Everyone knows how to buy and read a pocket guide.

Let's suggest and/or respond to common call issues that aren't in the books, because they have more to do with a logistical complaint rather than a clinical one.

Eg. what you do when a nurse calls you at 3am to renew a non-urgent order.

That might me more fun and useful.

 

[DD214_DOC]

What are some of the most common on call complaints and how do you deal with them?

Fever
Pruritis
Hypertension
Pain
Shortness of Breath
Chest Pain
Altered Mental Status
Hypoglycemia
Hyperglycemia

When I'm on crosscover, I'm not that interested in a firm diagnosis. I'm just interested in getting the patient to live until the primary team comes in. (I'm also not a medicine intern). I basically act like an ER doc -- do what I need until they're stable, then let someone else figure it out.

As usual, all of this depends on CONTEXT. ie, I won't approach hypotension in someone who came in for generalized weakness the same as someone who just had an IR procedure done (I once had to deal with an old lady who had a biliary drain placed who was bleeding out, got a stat CT in addition to the usual fluids and PRBCs and turfed her to surgery)

Fever - FFWU (full fever workup), which is CBC, UA, Urine Cx, CXR, Blood Cx x 2, put on broad spectrum abx, and let the primary team figure it out. Unless they came in and already had this stuff done, then just give them tylenol. This changes if your pt is neutropenic.

Pruritis - Benadryl, unless they're old. Then lower dose benadryl.

Hypertension - Have the RN check with a manual. Check the trends. If it's isolated and not super high, have them recheck it in about an hour or so. If it's still high (sustained) above SBP 160 or so, you can give hydralazine 10mg IV or metoprolol 5mg IV if HR tolerates it (hydralazine can increase HR, lopressor would lower it)

Hypotension - Always see the patient. They may be sleeping when the RN took vitals or looked at the tele. Have the RN repeat with a manual. See if they're symptomatic. If they don't have CHF or some other contraindication and they're stable, try a bolus of NS 500-1000 ml. If that doesn't work, call your senior.

Pain - Depends on where the pain is. Tylenol, and when that doesn't work, morphine 2mg IV PRN Q4H with hold parameters. Some medicine attendings hate NSAIDs, so know who will be reviewing your work. If the pain is in the belly, head, or chest, always go see it. If someone's complaining of foot pain, it can probably wait until the morning.

Shortness of Breath - Always go see them. The list of things to do here is too long depending on what the history is, so I won't write it all out. Likely, it will be a COPD exac patient who just needs a neb treatment. Get a VBG.

Chest Pain - Always go see them. If you think it's cardiac, get an EKG and initial Troponin, trend troponin q6h until it peaks or is negative x 3. The usual cardiac stuff on top of that if you're suspicious.

Altered Mental Status - Always go see the patient. This list could be huge as well. Could be anything from neuro to pulm to psych. Check the meds, especially if it's in an old person you gave 25mg benadryl to for pruritis. Might be anticholinergic delirium. Maybe they fell and have a SAH or SDH. Maybe it's because of hypercapneic respiratory failure. Could be anything.

Hypoglycemia - You probably won't get called on this, as the nurses usually give OJ and recheck. If it's still low, give an amp of D50.

Hyperglycemia - I've never been called about this. Diabetic patients are usually always on SSI. You may have to play with basal insulin or short-acting on top of SSI. Assess for HONKS and DKA.

This isn't a definitive list. What you do will always vary by the context and clinical situation, so don't take this as de facto. The most difficult thing isn't necessarily figuring out what to do, as there's always someone else around to help; I've asked the on-call ICU resident questions before when I wasn't sure. The most difficult thing will be convincing concerned nurses a problem doesn't exist when they are sure one really does.

 

[Buzz Me]

Fever - FFWU (full fever workup), which is CBC, UA, Urine Cx, CXR, Blood Cx x 2, put on broad spectrum abx, and let the primary team figure it out.

You start antibiotics on every patient that spikes a fever?

 

[WhoisJohnGalt]

I know you are getting frustrated by these replies, but generally speaking people aren't trying to be snarky; they're trying to be genuinely helpful. You will do something different for each of those complaints depending on what else is going on with the patient, and no one has any interest in describing the top 10 patient scenarios you might encounter with [insert fever, HTN, etc] and how to manage them. The ONLY way for you to learn is to see patients, make an educated guess about what you should do, check with your upper level before you do it, and learn from your mistakes. Then by the time intern year is over, dealing with these scenarios is old hat, and you're still not going to be able to answer the question you're asking us now but you'll understand exactly why we can't answer it.

EDIT: Also, always remember UpToDate is there with you with a wealth of information. I still use it frequently for things that aren't very common or that have standards of care that change frequently.

 

[Reductio]

I know you are getting frustrated by these replies, but generally speaking people aren't trying to be snarky; they're trying to be genuinely helpful. You will do something different for each of those complaints depending on what else is going on with the patient, and no one has any interest in describing the top 10 patient scenarios you might encounter with [insert fever, HTN, etc] and how to manage them. The ONLY way for you to learn is to see patients, make an educated guess about what you should do, check with your upper level before you do it, and learn from your mistakes. Then by the time intern year is over, dealing with these scenarios is old hat, and you're still not going to be able to answer the question you're asking us now but you'll understand exactly why we can't answer it.

EDIT: Also, always remember UpToDate is there with you with a wealth of information. I still use it frequently for things that aren't very common or that have standards of care that change frequently.

Well said.

 

[DD214_DOC]

You start antibiotics on every patient that spikes a fever?

"As usual, all of this depends on CONTEXT"

"CBC, UA, Urine Cx, CXR, Blood Cx x 2"

 

[1viking]

When I'm on crosscover, I'm not that interested in a firm diagnosis. I'm just interested in getting the patient to live until the primary team comes in.

If you were my resident I'd fire you for this statement. This is gross negligence. You have assumed care, but don't really care.

 

[Taus]

Agree with above. SEE THE PATIENT. But here are some things to consider when you're on your way. This is not meant to be complete, just the basic LIMITED DDX's to get your gears turning at 0300.


Hypertension - why is pt HTNsive:
baseline,
pain, anxiety,
ICP,
autonomic hyperreflexia,
hypervolemia,
hypercarbia,
hypoglycemia,
hypothermia,
pheo,
thyroid,
drugs (vasopressors, MAOIs, TCAs, cocaine), etc.
Investigate for signs of end organ damage. Don't overtreat (20% of baseline acutely.) If pheo or AH, alpha block before beta to avoid unopposed alpha stim.

[

Major props to you for considering autonomic dysreflexia. Most docs in acute care don't think of this in spinal cord injury or sympathetic storming in brain injury (they just haldol and restrain the #@*% out of them and send them to rehab)

 

[MediCane2006]

If you were my resident I'd fire you for this statement. This is gross negligence. You have assumed care, but don't really care.

Seconded.

 

[DD214_DOC]

If you were my resident I'd fire you for this statement. This is gross negligence. You have assumed care, but don't really care.

You should stop for a minute and use your brain. I never said I do *nothing* or that I don't *care*. You naturally have to figure out what is going on in order to treat it, right? So you do a workup. You just don't have time to do an extensive workup on stable patients who have already been hospitalized when you're covering 80 at the same time. You're also not going to start scheduled medications on patients who are stable, as you have no idea what the primary team will do. You make sure that nothing emergent or serious is going on, keep them stable, and handover to the day team in the same condition you got them.

If it was such a terrible approach, IM would not have been begging me to switch to their program.

 

[Apollyon]

If you were my resident I'd fire you for this statement. This is gross negligence. You have assumed care, but don't really care.

Seconded.

Whoa, hold on a minute, there, friends.

Your non-neutropenic patient, being cross-covered at night, spikes a fever. Exam, cxr, UA, urine/blood cultures, and tells you about it in the morning. You would fault the cross-cover for not following up the blood and urine cultures on YOUR patient in 2 days? Or would you rather the cross-cover doc, instead of you, gets the call about positive cultures?

I think you threw the baby out with the bathwater there.

 

[thesauce]

If you were my resident I'd fire you for this statement. This is gross negligence. You have assumed care, but don't really care.

Seconded.

Your programs allow residents to fire other residents?

 

[jackieMD2007]

Disclaimer: I'm just an intern too but...

1) I carry "Internal Medicine on-call" to jog my thoughts if I'm having a hard time thinking of good ddx while I'm in the elevator...we also have a intern manual which has some helpful tips and some places to start.
2) I go see the patient even if it sounds like total BS, just because I don't know everyone yet and am still figuring out what's what.
3) If I'm worried at all or have any questions I page a senior.
4) I try to not look as scared as I am

If you're really looking for lists there are some medical schools that have searchable databases of curriculum where you can find "Top Intern Calls" or whatever if you want to look through some powerpoints. Or email some colleagues at other Med/Fam Med programs to see if they have some good stuff just to look at.

 

[MediCane2006]

Whoa, hold on a minute, there, friends.

Your non-neutropenic patient, being cross-covered at night, spikes a fever. Exam, cxr, UA, urine/blood cultures, and tells you about it in the morning. You would fault the cross-cover for not following up the blood and urine cultures on YOUR patient in 2 days? Or would you rather the cross-cover doc, instead of you, gets the call about positive cultures?

I think you threw the baby out with the bathwater there.

No, and perhaps the statement "have you fired" was too strong. But I have noticed that cross-covering junior residents can sometimes feel divorced from the day-to-day management that goes on during daylight hours, and as a result, don't take ownership of the patients they cover at night. I tell all my junior residents, I never want to hear the phrase "that's not my patient, I'm just covering." When you are the cross-covering doctor, that patient absolutely IS your patient and you should treat them as such.

I may have somewhat jumped to conclusions as to what HooahDoc meant, but for example, if a postop patient spikes a fever, I don't want my cross-covering intern to order cultures, give some tylenol, and roll over and go back to sleep assuming "the primary team can figure it out in the morning" - and that, increasingly, is the attitude I see among the junior residents. The minimum that I expect is that the cross-cover resident goes to see the patient, examines them, checks any wounds, etc and then orders the appropriate studies with at least some kind of differential in mind.

Now, on the other hand, I don't expect a night-float resident to work up chronic longstanding problems, or take followup calls three days later, and if that's what you meant, then I retract my previous statement.

(and no, I can't fire residents just yet. Which is probably a good thing....)

 

[Mantis05753]

I found certain algorithims helpful while on cross-cover, such as EKG/trop for chest pain, CXR/ABG for SOB/hypoxia, CXR/blood cx/UA/urine cx for fever. However, these are all just strategies to get you more information on your way to see the patient to help you make decisions when you get there.
I think that thinking things through on your own as a X-coving intern is one of the most valuable parts of internship. I had a guy who developed a new UGIB overnight who I successfully managed on my own in one of my first ward months, and the confidence from handling that situation effectively helped carry me through the rest of the year. X-cover can often be a pain, but it can be fun and is often your only experience in managing pts independently as an intern.

 

[Instatewaiter]

Fever:
- pretty much every time you should get cultures (UCx, BCx) and a UA +/- CXR
- Check the other vitals- ie are they getting septic (do they need a line, should you give the MICU a heads up)
- Don't have to see every patient if they routinely spike but probably should check in on them all
- What antibiotics are they on?
- What are the possible sources from what you know about the patient

Chest pain
- EKG on basically everyone
- Troponins aren't going to be elevated unless they have been hadischemia for about 20-30 minutes 6 hours prior to drawing them. Everyone checks them but in the acute period it's not going to help
- EKG is what is happening now. Troponins are what happened hours ago.
- +/- CXR or CT.
- go from there

Shortness of breath
- go see all these patients
- EKG on your way to the room
- Stat CXR
- Get sats and other vitals (ie also tachy, fever)
- Strongly consider ABG
- Give oxygen and see if sats correct (ie is it a shunt)
- Listen to the lungs (crackles, signs of pulm edema)
- Do they have DVT prophylaxis on board and are they tachy?- Think PE. Remember most PEs are sinus tach without the Q3S3T1 that you learn about in med school. If they can get contrast consider PE protocol CT otherwise a V/Q scan (often cant get overnight). If suspicion is high and they can't get contrast, heparinize and let the dust settle in the AM

Hypotension
- check the baseline BP. Many liver players will run in the 80s-90s systolic normally
- Unless they are at their baseline, see EVERY PATIENT
- Check the other vitals (ie are there other signs they are in shock)
- Get EKG, lactate, troponins
- Are the extremities warm (ie distributive/septic), are the extremities cold (ie cardiogenic)
- Check the JVP, the lungs, the heart
- If they have a central line get a CVP
- Fluids for most but make sure they're not fluid overloaded causing hypotension.
- Check the meds for recent changes/culprits.
- Are they on steroids or have they been recently (ie do they need stress dose)

Hyperkalemia
- Get an EKG to see if there are hyperkalemic changes
- Calcium gluconate
- Taking down the K: Kayexalate vs IV insulin/glucose +/- albuterol (I use Kayexalate when there are no EKG changes but pretty high K and the others if there are EKG changes)
- Do not give kayexalate if they aren't pooping. If not pooping and no EKG changes, some lactulose often does the trick

Tachycardia
- EKG and rhythm strip to determine rhythm
- Is the BP preserved
- Are they mentating
- Any other symptoms (dizziness, chest pain, SOB)
- Is it wide or narrow (the rest per ACLS protocol)

Bradycardia
- are they mentating or symptomatic (lots of people overnight get brady just because of vagal tone overnight)
- Get an EKG
- Rest per ACLS

Flash Pulm edema
- Lactate, troponins, EKG, CXR (stat)
- while lasix is always good to do, the patient didn't get fluid overloaded in 2 minutes. Usually the issue is an afterload problem ie they got severely hypertensive. Give SL nitro (nitro drip has 10x less nitro) to reduce afterload. If you are a medicine intern, keeping it in your pocket on call isn't a bad idea.

Hypertension-
- in the hospital, overnight, I tend not to worry about SBP <160 at all and still little if <180
- Ask if it is urgency or emergency (ie PO vs IV meds and if they need transfer to a stepdown/unit bed)
- Clonidine sucks. Don't use it unless you have to
- ACEi is a good choice. Captopril can be titrated easily (check K and renal fxn)
- Hydralazine is another good choice
- Nifedipine XL is not a bad choice but take care in cardiomyopathy (ie heart failure)
- For emergency enalaprilat, IV hydral (be careful) or most often nitroprusside drip. Many consider a minor trop leak "HTN emergency" but where I train it is just demand ischemia. Big Trop leaks are a different story.

Hemoptysis
- This should get your panties in a twist. See every patient.
- Figure out if it is from the lung or from the upper resp tract
- Figure out which lung is the bad lung (ie the bleeding lung). Place the patient on that side to protect the good lung (ie the bad lung down, for almost everyother condition, good lung should go down)
- If a good amt (more than a few teaspoons) call either interventional pulm (for a bronch) or interventional radiology depending on the institution.

Nausea
- I like to use compazine or zofran. Zofran has more QT prolongation. Before giving it, you should know the QTc
- if QTc is long, ativan works wonders

Headache
- Is there reason to think it is something worrisome (AMS, bleed, meningitis)
- start with something minor like tylenol or ibuprofen (check liver and renal fxn before)
- If they can't get these or they don't work- is it a migraine (triptan) vs tension headache (most commmon)- either fioricet or fiorinil
- If that doesn't work can try opiates or IV caffeine

AMS
- you need to see all of these patients. This should essentially be treated as an unstable vital sign
- Check vital signs
- CXR, ABG, EKG, Troponins, Lactate, lytes, consider LP

 

[Mattchiavelli]

First question-
Is the patient dying now vs do I have some time? You pretty much need to see the patient to make this call unless it is something super benign or something you shouldn't have even been paged for**

If the first, you have become the life support. Whip out them ACLS cards.
If the second, have a pocket buy-you-some-time-answer. Mine is "I will be over here reviewing the EMR, let me know if this gets very bad very fast."

That is really the biggest point, other things are good advice as well. Fix the fixable, stabilize the rest, and have some appropriate labs cooking for the primary team in the AM (a blood culture isn't very helpful for a 4am spiked fever unless frank pus comes out, but it's one less thing to get accidentally left off later). Remember that on call you are there to support life, not to finally be the one to finally diagnose someone's rheumatoid arthritis.

**remember, nurses have a period where they are new and stupid just like you, treat them well so they'll treat you well

 

[Instatewaiter]

A few more notes:
Nausea or indigestion are not always benign- in heart failure and especially pulmonary hypertension these are often signs they are about to crash. If they have pulmonary hypertension and nausea, drop what you are doing and go see them. They crash and die very quickly.

Remember ACLS has changed. You no longer do ABCs. You do C-A-B. You go straight to C and do compressions. Don't stop for breaths anymore. Continuous compression unless checking for a pulse. Most common code is PEA. All the data support that the best thing to save a crashing patient are compressions and more compressions. Really the only 2 things that save coding patients other than correcting obvious underlying problems are shocks and compressions.

Memorize the ACLS cards so you don't have to look at them. This will take a few months to learn them but you will be happy you did

Know your SIRS criteria.

Know how to place A-lines and central lines and where to find someone at night who can help you until you can put them in unassisted.

Call the attending if any patient is crashing or codes, gets up graded to a unit or dies. Unless the patient is DNR/DNI, your attending or senior should know about the patient well before they die (Where I am, interns take call alone so seniors on your team aren't in house)

If the patient is sick, looks septic, call the MICU and let them know. They should help you and will be there looking over your shoulder if you need. Unless it is incredibly acute (sudden GI Bleed), the MICU should be aware of the patient prior to upgrade.

 

[Instatewaiter]

Large GI Bleed

1) Initial assess of the patient
- Get immediate vitals. If they are newly tachy you need to start fluids. If they are hypogensive you are in trouble and they need a lot of fluid until the blood arives.

- Are they having symptoms (dizziness, AMS, chest pain, SOB)

- is it upper or lower? Vomiting blood gives you the obvious source. Large bloody bowel movements don't. A life threatening upper bleed often presents with hematochezia. You have to drop an NG tube and do a lavage with NS to figure this out.

- If it is upper and the NG lavage clears quickly (ie after 200cc NS) it's probably not a terrible GI bleed. However, if it is lower and they don't clear quickly (ie after 500cc) they could crash very, very quickly. Get tons of fluid and at least 4 units of blood on hold. This should make your sphincter get tight.

- Do they have liver disease or known varicies. If so, your sphincter should get a little tighter. These patients crash hard and exsanguinate within minutes.

- Make sure they have access. They need at least 2 PIVs at least 18gauge (my hospital doesn't regularly stock 16 gauge on all floors so 18 has to do in a pinch). If a large bleed they need a central line. I have had patients where we had fluids wide open going through 2 IVs and blood going through a 3rd. The more large bore IVs the better

- If large bleed, let the MICU know. If they are unstable, you need to call the GI fellow as well. If they are vomiting lots of blood, they may need a blakemore.

- Draw pt, ptt, Abo, Heme8 and an emergency crit and emergency lactate ( both emercency labs will be sent to critical care lab and will come back in minutes as opposed to the hour it takes for a heme 8)

- Make sure they're not on an anticoagulant. If so, stop it and give FFP (unless antiphospholipid or mechanical valve... this gets tricky but if they are dying... you have to make them stable. Don't use FFP in these circumstances unless it is lifethreatening).

2) Initial stabilization
- If hypotensive or a large bleed, put blood on hold immediately and get at least 1-2 units sent ASAP. Start fluids immediately because the blood will take time to get there. Get the nurse to get at least 2 liters of NS (more like 4) and bring them into the room. Start them wide open (ie to gravity not through the pump) or pressure bag them in. Don't run them trough the pump. 999cc/h is not wide open

- If the patient is loosing a lot of blood, they need preload otherwise they will crash. NS will do this until you can get blood running.

- Check in their recent labs Plt, INR and Ptt. They may also need FFP and plt (if plt < 50 they need plt, if INR elevated give FFP)

- Central lines (except a cordis) are usually at most 18 gauge. Because they are long they have more resisitance than an IV so you can put in less blood than a regular 18 guage IV. However, IVs blow and central lines don't, so if they are sick, a central line is the way to go. If you know how, drop a cordis (very thick central line) if they are losing a lot of blood.

- They may need a rapid infuser if massive hemorrhage. Most places this only happens in the MICU or other ICU. A rapid infuser can get a unit of blood into the patient in 5 minutes (as opposed to 30min+ an IV takes). Cordis is the best way to use rapid infuser however central lines also work.

- For every 5-10 units of blood a patient gets, they also need FFP because the coagulation factors get diluted.

3) Getting them to the appropriate place
- If loosing a lot of blood, they need to go to the MICU. If you didn't have time before, call the MICU
- If they need MICU transfer, GI should be called so that an emergent scope can be set up or blakemore placed (Upper tamponade device). This will help the MICU out a lot.
- Put more blood on hold so that it can be rapidly infused in the ICU.
- Also put FFP on hold so they can get it fast.

 

[Instatewaiter]

Afib with RVR

Initial assessment
- How fast are they going? If only 110, not too urgent but needs to be treated. If 160, probably have to stop it now.

- Are they unstable (change in mental status, hypotensive).

treatment options

- Your main options are PO meds (dilt, metop) or IV meds (metop, dilt, amiodarone) or shocks (get familiar with the shocking devices your hospital uses and the amt of shock to give (often 75J then 100J then 120J)

- Is it new or old- if is new (ie less than 2 days) you can convert the rhythm to sinus without worry about throwing a clot (ie you can use shocks or amiodarone)

- Do they have BP to work with (if so Metop or dilt can be used) if not your options are shocks or amiodarone

- Do they have heart failure- bad cardiomyopathy shouldn't be given metop and often dilt because it will cripple the heart and they will rapidly decompensate. However, these are often decent options if they have decent EF

- If unstable they need to be shocked. Screw whether or not they have a clot

- Are they on anticoagulation (if so you can feel better about converting to sinus with shocks or amio) or a known clot (don't convert)

 

[Doctor4Life1769]

Afib with RVR

Initial assessment
- How fast are they going? If only 110, not too urgent but needs to be treated. If 160, probably have to stop it now.

- Are they unstable (change in mental status, hypotensive).

treatment options

- Your main options are PO meds (dilt, metop) or IV meds (metop, dilt, amiodarone) or shocks (get familiar with the shocking devices your hospital uses and the amt of shock to give (often 75J then 100J then 120J)

- Is it new or old- if is new (ie less than 5 days) you can convert the rhythm to sinus without worry about throwing a clot (ie you can use shocks or amiodarone)

- Do they have BP to work with (if so Metop or dilt can be used) if not your options are shocks or amiodarone

- Do they have heart failure- bad cardiomyopathy shouldn't be given metop and often dilt because it will cripple the heart and they will rapidly decompensate. However, these are often decent options if they have decent EF

- If unstable they need to be shocked. Screw whether or not they have a clot

- Are they on anticoagulation (if so you can feel better about converting to sinus with shocks or amio) or a known clot (don't convert)

I was under the impression it was < 48 hours....

 

[jdh71]

I was under the impression it was < 48 hours....

There's some controversy about just how long it takes to form an atrial clot, and it's probably a longer than 2 days or even 5 days. Most cardiologist types are nervous nelly's about everything.

 

[Instatewaiter]

I was under the impression it was < 48 hours....

You're right. Realized after I posted but was too lazy to change it. It's changed

 

[LolaAnesthesia]

This thread reminds me of my initial hesitance to become a doctor... Most are bigots and geeks on a power trip.