1. New Resident Orientation
Mariel Smith MD
Pediatric Chief Resident 2015-16

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

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, MICU
 The PICU is a 5-bed unit
 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

9. Inpatient Team Structure
Two Clinical Teams
Green – General Oncology/Surgery
Blue – Bone Marrow Transplant

10. M9 Inpatient Service
GREEN Team – General Oncology/Surgery
 Attending and Fellow (1st year)
 2 PGY-3 Senior Resident 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 fellow
 3-4 residents from Cornell, Downstate, Metropolitan…

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

18. Sign out/Sign In
 7 am: Sign Out/Sign In
 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 are only in the bedside chart
 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?
 The Senior and the Blue resident on-call for that
night should always go into the room
 All Green team housestaff unless patient is on special
isolation precautions or indicated by family

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
 When your patient’s name is called, either you or the
fellow will give a one-liner about who the patient is and
why you got the study
 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. Conferences
 About 3-4 times per week at 1:30pm in PDH classroom
or workroom
 Lectures given by Attendings, Fellows and Chief
Resident
 Residents also give short interactive case presentations
prior to the end of the block
 Lecture schedule posted in call room
 Grand Rounds Thursday mornings at 8:30am

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

26. Admissions
 Green Team Residents: Expect to get at least one
admission every day you are not in clinic
 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 a 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 EVERY
TUESDAY/FRIDAY

30. Resident E-mail Account
 Generic read-only e-mail accounts to improve
communication
 GREEN: login: pedoncres; pword: green123
 BLUE: login: pedbmtres; pword:blue 123

32. 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

33. 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

34. Weekday Call BLUE
 Responsibilities:
 Check to make sure all AM labs are appropriate
 “Midnight” rounds with on-call fellow
 “AM rounds” – Check VS and I/O, record AM labs  record
vitals on handoffs
 Notes on all admissions
 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
 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
 Midnight rounds with on-call fellow
 AM vitals & I/Os of all patients
 One fellow per team (unlike weekdays)
 Call room on the floor is provided; meal cards for
dinner are provided
 Cafeteria closes early on weekends

36. Weekend Call
 Green Team: Short Call (7-6pm)
 There are always two residents on call
 Divide patients equally
 Seniors on short call: this is not a supervisory role; just carry
the patients and do the work

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
 Mariel Smith, MD
 Pager #2244, Office 212-639-6005

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