Nithya Swamy

1
A Day in the life and Cross-Cover

• Nithya Swamy
• Chief Resident

2
Overview A Day in the life

• Wards
• Conferences
• ICU
• Electives
• Important Numbers

3
WARDS

• Call Days
• Day starts at 7a
• Call is every 4th night
• Admissions 7a-7a
• Resident will call with new admissions
• Sign-out by 1p on post-call day
• Intern can admit 5 patients for call. Intern cap
  10 patients.
• Resident clinic patients requiring admission
  should be followed by the teaching service.
• On-Call Team Code Team (Code Blue MET)
• Call rooms 10th floor BC are intern call
  rooms, D is the resident call room
• Call Jeopardy

4
WARDS

• Non-Call Days
• Arrive at 7a
• See patients in order of priority (ICU then
  floor)
• Discuss patients with attendings
• Teaching rounds MWF 1030-12p
• Conference 12-1p
• Sign out to cross covering intern/resident
• Check out pager at 5p on weekdays or noon on
  weekends unless post-call
• Off Days 4 days per call month (T, Th, Sa, Sun)
  all pre-call days.

5
WARDS- Intern Responsibilities

• Interview Patient HP, review labs/imaging
  formulate plan with resident
• Admission orders (Teaching Service Order)
• Present to the Attending
• HP write up
• Call consults
• Daily progress notes
• Daily orders
• F/u with all attendings
• Cross-cover list/Sign-out
• Discharge summary
• On one of your wards months, each of you will be
  in charge of setting up cases to present for
  interns conference.

6
CONFERENCES
To Present Journal Club 30min Two/year
article of your choice Residents Conference 1h
presentation Interesting medical topic of your
choice Potpourri 30min Any Interesting case To
Attend Noon Conference 12p-1p M, T, Th,
F Interns Conference Tuesdays 11a-12p Clinical
Grand Rounds Wed 730-8a IM Grand Rounds
1215-115p Coffee with Cardiology Fridays
730-8a Teaching Rounds M,W,F 1030a-12 on
Wards months ID Rounds Meet with Dr. Goodman
1-3p once a month on wards
7
ELECTIVES

• Contact the attending you are working with a few
  days prior to the start of the rotation to get
  details on their expectations
• Hours and responsibilities vary depending on the
  rotation and attending.

8
ICU ROTATION

• 6a-6p Mon-Fri
• Hamon 3 ICU
• Resident works with you
• Round on all your patients by 10a, try to
  complete all notes
• 10a Multidisciplinary rounds Present all
  patients to ICU attending, nurses, RT, SW
• Overnight events, vent settings, vitals,
  assessment/plan for the day, DVT/GI ppx.

9
VACATION

• 20 days per year
• Can be taken on any month except Wards and ICU
• Max 5 days/month (M-F surrounding weekends do
  not count)
• Categoricals Contact Sonya/Alma in the clinic 1
  month prior to let them know you are taking
  vacation
• Vacation Form signed by subspecialty attending
  (also by Sonya/Alma if you are a categorical).
  Turn this into Jason for approval 30d prior to
  vacation.

10
IMPORTANT NUMBERS
Residents Lounge Code 997722 Physicians Dining
Room Code 214 Residents Clinic Code
7802 Jason 6176 Sherie 7881 Page Operators
8480 Calling the hospital from the outside
214-345-XXXX
11
Overview - Cross Cover

• Making your Cross-cover list
• Emergency vs. Non-emergency
• When should I go and see the patient?
• Common calls/questions
• When do I need to call my resident???

12
How to make your Cross Cover list

• Log on to www.caregate.net
• Go to Cross Cover
• Under problems, put one liner about the patient
• Then list all important problems and what has
  been done about them
• Under to do section put MR number, pt
  allergies, important meds, anything for X-cover
  to follow up on

13
Cross cover list is kept current on CareGate
www.caregate.net
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16
Cross-Cover List

• ALWAYS check out FACE TO FACE
• ALWAYS include MR, allergies, things to do,
  meds, code status
• Update problem list and meds DAILY!!!
• Always include consultants on board, so that if
  something happens during the day the person
  covering can call someone else for assistance if
  needed.
• Write a progress note if an event occurs
  overnight.
• ALWAYS call the next morning to update on patient
  list (EVEN if there were no calls).
• If there is something important that you need the
  cross cover resident to do/follow up on, make
  sure you tell them in person.

17
Not Acceptable

• Patient intubated, sedated, in 1 ICU when the
  pt has been extubated and on the floor for 4 days
• Update room numbers
• Update DNR/Code Status
• Must put pertinent changes in status (e.g., if a
  patient went into afib or had GI bleed or is
  having a procedure)
• Must put all pending tests on the list
• If someone is really sick, include family contact
  info in the event of a code or critical change in
  medical status
• YOU MUST UPDATE THE WHOLE LIST EVERYDAY!!!

18
What do I do when Im called?

• Review basics by organ systems today

• Infectious Disease
• Heme
• Radiology
• Death

• Neuro
• Pulmonary
• Cardiology
• Gastrointestinal
• Renal

• -Ask yourself, does this patient sound stable or
  unstable?
• -Ask for vitals
• -Is this a new change?

19
NEUROLOGY

• Altered Mental Status
• Seizures
• Falls
• Delirium Tremens

20
Altered Mental Status

• Try naloxone (Narcan), usually 0.4-1.2 mg IV, if
  there is any possibility of opiate OD
• If elderly person is agitated/sundowning 
• try a sitter first 
• then medications
• haloperidol 2mg IV/IM
• ziprasidone (Geodon) 10-20mg IM
• Quetiapine (Seroquel) 25mg po qhs
• Restraints (last resort)

• Always go to the bedside!!!
• Is this a new change? Duration?
• Recent/new medications
• Check VITALS, Neuro Exam
• Review Labs cardiac enzymes, electrolytes,
  cultures
• Check stat Accucheck, 02 sat, ABG, NH3, TSH
• Consider checking non-contrast head CT
•  
•  
•  

Caution with Benzos/ambien in the elderly
21
Move Stupid

• Metabolic B12 or thiamine deficiency
• Oxygen hypoxemia is a common cause of
  confusion 
• Others - including anemia, decreased cerebral
  blood flow (e.g., low cardiac output),
•         CO poisoning
• Vascular CVA, intracerebral hemorrhage,
  vasculitis, TTP, DIC, hyperviscosity,
•         hypertensive encephalopathy
• Endocrine hyper/hypoglycemia,
  hyper/hypothyroidism, high /low cortisol states
  and
• Electrolytes particularly sodium or calcium
• Seizures postictal confusion, unresponsive in
  status epilepticus also consider
• Structural problems lesions with mass effect,
  hydrocephalus
• Tumor, Trauma, or Temperature (either fever or
  hypothermia)
• Uremia and another disorder, hepatic
  encephalopathy
• Psychiatric diagnosis of exclusion ICU
  psychosis and "sundowning" are common
• Infection any sort, including CNS, systemic, or
  simple UTI in an elderly patient
• Drugs including intoxication or withdrawal from
  alcohol, illicit or prescribed drugs

22
Seizures

• Go to bedside to determine if patient still
  actively seizing
• Call your resident
• Assess ABCs
• give 02, intubate if necessary
• Place patient in left lateral decubitus position
• Labs
• electrolytes (Ca/Mg), glucose, CBC, renal/liver
  fxn, tox screen, anticonvulsant drug levels,
  check Accucheck
• Treatment
• Give thiamine 100 mg IV first, then 1 amp D50
• antipyretics for fever or cooling blankets
• Lorazepam 0.1mg/kg IV at 2mg/min
• If seizures continue
• Load phenytoin 15-20 mg/kg IV in 3 divided doses
  at 50 mg/min (usually 1 g total) or fosphenytoin
  20mg/kg IV at 150mg/min
• Phenytoin is not compatible with
  glucose-containing solutions or benzos if you
  have given these meds earlier, you need a second
  IV!
• If still seizing gt30min, pt is in statuscall
  Neuro (they can order bedside EEG)

23
Falls

• Go to the bedside!!!
• Check mental status/Neuro exam
• Check vital signs including pulse ox
• Review med list (benzos, pain meds etc)
• Accucheck!
• Examine for fractures/hematomas/hemarthromas
• Check tilt blood pressures if appropriate
• If on coumadin/elevated INR or alteredconsider
  non-contrast head CT to r/o subdural hematoma
• Consider ordering sitter/fall precautions

24
Delirium Tremens (DTs)

• See if patient has alcohol history
•  Give thiamine 100mg, folate 1mg, MVI
• Check blood alcohol level
• DTs usually occur 3 days after last ingestion
• Make sure airway is protected (vomiting risk)
• Use Lorazepam (Ativan) 2-4mg IV at a time until
  pt calm, may need Ativan drip, make sure you do
  not cause respiratory depression
• Monitor in ICU for seizure activity
• Always keep electrolytes replaced

25
PULMONARY

• Shortness of Breath
• Hypoxia

26
Shortness of Breath

• Go to the bedside!!!
• History of heart failure? Recent surgery? COPD?
• Look at I/Os
• Physical Exam (heart and lungs especially)
• Check an oxygen saturation and ABG if indicated
• Check CXR if indicated
• Lasix 40mg IV x1 if volume overloaded
• Increase supplemental 02, if no improvement start
  on BiPAP, call resident
• Move to ICU/intubate if necessary

27
Causes of SOB

• Pulmonary
• Pneumonia, pneumothorax, PE, aspiration,
  bronchospasm, upper airway obstruction, ARDS
• Cardiac
• MI/ischemia, CHF, arrhythmia, tamponade
• Metabolic
• Acidosis, sepsis
• Hematologic
• Anemia, methemoglobinemia
• Psychiatric
• Anxiety common, but a diagnosis of exclusion!

28
Oxygen Desaturations

• Supplemental Oxygen
• Nasal cannula for mild desats. Use humidified if
  giving more than gt2L
• Face mask/Ventimask offers up to 55 FIO2
• Non-rebreather offers up to 100 FIO2
• BIPAP good for COPD
• Start settings at IPAP 10 and EPAP 5
• IPAP helps overcome work of breathing and helps
  to change PCO2
• EPAP helps change pO2
•  

29
Indications for Intubation

• Uncorrectable hypoxemia (pO2 lt 70 on 100 O2 NRB)
• Hypercapnea (pCO2 gt 55) with acidosis (remember
  that people with COPD often live with pCO2 5070)
• Ineffective respiration (max inspiratory forcelt
  25 cm H2O)
• Fatigue (RRgt35 with increasing pCO2)
• Airway protection
• Upper airway obstruction

30
Mechanical Ventilation

• If patient needs to be intubated, start with
  mask-ventilation until help from upper level
  arrives
• Initial settings for Vent
• A/C FIO2 100 Vt 700 Peep 5 (unless increased ICP,
  then no peep) RR 12
• Check CXR to ensure proper ETT placement (should
  be around 2-4cm above the carina)
• Check ABG 30 min after pt intubated and adjust
  settings accordingly

31
CARDIOLOGY

• Chest pain
• Hypotension
• Hypertension
• Arrhythmias

32
Chest Pain

• Go and see the patient!!!
• Why is the patient in house?
• Recent procedure?
• STAT EKG and compare to old ones
• Is the pain cardiac/pulmonary/GI?from HP
• Vital signs BP, pulse, SpO2
• If you think its cardiac MONA
• Give SL nitroglycerin if pain still present
  (except if low blood pressure, give morphine
  instead)
• Supplemental oxygen
• Aspirin 325 mg
• Cycle enzymes
• Call Cardiology if there is new ST elevation,
  LBBB, or if there is an elevation in cardiac
  enzymes

33
Hypotension

• Go and see the patient!!!
• Repeat BP and HR, manually
• Compare recent vitals trends
• Look for recent ECHO/meds pt has been given.
• EXAM
• Vitals orthostatic? tachycardic?
• Neuro AMS
• HEENT dry mucosa?
• Neck flat vs. JVD (CHF)
• Chest dyspnea, wheezes (?anaphylaxis), crackles
  (CHF)
• Heart manual pulse, S3 (CHF)
• Ext cool, clammy, edema

34
Management of Hypotension

• Anaphylaxis sob, wheezing
• epinephrine 
• benadryl 
• supplemental 02
•  Adrenal Insufficiency
• check, cortisol/ACTH level
• ACTH stim test
• replace volume rapidly
• Hydrocortisone 50-100mg IV q6-8h
•  

• Hypovolemia
• volume resuscitation
• if CHF,bolus 500ml NS
• transfuse blood
• Cardiogenic
• fluids
• inotropic agents
• Sepsis febrile gt101.5
• blood cultures x 2
• empiric antibiotics

Stop BP meds!   Don't forget about tamponade,
PE and pneumothorax!!
35
Commonly Used Pressors
Name
ReceptorAffected
Dose
Action
Phenylephrine (Neosynephrine)
Alpha 1
10200 mcg/min
Pure vasoconstrictor causes ischemia in
extremities
Norepinephrine (Levophed)
A1, B1
264 mcg/min
Vasoconstriction, positive inotropy causes
arrhythmias
Dopamine
Dopa
12 mcg/kg/min
Splanchnic vasodilation ("renal dose dopamine"
even though many doubt such effect exists)
B1
210 mcg/kg/min
Positive inotropy Causes Arrhythmias
A1
1020 mcg/kg/min
Vasoconstriction Causes Arrhythmias
Dobutamine
B1, B2
120 mcg/kg/min
Positive inotropy and chronotropy Causes
Hypotension
36
Hypertension

• Is there history of HTN?
• Check BP trends
• Is patient symptomatic?
• ie chest pain, anxiety, headache, SOB?
• Confirm patient is not post-strokeBP parameters
  are different initial goal is BPgt180/100 to
  maintain adequate cerebral perfusion
• EXAM
• Manual BP in both arms
• Fundoscopic exam look for papilledema and
  hemorrhages
• Neuro AMS, focal weakness or paresis
• Neck JVD, stiffness
• Lungs crackles
• Cardiac S3

37
Management of HTN

• If patient is asymptomatic and exam is WNL
• See if any doses of BP meds were missed if so,
  give now
• If no doses missed, may give an early dose of
  current med
• Start a med according to JNC 7/co-morbidities/alle
  rgies 
• PRN meds
• hydralazine 10-20mg IV
• enalapril (vasotec) 1.25-5mg IV q6h
• labetalol 10-20mg IV
•  
•  Remember, no need to acutely reduce BP unless
  emergency

38
Hypertension (continued)

• URGENCY
• SBPgt210 or DBPgt120 with no end organ damage
• OK to treat with PO agents (decr BP in hours)
• hydralazine 10-25mg
• captopril 25-50mg
• labetolol 200-1200mg
• clonidine 0.2mg

• EMERGENCY
• SBPgt210 or DBPgt120 with acute end organ damage
• Treat with IV agents (Decrease MAP by 25 in min
  to 2hrs then decrease to goal of lt160/100 over
  2-6 hrs)
• nitroprusside 0.25-10ug/kg/min
• nitroglycerin 17-1000ug/min
• Labetolol 20-80mg bolus
• Hydralazine 10-20mg 
• Phentolamine 5-15mg bolus

39
Arrhythmias

• Bradycardia
• Assess ABCs
• give 02
• monitor BP
• Sinus block 1st, 2nd or 3rd degree
• Hold BB meds
• Prepare for transcutaneous pacing
• Atropine 0.5mg IV  x3
• Consider low dose
• Epi (2-10mcg/min) 
• dopamine(2-10mcg/kg/min)

• Tachyarrhythmias
• Afib/flutter RVR 
• rate control (BB/diltiazem/digoxin if BP low)
• consider anti-arrhythmic (amiodarone)
• SVT/SVT with aberrancy
• vagal maneuver
• adenosine 6-12mg IV
• Ventricular fib/flutter 
• check Mg level, replace if needed (gt3.0)
• amiodarone drip

Remember, if unstable shock!!
40
Gastrointestinal

• Nausea/Vomiting
• GI Bleed
• Acute Abdominal Pain
• Diarrhea/Constipation

41
Nausea/Vomiting

• Vital signs, blood sugar, recent meds (pain
  meds)?
• Make sure airway is protected
• EXAM abdominal exam, rectal (considering
  obstruction, pancreatitis, cholecystitis),neuro
  exam (increased ICP?)
• May check KUB
• Treatment
• Phenergan 12.5-25mg IV/PR (lower in elderly)
• Zofran 4-8mg IV
• Reglan 10-20 mg IV (especially if suspect
  gastroparesis)
• If no relief, consider NG tube (especially if
  suspect bowel obstruction)

42
GI Bleed

• UPPER
• Hematemesis, melena
• Check vitals
• Place NG tube
• NPO
• Wide open fluids, typecross for blood
• Check H/H serially
• If suspect 
• PUD Protonix gtt
• varices octreotide gtt
• Call Resident and GI

• LOWER
• BRBPR, hematochezia
• Check vitals
• NPO
• Rectal exam
• Wide open fluids if low BP
• Check H/H serially
• Transfuse if appropriate
• Pain out of proportion? Dont forget ischemic
  colitis!

43
Acute Abdominal Pain

• Go to the bedside!!!
• Assess vitals, rapidity of onset, location,
  quality and severity of pain
• LOCATION
• Epigastric gastritis, PUD, pancreatitis, AAA,
  ischemia
• RUQ gallbladder, hepatitis, hepatic tumor,
  pneumonia
• LUQ spleen, pneumonia
• Peri-umbilical gastroenteritis, ischemia,
  infarction, appendix
• RLQ appendix, nephrolithiasis
• LLQ diverticulitis, colitis, nephrolithiasis,
  IBD
• Suprapubic PID, UTI, ovarian cyst/torsion

44
Acute Abdomen

• Assess severity of pain, rapidity of onset
• If acute abdomen suspected, call Surgery
• Do you need to do a DRE?
• KUB vs. Abdominal Ultrasound vs. CT
• Treatment
• Pain managementmay use morphine if no
  contraindication
• Remember, if any narcotics are started, use
  sparingly in elderly, ensure pt on adequate bowel
  regimen

45
Diarrhea              Constipation

• Is this new?
• check stool studies
• c.diff x 3
• culture
• op
• wbc
• FOBT x 3
• Do not treat with loperamide if you think it
  might be C.diff!!!

• Is this new?
• check KUB
• Ileus/bowel obstruction
• place NPO
• Treat
• Laxative of choice
• MOM
• Miralax
• enema
• tap water
• soap
• Bowel regimen
• colace 100mg bid
• dulcolax 5-15mg

46
RENAL/ELECTROLYTES

• Decreased urine output
• Hyperkalemia
• Foley catheter problems

47
Decreased Urine Output

• Oliguria lt20 ml/hour (lt400 ml/day)
• Check for volume status, renal failure, accurate
  I/O, meds
• Consider bladder scan (place foley if residual
  gt300ml)
• Labs
• UA WBC (UTI) elevated specific gravity
  (dehydration) RBC (UTI/urolithiasis) tubular
  epithelial cells (ATN) WBC casts (interstitial
  nephritis) Eosinophils (AIN)
• Chemistries BUN/Cr, K, Na

48
Treatment of Decreased UOP

• Decreased Volume Status
• Bolus 500ml NS
• Repeat if no effect

• Normal/Increased Volume
• May ask nursing to check bladder scan for
  residual urine
• Check Foley placement
• Lasix 20-40 mg IV

49
Foley Catheter Problems

• Why/when was it placed?
• Does the patient still need it?
• Confirm no kinks or clamps
• Confirm bag is not full
• Examine output for blood clots or sediment
• Do not force Foley in if giving resistance call
  Urology
• Nursing may flush out Foley if it must stay in
• The sooner its out, the better (when
  appropriate)

50
Hyperkalemia

• Ensure correct valuenot hemolysis in lab
• Check for renal insufficiency, medications
  (ACEI/ARBs, heparin, NSAIDs, cyclosporine,
  trimethoprim, pentamidine, K-sparing diuretics,
  BBs, KCl, etc)
• Check EKG for acute changes
• peaked T-waves 
• flattened P waves
• PR prolongation followed by loss of P waves
• QRS widening

51
Treatment of Hyperkalemia

• Severe (gt7mEq/L) or EKG changes
•         Protect myocardium
• Calcium gluconate 1-2amps IV over 2-5min
•  

• Mild (lt6.0 mEq/L)
•         Decrease total body stores
• Lasix 40-80mg IV
• Kayexalate 30-90g PO/PR
• Moderate (6-7mEq/L)
•         Shift K in cells
• NaHCO3 50mEq (1-3amps)
• D5010units insulin IV
• albuterol 10-20mg neb

Emergent dialysis should be considered in
life-threatening situations. Remember this is
a progressive treatment plan, so if your patient
has EKG changes you need to treat for
severe/mod/mild!!!
52
Infectious Disease

• Positive Blood Culture
• Fever

53
Positive Blood Culture

• You get called by the lab because a blood culture
  has become Positive.
• Check if primary team had been waiting on blood
  culture.
• Is the patient very sick/ ICU?
• Is the culture 1 out of 2 and/or coag negative
  staph? 
• This is likely a contaminant.
• If ½ Blood Cx are positive, consider repeating
  another set
• If pt is on abx, make sure appropriate coverage
  based on culture and sensitivity
• If you believe it to be true Positive then give
  appropriate empiric treatment for organism and
  likely source of infection/co-morbidities of
  patient and discuss with primary team in the AM

54
Fever

• Has the patient been having fevers?
• DDX infection, inflammation/stress rxn, ETOH
  withdrawal, PE, drug rxn, transfusion rxn
• If the last time cultures were checked gt24 hrs
  ago 
• order blood cultures x 2 from different IV sites 
• UA/culture 
• CXR 
• respiratory culture if appropriate
• If cultures are all negative to date, likely no
  need to empirically start abx unless a source is
  apparent and you are treating a specific etiology

55
HEME

• Anticoagulation
• Blood replacement products

56
Anticoagulation

• Appropriate for
• DVT/PE 
• Acute Coronary Syndrome
• Usually start with low molecular weight heparin 
• Lovenox 1 mg/kg every 12 hours and renally
  adjust 
• If need to turn on/off quickly (e.g., pt going
  for procedure)
• heparin dripprotocol in EPIC
• Risk factors for bleeding on heparin
• Surgery, trauma, or stroke within the previous 14
  days
• h/o PUD or GIB
• Pltslt150K
• Age gt 70 yrs
• Hepatic failure, uremia, bleeding diathesis,
  brain mets

57
Blood Replacement Products

• PRBC  
• One unit should raise Hct 3 points or Hgb 1 g/dl
• Platelets 
•  One unit should raise platelet count by 10K
  there are usually 6 units per bag ("six-pack")
• use when platelets lt10K in nonbleeding patient.
• use when platelets lt50K in bleeding pt, pre-op
  pt, or before a procedure
• FFP contains all factors
• DIC or liver failure with elevated coags and
  concomitant bleeding
• Reversal of INR (ie for procedure)

58
RADIOLOGY

• Which test should I order?
• Plain Films
• CT scans
• MRI

59
Plain Films

• CXR
• Portable if pt in unit or bed bound
• PA/Lateral is best for looking for
  effusions/infiltrates
• Decubitus to see if an effusion layers needs to
  layer gt1cm in order to be safe to tap
• Abdominal X-ray
• Acute abdominal series includes PA CXR, upright
  KUB and flat KUB

60
CT

• Head CT
• Non-contrast best for bleeding, CVA, trauma
• Contrast best for anything that effects the blood
  brain barrier (ie tumors, infection)
• CT Angiogram
• If suspect PE and no contraindication to contrast
  (e.g., elevated creatinine)
• Abdominal CT
• Always a good idea to call the radiologist if
  unsure whether contrast is needed/depending on
  what you are looking for
• Renal stone protocol to look for nephrolithiasis
• If you have a pt who has had upper GI study with
  contrast, radiology wont do CT until contrast is
  gonehave to check KUB to see if contrast has
  passed first
• If you are going to give contrast, check your
  Cr!!!

61
MRI

• Increased sensitivity for soft tissue pathology
• Best choice for
• Brain neoplasms, abscesses, cysts, plaques,
  atrophy, infarcts, white matter disease
• Spine myelopathy, disk herniation, spinal
  stenosis
• Contraindications pacemaker, defibrillator,
  aneurysm clips, neurostimulator, insulin/infusion
  pump, implanted drug infusion device, cochlear
  implant, any metallic foreign body

62
DEATH

• Pronouncing a patient
• Notify the patients family
• Request an autopsy
• How to write a death note

63
Pronouncing a Patient

• Check for
• Spontaneous movement
• If on telemetryany meaningful activity
• Response to verbal stimuli
• Response to tactile stimuli (nipple pinch or
  sternal rub)
• Pupillary light reflex (should be dilated and
  fixed)
• Respirations over all lung fields
• Heart sounds over entire precordium
• Carotid, femoral pulses

64
Notify the Patients Family

• Call family if not present and ask to come in, or
  if family is present
• Explain to them what happened
• Ask if they have any questions
• Ask if they would like someone from pastoral care
  to be called
• Let them know they may have time with the
  deceased
• Nursing will put ribbon over the door to give
  family privacy

65
Request an Autopsy

• Ask family if they would like an autopsy
• Medical Examiner will be called if
• Patient hospitalized lt24 hours
• Death associated with unusual circumstances
• Death associated with trauma

66
How to Write a Death Note

• DOCUMENTATION
• Called to bedside by nurse to pronounce (name of
  pt).
• Chart all findings previously discussed
• No spontaneous movements were present, pupils
  were dilated and fixed, no breath sounds were
  appreciated, etc.
• Patient pronounced dead at (date and time).
• Family and attending physician were notified.
• Family accepts/declines autopsy.
• Document if patient was DNR/DNI vs. Full Code.

67
Bottom Line

• When in doubt, call your Resident
• It is OK to call your attending if over your head
• You are Never All Alone ?
• Write a NOTE about what has happened for the
  primary team
• Call primary team in the AM about important
  events.
• Have funits gonna be a great year!