Floor Calls

1
Floor Calls.

• How to handle them

2
Doctorpt is febrile to 39

• Adopt a system for answering calls
• Info to request from RN
• Into to get from chart/carecast
• Info from patient
• Info from exam
• Tests to order
• Who should you call?
• For every complaint, remember Dr. Spains
  favorite saying round up the usual suspects

3
Abdominal Pain

• 1) Go see the patient
• 2) Information to request from RN
• New set of vitals
• New onset of pain?
• Bowel function?

4
Abdominal Pain

• Information from chart/care-cast
• What surgery has patient had?
• When did the patient have surgery?
• Is patient eating?
• Vitals (temp, BP, HR)
• Labs (WBC? HCO3?)

5
Abdominal Pain

• Information from patient
• New onset pain?
• Flatus?
• BM?
• Nausea/Vomiting
• Fevers/Chills
• Localizing pain

6
Abdominal Pain

• Information from exam
• Examine incision erythema, induration,
  fluctuance
• Abdomen tender?
• Abdomen rigid
• Rebound

7
Abdominal Pain

• Tests
• CBC, BMP/CMP
• KUB (distended bowel loops)
• CXR upright (Free air)
• CT Abdomen/Pelvis (PO, IV, rectal contrast)

8
Abdominal Pain

• Who you gon call??-
• In-house trauma chief
• SICU resident
• Service chief

9
Fever

• Definition of Fever 38.0C significant fever
  38.5C)
• Go see the patient
• Information to request from RN
• Vitals
• Nausea/Vomiting
• Change in mental status

10
Fever

• Definition of Fever gt 37.9C significant
  fever gt38.4C)
• 1) Go see the patient
• 2) Information to request from RN
• Vitals
• Nausea/Vomiting
• Change in mental status

11
Fever

• Information from chart/care-cast
• Vitals (look at trends)
• Date of operation (POD very important)
• Recent labs (WBC, UA, recent blood cultures
  within 24 hrs)
• Recent CXR

12
Fever

• Information from patient
• Associated symptoms (nausea, vomiting, abdominal
  pain/tenderness)
• Localizing pain

13
Fever

• Information from exam
• Look at incision (okay to take down dressing
  even at day 1)
• Erythema, Induration, Purulence
• Abdominal tenderness
• SOB
• Look at IV
• New meds
• Being transfused
• Remember which days post-op are associated with
  which common causes of fever

14
Fever

• POD 1/2 Atelectasis, necrotizing wound
  infection (clostridium, anaerobic strep)
• POD3-5 UTI PNA Superficial thrombophlebitis
  Post-op Abscess
• Any time Drug fever (diagnosis of exclusion)
• Transfusion reaction?

15
Fever

• Tests
• CBC, BMP
• KUB
• CXR
• CT abdomen/Pelvis (Do not order without speaking
  with chief resident)

16
Hypotension

• Info to request from RN
• New vitals
• Epidural?
• Urine output

17
Hypotension

• Info to get from chart/carecast
• Trend in vitals (HR and BP)
• Labs (Hematocrit, BUN/Cr)
• Urine output (last shift not total)
• Date of surgery

18
Hypotension

• Info from patient
• Chest pain
• Palpitations
• Dizziness
• Abdominal Pain

19
Hypotension

• Info from exam
• Febrile? (SIRS, sepsis)
• Mental status (Awake, alert, oriented?)
• Bilateral breath sounds, Subcutaneous crepitus
• Tracheal deviation
• JVD, Weak pulses
• Irregular heart rate/rhythm, murmurs
• Abdominal tenderness

20
Hypotension

• Tests
• CBC, BMP
• ABG
• CXR (PTX, PNA, Free air)
• EKG
• Bladder scan
• CTA chest
• CT abdomen/pelvis
• Swann-Ganz catheter

21
Hypotension

• Treatment
• Fluids, fluids, fluids
• Pressors

22
Shortness-of-Breath

• Round up the usual suspects
• Go see patient
• Info to get from RN
• Sudden onset vs progressive SOB
• Vitals (O2 sat, RR, BP, HR)
• Associated symptoms (chest pain, palpitations,
  leg or calf pain)
• Trauma patient?

23
Shortness of Breath

• Info from chart/Carecast
• Trends in vitals (Spainism patients often dont
  decompensate suddenly, rather, doctors notice
  suddenly!)
• Recent labs/notes/CXR
• Date and type of surgery (eg ventral hernia
  repair, CABG, lung resection etc)
• Diet (aspiration risk?)

24
Shortness of Breath

• Info from patient
• Palpitations
• Chest pain
• H/O asthma
• Timeline of onset
• Fevers/Chills
• Leg pain
• Ambulation

25
Shortness of Breath

• Info from exam
• O2 sat, RR, Febrile
• Awake, alert and oriented?
• Labored breathing (secondary muscle use)
• Bilateral lung sounds? Crackles, Wheezes?
• S1, S2, RRR, M/R/G?
• Tracheal deviation?

26
Shortness of Breath

• Tests
• CBC, BMP
• CXR (PTX, HTX, PNA etc)
• EKG (ST elevation, arrhythmias)
• ABG (calculate A-a gradient)
• CTA chest (speak with senior resident before
  ordering)

27
Shortness of Breath

• Treatments
• Place pt on mask ventilation
• If already on mask ventilation, can use bipap or
  can intubate (call senior for either of latter
  two)
• Tube thoracostomy for PTX/HTX
• Nebulizer treatments (administered by RT) for
  asthma
• Anticoagulation for PE (call senior before
  starting) or AMI
• Antibiotics for PNA

28
Chest Pain

• Info from RN
• Date of surgery
• Recent vitals
• New onset?

29
Chest Pain

• Info from chart
• Trends in vitals
• Recent labs/notes/CXR
• Date and type of surgery
• Diet

30
Chest Pain

• Info from patient
• Cardiac risk factors (age, sex, smoker, previous
  MI)
• Onset of chest pain
• Associated SOB
• Sense of impending doom
• Nausea/Vomiting

31
Chest Pain

• Info from exam
• BP, HR, O2 sat
• Awake, alert and oriented?
• RRR, S1, S2, murmurs, rubs, gallops?
• Repoducible?
• Lung sounds? Crackles?

32
Chest Pain

• Tests
• If any concern for HD stability of pt, transfer
  to monitored setting (D2/3 or ICU)
• CBC, BMP, Ca, Mg, Phos, Troponin
• EKG
• ABG

33
Chest Pain

• Treatment
• Tube thoracostomy for PTX/HTX
• Anticoagulaton for AMI/PE
• Supportive treatments for PNA (Antibiotics,
  oxygen, aspiration precautions)

34
Always remember

• Equanimity under duress
• Perrymans Principles of Sabotage