Rotation Director: Bronwyn Baz

Email: baz@ohsu.edu or Bronwyn.Baz@kp.org

Pager: 14279

Overview:

The Coast team includes a PGY2 Pediatric resident, PGY1 Pediatric intern, as well as a PGY1 OHSU Family Medicine intern. The service covers the following patients:

• Patients with Kaiser insurance admitted with a medical problem

• Patients admitted to the pediatric gastroenterology service

• Patients admitted to the pediatric endocrinology service

That said, while residents will be assigned to the Coast team, the inpatient unit is a collaborative place. Depending on census and acuity, residents may additionally cover patients from other services (Hood, SSA, SSB), especially on the weekend.

Rotation goals and objectives:

• Exposure to a wide range of pediatric diagnoses, including some subspecialty diagnoses such as sickle cell disease, cystic fibrosis, nephrotic syndrome

• Experience caring for children in a “closed system” by a group of pediatricians who care for children in the community both as outpatients in a busy pediatric clinic as well as inpatients on a diverse pediatric ward service.

• Demonstrate an understanding to standard clinical approach to many common disease processes in pediatric endocrinology, such as T1DM, T2DM, thyroid/parathyroid disorders, adrenal insufficiency, and diabetes insipidus

• Demonstrate an understanding to standard clinical approach to many common disease processes in pediatric gastroenterology, such as Crohn’s, ulcerative colitis, celiac disease, acute hepatitis, and pancreatitis

Prior to the start of the rotation:

• Received thorough and specific signout from preceding resident

• Updated your pager status (In hospital, available)

First day of the rotation:

• Arrive at Coast Workroom (9N by the nursing lounge) before 0700

• Be prepared to receive overnight signout at 0700. This includes printing patient lists, assigning patients, and other morning tasks.

• Reassign First Call as appropriate

• Pre round and see all patients prior to rounds. Triage ill or discharging patients

• Be prepared to round with each team at the appropriate time. Note: computers will be available for Gastro/Endo rounds but not Kaiser.

• Expect to actively work on admits and discharges in the afternoon.

• All admissions need an H&P documented by a resident. All daily notes must have a physical exam and plan of care for the day documented by a resident

• Update I-PASS prior to signout. Don’t forget to change First Call.

Intern Expectations:

• All patients must be examined prior to rounds and have a preliminary care plan in place at rounds: tell us what you’d like to do, rather than asking.

o Discovery rounds are highly discouraged unless the service is extremely busy and this has been discussed first with the attending.

• Present to senior. They are the team leader. Discuss questions with them first.

• Give clear SOAP format presentations on rounds with pertinent information that includes a daily review of new data as well as a thoughtful assessment (including current patient status) and complete plan. Discuss differential diagnosis as appropriate.

• Interns should write H&P, discharge notes, and daily progress notes if following a patient with an MS2-3. Daily notes should reflect your updates. Continue to modify patient ID, dx, status.

o You should also cosign MS2-3 notes.

• Sub-I’s should write their own notes, including progress notes, and assign to attending to cosign.

• Provide your goals and short teaching topic for the week to attending on first day.

• Be sure you have cleared a consult with SR/attending AND know the patient (see them 1st, review the chart) AND know your consult question prior to calling a consult. Be sure to address the consultant as “Dr.” and not by first name unless told otherwise.

• Morning discharges should be examined, discussed with SR/attending and have a signed discharge order in computer prior to rounds if possible.

• Follow up on your patients/action items in afternoon and report back to team.

• Help notify each RNs for family centered rounds when arriving to room.

Senior Expectations:

• Triage team in AM: order of seeing pts based on acuity and resident clinic/post-call need, call to schedule sedation/testing and consults early, etc.

• Should confirm rounding times briefly with GI attending to enable Kaiser rounds to start by 1000 daily. Senior is responsible for transition from GI to Kaiser rounds in a timely manner.

• Bedside rounding on sick kids/new admits, if needed, prior to team rounding.

• Lead daily 5-10 min informal teaching sessions. Teaching moments can include bedside, while walking down hall, while gowning up, etc.

• Active bedside involvement in patient care in the afternoon – i.e. facilitating discharges, participating in new admissions, assisting interns in creating care plans for children with active developing issues, etc.

• Run the list with the attending in AM after night-team sign-out, and PM prior to sign-out to triage patient rounding and review and solidify patient plans.

• Take charge of running efficient family-centered bedside rounds (FCR). This includes making sure orders are entered in the patient room, getting RN, and facilitating intern/student presentations. Don’t interrupt unless redirecting is required.

• Remind team (attending too!) to help get people out to clinic/post-call/conference.

• Bring any concerns regarding the team or patients to the attending early.

Attending Expectations (so you can hold them accountable):

• Empower the SR to take ownership of the team, and assist with the transition between intern and SR roles (encourage autonomy as appropriate).

• Meet with SR in AM to triage team and teaching for day (SR confirms rounding/teaching time with GI)

• Role-modeling bedside rounds early in the week as needed with expectation the SR will manage bedside rounds independently by the end of the week.

• Meet with residents and medical student briefly early in the week to discuss goals and expectations, and again at end of the week to give feedback (providing real-time feedback as well).

• Review notes with medical student (and feedback to interns PRN) as possible, goal once/week.

• Teaching sessions as time permits, both formal and informal (a majority of teaching and feedback will be on-the-fly, at bedside or immediately after).

• Provide continual, in-the-moment, constructive feedback.

General Schedule:

Evening Sign-out schedule:

Weekend schedule:

• Morning sign-out is still at 7am in the hood workroom. Please note that all teams receive sign-out in this room on the weekend.

• Evening signout starts at 5:30pm but happens in the hood workroom (not resident lounge!). There are only two residents on the weekend nights that split the 4 teams. There is no set order of team sign-out, it will be based on who is ready

Conference: You should ALWAYS attend grand rounds, morning report, noon conference and Friday Forum if possible

Continuity clinic days: The PGY2 resident does not have continuity clinic on SSB. Please work together with other seniors/teams to manage cross-covering of services when other seniors are absent.

If you are going to be absent for all or part of a day:

Please contact (page or text) chief on call as soon as possible to arrange coverage. A verbal exchange must happen with the chief on call because they may need to contact other individuals.

Any resident missing more than 2 days (or 4 half days) may be required to make up the difference at a future date at the discretion of the rotation director, chiefs, and program leadership

Resident Resources, Helpful Tips, and Further Readings:

Click here for link to BOX with pertinent articles

See below for ABP content outlines for the subspecialty services on COAST

Gastroenterology

A. Clinical presentation (eg, abdominal pain, nausea/vomiting, diarrhea, constipation)

B. Diseases, disorders, and conditions

• Esophagus

• Stomach

• Proximal bowel

• Liver

• Pancreas

• Distal bowel

• Rectal-anal

• Celiac disease

• Cystic fibrosis

Endocrinology

A. Clinical presentation

• Ambiguous genitalia

• Short stature

• Tall stature

• Abnormal onset/progression of puberty (eg, delayed puberty, premature puberty)

B. Disorders

• Adrenal disorders

• Thyroid disorders

• Pituitary disorders

• Parathyroid disorders

• Diabetes insipidus

• Type 1 diabetes

• Type 2 diabetes

• Turner syndrome

• Klinefelter syndrome

• Polycystic ovary syndrome

• Other glucose metabolism disorders

• Thyroid disorders

• Pituitary disorders

• Parathyroid disorders

• Diabetes insipidus

• Type 1 diabetes

• Type 2 diabetes

• Turner syndrome

• Klinefelter syndrome

• Polycystic ovary syndrome

• Other glucose metabolism disorders