Medicine Consult
General Information
Daily Workflow
Start of the day: Long call resident should arrive by 7 AM and get sign-out as well as pick up the transfer phone from the night hospitalist on Foreman 7AE (same as hepatology rotation). If it's unclear who the night hospitalist is, find provider under coverage text paging grid under "Medicine Teaching Service" and "Medicine Consult, 24hr"). Rest of residents may then meet in NW8 conference room (code 135).
Long call resident should then login to the coverage grid under “Medicine Consult, 24 hour”.
Long call resident sees as many consults and follow-ups prior to attending rounds as they can (usually 9 or 9:30 AM). Everyone else should come in by 9 AM at the latest.
End of the day: The long call resident is required to see all consults until 7:00 PM and leave no earlier than 8:30 PM (code team coverage until night code leader receives sign-out).
After 5 PM, any POMA that is likely to go to the OR the next day or urgent consult should be discussed with the liver/night hospitalist on the liver service, who arrives at 7 PM.
Please sign out and drop off cell phone with the liver hospitalist (go at 7:15-7:30 PM as the liver hospitalist is also receiving sign out from the liver service).
Consults: Most of the time, you are asked to either complete a preoperative medical assessment (POMA) or provide a medical consultation for a patient on a non-medical service.
We do not provide POMAs or consults for hospitalist, house staff, private, geriatric, or family medicine patients.
The medicine resident on oncology and neurology writes the POMA and discusses it with the medicine consult attending.
We do POMAs for SICU, CSICU, and NSICU.
Step down POMAs are covered by medicine consult if after hours (M-F after 7 PM and Sa-Sun after noon) AND if the patient is going to OR next day.
Code leader: The long call resident is code leader from 7:00 AM to 8:30 PM. If you are sterile for a procedure, you must assign someone else (another med consult resident or the floor resident) to act as the code leader.
*Please assume that all patients who have a RRT or CAC called could be COVID+/AGP and don the appropriate PPE. Appropriate PPE should be worn with all patient encounters given the current COVID surge. It is OKAY to delay patient care for the time it takes to don appropriate PPE.
MIDAS reports must be documented for all RRTs/CACs. This is the primary responsibility of the CCM team responding, but this task may be deferred to the code leader. If/when completing this task, please document it in the appropriate place as below.
Please note that EtCO2 application and measurement is now a standardized aspect of intubation during codes, so be sure to keep an eye out for it and document accordingly as applicable.
Death Certificates: From 6 PM – 7 PM, for patients on the PA medicine service, medicine consult is responsible to signing off on death certificates. From 7 PM onward, the night hospitalist is responsible.
Procedures: You may be contacted by other services in the hospital to perform various procedures (LP, paracentesis, etc). Please remember that it is not your obligation to provide procedures, and should only be attempted if you are certified, agree with the indication, and feel the procedure is safe to perform. If you are not certified (sometimes in the case of LPs), you can explore if neurology or medicine chief resident could come to supervise you.
Primary team should discuss procedure and obtain informal consent involving a discussion of general risks and benefits prior to calling medicine consult. Ultimate responsibility for obtaining formal written or verbal consent involving a discussion of specific risks and benefits will be the responsibility of the person performing the procedure.
For large volume paracentesis, after you insert the catheter, have established good flow and assured that the patient is safe and comfortable, you may verbally sign out to the floor PA. Floor PA should continue to observe q10minutes and change bottles and remove catheter/dress site as needed
You must write a procedure note.
Transfers: We are responsible for accepting transfers to medicine only. We are not involved in the transfer of patients to/from MICU/CCU/CSICU/NSICU/SDU, or to hepatology, and cardiology. We are not involved in transfer for private, geriatric, or family medicine patients. Discuss each transfer with the attending (this can be before or after acceptance).
In-hospital transfers: If patients are coming out of a monitored unit (SDU, SICU, CSICU, NSPCU, cardiology telemetry), the CCM or cardiology attending needs to document that the patient is safe to come off monitoring before you accept the patient. We also accept transfers from neuro and liver. For all in-hospital transfers, the med consult resident should tell the transferring team to place the transfer order and sign a transfer note. The med consult resident should notify patient logistics (ext. 6651) of the acceptance.
Out of hospital (OSH) transfers: Patient logistics will call med consult with transfer requests. The medicine consult resident will discuss with the requesting team. If stable/appropriate, the patient is accepted to medicine by the resident. The resident will then discuss with the attending and review the transfer summary. Please refer to “Medicine Consult Transfer Algorithm” below for more details.
Transfers from Mount Vernon ED can be accepted to Moses inpatient Medicine
Transfers from any other ED must go to the Moses ED first
Any patients that may need an urgent procedure on arrival should go to the Moses ED first
Transfers accepted by GI to the Medicine service should be triaged by Med Consult
The goal is for the transfer center to call you when the transfer summary is available, and for the records to be scanned into media for review by both the med consult team, and the accepting team.
In EPIC, under "Available lists" --> "Moses Hospital" --> "Transfer Center", you can see the list of pending transfers to Moses. If you single click on a patient, and review the tab "Transfer Request", you can see a record of the transfer process thus far.
Please use the dot phrase .medtransfereval to write a brief note for the accepting team. Be sure to write the details of the case that are relayed to you so that the accepting team has some information and context.
**SPECIAL NOTE** the transfer calls are recorded so be sure to maintain your usual high standards of courtesy and professionalism
On weekends: Attending covering consults is the Green team attending.
Pre-op Clinic: Thursdays are POMA clinic with Dr. Kristina Chae. POMA clinic starts at 1:15 PM. Go to 5th floor Practice B. POMA clinic is staffed by two short call residents.
Reading
See literature section
Schedules
Current Block
Upcoming Block
For Issues...
Please contact Firm 1 chief, Daanish Chawala, and Dr. Schafler. Letting us know of issues in real time allow us to better address them and find solutions
Goals and Objectives:
The third year rotation on the General Internal Medicine Consultation Service is designed to provide residents with broad experience in the practice of consultative medicine. To this end, third year residents will spend 4 weeks supervised by a medical attending as the medical consultant to the non-medical services. The goal of the experience is to provide training in the pathophysiology, diagnosis and management of medical problems particular to patients being cared for primarily by other services – particularly surgery, psychiatry, neurology, and OB/GYN. Residents shall gain experience in such care in a variety of settings, including intensive care units, pre- and post-operative settings, inpatient wards, and outpatient preoperative clinics. An additional goal of the rotation is to enhance residents’ effectiveness and communication skills with patients as well as consulting physicians.
Goals by Relevant Competency (all for 3rd year level residents only):
Patient Care: Learn to interview and examine preoperative and nonmedical patients in an effective, efficient, and sensitive manner; gain experience in culling information through chart review and discussions with primary providers; formulate thorough differential diagnoses and plans; appropriately tailor recommendations to a patient’s particular medical problems and reason for hospitalization.
Medical Knowledge: Use literature and reference sources to increase knowledge base relevant to the care of patients with medical illness on non-medical services; increase knowledge of pre-procedural risk-assessment; enhance knowledge of medical problems affecting pregnancy and post-partum states; broaden understanding of medical problems arising post-operatively; understand the underlying pathophysiology of conditions faced in consultative medicine; broaden knowledge of indications and interpretation of chest and abdominal X-rays, electrocardiograms, and pulmonary function tests.
Professionalism: Establish trust with patients, staff, and physicians requesting consultation; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients, staff and other non-medical services; work with team to fulfill the needs of patients; lead health care team in patient care; understand limitations and ask supervisors for help when indicated; accept assignments graciously; attend conferences.
Interpersonal Skills: Write understandable and legible notes; more fully develop ability to listen to patients and staff and communicate verbally with the physician requesting the consultation; work effectively as a member of the health care team.
Practice Based Learning and Improvement: Understand limitation of knowledge of medical illness in patients on non-medical services and patients being evaluated for preoperative medical risk; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed; learn from the outcomes of patients under your care and alter practice patterns to improve outcomes in the future.
Systems Based Practice: Advocate for patients; develop a sophisticated understanding about the health care system/structure and develop a relationship with the requesting service to ensure that the patient’s medical needs are met and coordinated with the care delivered by the primary service; utilize ancillary services to benefit patients; facilitate the delivery of care by assisting with scheduling tests; consider cost-effectiveness in diagnostics and management plans; facilitate the involvement of medical subspecialists or transfer to a medical service when appropriate.
Disciplines Covered
Cardiovascular
Goals and objectives: understanding the assessment and management of perioperative cardiac risk associated with surgery; understanding the prevention, diagnosis and management of post-operative cardiac complications and cardiac complications of pregnancy; understanding when a subspecialty consultation is appropriate
Principles, physiology and basic science
Practice skills unique to Cardiology
Specific tests and procedures: use and interpretation, eg. ECG, stress testing, echocardiography, cardiac catheterization
Preventive care and perioperative cardiovascular risk reduction
Patient education (attitudes/values)
Approach to presenting complaints/problems
Specific diagnoses in Cardiology (CAD, Valvular disease, Hypertension)
Emergencies
Treatment modalities
Technical skills
Endocrinology
Goals and objectives: understanding the diagnosis and management of diabetes in patients hospitalized for nonmedical reasons and perioperative glycemic control; understanding the prevention, diagnosis and management of perioperative complications of corticosteroid use; understanding the effect of pregnancy and post-partum states on chronic medical problems as well as medical issues particular to pregnancy; understanding when a subspecialty consultation is appropriate
Principles, physiology and basic science
Practice skills unique to Endocrinology
Specific tests and procedures: use and interpretation
Preventive care
Patient education (attitudes/values)
Approach to presenting complaints/problems
Apecific diagnoses in Endocrinology (Diabetes mellitus, Adrenal insufficiency)
Emergencies
Treatment modalities
Technical skills
Hematology
Goals and objectives: understanding the diagnosis and management of hematologic complications in patients hospitalized for nonmedical reasons and hematologic complications of pregnancy; understanding the assessment for bleeding risk and hypercoagulable states; understanding the principles of perioperative anticoagulation management; understanding the indications and regimens for DVT prophylaxis in surgery; understanding when a subspecialty consultation is appropriate
Principles, physiology and basic science
Practice skills unique to Hematology
Specific tests and procedures: use and interpretation
Preventive care
Patient education (attitudes/values)
Approach to presenting complaints/problems
Specific diagnoses in Hematology (Thrombophilic states, Hypercoagulable states, DVT and PE)
Emergencies
Treatment modalities
Technical skills
Infectious Diseases
Goals and objectives: understanding the diagnosis and management of infectious complications in patients hospitalized for nonmedical reasons and perioperative infection control; understanding the indications and regimens for antimicrobial prophylaxis in surgery; understanding when a subspecialty consultation is appropriate
Principles, physiology and basic science
Practice skills unique to I.D.
Specific tests and procedures: use and interpretation
Preventive care
Patient education (attitudes/values)
Approach to presenting complaints/problems
Specific diagnoses in I.D.
Emergencies
Treatment modalities
Technical skills
Pulmonary
Goals and objectives: understanding the preoperative evaluation and management of patients with pulmonary disease; understanding the prevention, diagnosis and management of post-operative pulmonary complications and pulmonary disease in patients hospitalized for non-medical reasons; understanding when a subspecialty consultation is appropriate
Principles, physiology and basic science
Practice skills unique to Pulmonary
Specific tests and procedures: use and interpretation, e.g. PFTs, CXR, ABG
Preventive care
Patient education (attitudes/values)
Approach to presenting complaints/problems
Specific diagnoses in Pulmonary (Pneumonia, COPD, Asthma, Respiratory failure, Atelectasis)
Emergencies
Treatment modalities
Technical skills
Toxicology
Goals and objectives: understanding the prevention, diagnosis and management of alcohol, sedative, and cocaine intoxication and withdrawal in patients hospitalized for non-medical reasons; understanding when a subspecialty consultation is appropriate
Principles, physiology and basic science
Practice skills unique to Toxicology
Specific tests and procedures: use and interpretation
Preventive care
Patient education (attitudes/values)
Approach to presenting complaints/problems
Specific diagnoses in Toxicology
Emergencies
Treatment modalities
Technical skills
POCUS
Your goals for the next 4 weeks in POCUS should be to learn the basics of Cardiac POCUS, develop some proficiency in image acquisition, begin the basics of image optimization, and learn some of the standardized metrics for interpretation and clinical integration of cardiac POCUS in internal medicine.
The course consists of 3 main parts:
The first is self-directed learning. Dr. Galen has compiled two online learning opportunities to familiarize yourself with the basics and terminology that are required to perform cardiac POCUS. We have removed one of the afternoon preop clinics per week to create protected time for you to accomplish this. Please choose an afternoon in the first week and review the following:
First, please watch the NEJM video and complete the post-video quiz.
After you have completed this video, Please follow the following link into chrome to complete a quiz. https://docs.google.com/forms/d/e/1FAIpQLSdF_x1jTNvYcugo1Ygq_JNrJlSUFQ0NJVjm0GG2dvd5ESY1TA/viewform?usp=sf_link
Please complete this quiz and see Frenchy on NW6 after completion. She will review your submission and give you an answer key as well as a USB drive for building a portfolio of images.
Next, watch this 1 hr video and review it with your co-residents. Provided by Dr. Galen, please don’t share this link widely it is copyrighted material:
Review this PDF and spend some time exploring the virtual TTE website. This exercise will be helpful as you work toward image optimization.
The second part will take place at the bedside. Each day, after rounds, please review the list and look for patient who have had a recent TTE. As there are a high number of preops, there should always be a few. One of the faculty will try to give you an introduction on image acquisition and use of the US with recording clips. You should be trying to practice this skill at the bedside as often as possible. If you are having trouble finding patients, working the machine, or getting images please give me a call or text Dr. Schafler (732-939-4569)
The final part is building a portfolio. Each resident will be expected to record a portfolio of cardiac pocus cases. The portfolio should consist of one clip of each of the following views (parasternal long axis, Parasternal short axis, Apical four chamber, sub costal, and IVC). You should aim to collect a total of 5 sets of these views. At the conclusion of your rotation, you will be required to select your two best cases and submit them in a PowerPoint format (see instructions below). One of the faculty will set up a group review session via zoom to go over your cases and provide feedback and help with clinical integration.
Please compile two of your best sets of images. We would like you to put them in a PowerPoint presentation in the following order. Parasternal Long, Parasternal short, Apical 4, Subcostal, IVC. Please be sure to set them to “play automatically” and “loop until stopped”. One you have your two best cases in this form, please email them to Dr. Galen and Dr. Schafler. The time is TBD but it should likely be around 12pm on the protected day.
First insert the video clop into the presentation either with copy and paste or drag and drop. Then select the video clip on the slide. When you do the follow menu option will appear:
