Pearls of Cross CoverJason B. Martin

What is cross cover?

• Covering for your partners• other interns who are off• teams signed out to you at night

• You are the patient’s primary physician after hours• labs, consult recs, consent (blood)• family concerns• ALL medical and nursing issues

• The sign out sheet• BRIEF explanation of why patient is here• Just the facts! Don’t editorialize.• Pertinent demographics (name, age, MR, room #)• allergies• CODE STATUS (and keep this up to date)

What NOT to sign out:

• Routine daily responsibilities• get your notes done before rounds

• Subjective comments

• Results that won’t affect patient care

• Non-specific plans

• RESTRAINT RENEWALS

Responding to pages

• Be prompt, especially with tagged pages

• Your tone• Irritated? Hurried? Rebuking?• Be polite

• What does the nurse REALLY want?• Reassurance? Appease patient or family?

• Empower the nursing staff• What do they think is going on?• What should WE do about this issue?

• Come to a decision and ask for read-back

• Leave tracks in the chart, sign-out sheet

Giving Medications

• Do I really need to give a medication?

• Does the patient have a medication on his/her list that I can use, or dose early?

• Review allergies

• Consider renal and hepatic function

• General principles• shorter-acting agents are better in the middle of the night• PO > IV• lowest dose to achieve• think about patient comfort and nursing care

• Use phenergan and ativan with caution in older patients

You are not alone

• Use your resources nurses and techs, residents, fellows, attendings

• ALWAYS call your resident if something’s not right• ALWAYS call early• Trust your instincts

Common Questions on Call

Disclaimer:This list in NOT comprehensive. Even seasoned veterans can be surprised on call

Common Questions on Call

• Insomnia• Constipation• Diarrhea• N/V• Electrolyte problems• Fever• Loss of IV• Decreased UOP• Confusion• EtOH withdrawl• Dyspnea• HTN• Hypotension

Insomnia

• Probably the most common call

• Consider prn orders at admission

• Why can’t they sleep?• pain• anxiety• noise• sundowning

• What normally works for the patient?

Insomnia

• Antihistamines• Diphenhydramine (Benadryl)

• 12.5, 25, or 50 mg (IV or PO)

• Benzos• Temazepam (Restoril) 15-30 mg PO great for older pts• Lorazepam (Ativan) 0.5 mg PO, IV

• Avoid alprazolam and valium

• Zolpidem (Ambien) 5-10 mg po qhs prn

Constipation

• Review medication list review with AM team• Iron• CCB

• Laxatives• Bisacodyl (Dulcolax)

• 5 or 10 mg pr

• Docusate Sodium (Colace)• 100 mg po BID

• Milk of Magnesia • 30-60 mL PO

• Metamucil

Constipation

• Lactulose 10-20 grams (15-30 mL)• Go easy• Tastes bad• Dramatic results

• The Green Bomb: Magnesium Citrate (300 cc bottle)

• Fleet’s Enema• Don’t order it• Just use soap suds

• Avoid Mg-containing compounds in renal failure

Constipation

Attention Interns:

The patient may need manual disimpaction.

“Diarrhea – Cha! Cha! Cha!”

• Is it diarrhea or just loose stools?

• Associated with fever or leukocytosis?• c.diff? Start empiric flagyl?• hemorrhagic colitis?

• Leakage around an impaction?

• Avoid anti-diarrheals acutely

• Immodium or lomotil if needed

Nausea and Vomiting

• Promethazine (Phenergan)• 12.5 – 25 mg PO/IV q 4-6 hours prn• Caution in elderly

• Metoclopramide (Reglan)• 5-10 mg PO

• Lorazepam (Ativan) 0.5 – 1 mg PO

• Serotonin antagonists (Anzemet, Kytril, Zofran) are available• generally second-line ($)• oncology patients• refractory cases

Hypokalemia

• Hypokalemia• normal range is 3.5 – 5.0

• replace PO/per tube when possible (immediate and SR forms)

• can replace IV if necessart • be aware of patient’s renal function

• be aware of any standing K orders

• conisder empiric Mg replacement if refractory

Hypokalemia

• KCL immediate release orally 40-60 meq is a standard dose• powder/elixir rapidly absorbed• tastes terrible; patients with nause may not tolerate

• Kdur tablets• slower onset, longer-acting

• IV KCl it hurts• slow replacement (10 meq/hour peripherally)• takes the IV port

Hyperkalemia

• Hyperkalemia can kill a patient (arrhythmia)

• Order EKG (and call your resident)

• Does it fit the clinical setting? Hemolysis?

• Swift action may be required

Hyperkalemia

• Calcium gluconate rapidly stabalizes the cardiac muscle membranes; effect is transient

• Insulin (10 units IV) with 1 amp D50• drive K into cells• onset 15-30 minutes

• Bicarbonate• transient cellular shift

• Beta agonists

• Dialysis

Fever

• ALWAYS EXAMINE THE PATIENT

• Draw cultures prior to abx

• You will rarely be faulted for choosing broad abx; just think about the possible sources

• Don’t forget about allergies

• Renally dose medications Use Sanford Guide

Loss of IV

• Does the patient need an IV?

• Any meds scheduled for tonight?

• Ask for IV therapy to assist (at VU)

• Attempt yourself?

• Can you convert to PO?

• What about a central line?

Low UOP

• Is the Foley placed properly?• Flush the Foley• Reposition it

• Assess patient’s volume status and read the history

• volume overloaded Lasix• crackles, elevated JVP, S3, edema

• volume depleted NS• orthostasis• hypotension• tachycardia

• Get your resident involved if unsure

Chest Pain

• Huge differential diagnosis from annoying to life-threatening

• Always evaluate CP in person get out of bed

• Have the nurse get EKG while you are on your way

• Think about GERD, PE, MI, dissection, anxiety

• Assess vital signs, careful physical exam• diaphoretic?• dyspnea?• acutely ill-appearing?• pleuritic?

Chest Pain

• EKG changes? Call for help Time is myocardium

• Cardiac enzymes

• CXR

• Transfer to another unit?

• If you think it’s cardiac:• ASA• nitro spray or SLNG in new pts, ask about sildenafil use• O2• morphine• βBs

Dyspnea

• Always examine these patients in person

• Vitals (RR and sats)

• Huge differential• failure, edema• bronchospasm• PE• ptx• MI• pneumonia• bronchospasm• acidosis• anemia

Hypertension

• Urgency, emergency, or no big deal?

• Physical exam• BP in both arms• funduscopic exam• rales?• neuro exam

• Labs / Imaging• BMP• EKG• UA• CXR

• AMS or focal neuro deficits CT head without contrast

Hypertension

• Is the patient in pain? Anxious?

• Use current medications• early dosing• increase doses

• Clonidine it works, but no style points• 0.1 mg to 0.3 mg po

• Nitro paste

• IV push (with consultation): labetalol

• IV gtt (with consultation): cardene, nitroprusside

EtOH Withdrawl

• Can be life threatening

• Be suspicious: agitation, tremor, hypertension, tachycardia in a drinker

• Treat with IV benzos

• Start low, titrate rapidly to achieve effect (Protocol in place?)• Ativan IV: 2 mg 4 mg 6 mg 10 mg

• MVI, thiamine, folate

• Consider transfer to a monitored unit

Confusion / Delerium

• Check VS, sats, glucose, consider ABG

• Discuss with nursing staff, family what’s the baseline? How acute is the change?

• Why?• hypoglycemia• recent fall? CT head?• infection?• medications?• ICU or hospital-induced delerium• EtOH withdrawl• iatrogenic (phenergan is a common offender)

Confusion / Delerium

• Sundowning

• very upsetting to families

• can worsen with ativan

• best therapy family and reassurance

• restrain for patient / staff safety

• try some haldol

AVOID

• Demerol

• Major changes in plan without consultation

• Treating patients without examining them

• Short temper with nurses

• Calling for help too late

Intern Companions

• Hemoccult cards, developer (and a gentle touch)

• Opthalmoscopes and tropicamide (Mydriacyl)

• Motivated medical students

• A supportive resident:

“ If the horse dies, the cowboy walks.”