"THE ART OF FLOATING"

Survival Hints for M. D. Anderson Solid Tumor Service Call

One of the major Intern responsibilities at MDACC is overnight call. Approximately once a week during the month at MDACC, you will be responsible for covering the patients included in the solid tumor service overnight. The Department of Cancer Medicine at MDACC and the U.T. Department of Medicine believe this experience to be of significant educational value. The following tips and strategies will hopefully provide information that will make the experience beneficial to the development of your skills as a clinician in managing both emergent and non-emergent matters while on call.

ORGANIZATION:

·Make sure your beeper is working. Replace battery if needed. (Pick up the Solid Tumor Pager (713-404-2537) promptly at 5:30 pm from Alison Allen’s Desk in the Fellows’ Office. Always return the pager to the Fellows’ Office at 7:30 am when your call is concluded).

·Carry a clipboard and/or make list of calls to answer.

·Return all pages as promptly as possible.

·Any urgent/emergent verbal orders should be signed before you conclude your call. Routine orders for anti-emetics, insomnia meds, etc. do not have to be signed as these will be cosigned by the primary teams).

PRIORITIZE YOUR CALL: Calls that you should respond to IMMEDIATELY include the following:

·CHEST PAIN

·SHORTNESS OF BREATH

·FEVER IN A NEUTROPENIC PATIENT

·FALLS

·CHANGE IN MENTAL STATUS

·HYPOTENSION

·WHEN THE NURSING STAFF IS IN DISTRESS

There obviously may be other calls that require your urgent evaluation and management. For these and any other serious issues—especially when a patient’s status has changed (e.g., pt being moved to telemetry or ICU, or pt requiring 1:1 sitter for agitated delirium)—you should contact the primary service attending, regardless of the hour.

ORDERS: We recognize that the call volume for the Solid Tumor Housestaff is quite high. Therefore, it is very important to keep a list of all requests as you move between wards. Good organization will go a long way in making this minor obstacle bearable. After writing an order on a particular ward, speak with the Charge Nurse to see if there is anything else that requires your attention. This will cut down greatly on the number of pages you may get for “minor things” and will allow you to respond to the blood drawing tasks and “emergencies” that you will be called to handle.

At MDACC, verbal orders ARE accepted. Be very judicious in using this privilege, especially early in the intern year. You don’t want to miss anything major, especially a drug allergy. For example, if one or two doses of Maalox fails to alleviate Mr. Jones’ dyspepsia, it might be a good idea for you to go evaluate the patient to see if something else isn’t going on (i.e., acute MI). Giving intravenous KCL to a renal failure patient is also a bad idea, but you may be called with a low K value. Don’t count on someone else giving you a detailed hx about the patient over the phone. Go evaluate the patient and read the chart if you are suspicious. Another word of caution, please be as pleasant and professional as possible when giving verbal orders over the phone. If you don’t you may run into one of our nursing colleagues who will take particular glee in paging you several times for Maalox during the night when you finally do get to sleep!!

DEATH PRONOUNCEMENTS: When called upon by a nurse with the news that Mr. Scott, the gentleman with the terminal lung cancer, has expired, it is the housestaff’s responsibility to make the death pronouncement.

·If family is in the deceased’s room, enter quietly and introduce yourself as the “Doctor on Call”. It is not inappropriate for you to ask the family to step out of the room.

·Palpate the chest wall for heartbeat and spontaneous respiration and feel for pulses.

·Auscultate for heart sounds and air movement for 2 continuous minutes.

·Apply painful stimuli to finger nails and sternum.

·Evaluate pupils for reaction and accommodation.

·If no response to painful stimuli and absence of heartbeat and spontaneous respiration, patient is deceased.

·Note time at which this evaluation is concluded; this is the official time of death.

·Notify nursing staff.

·Notify attending on service

·You should also ask if an autopsy is desired. This may seem like an uncomfortable subject after informing the family of their relative’s death. But if the deceased has an inheritable disease, it may be important for the family to know. At MDACC, a hospital administrator will always be on-hand to address the family’s concerns about “what happens from here on out.” Always assure them that you will be available should they have further questions or concerns.

·Write a brief note in the chart with the following verbiage:

Called to see patient by nursing staff for death pronouncement. Patient evaluated, found to be unresponsive to painful stimuli, with no palpable carotid pulse; pupils fixed and dilated; no spontaneous respiration and heartbeat during two continuous minutes of ausculation. Death pronounced at 8:45 pm. Attending notified. Family present and notified; autopsy accepted/declined.

**I also recommend spending a few moments with the family or next of kin. As much as pronouncements are not the most desirable thing to do on call, it is significantly more unpleasant for the family. Be sure and ask the family if there is anything you can do for them. Your presence and time, no matter how brief, will be of significant comfort to them.

SELF PRESERVATION:

·Get a good night’s sleep the night before your call.

·Eat a good meal and bring on-call snacks from home.

·When it’s quiet on call, SLEEP!!

·Keep the Washington Manual, Handbook of Most Commonly Prescribed Drugs, or other favorite pocket books to refer to for dosages, etc

HELP: Remember, IT IS NOT A SIGN OF WEAKNESS TO ASK FOR HELP!!! There is always back-up available for help in assessing previously unencountered problems and decisions. It is better to call earlier than later. The Hospitalists and/or MICU fellows will be happy to provide advice and/or help in uncomfortable situations. It is the duty of the hospitalist and the MICU fellow to cover the solid tumor resident and it is everyone’s responsibility to provide good care for the patient.

GOOD LUCK and have a GREAT YEAR!