1. “A survival guide”

2.  The ICU staff is here to help you learn the hands on of Veterinary medicine.  If you have any questions or concerns please ask! The only dumb question is the one you don’t ask.  Remember medicine is a “team sport.” The ICU staff’s primary responsibility is patient care, but our secondary responsibility is to teach you patient care.

3. Chelsea Graham, LVT Mindy Moreau, LVT Margaret Carmody, LVT, VTS (ECC) Angela Hintz, LVT, BS

4.  Dr. Julie Caldwell  Dr. Marie Lou Gauthier  Dr. Margaret Cohn-Urbach  Dr. Max Rinaldi

5.  Staffed 24 hours a day (including senior vet students, veterinary technicians and DVMs)  Shifts overlap each other by 30 minutes.  A schedule of shifts is sent out usually at least 2 weeks before the rotation starts.

6.  When handling patient, gloves must be worn at all times. This is for the patient’s safety as well as your own.  If the gloves become soiled…change them.  Do not handle records, medication boxes, etc. while wearing gloves. We don’t want to contaminate the rest of the ICU.  Remove gloves before leaving ICU.  Wash hands between patients-even with gloves!!!

7.  ICU orders should be filled out completely by 8 a.m. for the full day (even if you think they are going home early).  The student is responsible for the 7 a.m. and the 6 p.m. treatments.  Walk patients outside (when applicable). Always use 2 leashes when walking.  Clean kennels and change bedding each morning.

8.  Change the I.V. Catheter bandage each morning.  A complete physical will be performed each morning including (but not limited to):  TPR  Blood pressure (if required)  Administration of the 7 a.m. medications and treatments. Please fill out the physical exam on the back of the treatment form each morning.

9.  Please remember to feed and mark to feed during the day as needed for patients that are do not feed or NPO.

10.  Remove all bedding and dishes. Soiled bedding and dishes can be place in the basket by the door.  Spray the cage with water then scrub with soft scrub. Rinse well. Next spray with bleach solution (in hose sprayer.) After sitting for 10 minutes rinse then squeegee out.  Dry with a towel. Wipe off the clipboard and replace.  Please be sure to clean the heating pad before putting it away.

11.  If you discharge your patient, it is your responsibility to clean the cage as soon as possible (after discharging the patient).  The cages in ICU can be in high demand and need to be available as soon as possible.  Do NOT leave it for later.

12.  TPR  Administer any medications and treatments  Check to be sure the patient is clean and dry.  Feed and walk as appropriate.

13.  Any dog being walked must have to of the slip type leashes on at all times when going outside of the building.  Please walk all patients across the street in the official dog walking area.  Clean up any messes when done.

14.  Acepromazine, insulin and potassium chloride doses must be check with either a doctor or technician before being administered.  When reconstituting medications, mark the bottle with the concentration (i.e. 100mg/ml), as well as the date and time reconstituted. Be sure to refrigerate if needed. If the bottle is not marked it will be thrown away.

15.  When in doubt, label it (syringes, fluid bags, etc.)  Please be sure to have adequate levels of medication for your patient overnight and through the weekend. Your Interns will thank you.  Medications must be listed as mg, mcg, etc. not as ml.

16.  Please mark the medication on the record as it is marked on the label of the container it comes from. For example use the name Keppra instead of Levetiracetam if the bottle is labeled Keppra, to avoid mistakes

17.  From 8 a.m. to 6 p.m. Monday – Friday all controlled drugs are stored in pharmacy  From 6 p.m. to 8 a.m. during the week and all weekend the controlled drugs are in ICU locked box. The interns and the full time ICU technicians have access to this box.  All drugs must be logged out of the controlled substance book and documented on the patient’s record.  If a control drug needs to be discarded, have someone witness its disposal and mark the amount on the patient’s record.

18.  Medications added need to have the following:  An orange medications added sticker  What is being added (Fentanyl)  How much is being added (15ml)  What it is being added to (Saline)  How much is being added to (45mls)  Concentration per ml (12.5 mcg/ml)  Patient name and I.D. number  Date, time and initials of when solution is made

19.  Because the controlled drugs are stored in the pharmacy during the day and because there is usually only one technician on during the day, you will be required to pick up the medication. The technician will page you.

20.  Procedures notebook  Plumb  Books and reference sources need to stay in ICU. If you need a copy of anything please ask.

21.  We are using the Colorado State University pain scale for all patients.  0  Comfortable when resting  Happy, content.  Not bothering wound or surgery site.  Interested in or curious about surroundings.  Non-tender to palpation  Minimal body tension

22.  1  Content to slightly unsettled or restless  Distracted easily by surroundings  Reacts to palpation of wound or surgery site or other body part by looking around, flinching, or whimpering.  Body tension: Mild

23.  2Reassess analgesic plan  Looks uncomfortable when resting  May whimper or cry and may lick or rub wound or surgery site  Droopy ears, worried facial expression  Reluctant to respond when beckoned  Not eager to interact  Flinches, whimpers, cries or guards/pulls away from palpation  Mild to moderate body tension

24.  3 Reassess analgesic plan  Unsettled, crying, groaning, biting or chewing wound when unattended  Guards or protects wound or surgery site by altering weigh distribution (i.e., limping or shifting body position).  May be unwilling to move all or part of the body.  To palpation: Mild-shifting eyes or increased resp. rate, Dramatic-sharp crow, growl, bite or bite threat.  Body tension-Moderate

25.  4 Reassess analgesic plan  Constantly groaning or screaming  May bite or chew at wound but not likely to move.  Potentially unresponsive to surroundings  Difficult to distract  Palpation: Cries at non-painful palpation, may act aggressively.  Body tension Moderate to Severe.

26.  0  Content and quiet when unattended.  Comfortable when resting.  Interested in or curious about surroundings  Not bothered by palpation of wound or surgery site.  Body tension: Minimal

27.  1  Signs are often subtle and not easily detected in the hospital setting; more likely to be detected by owners at home.  At home may be withdrawn from surroundings or a change of behavior.  At the hospital, may be content or slightly unsettled  Less interested in surroundings but will look around.  May or may not react to palpation  Body tension: Mild

28.  2 Reassess analgesic plan  Decrease responsiveness, seeks solitude.  Quiet, loss of brightness in eyes.  Lays curled up or sits tucked up  Hair coat appears rough or fluffed up  Decreased appetite  May respond aggressively or try to escape when palpated.  Body tension: Mild to Moderate.

29.  3 Reassess analgesic plan  Constantly yowling, growling, or hissing when unattended.  May bite or chew at wound, but unlikely to move.  Growls or hisses at non-painful palpation, may act aggressively to palpation, adamantly pulls away to avoid any contact.  Body tension: Moderate

30.  4 Reassess analgesic plan  Prostrate  Potentially unresponsive to or unaware of surroundings, difficult to distract from pain.  Receptive to care (even mean or wild cats will be more tolerant to contact).  May not respond to palpation or may be rigid to avoid painful movement.  Body tension: Moderate to severe.

31.  Any patient receiving pain medication should be evaluated on the pain scale before medications are given.  Please mark on the treatment sheet a pain evaluation every time a pain medication is due or at least every 4 hours when on a constant rate infusion (CRI).

32.  If it is not written down, it did not happen! Document! Document!! Document!!!  When filling out treatment sheets be sure to include:  Dose in mg (not ml)  Route (PO, IV, IM, SQ)  Frequency (q 6 hours, 12 hours, 24 hours)  Initials

33.  When marking medications as given on the treatment sheet mark in the high lighted spot with the mg, route and your initials. This is especially important with any controlled drug. Your initials alone is not enough.  Do not mark with an “X”. This denotes that the treatment was not done.

34.  Patients staying in ICU need to have their records placed in one of the red binders. (This will make your life easier….trust me.)  Records need to stay in ICU. If you need to barrow them for rounds, etc. please let the ICU technician know that you are taking them.  The records must be returned in time for rounds.

35.  Any patient in ICU should have a completed treatment sheet within 30 minutes of entering. No patient in ICU shall be left without a record with the following minimum:  Patient sticker  Student name and pager number  Primary clinician and pager number  At least a partial list of problems  CPR code

36.  Be sure to mark walks outside when appropriate. Be aware that as the ICU must be manned at all times, you may be paged to take your patient outside for walks.  Flush all IV catheters (even if on fluids).  Peripheral catheters every 4 hours  Sampling/Jugular catheters every 2 hours  Arterial catheters every 1 hour  Be sure to check the area for any swelling or redness.

37.  Be sure to mark change recumbency at a minimum of every 4 hours for patients who are unable to move themselves.  An attitude and respiration count should be done every hour.  If giving pain medications an evaluation with the pain scale is needed.  You may use any color hi-lighter with the exception of green. Green is the “Oops I forgot something” ICU color.

38.  Try to group treatments together (if you want a TPR done at 10 don’t have a BP done at 11. Keep the treatments together.) Please remember, the patients in ICU are the ones that need the rest the most and are the lease likely to get it.  Sucralfate should be given either 1 hour before or 2 hours after being fed.

39.  Each patient that has a CPR code greater than DNR (do not resuscitate) will have a CPR sheet. The web site is usually minimized on the computer in ICU or the email address is on the cabinet.  vt1701-c.vetmed.wsu.edu:9910/icu/

40.  Rounds start promptly at 8 a.m. and 5 p.m. Monday through Friday without exception.  Be on time.  No other rotation’s rounds take precedence over ICU’s rounds.  Unless it is an emergency, please do not interrupt. If you need to be in ICU during rounds, please be quiet as possible.  If it becomes to loud you will be asked to leave.

41.  If you have to discharge a patient or will be in surgery or a procedure it is your responsibility to find someone to cover rounds for you or let your clinician know so that you can be excused to attend ICU rounds.

42.  If you are assigned a shift as either the ICU student, the ER student or one of the backups you will need to be at rounds at the time assigned.  As a backup you must be reachable and able to arrive at the ICU within 20 to 30 minutes of being called, (no trips to Spokane).

43.  If you are late you will be assigned an additional shift.  If we are unable to reach you for your shift or as a backup you will be assigned 2 additional shifts and your clinician will be notified.  Be aware that patient care in ICU is part of your grade.

44.  Do not let IV lines lay on the floor or in the drains.  Do not place urinary collection systems on the floor unless on top of a Chux pad.  Urinary collection systems need to be changed every 24 hours.  Date and time all IV lines as they must be changed every 3 days.  Wipe injection ports with alcohol or dilute chlorhexadine solution before injecting medications.

45.  Do not place equipment in the cage with the patient. If unavoidable, disinfect before putting it away.  Each patient will have their own blood pressure cuff for the duration of their stay in ICU.  Use thermometer sheaths when taking temperatures.

46.  Plug IV lines directly into the t-port do not stick a needle in to run fluids.  Always wear gloves when handling patients, even if it’s the only patient you have!

47.  Hand sanitizer-Please use on gloves between handling patient and getting items for the patient.

48.  You may wear either scrubs or nice clothes with your white coats. Please be neat and tidy

49.  Please be sure to return all collars and leashes to the client before they leave their pet. They are easy to be miss-placed.  Warn clients that any blanket left with their pet may be lost through the laundry.

50.  All supplies in ICU are to be used for ICU patients only. If you don’t know where to find something, please ask one of the technicians.  The equipment in ICU needs to stay in ICU! If you have a patient that needs a blood pressure or some other procedure that requires ICU equipment bring the patient to us.

51.  The ICU neurology kit needs to stay in ICU at all times. If you need a neurology kit, please check with Lori Lutskas from neurology.

52.  ICU has a list of doctor’s phone numbers and pager numbers. These numbers are not to be given out.  ICU has 2 phones. 5-8771 and 5-0707 (this is the emergency number).

53.  WSU currently uses 2 types of pagers:  Voice pagers (dial 5-0888 then enter a 3 digit number and leave a short message). When leaving a message please keep it professional, clients may hear it.  Long distance pagers (either dial 9 then the pager number and enter a number to call or go to Clark Communications, http://67.60.17234/ahul then enter the last 4 digits of the pager number. You can leave a message of up to 220 characters including spaces.http://67.60.17234/ahul

54.  If you are paged, please answer right away. If you are in a procedure or with a client, please let us know so that you can’t come in right away so we can stop paging you. If you don’t answer we will assume that you have not received the page!

55.  Clients are allowed in ICU with the following conditions:  You must notify the ICU staff before you bring them into ICU.  The client must be supervised by either a student or clinician for their entire visit.  Visits should last no longer than 10 to 15 minutes and the clients should be warned that the visits can be cut short in the event of emergencies in the ICU.

56.  Clients may not visit during rounds.  If longer periods of time for visits are required we request that the patient be moved to an exam room, the quiet room or the lobby for the visit if this does not compromise patient safety.  Please be consistent about the rules, if you make an exception once the clients will expect it always.  ICU staff has been requested not to give any information to the clients about their patient’s care to help reduce confusion.

57.  The pharmacy is open from 8 a.m. to 6 p.m. Monday through Friday and is closed evenings, weekends and holidays.  Be sure to have all prescriptions in as early as possible for the pharmacy to fill.  Patients with non-controlled medications will be assigned medication drawers. Please do not store medications in the baskets on the cage doors.

58.  If your patient is on specialized diets, please be sure that adequate amounts are available in the ICU before the evening or weekend begins. Some types of diets are in the kitchen (by the runs), other must be ordered from the pharmacy.

59.  Control drugs are store in the locked box in ICU during the hours that pharmacy is closed.  Some medications require refrigeration (i.e., Insulin, Famotidine). The refrigerator in ICU is for patient food and medications. Do not store human food here.

60.  ICU has several “Seizure Kits” located in the locked box for patients that have seizuring episodes. They contain Diazepam and Phenobarbital. If used, please write a prescription so that it can be charged out to the patient.

61.  ICU has a small amount of emergency drugs. If you need them for an emergency please write a Rx to replace them.  In the event of an arrest we have 2 “Crash kits”. The first are medications located in the red crash kit. For patients outside of ICU a portable kit is available

62.  ICU has several reference texts which include several books on toxicology, fluid therapy as well as the Manual of Small Animal Emergency and Critical Care Medicine.  ICU procedures notebook which contains descriptions of how to perform multiple different techniques.  Please do not remove them for ICU. If you would like a copy of any material please let us know.

63.  ICU Student:  Will care for the patients in ICU (including: monitoring, giving medications, etc.)  Assisting the ER student with treatments of emergency patients.  Monday-Friday 5 p.m. to 8:30 p.m.  Weekends & holidays 7 a.m. to 2:30 p.m. & 2 p.m. to 8:30 p.m.

64.  Answering messages from the answering service.  The student will call the clients, calls from the veterinarians will be answered by the intern  Get client name, patient, doctor treating the patient, problem, phone number, referring Veterinarian.  We do not see bats, skunks, or deer from outside Washington State.  If it is not busy it is the ICU student’s responsibility to be in ICU at least 10 minutes before the start of the hour to help with the treatments. The technician should not have to go looking for you.

65.  The ICU and ER shifts are:  Monday through Friday 5 p.m. to 8:30 p.m. Back-up shifts are: -Monday through Friday: 5 p.m. to 11 p.m. and 11 p.m. to 8 a.m. -Weekends/Holidays: 7 a.m. to 3:30 p.m., 3 p.m. to 11:30 p.m. 11 p.m. to 8 a.m.

66.  ER Student:  Will see all emergencies and with the intern come up with a plan of action as well as performing diagnostic procedures.  Will take a nightly census (this includes all patients in the wards and runs, excluding blood donors & exotics).  Is responsible for walking and treatments of patients in the runs and wards (excluding ICU).  Monday-Friday 5 p.m. to 8:30 p.m.  Weekends & holidays 7 a.m. to 2:30 p.m. & 2 p.m. to 8:30 p.m.

67.  There are 2 clipboards for after hour treatments-one is in ICU for treatments needed to be done from 8 p.m. and 8 a.m. and one in the technician’s station with treatments for the rest of the time. Please be sure to list any treatments needed for patients not in the ICU there.  If you would like a dog to be walked after hours list it on the dog walking sheet (found in the technician’s station.)  After hour discharges-if it has been approved by your clinician for an after hour discharge please list it on the clipboard w/ the patient, student and location of the patient, (also found in the tech. office)

68.  Sx on-call student:  Are responsible for assisting in any surgeries that come in after hours. Monday through Fridays the shift starts at 5 p.m. and goes until 8 a.m. the next morning.  Saturdays, Sundays, and holidays the shift starts at 8 a.m. and goes to the following morning at 8 a.m.  The Sx on-call student does not have to go to ICU rounds.

69.  Back up students:  Are responsible for assisting in the treatments of patients (both in ICU or the wards and runs).  Need to be in the hospital within 20 to 30 minutes of being called in.  Must be at rounds so that you will have some idea as to what is going on in ICU if you are called in.  Back up students may be expected to see incoming patients as needed depending on how busy it is.

70.  Treatments before 8 p.m. will go on the treatment sheet found on a clipboard on the ice maker in the technician station in 1604.  Treatments for patients after 8 p.m. and before 6 a.m. will go on the treatment sheet found on a clipboard in the small animal ICU.  All dogs that are ambulatory requiring walks must be listed on the dog walking sheet also found in the technicians station in 1604.

71.  The schedule is usually sent out at least 2 weeks before the block starts and is emailed to the class. Please check the schedule out before deleting.  Students on the Referral rotation will not be assigned E.R. shifts for those 2 weeks.  The number of shifts assigned will depend on the number of people on the different rotations.  Community Practice, Referral Medicine, Soft Tissue Sx, Orthopedic Sx, Oncology, Neurology, and Cardiology students will be on the rotations covering ICU and ER.

72.  It is the student responsibility to find their own replacement for a shift if a conflict arises. Be aware that if the person you trade with does not come in, it will be your responsibility. Please mark the changes in the “ICU schedule and important numbers” notebook.

73.  Please be aware that your performance in the ICU is part of your grade for each of the small animal rotations.