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Things I wish I knew as a PGY-1...

Discussion in 'Internship' started by turkleton, Mar 26, 2007.

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  1. turkleton

    turkleton Capeless Crusader

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    SDN Members don't see this ad. (About Ads)
    Hey the pre-meds are doing it. I'll take some tips before mid June.:cool:
  2. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    How to write effective sliding scales for insulin, potassium, etc. and how to write effective and comprehensive PRN orders.
  3. nradsoit3

    nradsoit3 Senior Member

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    how by signing out 5 minutes later can cause you to get stuck in the hospital for another hour:scared:
  4. jennyboo

    jennyboo Senior Member

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    That in IM, it's more important to get the morning work done than to get your progress note in the chart by morning work rounds. And that you save a LOT of time by NOT returning repeatedly to different charts, but simply work your way through the hospital floor by floor once in the morning (pre-rounds) and once more in the afternoon.

    Instead of writing each note one by one, just grab a blank progress note from each patient's chart, swing by their room and write down just their vitals and overnight events (and their meds, if you have time). Collect all of the notes. Then, right before work rounds, sit down at a computer and write down all the patients' labs on their progress notes.

    Then do work rounds and write orders in the chart (if your hospital has written orders).

    During noon conference or other downtime, you can then take out your pile of progress notes and finish all of them within a half hour.

    After lunch when you have free time to work, swing by each patient's chart to drop off the progress note. While you're there, write any additional orders and call consults.

    When your last progress note is out of your hands, you are DONE and ready to sign out while your colleagues are still running around. :cool:
  5. Doc Ivy

    Doc Ivy Miss Understood

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    One thing I learned on my Sub-I:

    Call consults early. I found that if you paged the consulting service in the AM it could shave hours off of the day b/c 1) they aren't backed up and your patient is the first on their list to see 2) the resident saw the patient earlier meaning 3) the attending heard about the patient earlier, 4) the team made their recommendations earlier, and 5) got the note in the chart earlier. Nothing worse than being done with your work but waiting on a consult til the early evening because you didn't call them until 3pm.
  6. danielmd06

    danielmd06 Neurosomnologist

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    (1) Be polite to everybody, regardless of the time of night. And especially in the Emergency Department.

    (2) If you just put an order on a chart, it helps speed up the process to actually tell the nurse that you did so. And they often appreciate the heads up coming from you personally.

    (3) Call consultants personally. They will greatly appreciate hearing from you instead of some random nurse, and will likely personally call you back with what you need to know. Plus, as the previous poster noted, it helps expedite the process and ultimately gets your patient out the door faster.

    (4) Be on time more often than not. ;)

    (5) Be enthusiastic and have a sense of humor. It's a hard job and most people appreciate a little levity and genuine interest.

    (6) Don't sign out ridiculous and non-essential labs and tests to your co-interns.

    (7) Never lie. The interns who try this on rounds are not exactly inspiring confidence from their colleagues. And it looks completely idiotic when an attending or nurse rips the facade away.

    (8) Oh, and I can't remember but I think there was something about not doing harm written down somewhere or other. To me, this translates into "knowing your limits." Don't be afraid to ask, and don't be afraid to err on the side of looking dumber in the interest of patient safety.

    (9) Take care of yourself so that you can care for others. Spend time with your wife, read books, work out, watch movies, go out to dinner, spend time on your hobbies, drink lots of scotch, or whatever. Just find some way of being able to decompress...you're gonna need it.

    Good luck.
  7. sophiejane

    sophiejane Exhausted Moderator Emeritus

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    That's really excellent advice. Thank you so much!
  8. Pox in a box

    Pox in a box 1K Member

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    Does your attending not frown on the fact that your "note" is entered in the chart after his? Seems like there's little for you to learn and you've already got the given plan handed to you (if you didn't already have it yourself) from your rounds with the team. Seems like you should have a note prior to rounds.
  9. DeLaughterDO

    DeLaughterDO Ghost in the Machine

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    I would actually have attendings stand in the hall while you wrote your note if it wasn't complete by the time we were rounding - usually 0700 - 0730. Nothing quite so nerve-wracking as having your attending tapping his feet as he (and the entire team) waits for you to complete your note so he can basically put his "saw patient on rounds and discussed with Dr. so-and-so. Agree with his/her note and plan." 4am really sucked that month!

    jd
  10. jennyboo

    jennyboo Senior Member

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    It's probably hospital dependent. At ours, we are faster when we don't bother getting it in before work rounds and the attendings don't care. I guess my philosophy is that getting the work done is (slightly) more important than getting the paperwork done. Obviously, if in your hospital they expect it, then you have to do it -- but I don't really feel that I learn less from it (as I more or less know "the plan" and the note just documents it).
  11. DeLaughterDO

    DeLaughterDO Ghost in the Machine

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    agreed, and many attendings think similarly. The attending I noted is notorious for 6-7 hour rounding sessions, daily. Talk about brutal. Noone ever got out before 8pm.

    Just glad I'm done with medicine wards!

    jd
  12. boston

    boston Junior Member

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    1. No matter what the situation, never look flustered or overwhelmed. Always remain calm on the surface even if you are scared ****less.

    2. Moving faster (like a frantic headless chicken) is not always the answer. Economy of movement, slow but deliberate is better.

    3. Critical situation? Take a deep breath -- think systematically: airway, breathing, circulation ... vitals, examine the patient ... what do you think is going on? (DDx) ... next appropriate step in diagnosis and management.

    4. Communication of facts is not enough, you need to paint a picture.

    5. Initial perceptions are hard to change. Doing a good job is important, but equally important is that you are recognized and perceived as doing a good job by superiors (seniors, attendings).

    6. Always smile and look relaxed. Never look upset, unhappy, or nervous no matter what your internal mood. Joke around with staff (nurses), colleagues, attendings -- this is key.

    7. Adjust your presentation to the attendings personality and what he/she wants. A quick summary one-liner to start is helpful before delving into supporting details.

    8. Attendings and seniors want you to synthesize information, not just gather information. I.e. what is really going on with the patient?

    9. Always have a plan for each patient. What does the patient need to leave the hospital? (Remove devices? Placement issues?)

    10. Always expect to stay late. If you end up leaving on time, you will be pleasantly surprised. If you stay late, you won't be as sorely disappointed.

    11. Pay attention to the different styles of running the service by different chiefs. Figure out what you like or don't like and what you want to incorporate or avoid when you are chief one day.

    12. Pay attention to how your seniors present to attendings -- what to talk about, what to leave out. (I still make a habit of this.)

    13. Help out a fellow resident in need if you are in a position to. I.e. if you are not busy and the other guy is overwhelmed, offer to do help him do some simple tasks like pulling lines, drains, etc. Being known as a helper engenders good will and you never know when you might be in need of a favor in return.

    14. Admit your mistakes when you screw up. But it is not always your fault. Know when it is appropriate to defend yourself and not be the victim / scapegoat.

    15. You can never be overprepared for a given situation. Whether it's an oral presentation or rounds or clinic or the OR. Neuroticism is your friend.

    16. Learn to navigate the political waters -- we are not in school anymore, but a work environment. Anytime there is someone who wields power over you, there are politics involved. You don't need to compromise your moral principles, but you do need to be practical and artful in speech. There is a taste of this during 3rd year of med school, but in some high-powered academic settings, this is magnified in residency.
  13. jennyboo

    jennyboo Senior Member

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    That's exactly what we tell our medical students, because the best way for them to learn IS to get the note done and in the chart before rounds. But you quickly learn that as an intern your job is not to further your education but to get crap done.

    At my fastest, it took about 30 minutes to see patient, examine, write down vitals, write down labs and complete the note. If you need to do this one at a time on 12 patients, that means you need to arrive 6 hours before rounds. If rounds are at 9am, do I want to arrive at 3am to start seeing patients? Nuh-uh.

    The medical student system that works for one or two patients is ridiculously inefficient for 12 patients. So when you start your internship you'll find yourself needing to do things in a different order just to get them done. Yes, during your first month you simply might not even finish the basics (getting labs, checking important stuff) before rounds. That is expected in July or August.

    I found very quickly that it's much more efficient to run by, see patients and start half the progress note by writing down the vitals and current medications; sit down with ALL the notes, log into the computer and write down labs in one sitting; then write ALL the plans and finish the notes in another sitting either before, during, or after work rounds. With time, you will not need to write the whole note in order to understand the "big picture" and the management plan. As a medical student, you learn primarily by writing those notes. As an intern, you learn by treating the patient. It's a different ball game altogether.

    Whatever gets your work done, gets you good evaluations from your residents and attendings AND gets you out at a reasonable time at the end of the day is a good system for you. I rarely had all my notes done before work rounds, but I found I had happy attendings, I had more time to do work and even (drumroll) talk to patients/families in the afternoon, and I was signing out at 4pm when some of my co-interns were signing out at 7pm with less happy residents/attendings and more loose ends. So if it's okay at your hospital, don't feel obligated to get the stupid progress notes done before rounds -- even though they take the longest amount of time, they are the least important part of the work.
  14. AF_PedsBoy

    AF_PedsBoy Stuffed Animal Overlord

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    1) If you can, typing notes is a big help (I have a template with the headers already entered); every note will have an up to date meds list (if it's QD I actually put the time given so you know if they got a dose or not) and you can remind yourself what you did the day before

    2) If you list a culture always put the date and TIME drawn so you know when it's 48 hours; if you are using an antibiotic know the time the first dose was given so you know how many doses a patient has gotten at any given time and when exactly their course is up. This can affect a discharge (especially in peds), or an outpatient course if you need to write for outpt abx

    3) Keep that hospital course updated for the discharge - it will help at discharge time and keep it clear in your head when signing out and talking to consult services.

    4) If you get distracted easily, find a quiet corner where you can do your work; the nurses, ED, etc. will take care of the small stuff if you're not around, but the temptation is irresistable if you're sitting right there!

    5) If you call a consult always have a definite question in mind - they like to have a direction to go, and more importantly you'll know why you're doing it!

    6) Never ever ever ever badmouth a colleague to a patient or a family; it may be a bull**** consult (like admitting a patient for simple constipation after a disimpaction, enema, and resolution of symptoms...!), but once you're done griping to yourself, get on board when you go down to the ED/Clinic/etc. No one likes their professional judgement questioned, and you may not know the whole story.

    7) Know your limits - no matter how busy you are, take ten minutes for lunch or a sanity break; you may think you have so much work you need to work non-stop, but ten minutes probably won't make or break the task but it WILL let you work more efficiently once you're refreshed.

    8) As an intern most attendings don't care if the note is there first or not because when you present to them first thing in the morning they know you've seen the patient and have a plan. Some days there's so much work the note goes on the chart at 2200 or 2300! With that said, if you lay hands on a patient or are paged on a patient you need a quick note documenting what you did and what you were thinking. This will help the team in the day if it was a call, and will cover your ass

    9) It's ok to say "I just need to go back and do a quick neuro exam after we round," but it is NOT okay to lie about doing it. They understand sometimes you don't have time to finish everything, but nothing will corrode a team faster than if you lie about it, even if you planned to go back and verify it later
  15. AF_PedsBoy

    AF_PedsBoy Stuffed Animal Overlord

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    You should have your plan in your head when you round, so the attending knows you've been thinking about it, and when you see their plan it confirms your thinking (or teaches you something new :D ). On the other hand, doing the monkey work of getting a note on the chart first doesn't help your learning - you're not telling the attending anything they don't know, and their plan will always trump yours!
  16. NewHope

    NewHope

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    Great advice. But where do you find time for #9 as an intern?

  17. Stimulate

    Stimulate

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    a) find yourself some comfortable shoes
    b) Get along with everybody. Remember that your senior resident today may be your fellow or attending next year.
    c) Get step 3 done early
    d) Get your permanent license sooner rather than later
    e) choose your battles wisely
    f) Nurses can make or break you. Try to get along with them and they can help you out. Remember that every year all the nurses and ancillary staff see a fresh crop of interns. The sizing up process begins from day one. Don't expect to be treated like a physician automatically, you usually need to earn respect.
    g) Expect to make some mistakes, some may even harm patients. Learn from them and move on.
    h) Keep yourself healthy, don't eat too much of the free cafeteria food. :)
  18. Leche

    Leche Junior Member

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    Good stuff gang, keep 'em coming. Sticky??
  19. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    Sure...we can sticky this.:D
  20. BADMD

    BADMD

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    Coming from an ER guy, so take it with a grain of salt. I've tried to not repeat what others have said.

    1) Know what help is available if you get in trouble. You'd be suprised who is actually available and willing to help at 3am if you are despirate and ask.

    2) When something bad start to happen, have a basic plan and follow you ABCs.

    3) When presenting a patient always include the chief complaint in the first line (after age, race and sex). Nothing is worse than hearing a laundry list of prior medical conditions if you don't know why the patient presented to the hospital.

    4) Anticipate discharges and have the discharge paperwork prepared before rounds. Not only will you look better if you can discharge a patient during rounds, but you will improve hospital flow significantly and improve overall patient satisfaction.

    5) Sign outs are ridiculously dangerous and so much gets lost or forgotten about. Make sure every patient has a plan for the night and a list of potential "if, thens." If a patient sounds "sick" make sure you see them with your co-intern before s/he goes.

    6) Listen to your nurses. Sometimes, they are idiots, but most of the time, especially if they are seasoned, they have an excellent handle of things.

    7) Find a way to bring the nurses food when you are on call. It doesn't have to be much, maybe just a few bags of chips. But the goodwill will serve you quite well.

    8) Write routine orders, such as labs, during rounds.

    9) a) Know your analgesic equivalents and aggessively switch patients to adequate oral medication. 5-10 mg of Oxycodone for a patient on 2 mg of morphine per hour on a PCA just ensures the patient spends an extra day in the hospital while the orals are titrated up. b) 2-4mg of morphine Q3 is rarely going to be adequate for pain management.

    10) Follow the blood pressure, blood sugar trends, and other routine trends while pre-rounding and adjust the meds. You'll save a huge amount of time on rounds.

    11) Make sure that if a med needs to be given NOW that you write it as such and tell the nurse. Don't rely on flagging for something important.

    12) Always present a plan (hmm I sense a trend). It is likely not what your attending wants, but it shows you are thinking and eventually, it will be what your attending wants.

    13) Actually look at the anion gap and think about it in relationship to the patient's albumin. A person can have "normal" labs and have a very abnormal gap.
  21. Mumpu

    Mumpu Burninator, MD

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    To echo some of the above comments:

    1) Always be polite. Say "thank you" and "I appreciate it" and try your best to make it sound like you mean it. Do this no matter how stupid the question, no matter how tired you are, no matter how critically low the BUN is. This is the one thing that will set you apart from your colleagues in the eyes of the allied healthcare workers (nurses, RTs, techs, etc.) as well as many attendings and fellows. This is the single most important thing you can do to make your intern year and the rest of your residency as painless as possible. Be absolutely, unflappably polite. You can bitch to your co-interns later over some beers.

    2) A corollary to the above: your job is to be an easy person to work with. Be nice, smile, be helpful, and others will want to work with you. A bad rep is very hard to shake.

    3) Teach. The best way to learn and reinforce the material for yourself is to teach it to someone else.
  22. EctopicFetus

    EctopicFetus Keeping it funky enough

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    In regards to nurses (my mom is a nurse).

    1) be polite and have a little fun, the nurses have an incredibly hard job. While we are rounding and bsing with our teams they are really taking care of the patients

    2) Im an ED resident and without our amazing nurses I would have really been an idiot. Dont pretend to know more than you do, nurses know "typical" dosing as much as anyone else. They can be a real big resource.

    3) Certain nurses call for no reason, the best way to cure this is to scut them out. Have them recheck vitals, check last dose given etc. I have gotten calls informing me that patients were getting their prn tylenol at 330 am, or a colleague with a call that his patient is eating pudding in the middle of the night. These nurses need to get scutted out to prevent retarded phone calls.

    4) medicine is a tough job and honestly keeping a sense of humor is easier said than done, but you should think about it and do your best to stay positive.
  23. Smurfette

    Smurfette smurfalicious Administrator SDN Senior Moderator

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    1. If you are unsure what to do or faced with an issue you know will cause "discussion" on rounds or sign-out, LOAD THE BOAT. This means call the senior and ask. This way, you are doing what you're told (and thus you did not make the controversial decision) and the senior is the one who will have to explain the action taken if the attending doesn't like the decision. Next year when I'm your senior, I want to know about things sooner than later. If you have a crumping pt, if you tell me asap I can help fix the problem and get the pt to an ICU, if I don't find out about it until he codes, I'm gonna be PISSED. Notify the senior on service or on-call immediately if the pt has something new and potentially life-threatening (acute MI on EKG, PE, unstable vital signs, stroke, hemorrhage, etc., etc.)

    2. GO SEE THE PATIENT. With time, you will learn what to see or not see and how to triage it. Until then, you need to talk with or examine the pt. Also know that sometimes you get called with incomplete or wrong info by the RN that makes you triage incorrectly (i.e. shoulder pain that turns out to be substernal chest pain, 10/10 pain that turns out to be from phlebotomy sticks, etc.)

    3. NEVER FOLLOW RULE #1 BEFORE DOING RULE #2. Unless you want to be chewed out.

    4. ALWAYS LOOK AT FILMS YOU ORDER. Do not just read the report. Sometimes the images get switched in the computer under someone else's name (I've seen it happen, rarely, but it happens). I've been consulted for portacath placements on pts with portacaths visible on CXR but that the radiologist did not dictate into the report. And sometimes the radiologist doesn't address the thing you were wondering about. Go to radiology to discuss findings you see that aren't addressed or to clarify the "read". This is a great learning opportunity for you.

    4. PHARMACY IS YOUR FRIEND. Learn the number at your hospital and use it. Clarify dosages, find out the PPIs or 3rd generation cephalos on formulary or drug interaction problems. A lot of time, this will be a huge timesaver since flipping thru a book and calculating a dose only to find out that the med is not available at your hospital or that it requires Heme/GI/ID approval before processing.

    5. CALL CONSULTS EARLY

    6. EAT/SLEEP WHEN YOU GET A CHANCE.

    7. Consolidate your questions so you only have to talk to the senior/attending/RN once.

    8. BE NICE TO THE RNs. Even the bad ones. Try to learn their names. If they question you, find out why (are you doing something opposite from routine?). If they keep screwing something up, tell them why it's important they do it as ordered, but in a polite way "I know it's an inconvenience, but Mr. A. needs his davol drain flushed every 2 hrs because if it clogs and stops working, he'll need to have surgery to replace it".

    9. DON'T TRUST ANYONE. Always follow-up with everything. Sure, you wrote that order at 7 am, but the RN with that pt had 2 other bowel preps and another pt code this morning and wasn't able to do the non-urgent orders on your pt. When you stop by to check, do what you can yourself. Take out the foley/tube/whatever, place the PIV and remove the central line, draw labs, etc. This will score you a point with the RN, and prevent you from looking like a fool at 4 pm when you end up rounding with the attending saying you've already taken care of these things. Oh, if you work at a county hospital, doing these things yourself is basically a given.

    10. ADMIT YOUR MISTAKES, even if you don't think you were that wrong. And don't argue, you won't win. Apologize and move on.

    11. Don't know how to do [insert random procedure here]? ASK. It's better than doing it wrong and harming the pt.

    There are many more...
  24. Mumpu

    Mumpu Burninator, MD

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    Do not scut out nurses -- you are the one with the pager, they can hurt you much more than you can hurt them, and it will damage your rep.

    Do not be afraid to say "I don't know but I will find out and get back to you" when nurses ask you management questions, and then actually do get back to them.
  25. njbmd

    njbmd Guest Moderator Emeritus

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    Write down everything and check off tasks as you go. If you order a chest film, labs etc, write down to check them. Be sure to follow-up with your studies and with your consults. Don't wait until the next morning. If you order studies late or if they are done late, sign them out and tell the overnight cover why your ordered the late test and what to do if there is a problem.

    If I am consulted, I try to get back to the person (or who is covering for that person) once I have seen the patient and have recommendations. It is a great idea to personally phone the consultant (early) and if you are the consultant, speak with the person who consulted you.

    I always pre-wrote my next AM notes in terms of introduction (meds & day), left spaces for labs the afternoon before and added vitals, overnight events, exam and plan the next morning. This made my note-writing go a little faster and reminded me of things like remembering to d/c foley, IVs, start diets a bit faster when I was an intern. It also helped me plan for signout too.
  26. EUA

    EUA Chief Resident

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    Everyone's responses have been insightful, but Boston's entry is superior.

    I think the hardest part of residency, for many people, is the shift from student to employee. The politics are new and uncharted territory for many, especially those with no work experience. Accept the fact that your behaviors and thought processes in medical school and college are probably not going to cut it in residency. Be flexible, be open, be accepting of criticism.

    Above all, lose the ego. We may delude ourselves, but it's still a big totem pole to climb, and as interns and residents, we are at the low end. Deal with it. Getting angry is not going to serve you well. You are going to eat large mouthfuls of sh*t over and over again. Be humble. Learn from it and vow not to do that to your students and residents when you are an attending.

    Relax and have fun. While it's a lot of work, it's also a unique period in your career where you are paid to learn and have a constant reliable safety net. Enjoy it.
  27. ReefTiger

    ReefTiger Junior Member

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    As I near the end of residency this thread has reminded me of how far I've come.

    My advice is similar to what has been said. Here are a couple of other things that help too.

    1) Try to keep your mouth shut more often than not. As long as you're working hard and present patients appropriately people will assume you know more than you do. Never interrupt fellow residents who are talking. If someone does it to you make sure you let them know you don't appreciate it. (Do this in private with the person. If they repeat the behavior then call them out on it in front of the team/attending.)
    1B) Never, never, never ask questions on rounds post call, or if a member of your team is post call. Some attendings will talk ad nauseum keeping everyone in the hospital.

    2) Write orders in the chart as you round. Other tasks need to be made into a checklist. Otherwise, there will be tasks forgotten. As rounds are ending prioritize and attack.

    3) If possible call consults/social workers during rounds while someone else presents their patients.

    4) Divide up tasks between the team so you work more efficiently-even if it means you are taking care of another members patients and they yours.

    5) Don't take (*&^ from nurses, but also don't be their friends. Be a co-worker and treat them with respect. If they call you with BS then make sure they have to do BS. Remember nurses will call "friendly" docs first. Also, they will ask any doc that is standing near the station. So, make sure you get away from them to do your work. Otherwise you'll be doing more crap than you have time for.

    Hope it helps!!!
  28. Mumpu

    Mumpu Burninator, MD

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    (this will be take three of the same, but judging by the number of posts, the "vindictive housestaff" syndrome is widely prevalent)

    Whatever you do, do not scut out nurses, make them "do BS", order punitive enemas, etc. You will get on their bad side and it is absolutely the single worst thing you can do as an intern. Bad reputations stick pretty much forever.
  29. Smurfette

    Smurfette smurfalicious Administrator SDN Senior Moderator

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    For the most part, RNs who know me will leave me alone if they know I am sleeping or busy and they don't have anything ultra-important for me to deal with. Or they will "group page" me and pass the phone around so they only bug me once. Or they will give a patient tylenol or a bolus and the next time they see me, will ask me to put in the order (obviously knowing that I would be ok with these things for those particular patients). This is because I am respectful to the RNs and try to be as polite as I can be. However, colleagues of mine who are not nice to RNs get paged often and about stupid stuff. And I KNOW who the RNs hate because they tell me stories of what my colleagues have done to earn their wrath.

    And as an intern, NEVER tell an RN to do something because you "are the doctor" and they "are the nurse" and their job is to "follow doctor's orders". If you've been a doctor for a month and the RN has been working there for 20 yrs, they are questioning you for a reason. Either tell them what you are thinking and why you want them to do xxx, or ask them why they disagree and what the usual remedy is.
  30. Mumpu

    Mumpu Burninator, MD

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    Exactly! I could consistently go to bed by 4 am on my MICU month and not get paged until 5:30-6 unless something urgent came up despite the fact that AM labs come back at 4:30. The effort you put into being 100% nice 100% of the time as an intern pays off in droves.
  31. gutonc

    gutonc No Meat, No Treat Administrator SDN Senior Moderator

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    This can pay off like you wouldn't believe. I went to bed @ 2am on call the other night and only got paged once (5:15) the rest of the night (by a floating RN who didn't know me). When I walked the floor @ 6 doing my pre-rounds, I got flagged down by pretty much every nurse who gave me the FYIs from the past 4 hours, all of which I had to know about by hospital policy/protocol but none of which I needed to be awakened for.

    Be nice (and yes, even friendly) to the nurses and they will make your life much easier. And believe it or not, many of them are actually interested in why you are doing the things you're doing so a little (non-condescending) teaching can be nice as well.
  32. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    Try to get to know the charge nurses and house supervisors. They can be a real help when you need to cut through some red tape, transfer a patient to the ICU, etc.
  33. chimichanga

    chimichanga misunderstood

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    just passing down to the clinician's forum, and I noticed this thread, and figured some nurse advice would be in here...

    As a house supervisor now, and a nursing instructor, I appreciate the nice words spoken about nursing...I struggle every day w/ incompetent nurses and students. I'm working on the problem.

    I like the comment about teaching...Most nurses ask because they genuinely don't know, and love to understand what you are thinking, and relish at being taught a new thing.
    And the seasoned nurses will ask questions, sometimes just to be a pain in the a$$...Can't help you there...

    I love students, residents, interns, and attendings, as long as there is mutual respect among us.

    The good ones among us know what to ask, when to call, and when to question...Hopefully we are in the majority, but (and it goes both ways) the bad ones stick out and cloud your memories of the good ones...

    Can't we all just get along??

    Thanks again
  34. tibor75

    tibor75 Member

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    1. Don't argue w/ nurses, unless it's patient care that's involved. They are not worth it. It's like arguing with a 7 year old. You have better things to do, and talking to a nurse just drains about 10 brain cells per minute.

    2. Placement is everything. The moment a patient is admitted, you need to think, "What do I need to do to get this patient discharged?"

    3. When calling in a stupid consult just say, "My attending wants this." They can't argue.
  35. chimichanga

    chimichanga misunderstood

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    You lose 100 brain cells for your "new" concept

    Time OUT

    Everyone is worth your time to debate any issue...Get over yourself

    We're not worthy

    Nurses have been valued since waaaaay before you were born...

    We value your opinion...Take a look at ours...

    It's (shhhhhockingly) about the patient, not you and your ego...

    good luck in your endeavors...

    We'll be there to explain away your shortcomings


    Educationally speaking, I'm not worthy...I get that...
  36. SeminoleFan3

    SeminoleFan3 Senior Member

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    Wow, insecure much? Jeez. And, no, I don't think EVERYONE is worth my time to debate things.
  37. chimichanga

    chimichanga misunderstood

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    wow, I'm suprised he gets off his throne to even speak w/ a nurse. jeez, funny how you focus on my alleged insecurity and gloss over your peer's arrogance.

    I was nothing but complementary to all, and thankful for the nice words by all other posters, and he takes a cheap shot...

    nice
  38. tibor75

    tibor75 Member

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    Please, the key is not to act condescending. Nurses love me. I never have any problems with them. I'm always amazed by how many clueless residents yell at nurses. It's easy. You smile and ignore half of what they say. ANd later, when amongst other residents, you laugh at how clueless they are. Pretty much the same that you do with patients when they act dumb.

    Now, this doesn't apply to the ICU nurses where most of the bad ones are already weeded out, and they can pretty much run the show. But the floor nurses, for every good one, there are 5 or 6 morons.
  39. chimichanga

    chimichanga misunderstood

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    point well taken, however, "morons" is sometimes a misnomer. They just haven't been taught the right way to effectively communicate to get the physician to give them what they want (i.e what the pt needs)...

    I'm not sure that ridiculing them serves anyone...I've seen docs gently educate them how better to communicate (arguably not the docs job, but it can make your life easier)...I am constantly "educating" floor nurses how better communicate w/ docs...

    open communication from both parties is key...

    And by the same token, for every good (nice, competent, whatever positive adjective you like) doc, there are bad ones as well...

    For both sides, the bad one sicks out the most, and can lead to sweeping generalizations...
  40. nutmegs

    nutmegs ASA Member

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    hey chimi? could you maybe... not do this in this thread? I agree with you, but you're really mucking up a great thread with some BS that has its place elsewhere. thx.
  41. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    You're kidding right?

    Chimi was simply responding to some very insulting comments about her colleagues and has every right to do so, especially in the fashion in which she has done so (many of her colleagues would not have done so). IMHO, she wasn't trying to derail the thread, only responding to the rude and inappropriate comments herewith - where else would you suggest she respond?
  42. Long Dong

    Long Dong My middle name is Duc.

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    Anyone have some examples, esp PRN stuff? My brain has been wasting away s/p match, please help soon to be clueless intern out.
  43. nutmegs

    nutmegs ASA Member

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    Nope! Was just reading the thread beginning to end and it was FANTASTIC up until one child came into another child's playbox and they both started throwing sand. I suggest they start a thread about egocentric residents vs overworked nurses and go from there. Thanks for your SUPER moderation, as always!!!
  44. tibor75

    tibor75 Member

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    rude and inappropriate? :laugh:

    I call a spade a spade

    Many nurses are clueless and dumb. Sorry for pointing that out.

    A dumb doctor probably still has more medical knowledge than the average nurse. As an incoming intern, I was sometimes intimidated by the suggestions of nurses who seemed to know what they were talking about and would go along with whatever they said. Later I realized, that for every time they are right, they are wrong the other half. Go with your guts and do what you think is right.

    Now, in the ICU things are different and I think many ICU nurses could actually run the unit without any housestaff. But on the floors, I wouldn't trust 75% of them.
  45. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    JCAHO is getting crappier and crappier about orders so check with your seniors about what's allowed at your house but here are some good starters:

    Insulin slide:
    FSBS q 6 hours or qac and qhs
    if glucose < 70 give 1/2 amp D50 po or iv and recheck FSBS in 30 min
    if glu 70 - 150 do nothing
    if glu 151 - 200 give 2 units reg insulin SQ
    " 201 - 250 " 4 "
    " 251 - 300 " 6 "
    " 301 - 350 " 8 "
    " 351 - 400 " 10 "
    " >400 " 12 " and call MD

    Potassium slide:
    If K < 3.0 call MD
    If K 3.0 - 3.2 give K riders x 40 meq iv over 4 hours or KDur 40 meg po
    If K 3.2 - 3.3 " x 30 meq
    If K 3.3 - 3.5 " x 20 meq
    If K > 6.0 call MD

    Tylenol:
    Tylenol 650 mg po/pr q 4 hours PRN pain/fever
    *only do the fever part if you expect the patient to have a fever and you don't need to work it up
    *remember to provide alternate routes. If the pt can't take it po it's gotta go pr. This goes for other stuff too. You don't want a call a 0200 to ask if the IV ativen could be given PO.

    Fever:
    If Temp > 100.6 obtain blood cx x 2, urine cx, sputum cx, CXR.

    Pain:
    Morphine 1-5 mg IV q 4 hours PRN pain
    Dilaudid 1-2 mg IV q 4 hours PRN pain

    Antiemetics:
    Phenergan 12.5 - 25 mg IV q 6 hours PRN nausea
    *write it as nausea because they technically can only give it after the patient pukes if you write "vomiting."

    Resp:
    Albuterol 2.5 mg Neb q 4 hours PRN wheezing
    Atrovent 0.5 mg neb q 8 hours PRN wheezing
    *write wheezing instead of SOB or they may keep giving Nebs to your worsening CHF patient.

    Sleep:
    Restoril 15 mg po qhs PRN sleeplessness
    *every oldster expects a sleeper. Your covering colleagues or night float will love you if you write for the sleepers.

    Anxiety:
    Ativan 1 mg IV/IM/PO q 6 hours PRN agitation
    Haldol 2.5 mg IV/IM/PO q 6 hours PRN agitation
    *be stingy on this one. The idea is to deal with the demented sundowner patients without over sedating a patient with unrecognized delerium.

    Vent:
    ABG PRN vent changes
    You don't want a call at 0200 asking if it's OK to get the gas just so you can get called 30 min later with the results.

    Disclaimer: I'm sure there are those who want to debate dosages and so on and maybe even the use of slides and PRN altogether. Instead of doing that I'll just say that you have to use judgement and know your patients. You have to base these things on your particular patient and your labs norms.
  46. fab4fan

    fab4fan TiredRetiredRN Gold Donor

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    tibor75 wrote:

    Which is a shame, because you can really assume incorrectly.

    For example, I work in a Day Surgery unit. You might think of it as "Slacker Central" since "no one ever gets sick in Day Surgery...it's all minor stuff." I've got three words for that: Ha, ha, ha.

    As far as staff, you've got three former ED nurses (myself included), three former critical care nurses, and two nurses with extensive med/surg experience. You need to get to know your support staff instead of just making sweeping generalizations. You might find that those "idiots" you refer to know more than you think they do, and would be happy to help you if you treated them with some common courtesy.

    One other thing to remember: Just as there are new interns and residents starting this time of year, there are new nurses starting. We "veterans" appreciate how hard it is for you guys to be the new kids on the block, so please try to be nice in turn to the new grad nurses. They're just as nervous.

    Sorry, had to say it. I apologize if someone feels this was a hijack.
  47. zver81

    zver81

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    docB,
    Thank you very much! This is going to be very helpful!
  48. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    I'm not the Moderator of this Forum, so its not my responsiblity to keep things on track here, but sometimes I just barge in anyway! ;)

    What I found interesting/confusing was your comment NOT to the "child who started throwing sand" but rather to the one who responded to being attacked.
  49. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    Considering you've been infractioned before for insulting other members, you might rethink your posts before sending them.

    Yes, your comments were rude and inappropriate.

    Yes, some nurses don't know what they're talking about and try to convince physicians that they do. And you are right to follow your training and instincts in patient care. We've all had experiences in which a member of the nursing staff doesn't understand the reason something is being done.

    However, there is a difference between being "dumb" and being ignorant. If they have less medical knowledge than we do, its because of the nature of their training, not because they are dumb. Are you dumb because you don't know how to program a PCA pump or the proper mixture for a Dobutamine drip? No, you're just ignorant because your training didn't teach you this.

    Besides, regardless of your experience or feelings on the subject, it had no place in the current discussion and I encourage everyone to get back to the original topic at hand.
  50. Long Dong

    Long Dong My middle name is Duc.

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    Yes again, thank you docB so much for taking the time to post that long post.

    Anyone else with some more tips. Cause right about now I'm :scared:

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