Hepatology

Welcome to the liver rotation. Please read the following carefully for some tips to help you make the most of the rotation.

To start, please get signout from last block’s liver rotators. This generally is easiest if you get signout from the person who is on the same call cycle as you. You can find out who was on last block on New Innovations.

 On your first day:  Please arrive at Foreman 7AE (end of hallway) at 7AM to receive signout from the overnight PA. Update your patients’ provider info field in Carecast at each shift change (tools-->batch update provider--> select MLV--> select your patients--> proceed with update). Pre-round on your patients/active consult follow-ups. Attending rounds begin at 9AM sharp, typically in the 7AE conference room (Drs. Reinus, Schwartz, Kalia like to do this while Massoumi may like to do walk rounds).

The only exception is when there are fresh transplants when rounds will start in the SICU.

Floor Structure: Patients can be listed either under the medical liver or transplant teams. Recent transplants will be taken care of by both the medical and surgical teams. These patients will be discussed together on morning rounds with both the surgeons and medical liver attendings.   Generally, pre-transplant patients are only taken care of by the medical liver team. If you’re in doubt, just ask the liver fellow. 

The liver fellow holds the day-call liver pager from 8AM-5PM during the week, with overnight call Tuesday and Thursdays, as well as 1-2 weekend calls per month. The rest of the time the GI fellow on call will be holding the liver pager. If there are new consults/admissions to-do the fellow will page everyone about it. Usually the person on call does the floor admissions, and if there is a slew of consults, they are usually split with whoever is not on call, excluding the person who has PM clinic. Whoever is on call should be taking notes on all of the patients.  

 

Structure of Call: -The on-call resident admits new patients up until 7pm and then leaves when he/she is done.
-If you are not on call over the weekend you do not come in
-If you are on call Friday you do not come in Saturday to present the case. If you are on-call Saturday you do not come in Sunday to present the new cases.
-You should call each other on weekend nights to give sign-out on the new pts and what happened.
-The residents keep a patient signout list on the computer in 7AE (ask one of the residents to show you which one)
-All notes are written on Carecast/Framework. Please use the Hepatology notes under the medicine subspecialty service.
- A useful resource about how to care for liver transplant patients can be found at: montefiore intranet--> clinical departments--> transplant programs--> clinical guidelines--> adult liver

Below are some important points about the Liver rotation:

 1. All MELD labs must be ordered on patients daily unless specifically asked not to (cbc/bmp/

liver tests/inr) order labs as 3AM. If pt is on tacro, then order all labs including a tacro level as

6AM (tacro is ordered as bid given at 8am and 8pm)

2. Do not put orders for patients on

1. transplant surgery service

2. SICU

3. MICU (but make sure that the PA puts the orders in and that no one forgets - if the pa still forgets after asking twice, put it in yourself if it is important AND TELL THE PA or ATTG IN SICU)

 

3. Do not put immunosuppression orders for patients (tacro/mmf/pred) - the pharmD will put

them in when she is around / or the transplant PA will put them in on transplant surgery patients. On

the medical liver  service patients ONLY, if pharmD is not around on weekend, then we put these orders in

 

4. The transplant surgery attendings names are listed below. Patients on the transplant service are listed under the names of these attendings:  

Dr. Kinkhabwala

Dr. Bellemare

Dr. Graham

Dr. Rocca

 

5. The medical liver attendings are:

Dr. Reinus

Dr. Kalia

Dr. Karkhanis

Dr. Schwartz

Dr. Chacko

Dr. Massoumi

 

6. notes must be written on ALL patients on the service list daily. for initial notes: admission

notes are written for medical liver service (like always) / hepatology initial consultation notes

for patients admitted to the transplant surgery service. then daily follow up notes as usual for

all patients on the list.

 

7.Do NOT sign in for the transplant surgery patients, the PA is around always and it is their

service. this will save you some pages. SIGN IN for all other patients including the step down

(sdu) patients. PLEASE, PLEASE put you name on the white board BOTH on 7AE and SDU if you

are on call.

8. Please make sure you have the MELD ready for all your patients daily. The MELD calculator

you use MUST have the word UNOS next to it (i google meld unos, and use the mayo calculator

online)

 

9. Call the attending directly with any crashing patients or urgent things

 

10. The following prophylactic meds must be ordered on post-transplant patients: (just remember three drugs and you will remember the rest):

1. tacro --> needs -->. bactrim or atovaquone

2. cellcept--> needs -->. PPI

3. prednisone --> usually needs -->. nystatin (or fluc)

7. aspirin

8. valgancyclovir

**lamivudine in fresh transplant who got a hepb+ core + donor organ

 

11. The step down unit and PACU has our patients sometimes --> they are on our service, put in

all orders and lab orders -->nurses need orders and all the work is done by us. the pa or attg is

only watching from a distance in case they crash

12. if patient needs a TIPS: follow the protocol on the intranet / PLEASE TELL the CCM attg on

step down unit 24hrs beforehand that patient is going for tips so they can make a bed

13. Any RUSH or STAT liver biopsy done by IR needs a resident to go down and pick it up after it

is done. we should ask them to call us so we know when to go down. samples are dropped off

on foreman 4 - surgical pathology - cutting room. then we call WILL BIVIN at pathology, x6040

to make sure the slides will be ready and to arrange a time for the team to go down (i do this if i

am around)

14. answer the phone if you are on the floor and they ask for MEDICAL LIVER

 

15. GET daily weights and daily urine lytes (na and K) for anyone being diuresed. this will make

our lives much easier.

16. weekends: check the consult list periodically and see consult patients w/ attending; there

must be a note written for all patients including consults esp new consults (unless attending

says your note is not needed, ask them-they will usually say no).

 

17. pick up all patients on the service list. this way they will be presented properly to the team,

we will fill in gaps as needed, don't worry.

 

18. new names without a room that pop onto the list are usually admissions, just an fyi.

 

19. rounds are twice daily--> at 9am and usually 3pm (after noonrounds are quicker, go over

new problems, new admissions). Call person leaves at 7pm (the non call ppl sign out to the

call person after afternoon rounds once your work is done), call person signs out to the night

hospitalist AND transplant PA (also sign out to PA on sdu or icu's if anything needs to be done

overnight)

20. AND... Dr. Reinus and some other attendings like a structured way of presenting all patients

during rounds: do not say LIVER FUNCTION TESTS, use LIVER TESTS instead. do not say denies,

or nauseous. start w/ source and reliability (for new admits), then chief complaint or reason for

consult (if it is a consult)--> one liner--> overnight events--> meds -->physical exam starting w/

vitals -->labs --> imaging or micro --> problems starting with most important. this will save us

lots of time on rounds since he will call you on it.

 

21. All abdominal ultrasounds are ordered as ‘with dopplers’ in comments section; all ECHO’s

for pts undering transplant eval should be ordered with bubble study.


22. There is a dedicated psychiatrist, Dr. Marcus who rounds with our patients who are under

eval or listed.

 

23. ALL CARDS consults done by bradlow group. All GI consults handled by service GI. The GI

fellow rotating with us adds patients to the endo suite schedule in case our patients need an

EGD or colonoscopy

 

24. The transplant co-ordinators are: KARA VENTURA and LISA BERGER. We call them to get

follow up appointments for eval patients on discharge – call them. If unsuccessful, email them

and cc the attending also so they can follow up.


25. All fresh transplant notes must have donor and recipient cmv and hepB core status on their summary line


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