CARDIAC SURGERY
Intern "Survival" Guide

Kirk J. Fleischer, M.D.


At most teaching institutions, there are junior surgical housestaff on the cardiac surgery service. Because they are often unfamiliar with the "routine" of the cardiac surgery service, we developed an "Intern Survival Guide" which outlines the responsibilities of the junior housestaff and provides guidance on how best to deal with common clinical scenarios.


We are presenting this for you to serve as a guide for your junior housestaff. We have made an attempt to keep this applicable to all institutions; however there are certain points which will clearly vary between programs. For instance, our thoracic and cardiac surgical services are split; therefore, our thoracic intern cross covers the cardiac patients every third night. Lastly, we are currently working on putting this into a downloadable format. Until then, you can simply print it out from your browser.


Introduction:

Cardiac surgery is a demanding service, but one where you will have the most direct experience in the management of arrhythmias and the care of patients with coronary/vascular disease. Interns are a critical component of the two person physician teams. During the day, the fellow is often in the O.R. and not immediately available (except for emergencies); at night, the fellow is ultimately responsible for the patients in the cardiac surgery intensive care unit (CSICU), the pediatric ICU (PICU), the ward, the preops, as well as for frequent communication with discharged patients. Needless to say, the fellows depend a great deal on the hard work of the interns.

Table of Contents
Rounds
Questions from Ward while fellow in O.R.
The "Book"
Notes
The "Routine" Cardiac Surgery Admission
Preops
Sign-out:   Daily "To Do" List Prior to Signing Out
Conferences
Postoperative Management of the Cardiac Surgery Patient:
   Anticoagulation
   Anemia
    Arrhythmias:   Atrial fibrillation/flutter:   Pushing IV Calcium Channel Blockers
    Ventricular arrhythmias
    AV Conduction Abnormalities
    Chest Pain
    Chest Tubes: Removal of Chest Tubes
    Chest X-Rays
    CPR
    Discharges
    EKG
    Hyperkalemia
    Hypokalemia
    Operating Room Experience
    Outside Calls and Consults
    Pacemakers: Pacing Wires: Use for Pacing
    Pacing Wires: Removal
    Transcutaneous Pacing
    Physical Therapy
    Premature Atrial Contractions
    Premature Ventricular Contractions
    ST Segment Elevation
    Staples
    Transplantation
    Transports from CSICU
    Unstable Patients on the Floor (and Urgent Transfers to the CSICU)
    Vascular Access
    Miscellaneous
Thoracic Surgery:   Role of the Thoracic Surgery Intern
Appendix: Preop Checklist Sheet
    Anticoagulation Sheet
    12 General Survival Tips for Intership
    Angiograms
The author has taken care to make certain that the treatment regimens and drug doses are correct and compatible with standards of care accepted at the time of publication. Changes in treatment or drug dosage become necessary as new information becomes available. Consult package insert for drugs before administration.


APPENDIX 		[Table of Contents]
APPENDIX 1
  1. Preop Checklist Sheet
    NOTE: You may need to adjust the size of the font used by your browser to fit the entire Preop Checklist on one page.
  2. Anticoagulation Sheet
  3. 12 General Survival Tips of Internship
  4. Coronary Angiograms
     
APPENDIX 2 (Pending)
  1. ACLS Algorithms
  2. Cardiovascular Drugs Commonly Used on the Cardiac Surgery Ward
  3. Defibrillation / Cardioversion
  4. Pacemakers (Temporary and Permanent)
  5. Valves
  6. Transplantation
  7. Novacor Left Ventricular Assist Device

 

12 GENERAL SURVIVAL TIPS for INTERNSHIP [Table of Contents]
  1. SYSTEMATIC APPROACH TO "SCUT"
    (e.g. that entity which consumes most of the intern's or junior resident's time)
    1. Checklists for:
      1. Daily scut
      2. Nights on-call
      3. Admissions
      4. Preops
      5. ER w/u's
    2. "Impossible" to be too compulsive
       
  2. KEEP THE "BOOK" COMPLETE AND UP-TO-DATE
    1. Squeeze as much patient information as you can in the small allotted space on the top of our standard "booksheet" (esp. cardiac/resp. history, etc.)
    2. Daily-up date of POD / HD / Diet and ABxD (antibiotic day)
    3. Do not misplace the Book !!!
       
  3. CALL SENIOR RESIDENTS EARLY if there is a problem
    1. ....Regardless, make sure chief knows about problems before AM rounds especially regarding preop patients !!!
    2. The classic dilemma of the junior HO » To call or not to call?
      1. Chiefs would rather be called for the great majority of things if you are concerned.
      2. Remember your decisions / actions are often directly reflected on the chief in the eyes of the attending staff.
         
  4. STAY CALM (or at least, look calm) IN A CRISIS
     
  5. ALWAYS (ALWAYS) LEAVE A NOTE (however brief) WHEN CALLED TO EVALUATE A PATIENT
    1. Document time, patient complaint, exam, intervention, and
    2. Brief algorithm of plan
    3. Also document if chief, attending, consultant, etc. contacted
    4. If patient deteriorates/ becomes unstable or if complication develops (especially if potentially iatrogenic):
      1. Complusively document events, etc.
      2. However, choose words carefully (ask chief if uncertain)
         
  6. "TRUST NO ONE" outside your team
    1. Sounds horribly cynical, but unfortunately true......
    2. Double check everything that's important. Were orders carried out? Was blood drawn? Did patient go for scheduled studies? Did patient receive bowel prep / antibiotics? Is patient NPO? etc.......
    3. Keep track of who you speak with in radiology, lab medicine, pathology, etc. Ask to speak with supervisor if there's a problem.
       
  7. IF UNCERTAIN ABOUT ANSWER TO QUESTION ASKED BY CHIEF, MAKE CERTAIN THAT HE/SHE IS AWARE OF YOUR UNCERTAINTY.
    1. Due to the innumerable tasks assigned to the chief, he/she cannot confirm laboratory / study results, etc. and thus depends on the junior housestaff to gather this information. The information relayed to the chief is often directly relayed to the attending staff and thus must be accurate for optimal patient care (and continued trust in the chief's ability to manage the service).
    2. The chief would much rather hear "I don't know for sure" rather than passing on incorrect information. You will find that admitting what you don't know is an very important part of "first do no harm".
       

  8. HELP YOUR FELLOW INTERNS

    1. "Many hands make light work...."
    2. Before leaving in the evening, volunteer to just do 1 or 2 items of scut (you'll be grateful on your night on-call)
       
  9. TRY TO GET ALONG WITH THE NURSES / ANCILLARY STAFF
    1. Many of these individuals will go out of their way to help you.
    2. If problems arise, take them up with the ward charge nurse or the shift coordinator.
    3. Chose your battles wisely » Your complaints will have a greater impact.
       
  10. REMEMER THAT SURVIVAL IS A TEAM EFFORT !
     
  11. BE EXTREMELY CAREFUL WITH "SHARPS" (a real survival tip!!)
     
  12. "SLEEP WHEN YOU CAN, EAT WHEN YOU CAN,....." (the classic surgery motto) and LAUGH WHEN YOU CAN (it helps!)

 
  1. Left anterior descending artery
  2. Diagonal artery
  3. Septal artery
  4. Circumflex artery
  5. Circumflex marginal artery
  6. Right coronary artery
  7. Acute marginal artery
  8. Posterior descending artery
IV Setup Diagram

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The author has taken care to make certain that the treatment regimens and drug doses are correct and compatible with standards of care accepted at the time of publication. Changes in treatment or drug dosage become necessary as new information becomes available. Consult package insert for drugs before administration.
COPYRIGHT© 1998 by Kirk J. Fleischer, M.D. All rights reserved.