General Principles
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During medical school, someone probably told you to eat when you can, sleep when you can, pee when you can. This is particularly true when you are on call!
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Each call night is different and unpredictable. You might have many admissions back-to-back, a few admissions spread out during the night, or no new admissions. Cross-cover may be very busy with an unstable patient or might be rather quiet.
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You can simply survive being on call, but what you really want to do is thrive in this learning environment.
Eat When You Can
Tip
· You need energy to work this hard, so get something to eat early and take snacks with you for later.
VAMC
o VA provides food in the refrigerator for call teams and overnight residents.
o Other food for on-call residents, including breakfast food, is available in a refrigerator located in 7W-07. Each team room has an individual fridge available for storing meals, beverages, etc. Please inform a Chief Resident if food supplies are running low.
o There is no food provided at conference at the VA. You will be provided meal cards which you can use to purchase food items at the VA Canteen prior to conference (which begins at 12:00 PM). Plan to get you food early to avoid the lines. You can also use your meal card to make purchases at the VA Coffee shop (Starbucks) and VA Patriot Store (3rd Floor).
UIHC
o At the start of the year, everyone receives a FLAT amount of credit that can be used at any time in the day (either while on call or otherwise).
o Please note that employee discounts are not applied to the purchase nor can the credit be used at the Bread Garden.
o Additionally, leftover call money at the end of the year does not carry over to subsequent years nor is it credited to a paycheck.
Admissions
· Your senior resident or fellow will notify you of any new admissions. Patients may come thru the ETC from home or from another facility, or may be directly admitted from an outside facility.
Admission Orders
o Both UIHC and VAMC utilize an electronic medical record for patient care (EPIC and CPRS). You will become familiar with admission orders during orientation.
o For questions, ask your senior resident or contact the appropriate computer help desk.
Admission H&Ps
o At UIHC you have the option of dictating your H&Ps and COC notes with Dragon. Refer to the Resources section for details. You are encouraged to update the Problem List, SH, and FH manually in EPIC first so that this data may be imported into your note without being dictated.
o Dragon Dictation is allowed at both UIHC and VAMC.
Getting Imaging Studies After-Hours
o This pertains to studies ordered after 5 pm on weekdays, and any time on weekends or holidays.
o Plain films may be ordered in EPIC or CPRS without further action needed, just like during the day.
o CT, MRI and ultrasound requests for patients at UIHC must be discussed with the Radiology resident on call on pager 3205. Be prepared to discuss your patient’s history, indications for the test, and how the results may change management overnight.
o CT requests for patients at VAMC must call the VA operator to call the CT technician. The CT will be performed at VAMC and read by Teleradiology.
o Patients at VAMC needing emergent MRI or ultrasound after-hours will need to be transported to UIHC. Call the VA operator and ask to be connected with the staff Radiologist on call to discuss the situation. If the test is approved, contact triage at UIHC (4-5000) and the AOD (VA pager 0554) to arrange transportation to UIHC.
o To transfer to UIHC from the VA for a test, complete:
1. I-med consent in CPRS (or a monitored phone call to obtain consent).
2. Fee Basis Consult for study.
3. Travel Rec (this is a note in CPRS).
4. For details regarding emergency transfers to UIHC and transfers to UIHC for a scheduled procedure refer to the transfer subfolder located in: My Computer/S:/Handoff.
Calling for Help
· All physicians need to learn to recognize their current limitations and know when to ask for help – it is NEVER a sign of weakness to do so! WE EXPECT YOU TO CALL!
When to Call
o Whenever you have a question
o Any significant change in a patient’s status
o Concern that a patient is unstable
o Concern that a patient needs to be transferred to telemetry or to an ICU
o All patient deaths
Who to Call
o There is always a senior resident assigned to you – call them first!
o In the MICU there is always a fellow on call with you.
o In emergencies you can call any of the other senior residents on call – the 6RC Float senior, Night Float senior, CVICU, and MICU senior. Use amion.com to look up pager numbers.
o There is always a chief resident on call who can help answer questions.
Patient Death
Before Entering the Room
o Contact your senior resident to inform them of the patient’s death.
o Determine the patient’s location and whether family members are present.
o Briefly review the chart for medical and family issues.
In the Room
o Introduce yourself to family members. Be empathetic. Use appropriate phrases like I’m sorry for your loss or This must be hard.
o Let the family know that you need to briefly examine the patient. They do not need to leave the room, but you should ask them whether or not they want to stay while you conduct your exam.
o Pronounce the patient.
§ Verify the patient’s ID by checking their wrist band.
§ Note general appearance.
§ Note response to verbal and tactile stimuli.
§ Examine for pupillary light reflex, listen/feel for breath sounds and heart beat, confirm absence of carotid and radial pulses.
§ Full neuro exam is unnecessary but can be performed along with an EKG if you’re uncertain.
§ Determine the time of death and relay this to the patient’s RN or unit clerk. Do not announce the time of death aloud in the room like on TV, especially if family is present.
Talking with Family
o Talk with the family either in person or over the telephone. Be brief and direct, and avoid using euphemisms for death. Ask whether they have any questions.
o If you reach an answering machine or voicemail, DO NOT leave a message that a patient has died – simply leave your name, phone number of the nursing station, and a request that they call you ASAP to discuss the patient’s condition.
o Always inquire about an autopsy. Consider and be aware of the religious beliefs of the patient and family. The autopsy is free of charge, does not disfigure the body, and does not delay funeral proceedings.
o Notify organ procurement services if the patient is a potential organ donor. Organ procurement services will then discuss donation with the family.
Writing a Pronouncement Note
o Use an Active Issue/Provider Note in EPIC. There will be an {Active Issue/Provider Note Templates} that is available, press F2 and select Death Note at the top. In CPRS use the template IC/Death Note.
o Sample note:
o I was notified by nursing staff at [time] that patient [patient name] had died. I arrived at the bedside to find [patient name] laying still in bed. There was no response to verbal or tactile stimuli. Pupils were fixed and dilated. There were no spontaneous chest wall motions. No breath sounds or heart tones were audible on auscultation. Carotid and radial pulses were absent. [Patient name] was pronounced dead at [time]. Family members were notified [in person or by telephone]. Autopsy was requested and [accepted or declined] by [name of family member, relation to patient]. Condolences were extended to the family.
o Include cause of death for you to reference later when you sign the death certificate.
Death Certificates
o Primary resident will fill out the death certificate.
o Nursing staff will contact the mortician (Pathology department) and arrange for the body to be transported to the Decedent Care Center (aka the morgue).
o You are required to complete the death certificate using the IVES (Iowa Vital Events System).
o To access IVES, right click the Citrix logo in the lower right hand corner. Hover over Applications ⇒ Web Applications ⇒ then click Electronic Death Certification.
o The cause of death should refer to the patient’s underlying condition. Cardiac arrest and pulmonary arrest are end-products of the underlying condition, not causes of death.
o Resources:
§ CDC Physicians Handbook on Medical Certification of Death
§ 5-minute tutorial from Fulton County Medical Examiner’s Center
Common Symptoms and Therapeutics
