Morning Rounds:

• • • Equal parts science, art, and choreography

    • The team is our unit’s first and most important patient!

      • If it flatlines, nothing gets done

      • Everyone – providers, nurses, RTs, pharmacists, nutritionists, social workers – has a role in keeping it healthy

    • When presenting, focus on synthesizing information and seeing the bigger picture

      • • We do not need people to simply read numbers off a computer screen!

        • Practice interpreting that data and using it to inform a management plan

          • • It may not end up being THE plan – who cares?

        • When things get overwhelming (and they will occasionally), take a breath and ground yourself in the system-by-system approach

    • See all of your patients before rounds:

      • • Talk to the overnight team and talk to the nurses!

        • Examine at least the pertinent/active systems

          • • • Altered mental status – do a neuro exam!

              • Septic shock, on pressors – how are the pulses and capillary refill?

        • It’s not a hotel – the hour is not a reason to forego a physical exam

        • Know what medications/doses your patients are on

    • For overnight events:

      • • “Got Tylenol for teething” is not what we are looking for

        • Stick to major events and issues from the overnight team:

          • • • If the pediatrician were to call for an update, what would you say?

    • For labs:

      • • What’s your interpretation? Is 5.5 high or low? Are we trending down or climbing?

Most importantly: What’s your assessment?

• • • • • Key word:  YOUR

        • What are they admitted for and how is it going?

        • Can be as simple as “better” or “worse”

        • Avoid regurgitating the “one-liner” that is actually a 6-liner

    • What’s your plan?

      • • Make one and stick to it

        • Keep your systems’-based approach

        • Be brief, direct

        • It’s ok to ask for input/help, but give your ideas first

Odds and Ends:

• • • Talk to the overnight RN before they leave, they’re a great resource

    • Almost everything you need for rounds (except labs and meds) is at the bedside:

      • • Infusions:  Look at the pumps (the EMR is almost never up-to-date when things have changed overnight)

        •  Feeds/Fluids/TPN:  Look for a feeding pump or a TPN bag, verify with the nurse

        • Vent or BiPAP settings:  Although RT will usually be on rounds to report this, you should know it (and understand it - if you don’t ask the fellow or RT)

Communication:

• • • Check in with bedside providers frequently

      • • May seem obvious but is often overlooked 

        • Enables the RN to identify you as the point person for the patient (vs. going directly to the fellow)

        • Sometimes (or often) the fellow or attending will make changes without letting you know, and the RN can be the quickest way to stay updated

        • Most importantly—you get to know the patients and can learn from them!  Things can change very quickly!

    • Tell the nurses about your orders - seems obvious but frequently does not happen  

    •  If someone comes to you with a concern: Get up, go to the bedside, and see what they are seeing

    • “I don’t know” is a perfectly acceptable response to a question. No one knows everything. But it should be followed by “I can find out…” 

Paperwork:

• • • Sure, it is important, but we want you to be more than “note and order writers.”

    • Try to have notes prepped before rounds so that you just have to sign them afterward

      • • More time for teaching!

    • Proofread and make sure your notes are up-to-date

Procedures:

• • • You should learn to bag – ask the RTs, fellows

    • Take advantage of chances for IVs, LPs, art sticks, foleys, etc.  in sedated patients  – check with the nurses and fellows

    • Because of our other learners, you will probably not get many other procedures (intubations, arterial/central lines) but watch and see how it’s done.   Ask how and why.

    • Go to RRTs, codes; follow the fellows if they are called into your patient’s room