3. What Should You Learn At MSK?
Pediatric Oncology
Basics of Chemotherapy
Pain management
Nausea and vomiting
Electrolyte imbalances
Constipation
Antibiotic management
Infections from A-Z
Dermatologic findings
Fever and neutropenia
In addition, you will gain experience working with end-of-life
issues and difficult family situations
4.
5. Organization of clinical services
The entire 9th floor is devoted to Pediatrics
9th floor is divided into three areas:
Inpatient M9
PICU
Pediatric Day Hospital (the PDH)
6. Pediatric Day Hospital (PDH)
The PDH is the outpatient side of Pediatrics
at MSK
Patients come to see their primary team for
everything from check-ups to chemo to
transfusions to procedures
The PDH sees >150 pts per day
Most of the floor admissions come
directly from PDH
7. MSK Primary Teams
Patients are assigned a Primary Team (i.e., leukemia,
neuroblastoma, sarcoma) based on their primary disease
at diagnosis
Followed by Primary team throughout their disease course
While inpatient, primary team will give input on their care;
the fellow is the liaison for this communication
Bone Marrow Transplant (BMT, Blue Team) is its own
Primary Team
8. PICU
The PICU is a 5-bed unit, opened June 2014
Manages all unstable patients w/ exception of patients
requiring CVVH/Dialysis or Oscillation
Patients requiring renal exchange or escalation of
respiratory support beyond standard mechanical
ventilation are transferred to NYP Cornell PICU
PICU Consult (Call x6443)
PICU NP within 30 minutes
Rapid Response (Call x5000 or x6000)
PICU NP + Charge RN + RT within 5 minutes
Pediatric Code
10. M9 Inpatient Service
GREEN Team – General Oncology/Surgery
Attending and 1st Year Fellow
2 PGY-3 Senior Residents from Downstate
3-5 PGY1/PGY2 residents from Cornell, St. Barnabas,
Harlem, Lincoln…
3 Nurse Practitioners
Each NP works ~3 days/week
Most days: 1-2 NP on the team
Schedule is posted up in the workroom
11. M9 Inpatient Service
BLUE Team – Bone Marrow Transplant
(BMT)
One attending, one 1st year fellow
3-4 residents from Cornell, Downstate, Metropolitan
12.
13. Nurse Practitioners
Incredible resource: whom to call, how to get things
done, great understanding of patient pathology
Will help senior resident with admission
assignments/distribution of patients in the morning
Hours are 7am-7pm
They cap at 6 patients during the week
Include them when you are assigning NPs/Residents to
cross cover patients when residents go to clinic
Don’t be shy!- Ask them questions, their office number
is # 6403
14. Nurses
RNs at MSK know the kids
and know the oncology
Many of the kids are well-
known by the nurses
If they think something is
wrong, it is wrong!
If they ask you to speak to
the parents or the patient,
GO!
15. Nurse Case Managers
The Nurse Case Managers are wizards with
discharge and insurance issues
Devin Price and Lisa Nicholson
ESSENTIAL TO COMMUNICATE DISCHARGES
TO THEM EARLY!
16. Green Team Senior Resident
Supervises PGY-1 and PGY-2 residents on Green
Supervises AM and PM sign-out
Updates electronic hand-offs
Works with the fellow / attending to make sure plans
are being carried out by residents
Facilitates rounds by checking labs, entering orders,
updating hand off tab
Communicates problems/concerns about residents to
chief resident, fellow and attending
Acts as ADMITTING RESIDENT
17.
18. Sign Out
7 am: Sign Out
Green: Supervised by the Green team Senior; Blue Team more
individualized
Night float resident comes in at 6pm and leaves after sign out at around
8am
Blue On-call resident should leave by 8:30 am
Before Rounds:
Get your pager & locator from the drawer
Pre-Rounding:
Vital signs, I/Os, PCA doses/ attempts
Review lab results and discuss problems or questions with the senior
RENEW ORDERS for IVF and all drips (PCA, zofran drip, etc.)
19. Labs/Phlebotomy
Most labs will be back by the time you arrive in the
morning
You must order routine morning labs before
signing out in the evening
AM Labs are drawn by the night nurses
All labs are drawn off of central lines, including blood
cultures
When labs are needed at other times, ask the patient’s RN
and enter the order in the computer
If a patient does not have central access the RNs will
draw the labs
You will rarely have to attempt venipuncture at MSK
20. Rounds
Attending Rounds - 9am
You MUST facilitate rounds by:
Being prepared to present on your patients
Helping to look up labs, move computers when your
patients are not being presented
Who goes into the patient’s room?
Green team: all housestaff unless patient is on special
isolation precautions or family preference
Blue team: primary resident & blue resident on call for
that night
21. Presentations on Rounds
Presenting: New Admissions
HPI, then summary of their Onc History (which
you should have read carefully before presenting)
Presenting: Patients known to the team
One liner, then the rest of your presentation by
systems
Relevant lab results only
22. Radiology Rounds
Mondays, Wednesdays and Fridays at 11am in the
PDH Classroom
Review all radiology for the team for the past 24 hours
with the pediatric attending radiologist
Fellow gives one-liner about patient & why study
performed
Ex: “Maggie is a 2 year old girl with Stage IV neuroblastoma
who was having increased vomiting and abdominal distention
and that’s why we got the CT.”
23. Lectures/Conferences
About 3-4 times per week at 1:30pm in workroom
Lectures given by attendings, fellows, pharmacists,
chief resident
Green Team residents also give short interactive case
presentations prior to the end of the block
Lecture schedule posted in workroom
Grand Rounds Thursday mornings at 8:30am (except
during the summer)
Tumor Board (C-569) on Tues 2pm, Thurs 3pm
Neuro-Onc Tumor Board on Wed @ 2:30pm
24. Notes
Daily notes
You may copy/forward from previous notes
BUT, you must UPDATE EVERY LINE, EVERY
DAY!
Yes, the Attendings DO read and sign your notes!
DO NOT hit ‘resident complete’ or forward
your note to the attending until you are
absolutely 100% finished
Everything in your note should be clear and
correct
Your assessment should be up-to-date and specific
Your plan should be listed by systems OR problems
25.
26. Admissions
Green Team Residents: Expect to get at least one
admission every day you are not in clinic
Chief resident gets sign-out on admissions from PDH
Admissions are assigned by the Admitting Senior
Blue Team: Admissions are less common
In general, you will decide among yourselves who will
do which admission
Be kind and fair to each other
27. Admissions
Admissions from 9am-5pm come from the PDH after being assessed by
the Primary team
Do not wait for the patient to arrive on the floor – go to the PDH to begin
the admission process with your HPI, ROS and PE.
At night, they come from UCC after being assessed by the fellow on-
call
UCC is the MSK Emergency Room; it is an ED, but for established MSK
patients only
The fellow will discuss the patient and plan with you and the hospitalist.
If this does not happen, PAGE THE FELLOW!
28. Admissions
Use the M9 Admissions Sheet as a Guide
Review the most recent notes
Perform a careful HPI, ROS, review meds & allergies
Bridge any gaps in their history since the last note
Do NOT do a full PMHx with the pt/family (although make sure
it is in your note)
Your plan will be discussed with the senior/fellow
Orders
Use the Admission Order set in the computer for admissions!
There are order sets for Blue and Green teams
For patients in PDH can write pending orders ask the clerk to
make an ‘overflow bed’
You must print 3 copies of the Code Sheet at admission
(Google ‘cornell emergency medications’)
29. Discharges
Anticipate discharges so you can get prescriptions
filled and follow-up appointments set-up early on
Use the M9 Discharges sheet as your guide
Prescriptions must be given to Pharmacy at least
one day in advance
Communicate with the case managers; setting up home-
care, getting supplies, etc. requires advance planning
Discharge orders and instructions are computerized in
HIS
Discharge Notes/Hospital Courses must be started
on ALL patients on HD #2 and updated twice per
week (especially FRIDAYS)
32. BLUE TEAM PM Signout
Blue Team PM Sign-Out: 5pm
May start as early as 4:30pm only if the person on-call is done with their
work
Do not be bullied into allowing early signout if you are still
completing notes!
Give good signout – make sure electronic Hand-Off is updated
Indicate clearly what might happen, and what the resident
on-call should do
If labs are expected, tell the on-call resident the time they
will be drawn
33. Weekday Call: BLUE TEAM
On weekdays, call starts at 5 pm
On-call resident is responsible for all admissions to the
floor posted after 4:30 pm
Call room and meal cards available
One fellow supervises both teams and Urgent Care
Center
Fellow is available to you – if not, page him/her
34. Weekday Call: BLUE TEAM
Responsibilities:
Check to make sure AM labs for ALL patients are
appropriate
Review plans with on-call fellow
Notes on all admissions
“AM rounds” – Check VS and I/O, record AM labs record
vitals on handoffs
Print sign-out sheets from electronic hand-off tabs on
all patients (labs and meds auto-populate)
If there is a problem, there is always an NP in the PICU who
is happy to help
35. Weekend Call: BLUE TEAM
24 hour call (7am-7am)
Sign-out at 7 am; rounds at 9 am
On-call resident responsible for:
Daily progress notes on all patients on the service
All admissions, discharges, and transfers with notes
AM vitals & I/Os of all patients
One fellow per team
Cafeteria closes early on weekends
36. Weekend Call: GREEN TEAM
There are always two residents on call
7am-6pm
Divide patients equally
Seniors on short call: this is not a supervisory role; split
the patients w/ the other resident
37. Call Schedules
Adheres to ACGME rules (<80 hours/ week)
Call schedules are made monthly by the Pediatric Chief Resident
Please let the Pediatric Chief Resident know if there are any conflicts,
emergencies, illness as early as you can
Molly Smith, MD
Pager #2244, Office 212-639-6005
38.
39. Medication Reconciliation
Definition
A process for obtaining a complete and accurate list of the patients’ current home
medications, including OTC’s and herbals, and comparing the practitioner’s
admission, transfer, and/or discharge orders to that list.
Accurately and completely reconcile medications
Document a complete list of the patient’s current medications upon the patient’s
admission to MSKCC
This process includes a comparison of the medications the organization provides
at admission, transfer, and discharge to the medications on the list.
Instructions found in Resident Manual
40. Security
M9 is a secured/card access only unit which prevents unauthorized entry on to
the unit and unauthorized exit (i.e., abduction).
Residents are assigned coded ID cards to allow access to M9 during
their rotation.
Refer all visitors to the Guest Services or Unit Assistants; do not allow visitors
to enter or exit M9 without checking with the unit or reception staff.
Anyone attempting to leave the unit via stairwells without coded ID cards will
encounter a 15 second delay before the door releases. An alarm will sound in
the RN Station and in MSK Security.
The assumption is that anyone using the stairwell without a coded ID is
an unauthorized departure.
If a pediatric patient is seen leaving the unit via the stairwell (assumed to be
suspected abduction, missing child, or unauthorized exit of a patient) or if you
hear a door alarm, you must call Security (x7866) to inform them of
unauthorized departure and identify the stairwell used (i.e. North or South)
a ‘Code Pink’ will be activated.
41. Dress Code
Men
Shirts & Ties
No Jeans
Women
Business Casual
No Jeans.
No tight/ revealing / midriff exposing clothes !
All: Yes! Scrubs are only acceptable for on call days
42. Mandatory Learning Module
All resident must complete online MSK Modules
Can only be done from MSK computer
Instructions are provided with orientation packet
