Scripps Green/memorial MICU

Please contact the Rotation Director and Rotation Coordinator at least 4-5 weeks prior to the start of the rotation. Points of contact may be found under Rotation Information.

Please also complete the rotation paperwork below NLT 8 weeks in advance and submit to Castor.

First and foremost: You will probably work  harder on this rotation than on any other month during PGY-3 year. It may be one of the most valuable and worthwhile rotations of your entire residency.

Scripps Green Hospital is in La Jolla next to Torrey Pines golf course. This is a small boutique hospital with an Urgent care clinic (UCC) but no ED. You will be handling patients that are admitted through the UCC, direct admits from outlying clinics and patients transferred from the ward floors to the ICU. The patients are surprisingly sick despite having no ED.

Scripps Memorial (La Jolla) is down the street on the other side of the highway is a high-speed facility with a large ICU spanning 2 floors of the new hospital building (Prebys). It has a large volume ED and the hospital is a trauma center with a large interventional cardiology/ECMO service. There will be a large number of cardiac patients on the service at this facility.

I did not have a negative interaction with a single staff the entire month. They do not see us as scut monkeys. Most people love Dr. Serio and he is a great teacher. Dr. Grudko is also great. I can honestly say I enjoyed working with all of them.

Important: There are two possible scenarios for how your schedule will be set up. Depending on the number of residents available, you may be on a Q-3 call schedule run similar to CCU, or you may be on a 12 hour shift-work schedule. I chose to leave the shift-scenario gouge previously written by our forefathers (shift-specific gouge in italics) because this is still plausible and I don’t have any experience with it. Most of the day-to-day stuff won’t change either way. Please see the Q3 specific addendum below.

The service consists of post-op patients which are taken care of by the surgical service who operated on them primarily with ICU serving as a consult service. The staff may or may not ask you to follow these patients depending on how big the service is. Just go with the flow and be sure to know whom the team is expected to follow. Other patients are direct admits from the outside and transfers from the ward (house staff patients). The ICU is primary on them and they usually have the more interesting problems (sepsis, liver bombs, etc.).

You get there at 0600 and pre-round on your patients. The first day of the rotation just show up at 0630-0700 to get familiar.  The residents and others will be busy pre-rounding, so say hello and then meet them at the white board at 0700. Just ask and anyone will show you where that is.

After you pre-round, you do a turnover with the night ICU staff to the day staff at the white board at 0700. This is turnover primarily between staff but they may occasionally ask you to contribute specific information about a patient you know best.

Next is x-ray rounds where you go over all patients on the service, good teaching. The interns and medical students will do most of the reading but you will be expected to read for your patients. The on call resident will run the PACS machine, which is pretty intuitive.

Next you will do walk rounds starting with the patients that are covered by the residents/interns/med studs. Usually, two staff are on during the day and split up the patients. For walk rounds I printed out the progress note from the day before and record my pre-rounding info on that for reference and presentation.

After walk around rounds you will usually be excused to update notes, carry out orders, etc. As for note writing, all progress, procedure notes and H&P’s are done electronically. The way we did it when I was there was to copy the note from centricity into a word file, update it, and then email it using outlook to the staff that you saw the patient with to add an addendum and place in the Centricity. This format is ever changing over there.  If there are med studs, you will be expected to sign off on their notes as well. They will email them to you and you email them to the staff. You will receive a dictation code but likely never use it. Dr. Serio has created templates available on the Scripps website for all the different types of notes you will need to write.  Just ask someone to show you where they are. For established patients, I copied the prior day’s not and edited it.  

A note on house staff patients. These are patients transferred from the ward to the ICU, not pre/post-ops. Try to remember which residents transferred them as they will go back to that resident when you tx them out. 

At noon there is usually a grand rounds or conference (in various rooms in the hospital depending on the day) with food that you are expected to go to.  If you find it totally non-applicable to emergency medicine, you can leave and get back to the unit to do work and look for procedures. Make sure you put your pager number on the white board each day and let the staff know you are available and interested. You should also call the hospital operator when you first start to let them know your schedule and pager number so you can be reached.

Noon conference is followed by ICU rounds in the ICU break room at 1300-ish a couple days out of the week. They will tell you when exactly. I was asked to give a brief critical care talk during one of them. I was also asked to create a code scenario for the IM residents and interns. No big deal for us.

After noon conference come back to the floor and finish up your notes. You are expected to carry anywhere from 4-8 patients. It is pretty hard to see more than 6 by yourself.   If you have a lot of patients and just can’t get to everybody before 0700, see the sick ones and be honest with the staff. They are usually really cool about it and will do bedside rounds or let you get to that patient after rounds.

Sometimes you will be on with an R2 during days for the first 1-2 weeks and maybe a fellow as well. You will alternate accepting admission with the other resident if this is the case but if you’re alone then you accept all admits from the floor and UCC/outside clinics. You spend the rest of the day working on notes, taking care of your patients and waiting for admits. You do 1900 turnover at the board with the oncoming night staff and then you are outta there!

The schedule is M-S the first 2 weeks. You round on SAT until about 1200-1300. You are supposed to cover the other residents patients if you have an R2 on with you that week and he/she yours on SUN but I suggest you cover 1 or 2 just as a courtesy. Otherwise you are there all day writing notes.

You switch to night the 3rd week so you’ll have that Sunday off and start at 1900 the next Monday. You work M-S and on that SAT you will stay and do the rounding until 1200 with Sunday off. You have no teaching or note writing responsibilities except for any progress notes, admit notes or sig event notes so it’s much better than days.

The pertinent difference is the schedule are as follows: On call days, you arrive at 0600 and pre-round as above. Prior to X-ray rounds, you will round immediately on all the post-call residents’ patients. They have a policy that the post-call resident only rounds on three patients. I occasionally saw more if the service was busy. After that, the post call resident is excused. Usually by about 0900 in my experience. Not Bad at all!! Nights are hectic but there is a sleep room one floor down from the ICU in the Cardiology clinic. Someone will have to show you where it is. Whenever I was getting slammed with admits overnight, the staff on would usually help out by taking care of an uninteresting admit for me.  Your day off will be either Saturday, Sunday or Monday. Make sure they give you four days, because the way the schedule worked out for me, I only got three and it had to be changed.

Prior to your rotation contact the GME office, Melissa should get you this info and it has not been included because this always changes. I strongly recommend checking in there prior to the start of your rotation to get your badge, computer access and parking access. Also contact Dr. Soghikian about your upcoming rotation for resources, policy and expectations and general gouge sheet. She is the resident/intern coordinator and very nice, loves to teach and wants you to enjoy the rotation.

(Uploaded 16 Aug 2022)

Random Memorial ICU things:

-Getting there: park in the D parking garage first floor (map attached) and walk in through the ED  entrance to Prebys. Turn left and go past the security desk and front desk, then turn right, then left. Scan your badge and go through the double doors straight ahead and use the elevators there to go up to the 3rd floor (have to scan your badge for this elevator). When you get off the elevator, turn left and go past the nursing desk to get to the resident workroom. If that’s confusing or your badge doesn’t work, just follow the signs to the Prebys main lobby and use those elevators to get up to 3 - use the speaker to ask the nurses to let you in and then ask them for help getting to the resident work room. 

-steal the dot phrases from Dr. William Ring for things like the ICU progress note, H&P, procedure notes, dc sum. You can also search my name and snag them that way.

-the rotation instructions said to use the Dr. Ring order sets but those aren’t a thing so don’t waste your time

-patient list is Prebys Crit Care

-Morning routine: get there at 5:30. Post call resident gives you signout on your 1-2 patients. Right click on your patient on the list to “assign” yourself to them. That way nurses know to contact you. Table signout is at 6:45 in the conference room. The attendings/post-call resident run the list and then you walk round right afterwards. Post-call resident goes first for their 1-2 patients and then they leave by 9:30. The call resident uses one computer to put in orders. The person presenting their patient uses the other computer to read off their notes/reference labs. Rounds are usually done by 10:30. 

-Calling consultants is super weird so just have the Scripps residents or PA help you

-To transfer patient out of ICU, call operator (dial 0) and ask for the on-call Scripps Clinic hospitalist for the day. Epic chat them with a quick run-down on your patient. Wait for them to accept the patient before putting in transfer orders using transfer tab like on trauma. 

-bathroom code is 1357*

-Resident room free lunch: take the main lobby elevators to 1st floor, turn right and then turn left just past the main desk. Take the stairs on the left before you exit the building to get to the lower level. Turn right and there will be double doors on your right. Code is 6565*. Bougie lunch every weekday. Hang out there for 12-1pm conference lecture. 

-There’s also a doctor’s lounge on 2nd floor with bagels, fancy coffee, etc that’s nice post-call. 

-Cafeteria in Prebys main lobby kinda sucks. There’s one in the Browning building if you walk 10 miles through the lower level but I usually door dashed food on call. 

-pre-call resident has to leave by 1:30. Take the first admit with the intern if it comes before 11am. Sign out to the on-call resident.

-call resident takes new admits with the intern until about 3 and then you’re on your own for new admits. Go see them in the ED. Use the “admit” tab for admission orders or else they get lost when they transfer. 

-On call you have 7pm signout in the conference room and then overnight attending will tell you when they want to walk round (usually 7:30). Usually have time to grab/order food after that. 

-Interns leave after 7pm turnover but get them out before 5 at least once a week. They leave by 2 on weekends. 

I don’t know about Dr. Chun but all the attendings I worked with were chill and the workflow/hours were way better than PICU. Senior resident life >>> 

Check out Pinpoint Cafe and Caroline’s for breakfast post-call!