Toledo Hospital Inpatient Pediatrics Pro-tips

park in the south parking structure (there is a south and a north), which is off of north cove blvd. try to park on the second floor of the structure because it connects to the first floor of the hospital. from there you'll head up to the 5th floor in the elevators off of the lobby across from Croxton audiotorium. once you hop off the elevators, swing a right and you'll see some closed double doors. try just opening the doors or swiping your id at the console on your right but if you're like me, it wont work. if you press the intercom botton, the unit clerk will be less than happy to open the doors for you. from there, head through the doors and you'll see the conference room on your left. it's called something like "hospitalist inpatient service conference room." sign-outs start at 6am (gasp), so leave a little leeway on your first day to gauge how long it will take to get there. ask for the code to the room.

from there, you'll go through sign-out with the whole team. you'll be most closely working with the interns. they are all pretty willing to teach, and let you write orders, but it would be a good idea to brush up on how to write soap notes, admit orders, discharge summaries so they don't get annoyed with you as they did me. don't get the wrong idea though; they're all really nice, they just have a lot of work to do so it sucks if they let us "help" and it then takes thrice as long. there are also PA students and are pretty cool. they are training alongside us and basically have the same responsibilities we do.

during sign outs, you'll be assigned 1-4 patients to follow each day. after signouts you'll go out on pre-rounds, where you'll wake up moms and make babies cry trying to ask if they pooped overnight so you can write your SOAP notes. often, your intern (who is also covering your patient) will also write a SOAP note, and they'll have done it in 1 min before you get there. from here, brush up on your patient's history from the green & red charts. green is for physicians and red is for nursing. nursing is often more pertinent for rounds because it will have the patients temperature overnight and their ins/outs. i had a couple failure to thrive kids when i was there, so it was important to look @ the nursing chart to see how much formula they took in the last 24 hours. (side note: for FTT kids, calculate their caloric intake/kg. 30 mls formula = 1 oz. there are 20 cal/oz in normal formula. you want their intake to be 120+cal/kg in order to "catch up" in growth).

make sure you write stuff down on something other than your soap note, since you wont have that in hand when you are presenting your patient on rounds. things to note for your presentation: if it's a patient thats been there for a while and most ppl on the team are familiar, present only the changes overnight and maybe what day of a course of antibiotics they are on (ex day 3 of 7 clindamycin), and how well they are taking food and fluids. know the background info so youre ready if they ask you, but it isn't necessary to do a complete formal presentation up front because the attendings dont want to take 20 hours to do rounds.

rounds start at 8 or 8:30 depending on how many patients are on the ward. someone, usually the chief resident, will grab a computer on a mobile cart and the team will start amassing outside the conference room. there are three sections to the floor, south (to the right of the conference room if facing away from it), northeast (in the middle, across from the picu), and "the tower" which is the newest wing and a 5 min walk from the rest. from there the attending will listen to your/the intern's presentation and then go see the patient themselves. then the will quickly rattle off orders/changes in the patients care which you have to write down furiously so you can put the orders into the chart.

usually rounds finish by 12 and you can grab lunch. if you're buying lunch in the cafeteria, don't purchase it at the cashiers, walk to the physician room and Sheila will come around and charge you next to nothing for your meal. in the afternoon, you'll be following up on labs, writing discharge orders, and doing new admissions. try to stick with the interns because they'll show you the real shit.

sign out is around 5, so be back at the conference room around then.

for your on-call night, your ID will likely not work on anything, so you'll have to get swiped downstairs to get to your room (4th floor of south i think). you'll see the peds intern room on the right. ask for the code beforehand! also, you can't get back upstairs in the morning without someone swiping you in the elevator, so latch on to someone then. call is awesome - its when you get to do the most (i did an lp!) and when you learn the most, so take advantage. you also will get 1-on-1 time with the attending which is cool. try to stick with them all night because if you lose then, they'll never page you and you'll just end up doing nothing the whole night. (happened to one of the other med students)

sidenote: you might want to just call security on the first day to get your badge enabled for everything so you dont have to mess around.

things to brush up on. if you know these, you'll look like a champ on rounds:
  • IV fluid maintenance and how to calculate it (100ml/kg for first 10 kg, 50 ml/kg for second 10 kg and 20 ml/kg for anything above 20kg). check out the chapter in harriet lane about fluid & electrolyte therapy.
  • asthma. i must have personally seen 5 patients with it. they call it "reactive airway" disease if its just their first episode. if you want to be a big baller, brush up on albuterol/salumederol dosing. toledo hospital has a asthma protocol, it's like a flowchart algorithm like from ACLS that they use to determine dosing. this makes it really easy to write an order, because you just write "per asthma protocol" and you're done. they usually start a patient on q2 hour albuterol treatments if they are really bad. discharge criteria: once the treatments get down to q4 hours or less, they can be discharged.
  • caloric intake per kg for FTT patients, and others who have decreased PO intake. infant formula comes in 20, 22, and 24 cal/oz but unless otherwise noted, assume its 20cal/oz. the intake is noted in the nursing (red) chart in ml's so you have to convert to ounces (30ml/oz) and then from oz to calories, then divide by kg. 100 cal/kg intake is the baseline for a normal patient, but for FTT patients, you want it to be 120+. i had a FTT patient sucking down 160 cal/kg which was great
  • spectrum and route of intake of antibiotics (cephalosporins and clindamycin especially). look up their trade names too.
  • its really common to follow a "rule out sepsis" protocol on a patient with a fever or other symptoms of unknown origin. it's a hospital protocol where they take blood, urine, (and sometimes) urine samples for culture/pcr. once the patient has no growth in their cultures for 48 hours, (and they are eating and drinking), they get discharged.
  • a favorite pimp question on rounds is why a patient gets admitted with a fever. they love to remind you that "a patient can have a fever at home just fine lol, why are they here?" the answer is once a little tyke starts feeling sick enough, he/she stops eating and drinking. thats the real reason they get admitted - iv fluids and nutrition. another reason to know IVF therapy. in fact this is part of the discharge criteria for any patient admitted. we cant really send them home unless they are drinking on their own -- or, as they love to say "they'll come right back lol".
  • know the neonate hyperbilirubinemias. specifically, know the difference between breastfeeding jaundice (increased enterohepatic cycling due to insufficient milk letdown from mom) and breast milk jaundice (from a change in the composition of milk from mom, increased β-glucuronidase).
  • while i was there i saw a lot of patients with seizures, FTT, asthma ("reactive airway disease"), coxsackie virus (a + b), and somehow i saw two patients with pertussis (think this is uncommon tho), and a ton of viral uri's, as well as meningitis usually from herpes. a lot of preemie issues too and kids that are there chronically secondary to parents' drug abuse while they were in utero.

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