Nights

Nights : Even if you're on Chiefs days, you may have to cover some Saturday nights. If so, you'll cover both the Chiefs and the Cutler services. Show up around 5:15 or so (particularly when you're first starting off), to print service rosters and go through any emails that were sent out that day. Before I get signout I also print out progress notes for the next day. Then you'll get signout from two teams. Before the day teams leave, find out when and where each team will found in the morning. You'll usually round with both services. As with days, I'll make a "to do" list when I get signout, and I'll work on that and writing patient names/MRNs on the progress notes up until around 12am. Just after 12am I print out new rosters (after 12am the POD/HD's are updated automatically) and electronic signouts (the signouts give you the meds the patients are on as well as antibiotic days, which you'll need when you make the am list).

Printing rosters from BICS: -Open BICS - Type in your key, hit enter - Type "CI" under system, hit enter - Hit "L" (shortcut for patient list options, or you can just click on "patient list options") - Hit "R" (short cut for roster, or you can just click on "roster") - Type in Chiefs, hit enter - Choose Chiefs/Labs- PEPL, hit enter - To print hit alt-P - You can choose the number of spaces between patients (usually you can do 5, sometimes you need to reduce it to keep all the patients for each service on one page). Unclick "blank line after every 5th patient." Find out if your chief likes a horizontal line between patients and decide whether or not to choose that option.

(for cutler, under roster, just type cutler, then choose the cutler/labs- PEPL list). Printing signout list: Same as above to get to the patient list options menu - Under patient list options, hit "I" (shortcut for signout inpatients, or just click on "sign out inpatients") - In the top right corner click on "cHoose a roster", or hit alt-H (a shortcut) - Type in the name of the list you wish to access (same process as with printing out a roster) - Hit "esc" - To print, type in alt-L (all patients)

If I have time, I'll then write the POD (which I circle), or the HD (which I put a square around) next to the patient's name, and write the IV fluids/diet/painmeds/anticoagulation under their name. If I don't think I have time to sit around, I go straight to the pods for vital signs. Write the tmax (for 24 hours), t current, current vitals, 24 hour I's and O's. Check the back of the vitals sheets for flatus status. I'll put in any orders I think need to be put in (if a patient's finger sticks are high and they're diabetic I'll increase their insulin sliding scale, if the Uop is low I'll give a bolus). Once the list is done, I go back to the progress notes and fill out the vitals and any overnight events. I'll start coming up with plans (you probably won't feel comfortable doing this initially). Then, around 5am, I start walking around and check on stuff I was tweaking overnight (if I bolused I'll check and see if the Uop increased, etc.), so I can report the results on morning rounds. There's no phlebotomy at night. If you need to draw cultures for a febrile patient, or MI w/u labs, you'll need to draw them yourself.

Radiology reads at night: Always try to get at least a resident read on any studies done overnight. To get in touch with the on-call radiology resident, page b11883 with the patient info (always name, MRN, the study) and your callback info (include a phone and pager number). They won't always get back to you, so be persistent. If you haven't heard anything for a half hour, and you're worried about the patient (if they got a CT scan to r/o a leak, for example), keep calling. If you still can't get a call-back, physicially go down to the radiology reading room in the ED.

Overnight admits: If coming up from the ED, you'll get an admit note in an email and often a page from the surgical resident in the ED. Read the note, call the resident with any questions, find out if there's anything to f/u. The ED resident should place all the orders. Once the patient is on the floor, go eyeball them. Sometimes new direct admits will also come, usually a transfer from an OSH. When this happens, find out if they're stable, if so go through the chart, see the patient, then call your chief to discuss the plan. Put in admission orders ASAP (this helps you to avoid being hammer-paged from nursing). Draw labs yourself if it's the middle of the night. Then get started on the admit note. Place 1 copy in the cart, email copy to the team.

Never feel like you're alone at night. If a patient is unstable, and you need immediate assistance, page the in-house senior surgical resident (and this goes for when you're covering any surgical service at night, including ENT, urology, or plastics who don't have in-house senior residents at night). To find out who this is: go to the paging directory, on-call directory, surgeyr nights from dropdown menu then go, cushing ESS consult resident). Otherwise you can page your chief (on weekends the acting chief will often be a 4th year resident, but you'll know who this is). If you need and extra hand, can't draw labs, etc., utilize your fellow interns.

'''NIGHT FLOAT: General Surgery '''

OVERVIEW

-Be ready (ie, list printed and pen in hand) at 6pm to get signout from the day team.

-Complete all tasks assigned to you during signout.

-You are 1st call for all patients on your service. Respond to all pages appropriately.

-Complete all paperwork (see below)

-Present on AM rounds

'''PAPERWORK '''

'''1. The List '''

           -Pull up your BICS/Pepl roster, sort, and print. A safe default for print settings is 4 spaces and no lines, but your chief may have different preferences.

-First line: POD/HD (put a circle around the number for POD, put a square around it for HD), antibiotics (include current day of treatment as well as total course if known), Tm, Tcurrent, HR, BP, RR, O2 sat, O2 amount and delivery method vs RA

           -Second line: diet / IVF / anticoag / pain meds (your chief may request slight differences in the order, but this is a safe starting point).

           -I/O: to the right of all of the above in the following format:



            -The next day’s OR schedule needs to be copied on the back side of the list. Print from BICS, shrink to 50 or 60%, copy/paste as needed if there are multiple pages.

-Helpful hints: copiers can be found in the small room outside 16B, on 12A, and in admitting on the 1st floor.

<p style="margin: 0in 0in 0pt">'''2. Notes '''

<p style="margin: 0in 0in 0pt">           -Print the attached template on lined Progress Note paper.

<p style="text-indent: 0.5in; margin: 0in 0in 0pt">-Write the name and MRN in the ID box at the top right corner of the progress note.

<p style="margin: 0in 0in 0pt">           -Fill in overnight events, POD/HD, antibiotics, vitals, I/O’s, and a brief assessment/plan (sometimes your team may prefer to write down the plan during AM rounds—at the very least your assessment should include the one-liner about the patient).

<p style="margin: 0in 0in 0pt">           -Sign, date, and time the bottom of every note. Pager number and name must also appear typed at the bottom of every note. Note: you may NOT include a whole list of people at the bottom—only your name should be there.

<p style="margin: 0in 0in 0pt">           -Helpful hints: skeletonize your notes with name/MRN, signature/date/time, one-liner if you have down time early in the night. Then fill in POD/HD/Abx and vitals/I+O’s after your midnight rounds.

<p style="margin: 0in 0in 0pt">'''3. Cards '''

<p style="margin: 0in 0in 0pt">           -Make any cards on patients admitted overnight. This will usually include cards on any patients you’ve been assigned to post-op check.

<p style="margin: 0in 0in 0pt">           -Update the cards (meds, diet, ivf, etc), if you have time.

<p style="margin: 0in 0in 0pt">'''

'''

<p style="margin: 0in 0in 0pt">'''AM Rounds: '''

<p style="text-indent: 0.5in; margin: 0in 0in 0pt">-You will present the patients in the morning. “No events, AVSS. Took in good Pos. Plan for the day is ….”

<p style="text-indent: 0.5in; margin: 0in 0in 0pt">-Drive the bus: it’s your job to lead the way as you go to see patients in the morning.

<p style="text-indent: 0.5in; margin: 0in 0in 0pt">-You will learn as a team what makes sense in terms of divvying up tasks like completing notes, finding charts, and doing dressing changes.

<p style="margin: 0in 0in 0pt">           -Helpful hints: don’t take it personally if  your chief interrupts or corrects you. Keep trying to present the plan—it’s good experience!

<p style="margin: 0in 0in 0pt">'''Who to call for help: '''

<p style="margin: 0in 0in 0pt">In House Senior

<p style="margin: 0in 0in 0pt">Your Chief

<p style="margin: 0in 0in 0pt">Rapid Response

<p style="margin: 0in 0in 0pt">Code Blue

<p style="margin: 0in 0in 0pt">'''A Typical Shift: '''

<p style="margin: 0in 0in 0pt">5:30-5:45: show up, print a list, go over your emails from the day. Usually helpful to write down the plans that were sent out in post-op emails because they often help when you present in AM rounds.

<p style="margin: 0in 0in 0pt">6:00-6:30: get sign out

<p style="margin: 0in 0in 0pt">6:30-10:00: post op checks, complete your SCUT, see as many patients as possible (but triage!)

<p style="margin: 0in 0in 0pt">10:00-12:00am: often a bit quieter. Work on your notes for the morning, update cards.

<p style="margin: 0in 0in 0pt">12:00-3:00: print list, get vitals, complete notes, copy list.

<p style="margin: 0in 0in 0pt">3:00-5:00: nap time if you’re lucky!

<p style="margin: 0in 0in 0pt">5:00-5:50: go over your list one more time, tie up loose ends, gather your thoughts for AM rounds

<p style="margin: 0in 0in 0pt">5:50:  go to the assigned meeting place, list/cards/notes in hand. Cards and notes should be in order. Open up BICS, Centricity, your email…whatever tools you think might be helpful to have at your fingertips during rounds.

<p style="margin: 0in 0in 0pt">6:00: great your team with a smile on your face!

<p style="margin: 0in 0in 0pt">7:00-7:30: d/c home