PGY-1 MICU

This is the rotation that is typically loved and feared as an intern. You will get most of your lines on this rotation and you exposure to taking care of some of the sickest people in the hospital.

Useful Links

Medicine Call Schedule

TEAM: Consists of you and a second year EM resident. You will also round in the morning with a sister team (consisting of a medicine G2, a medicine G1 and 2 medical students), a fellow and a critical care attending.

Writing a Note...

A daily note should include…

Vital Signs

Include a range for BP, HR, RR, Pulse Ox, and Temp (Tmax & Tcurrent)
Can go at top of note or top of objective section

Glucose checks – if recorded, over last 24 hours
I/O – over last 24 hours (go to Input/Output tab – this calculates it for you)
Subjective

What you talked to your pt about…pertinent ROS (F/C, CP, SOB, N/V).
Start with “No 24 hour events.” but before you say this, check with intern on call overnight and read the nursing notes to make sure that something didn’t come up with your pt overnight

Objective = Physical Exam, Labs, and Imaging (all separate sub-sections within this section)
A/P:

Assessment = One line review of pt’s PMHx that is pertinent and how they presented/why they are here
Sections on CV, Resp, Renal, ID, GI, FEN, Endocrine, Neuro, Psych, Prophylaxis, Dispo with relevant finding/workup/consults/etc

Not all sections will apply to all pts

Shortcuts in Epic that pull pertinent info directly into your note:

.cmedshort (pulls in the inpt meds your pt is on)
.prob (pulls in your pt’s problem list…will need to update this in order for this to be useful in your notes)
.ipvitals (pulls in vitals…you can use this or get vital from IP Accordion and insert them into your note…up to you)
.iobrief (pulls in I/O)
.cbcresult (pulls in most recent cbc)
.bmpresult (pulls in most recent bmp)
.abgresult (pulls in most recent abg)

Daily Orders...

Before you leave for the day, order CXR (as AM rounds and set the date for tomorrow) and ABG on anyone who may need these in the AM, double check that daily labs (cbc, bmp, mag, phos) are ordered too if you are following these
If your patient in the AM has…

Low Phos – order sodium phos or potassium phos (depending on what else may be low, Na or K)
Low Mag – order mag sulfate, just always order 2 grams, 1 gram is worthless
Low K – double check pt is on K protocol, if not…

Order K protocol from MICU admission order set or
Replace with KCl – 10 mEq IV x 1 every hour x as many hours as they are down (10 mEq replaces ~0.1
Replace with KCl – 40 mEq po at a time
If not on K protocol, good idea to recheck their K after you’ve replaced it

Low Calcium – if calcium is low, adjust for low albumin, if still low…first order an iCa

Then if iCa low, order 1 g of calcium chloride (this replaces ~4x as much as 1 g of calcium gluconate)

Admit...

Order Set: MICU admission
Review their home meds and start any of the ones that may be pertinent to start right away, e.g. BP meds, anticoag, antidepressants (some can wait until later)

Discharges...

Order set: Gen Medicine Adult Discharge (unless going to health care facility, then use that one)
If pt is going to NH, discharge summary must be done before pt leave, press *1 when done dictating to get transcription within 1 hour so you can sent it with them
Dictate the “official” DC summary
Enter the written “Brief DC summary” with diagnoses and final exam. There is a template under the smart text shit….called discharge summary – brief, use this. If you do this first, it makes dictating your DC summary easier.

Transfer...

Just put in the IP transfer order
Then review all other order and modify as necessary…don’t use that pre/post transfer stuff, it is more trouble than it’s worth
I/O should be per shift on floor
Vitals should be q4 hours on floor
D/c cardiac monitor unless going to CARE
D/c foley if possible
D/c ICU oximetry, order pulse oximetry – non-ICU
On floor, no diltiazem gtt, no insulin gtt, no IV beta blocker, no nitroprusside, gtt, no IV valium (only po valium 1x every hour)

Cross Cover...

On floor, if called for concern about high BP…first, recheck, next, prn IV or po hydralazine
If concerned about cross cover call you get, and don’t know what to do…talk to senior on call with you…this what they are there for…they will not mind and can be very helpful
If called for fever…check cross cover sheet…if says, do not culture, do nothing and give antipyretic. If says pan culture, order CXR, UA, Ucx, blood culture x 2 (if port or central line, one culture should be from this). Depending on situation, you should also consider broad spectum abx dose…talk to your senior about this (e.g. levo or clinda if covering aspiration, vanco and zosyn if covering everything and it’s mom)
If called for desat…if on floor, go see pt. If not on continuous pulse ox…order this. Get CXR. Put on oxygen, lung exam, etc.
If called for prn meds…just order it…if it was ordered before, reorder it.

Cough (guaifenasin or tessalon pearls/lozenges)
Constipation (colace, senna, glycerine suppository, milk of mag, mag al or maalax, fleets enema, pink lady enema – in this order ask what they are on, ask nursing what they think you should add)
Insomnia (benadryl 50 mg, trazadone 50 mg, ambient 5-10 mg – careful with old people, limit ativan, benzos)
Agitation – check signout b/c may be trying to avoid benzos (benadryl 50 mg, give bump of propofol 40mcg or fentanyl 50 mcg, ativan 1 mg, droperidol 1.25 or 2.5 mg, haldol 5 mg, seroquel 50 mg, zyprexa)
Pain – check sign out b/c sometimes team is trying to avoid narcotics, depends on origin of pain, how valid you think pain is, check prn pain meds first, be aware of your pt’s age and narcotic naïve pts, and allergies (Tylenol, ibuprofen, tramadol, vicodin/percocet, fentanyl – start low, morphine – start low, dilaudid – start low)
Low BP – check sign out, often gives goal MAP, if no…start with bolus 500 ml to 1000 ml (unless they are CHFer or renal pt) and go see pt, could consider Hgb stat if know at risk for bleed
Tachycardia – access pt, determine if pain or agitation or low BP or fever and treat accordingly, if none of these, consider CXR/EKG/ABG, prob talk to senior
Don’t be a jerk when you return a page…just address the problem and be professional…this will kick you in the ass if you are crappy on the phone
If nurse if calling…and doesn’t really sound like pt has an issue that is important (e.g. lots of gas, no diet ordered)…it’s ok to defer to primary team, make note of it, communicate to primary team in AM, and blow this off
Feeding tube placement –check abdominal Xray…should make TWO turns and be in the duodenum, ending on the L side of pt…if in place…tell nurse it is ok to use and if no tube feeding diet ordered…go to diet-combo, then to tube feeding…then look at dieticians note and order whatever they say in their assessment

If doubt, GO SEE THE PATIENT, e.g. new chest pain, agitation vs. pain, AMS

Other Order Sets...

MICU DKA protocol
Heparin protocol (for thromboembolism)
Alcohol Withdrawal protocol
Sedation (this will give you sedation options for people on vent (ativan, propofol, fentanyl CADD, etc.)

Call Room (use the call room by the red elevators, which has phone and computer and works, your ED senior will know which one this is, b/c it was the one they used when they stayed overnight in the past, it attached to the night float MICU resident’s call room)

The Lists – on the computers by MICU room 6 and 7, add new pt’s to regular list and if pt is discharge, delete and copy to discharge list….password for both lists is purplesurg

Ultrasound is in the closet between room MICU room 4 and 5. Ask nurses where US probe covers are if you need to be sterile (e.g. for central line).

Supplies – anything you probably would need for whatever is in the supply room by MICU room 1. It is open. Or just ask.

Be nice to nurses. Introduce yourself early by your first name. Make friends with Teri, the charge nurse in the MICU. She is good to have on your side.

Logistics of returning pages: Say…this is First Name, Last Name from Yellow Medicine, returning a page.