Chiefs

Days :

Morning: -Rounds: The Chiefs/Cutler night float rounds with the Chiefs service in the morning (and signs out to Cutler day intern prior to rounds). Rounds usually start at 6am at the top of the list. The night float will print out progress notes and should try to fill out any events, vitals, labs, and start a plan (this may be difficult because you guys are just starting out, so you'll probably write the plan on both your list and the progress note as it's discussed with your chief). Right now our chief likes to run the list and come up with plans before we've seen anyone, and lets us know if plans change after we've examined the patients as a team; your incoming chief may prefer to do things differently. Jobs will be split up between members of the team. Generally one person will write notes, one will help with dressing changes, one will flush the NG tube, etc. After you've seen the patient, drop the note in their green chart (located on a rack somewhere on each pod) before you move on to the next one. Write a "to do" list for each patient as you go along so you can remember the plan (trust me, write everything down). Rounds will end around 7am. If you have a conference or are assigned to an OR case, decide who will put in orders (generally the PA if you have something academic). Otherwise you'll split the list with the other interns/PA on the team. Jen Herlihy is currently our PA and comes in Tuesday-Friday. So Monday you will be on your own.

- Orders: As soon as rounds are over, put in orders for your patients. I usually try to sit down and write all the labs/studies/diet orders etc. in BICS first. This avoids unnecessary and annoying pages from nurses about whether patients can start eating toast, etc. It'll take you awhile to learn how to order meds, labs, etc. in BICS. Once you learn you'll be able to do this quickly.

- Consults: After all the orders are in, start calling consults if they're needed. You can find the pager numbers for consults in the paging directory. When you start out, you'll probably page a lot of the wrong people attempting to find the consult you're really looking for. It's July, this is expected. Care coordination, nutrition, wound/ostomy nurses don't show up until after 9am. If you need to place a PICC consult, this is actually an order in BICS (under orders, order sets, other, PICC consult). If you’re told to consult nutrition for TPN, go ahead an order TPN labs (basic metabolic panel, magnesium [magnesium is not included in the basic panel], phosphate, triglycerides, albumin, prealbumin, CRP). I usually page people to my cellphone to avoid missing them when they call-back.

-Discharges: Start these early on in a patient's hospital course so that you can update as you go along. Trust me. This will save you when you're discharging someone with a complex or long course, or on Friday nights when you're prepping discharges for the Cutler intern if they're going to be covering weekend days. When someone comes out of the OR, the person who operates will send out an operative note and postop email with HPI, PMH, PSH, etc. as well as the operative course (procedure done, any complications, ins and outs during the case) and postoperative plan. When you're making the patient's card with this history, just cut and paste it into BICS as well. Then just cut and past the templates for patient instructions and hospital course. That way most of the work will be done for you when it's finally time to discharge the patient. If I know someone will be leaving soon, I will print out their scripts and place them in the cart in advance. If your patient has an ostomy, the ostomy nurses will place ostomy-related scripts into the chart. If you see these, sign them.

- Page Jan Hogan from care coordination: Usually Jan will contact you regarding the plan for patients, who will need services, etc. mid-morning. If you haven't heard from her by 11am or so, page her with your callback number.

- Check labs: Morning labs usually start coming back around 10am or so. Write them on the back of each patient's card as they come back. Replete electrolytes as needed (for GI surgery patients we try to keep Mg >2.0 and K>4.0). When you order K, if a patient doesn't have a central line and hasn't had return of bowel function, you have to order it IV in 10meq increments. If a K is <3.2 and I'm repleting it, particularly if the patient is on lasix or has high ostomy output, I'll write to have the lab repeated in the pm. If a Hct comes back much lower than the previous day, repeat it. If there are any labs that are crucial for management (such as an INR that needs to be therapeutic or below 1.5 (our cut off for safe surgery), a WBC for a patient you're worried might have an anastomotic leak, etc), you can page the lab value to your pager in BICS. Go into the patient, hit order entry, then lab value notification. Type in the name of the lab, select the one you want, and hit OK (or enter x 2).

Afternoon: -Walk rounds: Start seeing your patients around 12:30 or so. Write the tmax for the day (midnight to noon), noon temp and vitals, ins and outs since midnight). Also include the postop day and day of any antibiotics the patient may be on.

- Rounds with your chief: Time depends on when your chief gets out of the OR. Usually 2pm-8pm depending on how busy the day is.

- Postop checks: When someone does a case that's being admitted, they'll send out a postop email. Make a card for the patient and go see them 2-3 hours postop for a postop check. Gather vitals and put them on the card in preparation for rounds.

OR: - Your chief may assign you to intern level OR cases (or another service may borrow you for a case). Generally as an intern you'll assist with anal sphincterotomies, fistula excision, breast cases, hernia repairs and lap choles. Try to go down to the PACU (also the preop area) to meet your patient before the case (this can be hard for the 7:30am cases). Make sure they have a consent form signed and placed in the chart (if they don't, consent them), surgical site is marked, and that the preop form at the front of the chart (it has an orange line on the right side) is filled out. Make sure they have an H&P in the chart. If not, go to LMR and print one out.

- Postop: 1. Day surgery: (Labelled as DS on the OR schedule). Ask the attending for any specific discharge instructions, such as when the patient can resume anticoagulation, any antibiotics needed, any specific diet/activity restrictions, before the case is over. Fill out the PACU orders form (the nurses can show you where this is). Print scripts from LMR to put in the chart. Print out discharge instructions. Most of the day surgery discharge instructions are standardized. You can access them from the day surgery computers (DSU) by going to start menu, partners applications, BWH patient education, care notes. There's a link on the right side of the screen for "day surgery instructions." Each of these also includes a free text portion where you can write in any additional instructions. Print out and sign 2 copies and place them into the chart. Place the BON in the chart (see below). There's no need to send out a postop email to the team unless the patient might stay (if they're having pain control issues, can't pee, etc.)

2. Inpatient surgery: (Labelled as SD on OR schedule). Again, ask the attending for any specific instructions, including po status, when NGT can be removed, when safe to take out foley if any dissection in the pelvis, when to restart anticoagulation, etc. before the case is over. Write an email to "BWH surgery chiefs service" with the operative course, intraop ins and outs, and plan. At the bottom of the note, include an LMR note with the HPI, PMH, etc. so that everyone will know about the patient.

3. Postop notes: both inpatient and day surgery patients need a postop note. This is being done electronically through the BWH general surgery portal. To get there, go to the start menu, partners applications, BWH gen surg portal. Type in your key, the patient MRN. Then hit the tab that says "create BON." If you're an anesthesia intern, someone else will have to write the note for you in the portal, or you'll need to hand write it. BON's written on the portal should be printed and placed in the patient chart (ideally within an hour). When you generate a BON, it'll automatically be emailed to the BWH chiefs surgery listserv.