2nd year resident gives a few gems of advice from her experience as an intern

[Mandelbrot]

http://doctorontheside.com/2012/08/19/intern-year-my-te-commandments/

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[turkeyjerky]

Pretty useless advice

 

[Mandelbrot]

Would you rather have another "What to do when your patient has a hangnail at 3am" post? How well you are liked by the nursing and ancillary staff can make a huge difference in your experience as a resident. It may be a lot of common sense stuff, but from my experience common sense is not a common affliction among med students and new interns.

 

[turkeyjerky]

well, common sense would dictate that if your blog was any good you wouldn't need to pimp it on sdn

 

[deleted263296]

I wish I could be as positive as this person is. I just really can't stand being in the hospital, though, and I dread every single time a new admission comes in because I always know there will be some question I forget to ask or some piece of information the attending will want that I didn't obtain.

 

[xanthomondo]

Pretty useless advice

At first I thought this response was harsh. It is spot on though.

I had the same attitude that you presented coming into internship. Two months in it couldn't be farther from the truth. Aside from ICU nurses, nurses typically don't know **** and are lazy as hell. Their #1 mission at work is to do the minimum amount of work required.

Oh...and these lazy bums work 1/2 the hours you do, have 1/4 the education, and make 2-3x your salary...and we're the ones who are greedy complaining bastards.... We're allowed to complain and not be happy about that. (that's #4 on your list)

 

[Carotenoid]

I wish I could be as positive as this person is. I just really can't stand being in the hospital, though, and I dread every single time a new admission comes in because I always know there will be some question I forget to ask or some piece of information the attending will want that I didn't obtain.

I dread that it is going to be another "cover our butt" admission where the ED folks are admitting "just in case". 50% (conservative estimate) are of this type. Hence, for me they are only busywork, and carry no educational (or even humanistic) value whatsoever. Oh, and I am p--**ed off every time I think that my taxes are going to pay for a week's worth of hospital stay/tests/imaging on someone who should be managed as an OP.

 

[Carotenoid]

At first I thought this response was harsh. It is spot on though.

I had the same attitude that you presented coming into internship. Two months in it couldn't be farther from the truth. Aside from ICU nurses, nurses typically don't know **** and are lazy as hell. Their #1 mission at work is to do the minimum amount of work required.

Oh...and these lazy bums work 1/2 the hours you do, have 1/4 the education, and make 2-3x your salary...and we're the ones who are greedy complaining bastards.... We're allowed to complain and not be happy about that. (that's #4 on your list)

Totally agree with you. Last night (I am on NF) I was paged for patient being "bradycardic" with an HR of 56 - I asked the nurse if she thought this HR warranted the phone call, and if the patient is symptomatic. She said that "it is a bad heart rate", and that "yes, the patient is symptomatic, he is walking all over the floor, and we found him sneaking ice cream from the fridge. And you know, he is diabetic". I just wanted to see her thought pattern, so I asked if she thought if I needed to intervene as a doctor in this situation. She said that I needed to do something so that his HR were "over 60", and that she thought he needed "a sugar check" because of all the ice cream he ate. Not all nurses are like this - about 20% of them are smart, sharp and knowledgeable - and fit poorly with the 80% who are just...

 

[Perrotfish]

http://doctorontheside.com/2012/08/19/intern-year-my-te-commandments/

People are going to act how they act. I'm not sure how a confrontational attitute towards bad ancillary staff compares to the deference that this blogger suggests, but lets be honest, people aren't going to change how they act based on a blogs advice. People who smile are gonna smile. People who argue are gonna argue. People that put on lipstick and high heels before they go into the NICU aren't going to be detered by any amout of eyerolling from not recently showered peers. I am willing to bet that this blogger was not previously a sullen, type A, confrontational know it who just discovered that smilling and avoiding your title is what works in Intern year. I'm willing to bet she's someone who is acting the exact same way she's acted since around late high school, and is advising everyone else to act just like her so that they can profit by her fine example.

 

[Doctor4Life1769]

I'd written up a few nurses as an intern, I won't lie.

Watching Grey's while in the ICU and your pt is getting sicker? - you betcha!

Making the patient and the patient's family cry? - you better believe it hunny!

You gotta show tact. Being meek isn't gonna get you anywhere. Of course, don't be all "im the doctor, bish!" but don't let nurses run your days/nights either. They're not doctors, you are. I've ignored requests all the time for sleeping pills, diet modifications (a diabetic vasculopath wanted a cheese burger and the RN was pushing for me to change it.. yeah, talk to the day team, til then you eat what's within your diet!), etc... you want a bowel regimen at 3am? you just won yourself an order for a rectal suppository. Enjoy waking up your now pissed off patient and attempt to shove something into his/her butt at that wee hour in the night. I betcha wont pull that **** again!!

 

[anonperson]

At first I thought this response was harsh. It is spot on though.

I had the same attitude that you presented coming into internship. Two months in it couldn't be farther from the truth. Aside from ICU nurses, nurses typically don't know **** and are lazy as hell. Their #1 mission at work is to do the minimum amount of work required.

Oh...and these lazy bums work 1/2 the hours you do, have 1/4 the education, and make 2-3x your salary...and we're the ones who are greedy complaining bastards.... We're allowed to complain and not be happy about that. (that's #4 on your list)

Quoted for emphasis. Nurses are like children. You can't really expect too much out of them.

 

[xanthomondo]

I'd written up a few nurses as an intern, I won't lie.

Watching Grey's while in the ICU and your pt is getting sicker? - you betcha!

Making the patient and the patient's family cry? - you better believe it hunny!

You gotta show tact. Being meek isn't gonna get you anywhere. Of course, don't be all "im the doctor, bish!" but don't let nurses run your days/nights either. They're not doctors, you are. I've ignored requests all the time for sleeping pills, diet modifications (a diabetic vasculopath wanted a cheese burger and the RN was pushing for me to change it.. yeah, talk to the day team, til then you eat what's within your diet!), etc... you want a bowel regimen at 3am? you just won yourself an order for a rectal suppository. Enjoy waking up your now pissed off patient and attempt to shove something into his/her butt at that wee hour in the night. I betcha wont pull that **** again!!

That last part is something I learned REALLY well. If a nurse ever calls me for one of those "The patient's BP is 90/60 right now...I see they have been running in the 80s-90s for the past few days but I just wanted to let you know." I ALWAYS ask for a complete set of orthostatic vital signs (and sometimes an EKG for fun). Its even better when the person is morbidly obese and can't stand well on their own so the nurse has to hold them up

They eventually stop with that

 

[Winged Scapula]

Totally agree with you. Last night (I am on NF) I was paged for patient being "bradycardic" with an HR of 56 - I asked the nurse if she thought this HR warranted the phone call, and if the patient is symptomatic. She said that "it is a bad heart rate", and that "yes, the patient is symptomatic, he is walking all over the floor, and we found him sneaking ice cream from the fridge. And you know, he is diabetic".

Although I'm not diabetic, my resting HR runs under 60 and I sometimes get up to eat ice cream. Thank goodness I don't have this kind of nurse "caring" for me.

 

[smq123]

That last part is something I learned REALLY well. If a nurse ever calls me for one of those "The patient's BP is 90/60 right now...I see they have been running in the 80s-90s for the past few days but I just wanted to let you know." I ALWAYS ask for a complete set of orthostatic vital signs (and sometimes an EKG for fun). Its even better when the person is morbidly obese and can't stand well on their own so the nurse has to hold them up

They eventually stop with that

Awesome.

 

[deleted103644]

That last part is something I learned REALLY well. If a nurse ever calls me for one of those "The patient's BP is 90/60 right now...I see they have been running in the 80s-90s for the past few days but I just wanted to let you know." I ALWAYS ask for a complete set of orthostatic vital signs (and sometimes an EKG for fun). Its even better when the person is morbidly obese and can't stand well on their own so the nurse has to hold them up

They eventually stop with that

You can get your nurses to do orthostatics?!??

I'm lucky if they give me a heart rate with the BP....

 

[DrAwsome]

You can get your nurses to do orthostatics?!??

I'm lucky if they give me a heart rate with the BP....

You are getting totally screwed dude. Are you the one training in NY? We never had to lift a finger in such situations, nurses and aides did all of that. Another reason not to work in NY!

 

[deleted103644]

You are getting totally screwed dude. Are you the one training in NY? We never had to lift a finger in such situations, nurses and aides did all of that. Another reason not to work in NY!

Meh. I use medical students for orthostatics - it is a valuable educational experience after all.

 

[DrAwsome]

Meh. I use medical students for orthostatics - it is a valuable educational experience after all.

I don't know how educational it is to be honest. But it really bothers me when support staff does not do its job. That's their role. I used to tell the nurses that before paging me, they should make sure they have all sets of needed vitals ready to go, particularly at night.

 

[deleted103644]

I don't know how educational it is to be honest. But it really bothers me when support staff does not do its job. That's their role. I used to tell the nurses that before paging me, they should make sure they have all sets of needed vitals ready to go, particularly at night.

Oh, yeah, when they call me about a BP I immediately ask for other vitals (which they rarely have) and try to get them not to call me again without them. So far not very successful, but I've only been on the floors a few weeks.

The educational content comment was obviously not serious.

 

[Doctor4Life1769]

I've ordered orthostatics.... it just wouldn't be done. Hell, theyre barely done in the day as it is... nurses just dont like doing that ****. So, they don't do it but they also wouldn't bother me again over it because they knew if paged again that'd be the first thing i'd ask for. i dont usually order EKGs unless the nurse is saying "he has CP" and Id ask if it's reproducible or not, GERD/gastritis related, etc... and can't get a clear idea b/c the nurse isn't giving proper info over the phone.... "well, then, get this patient an EKG... stat like now!"

 

[Doctor4Life1769]

You are getting totally screwed dude. Are you the one training in NY? We never had to lift a finger in such situations, nurses and aides did all of that. Another reason not to work in NY!

yeah, I think an important lesson for all is to avoid NY programs unless you want to be eaten alive by unionized nursing.

 

[Perrotfish]

I don't know how educational it is to be honest. But it really bothers me when support staff does not do its job. That's their role. I used to tell the nurses that before paging me, they should make sure they have all sets of needed vitals ready to go, particularly at night.

How experienced are your nurses? A lot of training hospitals train nurses as well, there's a good chance they really are new at this and don't know what to do. Normally on my floor the only experienced nurse is the charge, who is mostly focused on admits and a handful of the sickest patients.

 

[KnuxNole]

If the NY nurses are that bad, why can't they just get kicked out? It sounds like all they wanna do is smoke and eat and do nothing. I guess it's lame that they have a union that is undeserved.

 

[Khaos]

Oh, oh, my turn....with all the nurse bashing, I thought I'd put out another idea. Residents can be idiots at times also. Yes, some nurses are inexperienced and don't understand that some of the things they are worried about amount to nothing. You have had 3 times the amount of training they had. They are on the floor with the patient at the patient's beck and call. They are the ones telling the patient to stop with the ice cream, get to bed, and telling with the crap that you think you are too high and mighty to deal with. I've had residents whine and complain about the patient that kept them in the room for 30 minutes talking. The nurse is going to deal with that patient for the next 2 days. Heck, one of my favorite moments was when the intern came running out of the room with a patient saying the patient was in V-tach and asking for the code cart. She was nudging the guy on the chest over one of the leads trying to wake him up and made the monitor alarm. One intern during her first call in the CCU was paged to her first code. She walked in, saw the nurses doing CPR and walked out. She didn't answer any of her pages and guess who had to go and run a code. Not to mention things as common as an order for the wrong drugs, overloading the patient with fluids, causing renal failure in a patient, not properly treating DKA or actually in one case causing the patient to go into DKA for not properly treating her type I diabetes before a procedure which then leads to renal failure which ends up in the patient starting dialysis, then from a first year fellow giving an accidental bolus of heparin after putting in a line and bleeding to death...

Don't even get me started on medical student mistakes...which luckily aren't as severe since they can't order anything.

Before you go and bash on nurses, realize where you are coming from. I've been an attending for a little bit now and I can tell you one thing for sure; that is a job that I would never want and I will gladly answer any question they have. All I ask for is that they work hard, which can be a problem in any field.

I think if this just continues as nurse bashing the moderator should step in.

 

[Bartelby]

Before you go and bash on nurses, realize where you are coming from. I've been an attending for a little bit now and I can tell you one thing for sure; that is a job that I would never want and I will gladly answer any question they have. All I ask for is that they work hard, which can be a problem in any field.

There are some lazy or aggressive nurses for sure, but they make me appreciate the good and caring ones that much more.

 

[Carotenoid]

There are some lazy or aggressive nurses for sure, but they make me appreciate the good and caring ones that much more.

Totally. So many nurses are truly awesome and I could not do any of my work without them. The good ones know when to page and when not to page... and heck, even know how to intervene. Bashing is not cool.

 

[Mr hawkings]

Totally. So many nurses are truly awesome and I could not do any of my work without them. The good ones know when to page and when not to page... and heck, even know how to intervene. Bashing is not cool.

Do any senior nurses come to the defense of med students and interns when they are being treated poorly by those bad ones you mentioned?
It feels like the last 4 years i've been told 1000 time to remember to appreciate and be nice to nurses because it is impossible to do your job without them. I wonder if someone ever says a similar statement to them during their training. It feels like the few bad ones are "allowed" to behave badly by their peers without someone pulling them aside to le them know that we are on the same team.

 

[xanthomondo]

Oh, oh, my turn....with all the nurse bashing, I thought I'd put out another idea. Residents can be idiots at times also. Yes, some nurses are inexperienced and don't understand that some of the things they are worried about amount to nothing. You have had 3 times the amount of training they had. They are on the floor with the patient at the patient's beck and call. They are the ones telling the patient to stop with the ice cream, get to bed, and telling with the crap that you think you are too high and mighty to deal with. I've had residents whine and complain about the patient that kept them in the room for 30 minutes talking. The nurse is going to deal with that patient for the next 2 days. Heck, one of my favorite moments was when the intern came running out of the room with a patient saying the patient was in V-tach and asking for the code cart. She was nudging the guy on the chest over one of the leads trying to wake him up and made the monitor alarm. One intern during her first call in the CCU was paged to her first code. She walked in, saw the nurses doing CPR and walked out. She didn't answer any of her pages and guess who had to go and run a code. Not to mention things as common as an order for the wrong drugs, overloading the patient with fluids, causing renal failure in a patient, not properly treating DKA or actually in one case causing the patient to go into DKA for not properly treating her type I diabetes before a procedure which then leads to renal failure which ends up in the patient starting dialysis, then from a first year fellow giving an accidental bolus of heparin after putting in a line and bleeding to death...

Don't even get me started on medical student mistakes...which luckily aren't as severe since they can't order anything.

Before you go and bash on nurses, realize where you are coming from. I've been an attending for a little bit now and I can tell you one thing for sure; that is a job that I would never want and I will gladly answer any question they have. All I ask for is that they work hard, which can be a problem in any field.

I think if this just continues as nurse bashing the moderator should step in.

I think this kind of post is much easier to make when you've graduated residency. You probably get a LOT more respect from the nurses (and they might even do what you ask). It's very easy to remember the past as being not so terrible when life is good now.

As a resident the floor nurses at my hospital will just ignore orders (strict I/Os on a heart failure patient? lol!!!!!) even if they're requested in person with an explanation why. That's the most frustrating thing - they're getting paid $35/hour (over $60 if it's overtime) and they just ignore whatever they want. I've tried to go to the nurse manager but my experience has been that her priority is to protect the nurse. So if you report that the CHF patient isn't getting daily weights or some other complaint she responds "well, that's ok" and won't even mention a thing to her union buddy. There's no accountability.

How has a medical student hurt a patient or do something stupid on the floors in medicine? We had zero autonomy and chance to do something - the only thing we did was in rounds tell the attending what our plan was (and they would correct us).

 

[xanthomondo]

yeah, I think an important lesson for all is to avoid NY programs unless you want to be eaten alive by unionized nursing.

I think this applies to any urban hospital

 

[cpants]

I think this kind of post is much easier to make when you've graduated residency. You probably get a LOT more respect from the nurses (and they might even do what you ask). It's very easy to remember the past as being not so terrible when life is good now.

As a resident the floor nurses at my hospital will just ignore orders (strict I/Os on a heart failure patient? lol!!!!!) even if they're requested in person with an explanation why. That's the most frustrating thing - they're getting paid $35/hour (over $60 if it's overtime) and they just ignore whatever they want. I've tried to go to the nurse manager but my experience has been that her priority is to protect the nurse. So if you report that the CHF patient isn't getting daily weights or some other complaint she responds "well, that's ok" and won't even mention a thing to her union buddy. There's no accountability.

How has a medical student hurt a patient or do something stupid on the floors in medicine? We had zero autonomy and chance to do something - the only thing we did was in rounds tell the attending what our plan was (and they would correct us).

RN's can definitely save your ass, and when they call at night, you always have to at least listen to what they are calling about. Even if they don't know what's going on, sometimes you can catch something serious (eg. "patient is febrile to 103, can I get some Tylenol?" Can turn out to be a patient going into septic shock). If they think a patient is sick, you need to respond promptly, because they are usually right.

As far as the little stuff goes, you have to pick your battles. Best way to avoid a lot of nonsense is to show up on the floor and offer your services around 9PM. Can head a lot of "clarifications" off at the pass. Middle-of-the night pages about routine orders like bowel reg are not appropriate in my opinion. Usually, I'm not going to change any routine orders in the wee hours, and I flat out tell the nurses that. I/O's can be a constant battle, especially on the medical floors. Write the order, tell the nurse, document in chart the need for strict I/O. If it still isn't getting done, start generating paper daily until it starts getting done. That's how the nursing world works, and believe me it will start getting done when 2 or 3 writeups get submitted. The RN supervisor gets mighty pissed when her floor starts looking bad. I once had an attending who refused to allow his pt's to be admitted to a certain floor for this and other issues, and the whole unit ended up getting restaffed/retrained because it generated such a headache for RN supervisors and bed management.

 

[KnuxNole]

I think this kind of post is much easier to make when you've graduated residency. You probably get a LOT more respect from the nurses (and they might even do what you ask). It's very easy to remember the past as being not so terrible when life is good now.

As a resident the floor nurses at my hospital will just ignore orders (strict I/Os on a heart failure patient? lol!!!!!) even if they're requested in person with an explanation why. That's the most frustrating thing - they're getting paid $35/hour (over $60 if it's overtime) and they just ignore whatever they want. I've tried to go to the nurse manager but my experience has been that her priority is to protect the nurse. So if you report that the CHF patient isn't getting daily weights or some other complaint she responds "well, that's ok" and won't even mention a thing to her union buddy. There's no accountability.

How has a medical student hurt a patient or do something stupid on the floors in medicine? We had zero autonomy and chance to do something - the only thing we did was in rounds tell the attending what our plan was (and they would correct us).

This. A med student barely has any pull at all. They don't have to be there and everything would run the same.