VA - General Medicine

[Betsy]

This was posted by Kelly Phelps from the Class of 2006 Forum.

I hope you find this is helpful. I'm sorry it seems like a lot of information, but I kept thinking of things that "I wish I had known". Thankfully my team, nurses, and other staff were very helpful, and I couldn't have made such a document without them. If anyone would like to make suggestions to it, feel free.

VA staff: if you have time, please double check for errors, Thanks

I had a great time at the VA, I'll miss it
Good luck to everyone on their new rotations, hopefully it'll be a smoother transition

VA MEDICINE: “What I wish I had known” For Students and Whoever:
-I take no responsibilty for any inaccurate information, I tried my best however to make it accurate and helpful; KP HELPS

The Hospital Map: The VA is set up like a cross, each wing is a letter A,B,C,or D
Blue, Gold, and Yellow are located on “6A” 6th floor, A wing
Morning Report is located 4D 102

Call Schedule: (confusing but you’ll get the hang of it)
1-No Call= no new patients
2-Short Call= Team gets up to 3 new patients for the day
3-Long Call= Sunday thru Thursday 7am til 7pm admitting new patients, taking care of ‘signed-out’ patients from other teams
Friday and Saturday= “overnight call” see below
Cycle Begins again………….
‘Night Float’ Sun thru Thursday at night they take care of night admissions and signed-out patients; these are interns/residents, thankfully no JMS!!
Overnight call due to no night-float = 24 hours: if you have Friday, 7am til 7am Saturday; If Sat=7am til 7am Sunday; not allowed to leave campus; get key for assigned call room at security located by main entrance, linens provided; give key back for call room by 10am following day

Food: Warning- JMS do not get $ for call days, you get provided meals at cafeteria on days of call for free; find cafeteria kitchen on 1st floor, sign-in, ask for a tray; you’ll get hospital breakfast/lunch/dinner around appropriate meal times (sorry guys, doesn’t include food court)
Food court- 1st floor near gift shop, Burger King last to close at 2pm; get there by 1:30 for yummy subs
If you like the vending machines, make sure you have appropriate change; can’t get change after 3pm

Nurses Orientation:
-Suggest you meet as a group with a head nurse to get a quick orientation of how things work on 6A
-things mentioned previously:
Supply room code: ? (ask) fecal stool test, PPD control, thoracentesis kits, surgical gloves, stockings
Renew IVs every 3 days! (told to remind interns)
Renew Restraints every 24 hours (told to remind interns)
Ins/Outs kept in black note books with room numbers written on front, as well as glucose checks
Important Paper Forms: Cabinet above middle/back computer
Transfusion= 3 forms- Consent, Carbon copy, Reaction sheet
Procedure= (like thoracentesis) Consent excluding transfusion
Transportation= if patient leaving hospital by means other than family
PPD: Med students place them: 1- tuberculin vial in fridge in room behind nurses station
2-storage room for syringe 3- 0.1 under skin 4-write “PPD Note” in computer 5-check in 48 hours 6-“PPD result note” in computer

Good to know locations:
LSU (‘ER’ everywhere else in the world): 1st floor, students don’t have ID scan privilege (wave someone down)
MICU: 3rd floor
Labs: Chemistry and Hematology 2nd floor almost directly across from main elevators; has a receiving window, the buzzer doesn’t work
Microbiology 2nd floor on way to MCG tunnel with the lighted door bell
Cytology- tissue samples like pleural fluid; hallway to the left before you get to microbiology; needs ‘tissue form’ not a computerized order!!
XRAY: 2nd floor on way to MCG tunnel; can’t miss big sign





COMPUTERS
Training for it, need Password for windows log in (usually computers are already logged in)
need Login and Password for “CPRS”
you get pretty good training, expect it to take 2 hours, it’s a lot of information but it’s a pretty user friendly as far as keeping track of your patient; can get a bit frustrating when you want to make a specific order
CPRS
Coversheet= known drug allergies, current meds, vitals, active problems
Meds= out-patients and in-patient medication info
*with in-patient med: highlight med, right click, ‘details’, see when nurse gave medication and dosage
Orders= -> each order gets printed at the nursing station, clerk notifies appropriate person (lab,nurse,etc)
labs (‘complete’ results are done, ‘active’ means lab got specimen, ‘pending’ means lab hasn’t got specimen or order yet) double check a prolonged ‘pending’!
text only message: a typed message similar to a verbal command to nurses
Medications- changes from medicine tool bar pops up here
Notes= You’ll find admission notes, nurses notes, resident notes, medical student notes, DNR, PPD, etc
*For students, click New Note then type ‘Student’ and “Medical Student Note” pops up; your cosigner is your intern, resident, whoever your teams says it is….

UpToDate: Great reference program to find quick info about a disease, medication, etc; no pswd required!
Look for it “Library References” icon on Desktop

Social Workers: Get to know them, They are great people; if you suspect nursing home placement, hospice, financial burdens, end of life issues, etc; notify them as soon as possible

Nursing Home Placement: If a patient has never been in a nursing home, a PPD must be placed and read in 48 hours!! (see above)

XRAY:
CPRS: In Tool Bar ‘Tools’ ‘Imaging Display’ Login with your CPRS login/pswd click on images to increase size, mess with brightness buttons
To pull up two Chest Xrays at the same time, right click on second image and highlight ‘display in new window’ ~something like that
Usually there are NO written reports about the images, you must listen to dictation:

**Cut out these directions and pasted them to an index card!!** (photo copy them for teammates, they’ll appreciate it)

1.From a touch tone phone within the hospital dial 1650 (if outside the hospital dial 733-0188, then 1650)
2. Enter your 4-digit Physician ID (usually the last 4 digits of your SSN) If you do not have a number you may use 7777 ( us students use 7777)
3. Press [/li][li], then press [1]
4. Press [1] to review by patient social security number
5. Enter the last 6 digits of the patient’s social security number
6. The system will now search for your request
7. Enter [9] to disconnect

**If you have more than one Imaging Report on that patient press [5] to hear the previous report!


Admissions:
Watch it being done!
Transfer patient from LSU to floor like 6A
Discontinue outpatient meds
Make new in patient meds
Specify type of IV, catheters, diet (especially, as nurses get annoyed if you leave this blank and they hunt you down), activity level, diagnosis, vital sign instructions, labs, history and physical, etc

Discharge:
Put inpatient medications into outpatient meds:
Highlight meds, tool bar “change inpatient to outpatient” usually will transfer it to comparable medication
Give pharmacy plenty of notice
*If patient leaving with narcotic, needs hand written and signed prescription pad note!!
Fill out discharge form with instructions of care, etc
text message ‘discharge patient’
fill out paper transportation form if patient leaving by ambulance (anything other than family/friend)

MOST LIKELY WHAT YOU WILL SEE AND NEED TO STUDY FOR VA CARE!!
COPD, All types of lung cancer, pneumonia, pleural effusion, ABGs, O2 sat, inhalers-bronchodilators vs. steroids
GI: Liver- LFT’s, Cirrhosis, Ascites, Albumin, Total protein
Pancreatitis, EGD, colonoscopy, diverticulitis, upper/lower GI bleeds
Renal- acute and chronic renal failure; contrast-mediated RF
Anemia- Chronic disease, Fe deficiency, Alcoholic
Heme/Onc- what strikes the older/elderly
Electrolyte disturbances: dehydration, hypernatremia, hypokalemia, anion gaps
CV: Mitral regurgitation, Aortic stenosis hear them!!, ECHO, CK enzymes, EKG, S3, S4, “2/6 SEM heard best at LSB radiating to axilla”, atrial fibrillation, edema of extremities, JVD; PT/INR/PTT relating to coumadin level?
Neuro: Dementia, MMSE, Stroke symptoms, Diabetic neuropathy
Alcohol withdrawal[/i]

[Betsy]

I would agree with everything the above poster mentioned, and would say that is a good explanation of how it is at the VA. Overall, its a good rotation for medicine. You get to see a bunch of stuff. I was lucky enough to have an awesome team. It all depends on your interns and resident, and the other students. There are 3 teams at the VA: yellow, gold, and blue. They are all general medicine teams. Usually, the consist of: 2-3 JMS, 1 sub-i, 2 interns, 1 resident (3yr medicine resident), and 1 attending. I usually carried around 2-3 pts, admitting and writing H&P 3-4 times a week. The computer system at the VA ROCKS!! Repeat after me: COPY AND PASTE!! Sweet!

Days were usually 7am-5pm on non-call days. Call is every 3rd day. Weekday calls stop at 7pm, so you get done usually by 8pm. Weekend calls (Fri and Sat) are overnight calls. I got to sleep the whole night both nights I was there. The call schedule is confusing so I will try to explain:

Sun-Thurs operates on long call, no call, short call, in that order. Example:
Sun - Long call = admissions 7am-7pm
Mon - No call = post call days, no admits
Tues - Short call = get all overnight admissions, up to 3 pts
Wed - Long call
Thurs - no call

Fridays and Sat are different - its call or no call
Fri call = 7am Fri - 7am Sat
Sat call = 7am Sat - 7am Sun

Call rooms are pretty nice, if there are 2 guy students or 2 girl students, you will have to share a room. There is one male student room, one female student room. There are 3 beds per room, bathroom, and computer. As mentioned by the above poster, there is one free meal on call days. But, there is a big difference between "free" and "good". Don't say I didn't warn ya!

You will learn quickly that the VA is a very different place than MCG. There are alot of ridiculous admissions, and people tend to stay a while. If you are following one of these patients, just ask your resident if you can follow someone else. There is no need to follow people that are just sitting there, granted that the daily notes would be pretty easy. Alot of pts are admitted for nursing home placement, and the whole place can sometimes feel like a nursing home. I would say that 98% of your pts will be 60+ yo men with multiple medical problems. There will be alot of PPD placing, because all pts must have these before being transferred to a nursing home. Just make sure your pt is still alive before administering the PPD. Yeah, I went to place a PPD in one of my pts and found them dead. (I wish I was kidding, trust me).

If you are on gold or yellow, you will get good exercise going up and down the steps. Most pts are on 6A, and the team rooms are on 4A. Overall, I really enjoyed my time at the VA. Have fun!

[Kim]

I had VA Medicine at my very first rotation. It was great and I learned so much more during that month than I did during my General Medicine month at MCG. The VA is great b/c students are able to write orders!!! Don't worry - they won't be carried out until someone else signs them, so you won't kill anyone. I felt like I was actually participating in patient care and it gives you a way to show that you're thiking about what to do next for the patient. I did really well and got great comments even though it was my first month of 3rd year.
Here are come tips:
1. Start writing your notes as soon as you get there in the morning - you don't have to write a complete note, just get the skeleton started and then go back and fill it in later. I usually started my day by reading nurses notes form overnight before going to see my patients and I'd start notes at that time. The note is time stamped when you START it, not when you sign it. It was actually mentioned in my comments that I had my notes written before whatever time (even though I'd only started them at that time).
2. Hang out in the team room w/ your interns as much as you can. Computers are limited, so students often wander off to a workroom for computer access. That's fine, but on my team I was the only student who tried to stay in the team room instead of hiding out in the work room. Of course, you might be given more random stuff to do, but it was worth it. Our Resident was constantly asking, "Where are the other students?". When another team is consulted, they'll often stop by after seeing the patient and before writing a note and discuss the pt w/ your interns/resident - if you're there for the conversation, you'll learn more than from reading a note. Your notes (specifically the A/P section) will be much better b/c you'll already have heard what they're planning to do for the pt. Since I was there for most of the conversations about patients, I was able to answer questions about the Sub-I's patients one day when he had to miss rounds for some reason. That also ended up in my comments.
3. MAKE USE OF THE COMPUTERIZED RECORDS!!! I always seemed to have a lot of downtime and I'm not good at studying when there are people around, so I'd make sure I knew everything about my patients, but then I'd scan through all the other patients on the team (particularly if they had interesting stuff going on).

The free food on call days isn't bad (if you can make your way through the maze and find the right kitchen....).

I had 2 overnight calls and was able to sleep for both of them - one night the VA was on diversion (it happens a lot) and the other night our team capped at 8pm.

I loved medicine at the VA. I liked that it was small and there weren't many students/residents around. I participated in two codes - at MCG the closest I've gotten so far is outside the door of the patient's room.... The computer system is very convenient - no need to run up to a floor to look for a note from cardiology, etc. Being able to write orders was definitely the highlight of the VA - I actually felt like a doctor.

[LesmoInge]

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