CARDIAC SURGERY
The Johns Hopkins Hospital
Intern "Survival" Guide

Kirk J. Fleischer, M.D.
 

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

1. SYSTEMATIC APPROACH TO "SCUT"
   (e.g. that entity which consumes most of the intern's / AR's existence)
   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 compliants 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!)

Left anterior descending artery Diagonal artery Septal artery Circumflex artery Circumflex marginal artery Right coronary artery Acute marginal artery Posterior descending artery