VA MICU

Last updated 5/3/2018 (Loehr)

*** Get your computer and badge access early - at least 2 weeks before ***

Talk to Jim Yarborough (2nd floor west, education offices) about this; he can get you started.

GENERAL INFO: This month is split into half MICU and half CCU. You will take sign out from the previous EM resident on the first day of the month, so you may start with CCU or MICU depending on what the previous resident was on. Or get sign-out from whoever they tell you to get sign-out from!

HOME BASE: Fourth Floor - 4NW Workroom. Most patients are in MICU, CCU, or 4NW, all on 4th floor. Some patients may be on 3SICU (usually ICU patients not on ventilators).

TEAM: Two senior residents (you are one of them), one IM intern (and sometimes some FP/transitional interns), and one attending (Cardiology or Intensivist). Occasionally, there will be one fellow during MICU, and one or more medical students. On CCU and MICU, there is a pharmacist who will round with the team and help you with discharge medications.

CALL: Call is Q4. The pattern is Long Call, Post Call, Short Call and Regular.

Long Call: Come in at 8am and admit all patients to your service until 8am the next morning. The Short Call resident will take admits on to their service until 2pm (unless you agree with the other team that short call will only take new patients until noon). Then you will take admits to both CCU and MICU. There may also be transfers from the MOD floors and the hospitalists. During long call, you carry the Code Blue/Rapid Response Pager and will be the senior running all codes in the hospital, including the ED. Some are bogus and some are real. Since LC starts at 8am, the 28 hr day can potentially extend until 12pm. The intern will help you admit patients and accept transfers until 6pm, and then you’re on your own. Sometimes you will have a medical student take overnight call with you. Some attendings like for you to call them about each admit, i.e. Dr. Specht, Dr. Chooljian and Dr. Roos. Others want you to call if you have questions or need help. The fellows will also have various preferences regarding contacting them for questions, make sure you ask so you know what your team expects from you before you're by yourself.

Short Call: Come in at normal times to pre-round on your patients, you will take admissions and transfers from 8am to 2pm (or 12:00pm) to your service, i.e. if you’re on MICU you take all MICU patients and if you’re on CCU, you admit all CCU patients.

COMPUTER PROGRAMS:

• Vista CPRS – This is where we do our documentation: H&P, Inter-ward Transfer Notes, Progress Notes, Code Blue Note, DNR note, D/C summaries, etc. Also used for admit orders, labs, meds, radiology request, consults, & nursing orders. Lastly, you can find results of lab tests, old EKGs, CXR, and view radiographic images (not the best image quality). Get the log-in and password by emailing Kevin Morris. The first few days, there is an orientation to the software program, so ask Patricia about when and where (although this sometimes does not happen, and you get to figure it out on your own).
• ICCA app: Used to get vitals, drips, I/O’s for patients in CCU, MICU, and SICU. On floor patients, VS are at foot of bed/hallway in paper chart. It can be accessed from within CPRS, but takes almost 12 years to load.

​CALL ROOM/MEALS:

Located between CCU and MICU on the 4th floor. There is a computer, bed, and bathroom for your use. If you call housekeeping in the morning on your call day, they will come to empty the trash and change the linens. To get card access, go to 2A-04 on the day you start. This card also gives you access to resident lounge near 4SW, where there is a bunch of snacks and microwaveable foods. You will also get a number of $6.00 meal tickets meant for call days. The VA Canteen hours are M-F 7am-4:30pm, Saturday 8am-3pm, and closed on Sundays. Bring food with you on the weekend if you’re on call.

​Days off: There are 4 days off, unless it is a holiday month where there is an additional day. The days off are on the weekends, when you are Short call or No call. If there is a holiday, work out a weekday when you are not on call for the extra day off.

If your service isn't too busy, you can sometimes take extra days off when you are "regular"/no call (when your co-senior is on long call). Work this out with your co-senior.

TYPICAL DAY:

6 - 7am: Get labs, vitals (use ICCA), pre-round on patients. Begin a progress note in CPRS, which can be completed later during the day (med students will sometimes start the notes for you on the patients they are seeing).

7am ~ 8:30am: Round with the attending, the start time may vary depending on which attending is covering. Normally, rounds end before noon.

12pm – 1pm: Most weekdays, there are Internal Medicine Resident conferences (occasionally free food)

1pm - afternoon: Finish up progress notes, discharges, transfers, procedures, & paperwork. Sign out to long call resident before you leave.

ROUNDS:

MICU: Meet at 8:30am (time depends on your attending) in MICU. Start with a brief one liner about your patient. Then give interval events, vital signs, I/O’s, relevant physical exam findings, and pertinent labs/radiology. Then address organ system and plan. If you are post-call, the attending will usually round on your patients first.

CCU: Meet at 8:30am in Cardiology attending office in Card Dept (4th floor). If attending on service is Dr. Ferry and you have new admission, he prefers you start with CC, then ALL known cardiac history, then risk factors, vital signs, exam (specifically for JVD, s3, edema, i.e. signs of heart failure), relevant labs, and plan. There is a lot of teaching based upon ACC guidelines. Also, be sure to ask the patient “Ferry’s Questions." Dr. Silvet also has similar expectations as Dr. Ferry and will ask for JVD and hepatojugular reflex. Pro-tip: if the pt is obese use an ultrasound to assess JVD.

1. Describe discomfort.
2. What reliably worsens the pain?
3. Does it occur at rest?
4. What’s the most active thing you do? And does that cause pain?
5. What limits your exercise?
6. What is the duration that the pain/discomfort lasts?

DOCUMENTATION: Use Vista CPRS for your notes, you will have to type in vitals signs, but can copy/paste labs into your note. Click,“New Note,” then choose the template "History and Physical" or “Med/MICU/Prog note” for MICU patients and ‘Med/CCU/Prognote’ for CCU patients.” There are also templates called, “Tools for Prog Notes,” which will automatically enter some labs. The co-signer will be the attending for your service. Once you electronically sign the note, it will be sent to the attending. Once signed, you will not be able to edit it, however, you can make an addendum.

If you accidentally sign the note early and want to delete it, make an addendum stating “signed in error,” with your attending as co-signer. Then click “Add Additional Signer,” and choose Howard Miller. (IT guy). He will delete it later in the day.

ATTIRE: Scrubs. No white coat needed as of November 2017 (unless you want everyone to think you're a medicine resident). You can choose to dress up, if you desire.

PARKING: Currently you have to park in the outer-most ring of spaces. This changes frequently due to construction so ask one of the IM residents or chiefs. Generally you can also use the parking structure.

When you come in for long call at 8am you will have a hard time finding a spot, plan accordingly.

STUFF TO REVIEW:

• MICU: Sepsis/Antibiotics, Alcohol Withdrawal, Pancreatitis (Ranson’s Score if greater than or equal to 2 = MICU), Shock, Pressors, Hyponatremia, ARF, OSA, Delirium
• CCU: EKG, risk stratification in ACS, TIMI score, A.Fib with RVR, SVTs, HTN emergencies/urgency, CHF exacerbation
• Read the American College of Cardiology “Pocket Guideline” for Chronic Stable Angina, UA/STEMI, A. Fib, Heart Failure, and Valvular disease. They are found at ACC clinical statements/guidelines:
• http://www.acc.org/qualityandscience/clinical/topic/topic.htm

PEARLS

• Philips U/S is available in the ED and all ICU’s, there are also older sonosites and Siemens in the storage closet by the MICU/CCU and the nurses have access.
• STEMI’s go immediately to Loma Linda ED. Talk with Cardiology attending to find out exactly the process for this transfer. Page cards FELLOW with any questionable EKG, do NOT let the VA ED admit the STEMI if possible and try to arrange an ED to ED transfer (goes faster)
• You can use Vista CPRS at home. This is the link but you will have to speak with Kevin Morris or Jim Yarborough in the GME office to get access and your account set up.
• There are guidelines for what kind of chest pain rule-outs get admitted to MOD and which go to CCU, make sure you have a copy
• For ANY altered pt, or any pt you have the slightest concern for ICH, make sure the ED gets a CT head w/o contrast prior to placing admission orders as there is NO neurosurgery and inpatient transfers at the VA take exponentially longer than ED to ED transfers.
• There is no order set for DKA. Here's a cheat sheet: