How to Survive Your First Night On Call Suggestions from a former intern Matthew Deneke, MD April 12, 2006
Your first night on call <ul><li>The pager goes off… </li></ul>
Potential news on the other end of the phone <ul><li>“ You have (another) admission in the ER.” </li></ul><ul><li>“ Your p...
When it is scenario #3 <ul><li>Many calls you receive will be for non-urgent patient complaints </li></ul><ul><li>When cal...
Cross-Cover <ul><li>When on call, many (if not most) of the patients for whom you are responsible will not be YOUR patient...
Check Out List <ul><li>List of patients on a service </li></ul><ul><li>Used by on call person (usually intern) when called...
Check Out <ul><li>Should  also include any other information someone might need on call </li></ul><ul><ul><li>Diabetes </l...
Check Out <ul><li>Unless not possible, should also include a face-to-face discussion of major issues </li></ul><ul><li>Rem...
Specific issues <ul><li>Pain </li></ul><ul><li>Nausea/Vomiting </li></ul><ul><li>Insomnia </li></ul><ul><li>Anxiety </li><...
<ul><li>Obviously, for any new, unexpected change in a patient, the first thing to do is to GO SEE THE PATIENT. </li></ul>
The “simple,” “mundane,” and often annoying…
Pain <ul><li>Opioids </li></ul><ul><ul><li>Morphine 2mg IV  </li></ul></ul><ul><ul><ul><li>May repeat q 4 hrs prn </li></u...
Pain <ul><li>Opioids (cont) </li></ul><ul><ul><li>Dose adjustments </li></ul></ul><ul><ul><ul><li>Start with ½ dose in eld...
Pain <ul><li>Acetaminophen </li></ul><ul><ul><li>650mg PO/PR </li></ul></ul><ul><ul><li>Avoid in liver dysfunction </li></...
Pain <ul><li>Opioid/acetaminophen combinations </li></ul><ul><ul><li>Percocet </li></ul></ul><ul><ul><ul><li>Oxycodone 5mg...
Pain <ul><li>Implications </li></ul><ul><ul><li>2 Percocet q 4 hrs (6 x/day) = 3900mg APAP </li></ul></ul><ul><ul><li>2 Ty...
Pain <ul><li>NSAIDs </li></ul><ul><ul><li>Naproxen 500mg PO q 12 hrs </li></ul></ul><ul><ul><li>Ibuprofen 800mg PO q 8 hrs...
Nausea/Vomiting <ul><li>Promethazine (Phenergan) </li></ul><ul><ul><li>25mg IV q 4 hrs prn </li></ul></ul><ul><ul><li>50mg...
Nausea/Vomiting <ul><li>Metoclopramide (Reglan) </li></ul><ul><ul><li>10mg IV/PO q 6 hrs prn </li></ul></ul><ul><ul><li>Re...
Nausea/Vomiting <ul><li>Ondansetron (Zofran) </li></ul><ul><ul><li>4mg IV q 8 hrs prn </li></ul></ul><ul><ul><li>8mg po q ...
Insomnia <ul><li>Diphenhydramine (Benadryl) </li></ul><ul><ul><li>50mg po </li></ul></ul><ul><ul><li>25mg IV </li></ul></u...
Insomnia <ul><li>Trazodone </li></ul><ul><ul><li>50-100mg qHS </li></ul></ul><ul><ul><li>Safe in elderly </li></ul></ul><u...
Insomnia <ul><li>Zolpidem (Ambien) </li></ul><ul><ul><li>10mg qHS </li></ul></ul><ul><ul><li>5mg in elderly </li></ul></ul...
Acute Anxiety <ul><li>Short-acting benzodiazepines </li></ul><ul><ul><li>Lorazepam (Ativan) </li></ul></ul><ul><ul><ul><li...
Agitation <ul><li>Haloperidol (Haldol) </li></ul><ul><ul><li>2mg-5mg PO/IM/IV </li></ul></ul><ul><ul><li>In elderly, use 0...
Constipation <ul><li>Milk of Magnesia </li></ul><ul><ul><li>30 mL PO </li></ul></ul><ul><li>Magnesium Citrate </li></ul><u...
Constipation <ul><li>Lactulose </li></ul><ul><ul><li>30mL PO </li></ul></ul><ul><ul><li>Can cause bloating/gas </li></ul><...
Heartburn <ul><li>MgOH/AlOH (Maalox) </li></ul><ul><ul><li>30mL PO </li></ul></ul><ul><ul><li>Avoid in dialysis patients <...
Heartburn <ul><li>GI cocktail </li></ul><ul><ul><li>Usually combination of Maalox, viscous lidocaine, and another medicati...
Pruritus <ul><li>Benadryl </li></ul><ul><ul><li>25-50mg PO/IV q 4 hrs </li></ul></ul><ul><ul><li>Avoid or reduce dose in e...
More Urgent Issues
Chest Pain <ul><li>Give nitroglycerin 0.4mg sublingual </li></ul><ul><ul><li>Response does not predict cardiac source, but...
Chest Pain <ul><li>7 lethal causes </li></ul><ul><ul><li>Acute MI </li></ul></ul><ul><ul><li>Pulmonary embolus </li></ul><...
Fever <ul><li>Obtain blood cultures  before  starting antibiotics </li></ul><ul><li>Causes in hospitalized patients </li><...
Electrolytes: some quick reminders
Electrolytes <ul><li>Potassium </li></ul><ul><ul><li>10mEq for every 0.1mEq above 3.0 </li></ul></ul><ul><ul><li>20mEq for...
Electrolytes <ul><li>Potassium (cont.) </li></ul><ul><ul><li>For urgent replacement, give PO liquid or IV, do not give PO ...
Electrolytes <ul><li>Magnesium </li></ul><ul><ul><li>Must be replaced IV </li></ul></ul><ul><ul><li>Safe to give in large ...
Electrolytes <ul><li>Calcium </li></ul><ul><ul><li>If low, first check serum albumin </li></ul></ul><ul><ul><li>[Measured ...
Electrolytes <ul><li>Phosphorus </li></ul><ul><ul><li>If mildly low (>1.5), replace PO </li></ul></ul><ul><ul><ul><li>Neut...
Special Thanks <ul><li>Kelly Thomas, PharmD </li></ul><ul><li>Drs Menna and Thompson </li></ul><ul><li>My wife n’ kids </l...
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HoCall

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HoCall

  1. 1. How to Survive Your First Night On Call Suggestions from a former intern Matthew Deneke, MD April 12, 2006
  2. 2. Your first night on call <ul><li>The pager goes off… </li></ul>
  3. 3. Potential news on the other end of the phone <ul><li>“ You have (another) admission in the ER.” </li></ul><ul><li>“ Your patient in 305 is crashing.” </li></ul><ul><li>“ The lady in 663 would like something to help her sleep.” </li></ul>
  4. 4. When it is scenario #3 <ul><li>Many calls you receive will be for non-urgent patient complaints </li></ul><ul><li>When called for such complaints, you have several options: </li></ul><ul><ul><li>Ignore them </li></ul></ul><ul><ul><li>Be careless </li></ul></ul><ul><ul><li>Be overly cautious </li></ul></ul><ul><ul><li>Respond appropriately </li></ul></ul>
  5. 5. Cross-Cover <ul><li>When on call, many (if not most) of the patients for whom you are responsible will not be YOUR patients. </li></ul><ul><li>You must depend upon your colleagues to tell you what you need to know about these patients when they check out </li></ul><ul><li>Once your colleagues leave, it’s all YOU </li></ul>
  6. 6. Check Out List <ul><li>List of patients on a service </li></ul><ul><li>Used by on call person (usually intern) when called about a patient </li></ul><ul><ul><li>Often the only information the person on call will know about the patient </li></ul></ul><ul><li>Usually includes patient names, locations, principal diagnoses, and any issues that need to be followed up overnight. </li></ul>
  7. 7. Check Out <ul><li>Should also include any other information someone might need on call </li></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Renal dysfunction </li></ul></ul><ul><ul><li>Hepatic dysfunction (cirrhosis) </li></ul></ul><ul><ul><li>Unstable psychiatric conditions </li></ul></ul><ul><ul><li>Any medications you want or don’t want given </li></ul></ul><ul><ul><li>Known potential for instability/overnight issues </li></ul></ul>
  8. 8. Check Out <ul><li>Unless not possible, should also include a face-to-face discussion of major issues </li></ul><ul><li>Remember, check out unto others as you would have them check out unto you. </li></ul>
  9. 9. Specific issues <ul><li>Pain </li></ul><ul><li>Nausea/Vomiting </li></ul><ul><li>Insomnia </li></ul><ul><li>Anxiety </li></ul><ul><li>Agitation </li></ul><ul><li>Constipation </li></ul><ul><li>Heartburn </li></ul><ul><li>Pruritus </li></ul><ul><li>A couple of more urgent issues </li></ul><ul><li>Electrolytes </li></ul>
  10. 10. <ul><li>Obviously, for any new, unexpected change in a patient, the first thing to do is to GO SEE THE PATIENT. </li></ul>
  11. 11. The “simple,” “mundane,” and often annoying…
  12. 12. Pain <ul><li>Opioids </li></ul><ul><ul><li>Morphine 2mg IV </li></ul></ul><ul><ul><ul><li>May repeat q 4 hrs prn </li></ul></ul></ul><ul><ul><li>Oxycodone 5-10mg PO </li></ul></ul><ul><ul><ul><li>May repeat q 4 hrs prn </li></ul></ul></ul><ul><ul><li>Avoid Demerol if possible </li></ul></ul><ul><ul><ul><li>Increased euphoria, risk of seizures </li></ul></ul></ul>
  13. 13. Pain <ul><li>Opioids (cont) </li></ul><ul><ul><li>Dose adjustments </li></ul></ul><ul><ul><ul><li>Start with ½ dose in elderly or in renal/hepatic dysfunction </li></ul></ul></ul><ul><ul><ul><li>Use caution in patients with respiratory illness </li></ul></ul></ul><ul><ul><ul><li>May have to use more in patients on chronic opiates </li></ul></ul></ul><ul><ul><ul><li>PO:IV conversion for morphine is 3:1 </li></ul></ul></ul><ul><li>If you give too much, remember: Narcan 0.4mg IV </li></ul>
  14. 14. Pain <ul><li>Acetaminophen </li></ul><ul><ul><li>650mg PO/PR </li></ul></ul><ul><ul><li>Avoid in liver dysfunction </li></ul></ul><ul><ul><li>Also good for fever </li></ul></ul>
  15. 15. Pain <ul><li>Opioid/acetaminophen combinations </li></ul><ul><ul><li>Percocet </li></ul></ul><ul><ul><ul><li>Oxycodone 5mg/APAP 325mg </li></ul></ul></ul><ul><ul><li>Tylox </li></ul></ul><ul><ul><ul><li>Oxycodone 5mg/APAP 500mg </li></ul></ul></ul><ul><ul><li>Lortab/Vicodin </li></ul></ul><ul><ul><ul><li>Hydrocodone 5-10mg/APAP 500mg </li></ul></ul></ul>
  16. 16. Pain <ul><li>Implications </li></ul><ul><ul><li>2 Percocet q 4 hrs (6 x/day) = 3900mg APAP </li></ul></ul><ul><ul><li>2 Tylox (or Lortab/Vicodin) q 4 hrs = 6000mg APAP </li></ul></ul><ul><li>Maximum dose of APAP in 24 hrs is 4g </li></ul><ul><li>So, if giving 2 Tylox/Lortab/Vicodin, do not give more often than q 6 hrs </li></ul>
  17. 17. Pain <ul><li>NSAIDs </li></ul><ul><ul><li>Naproxen 500mg PO q 12 hrs </li></ul></ul><ul><ul><li>Ibuprofen 800mg PO q 8 hrs </li></ul></ul><ul><ul><li>Ketorolac (Toradol) 60mg IM/IV once, then 30mg IV q 6 hrs </li></ul></ul><ul><ul><ul><li>Cannot use for > 5 days </li></ul></ul></ul><ul><ul><li>Avoid in renal dysfuction (acute or chronic) or uncontrolled HTN, caution in CHF </li></ul></ul>
  18. 18. Nausea/Vomiting <ul><li>Promethazine (Phenergan) </li></ul><ul><ul><li>25mg IV q 4 hrs prn </li></ul></ul><ul><ul><li>50mg PO/PR q 4 hrs prn </li></ul></ul><ul><ul><li>Use lower doses in elderly due to increase side effects </li></ul></ul>
  19. 19. Nausea/Vomiting <ul><li>Metoclopramide (Reglan) </li></ul><ul><ul><li>10mg IV/PO q 6 hrs prn </li></ul></ul><ul><ul><li>Remember it stimulates gut motility </li></ul></ul><ul><ul><ul><li>Avoid in suspected bowel obstruction or diarrhea </li></ul></ul></ul><ul><ul><li>Use half dose in dialysis patients or elderly </li></ul></ul><ul><ul><li>Dystonic reaction </li></ul></ul><ul><ul><ul><li>Treat with Benadryl 25mg IV </li></ul></ul></ul>
  20. 20. Nausea/Vomiting <ul><li>Ondansetron (Zofran) </li></ul><ul><ul><li>4mg IV q 8 hrs prn </li></ul></ul><ul><ul><li>8mg po q 8 hrs prn </li></ul></ul><ul><ul><li>Best effect is in chemotherapy induced nausea </li></ul></ul><ul><ul><li>Very expensive </li></ul></ul><ul><ul><li>Safest side effect profile for elderly </li></ul></ul>
  21. 21. Insomnia <ul><li>Diphenhydramine (Benadryl) </li></ul><ul><ul><li>50mg po </li></ul></ul><ul><ul><li>25mg IV </li></ul></ul><ul><ul><li>Avoid in elderly (anticholinergic) </li></ul></ul>
  22. 22. Insomnia <ul><li>Trazodone </li></ul><ul><ul><li>50-100mg qHS </li></ul></ul><ul><ul><li>Safe in elderly </li></ul></ul><ul><ul><li>Side effects </li></ul></ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul><ul><ul><ul><li>Priapism </li></ul></ul></ul>
  23. 23. Insomnia <ul><li>Zolpidem (Ambien) </li></ul><ul><ul><li>10mg qHS </li></ul></ul><ul><ul><li>5mg in elderly </li></ul></ul><ul><ul><li>Expensive </li></ul></ul>
  24. 24. Acute Anxiety <ul><li>Short-acting benzodiazepines </li></ul><ul><ul><li>Lorazepam (Ativan) </li></ul></ul><ul><ul><ul><li>1-2mg PO/IV q 4-6 hrs prn </li></ul></ul></ul><ul><ul><li>Alprazolam (Xanax) </li></ul></ul><ul><ul><ul><li>0.5-1mg PO TID prn </li></ul></ul></ul><ul><ul><ul><li>Do not use in patients with liver disease </li></ul></ul></ul><ul><li>Avoid in elderly or use very low doses </li></ul><ul><li>Can try trazodone in elderly first </li></ul><ul><li>Can use hydroxyzine if drug-seeking </li></ul>
  25. 25. Agitation <ul><li>Haloperidol (Haldol) </li></ul><ul><ul><li>2mg-5mg PO/IM/IV </li></ul></ul><ul><ul><li>In elderly, use 0.5-1mg PO/IM/IV </li></ul></ul><ul><ul><li>Watch for dystonic reaction </li></ul></ul><ul><li>Ativan </li></ul><ul><ul><li>2mg PO/IV </li></ul></ul><ul><ul><li>Avoid in confused elderly patients </li></ul></ul><ul><li>May need higher dose if patient uses medication chronically </li></ul>
  26. 26. Constipation <ul><li>Milk of Magnesia </li></ul><ul><ul><li>30 mL PO </li></ul></ul><ul><li>Magnesium Citrate </li></ul><ul><ul><li>8 oz (240mL) bottle PO </li></ul></ul><ul><li>Fleet’s enema </li></ul><ul><ul><li>One enema PR </li></ul></ul><ul><li>AVOID THESE IN DIALYSIS PATIENTS </li></ul><ul><li>Risk of hyperMg/hyperPO4 </li></ul>
  27. 27. Constipation <ul><li>Lactulose </li></ul><ul><ul><li>30mL PO </li></ul></ul><ul><ul><li>Can cause bloating/gas </li></ul></ul><ul><li>Bisacodyl (Dulcolax) </li></ul><ul><ul><li>10mg PO/PR </li></ul></ul><ul><ul><li>Can cause cramping </li></ul></ul><ul><li>Combinations also work well </li></ul>
  28. 28. Heartburn <ul><li>MgOH/AlOH (Maalox) </li></ul><ul><ul><li>30mL PO </li></ul></ul><ul><ul><li>Avoid in dialysis patients </li></ul></ul><ul><li>CaCO3 (Tums) </li></ul><ul><ul><li>2 tablets PO </li></ul></ul><ul><ul><li>Safe in dialysis patients </li></ul></ul><ul><li>Ranitidine (Zantac) </li></ul><ul><ul><li>150mg po BID prn </li></ul></ul><ul><ul><li>Dose once daily in dialysis patients </li></ul></ul>
  29. 29. Heartburn <ul><li>GI cocktail </li></ul><ul><ul><li>Usually combination of Maalox, viscous lidocaine, and another medication (Benadryl or Donnatal) </li></ul></ul><ul><ul><li>Usually complicated to order and is delayed by Pharmacy </li></ul></ul><ul><ul><li>Some studies say no better than Maalox alone </li></ul></ul><ul><li>Do not give PPI alone for acute heartburn </li></ul><ul><ul><li>Onset of action is delayed by several hours </li></ul></ul>
  30. 30. Pruritus <ul><li>Benadryl </li></ul><ul><ul><li>25-50mg PO/IV q 4 hrs </li></ul></ul><ul><ul><li>Avoid or reduce dose in elderly </li></ul></ul><ul><li>Hydroxyzine (Atarax, Vistaril) </li></ul><ul><ul><li>25-100mg PO/IM q 6 hrs </li></ul></ul><ul><ul><li>Avoid in elderly </li></ul></ul><ul><ul><li>Cannot be given IV </li></ul></ul><ul><li>If one does not work, try the other </li></ul>
  31. 31. More Urgent Issues
  32. 32. Chest Pain <ul><li>Give nitroglycerin 0.4mg sublingual </li></ul><ul><ul><li>Response does not predict cardiac source, but may give the patient relief </li></ul></ul><ul><li>EKG </li></ul><ul><li>Troponin/cardiac enzymes </li></ul><ul><li>If no response to NTG x 3 and EKG is negative, can try Maalox or GI cocktail </li></ul>
  33. 33. Chest Pain <ul><li>7 lethal causes </li></ul><ul><ul><li>Acute MI </li></ul></ul><ul><ul><li>Pulmonary embolus </li></ul></ul><ul><ul><li>Pericarditis with tamponade </li></ul></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><ul><li>Aortic dissection </li></ul></ul><ul><ul><li>Boerhaave’s syndrome (esophageal rupture) </li></ul></ul><ul><ul><li>Severe pneumonia </li></ul></ul>
  34. 34. Fever <ul><li>Obtain blood cultures before starting antibiotics </li></ul><ul><li>Causes in hospitalized patients </li></ul><ul><ul><li>UTI (foley) </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Wounds (surgical, trauma, decubiti) </li></ul></ul><ul><ul><li>Plastic (IV’s, CVL’s, drainage catheters, etc.) </li></ul></ul><ul><ul><li>DVT </li></ul></ul><ul><ul><li>C. difficile colitis (if diarrhea present) </li></ul></ul><ul><ul><li>Sinusitis (if NG tube has been used) </li></ul></ul>
  35. 35. Electrolytes: some quick reminders
  36. 36. Electrolytes <ul><li>Potassium </li></ul><ul><ul><li>10mEq for every 0.1mEq above 3.0 </li></ul></ul><ul><ul><li>20mEq for every 0.2mEq below 3.0 </li></ul></ul><ul><ul><li>K 2.8, want to correct to 4.0 </li></ul></ul><ul><ul><ul><li>(20x2)+(10x10) = 140mEq </li></ul></ul></ul>
  37. 37. Electrolytes <ul><li>Potassium (cont.) </li></ul><ul><ul><li>For urgent replacement, give PO liquid or IV, do not give PO tablets/capsules </li></ul></ul><ul><ul><li>IV rates </li></ul></ul><ul><ul><ul><li>10mEq/hr through peripheral </li></ul></ul></ul><ul><ul><ul><li>20mEq/hr through CVL </li></ul></ul></ul><ul><ul><li>Use caution when replacing patients with chronic kidney disease </li></ul></ul><ul><ul><li>Do not replace in dialysis patients unless absolutely necessary </li></ul></ul>
  38. 38. Electrolytes <ul><li>Magnesium </li></ul><ul><ul><li>Must be replaced IV </li></ul></ul><ul><ul><li>Safe to give in large amounts </li></ul></ul><ul><ul><li>Can be given quickly </li></ul></ul><ul><ul><li>Give 2-4g MgSO4 IV </li></ul></ul><ul><ul><li>Only replace if absolutely necessary in dialysis patients </li></ul></ul>
  39. 39. Electrolytes <ul><li>Calcium </li></ul><ul><ul><li>If low, first check serum albumin </li></ul></ul><ul><ul><li>[Measured Ca] + [(4.0 – albumin) x 0.8] = corrected Ca </li></ul></ul><ul><ul><li>If replacing, know PO4 first </li></ul></ul><ul><ul><li>Replacement </li></ul></ul><ul><ul><ul><li>Ca gluconate 1 amp (10mL of 10% solution) = 1g </li></ul></ul></ul><ul><ul><ul><li>1g Ca gluconate = 4.65 mEq </li></ul></ul></ul><ul><ul><ul><li>Usual replacement is with 1-2g Ca gluconate IV </li></ul></ul></ul>
  40. 40. Electrolytes <ul><li>Phosphorus </li></ul><ul><ul><li>If mildly low (>1.5), replace PO </li></ul></ul><ul><ul><ul><li>Neutra-Phos 2 packets BID-TID </li></ul></ul></ul><ul><ul><ul><li>Fleet’s phospho-soda 5-10mL TID </li></ul></ul></ul><ul><ul><li>If very low or symptomatic, pt needs IV </li></ul></ul><ul><ul><ul><li>Ask for help </li></ul></ul></ul><ul><ul><li>Do not replace in dialysis patients unless absolutely necessary </li></ul></ul><ul><ul><li>(tired of hearing this yet?) </li></ul></ul>
  41. 41. Special Thanks <ul><li>Kelly Thomas, PharmD </li></ul><ul><li>Drs Menna and Thompson </li></ul><ul><li>My wife n’ kids </li></ul>

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