Being pimped at 3:00am

[han14tra]

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This happened last night in the ED. I was asked to explain sensitivity and specificity (which I know because I just took step 2, but I got it backwards because I was so tired I couldn't think straight). It was my 3rd midnight to 8am shift in a row, and I haven't been able to sleep much during the day. Hopefully, the attending has mercy on me when he grades me. Anyone have similar stories to share?

 

[da8s0859q]

Anyone have similar stories to share?

Too many to think of one to tell you. Pretty sure we've all had those moments where we screw something up that we would have never screwed up on any other day.

 

[Wilf]

This happened last night in the ED. I was asked to explain sensitivity and specificity (which I know because I just took step 2, but I got it backwards because I was so tired I couldn't think straight). It was my 3rd midnight to 8am shift in a row, and I haven't been able to sleep much during the day. Hopefully, the attending has mercy on me when he grades me. Anyone have similar stories to share?

You're getting pimped on sensitivity and specificity as a 4th year?

 

[KnuxNole]

I got pimped at 4:00ish AM in OB/GYN about C-sections. The first few things I answer alright and then she talks about post-op sterilization. Then the attending goes "So, do you wanna talk about the pill, patch, or ring first?" with the intent that I explain to her in detail everything about those three. So I troll her and say that the pill involves making the woman increase her chance of pregnancy, gives the baby kidney problems and the mom has a higher chance of blindness. She goes "No, not quite." and ends the pimping barrage 🙂

 

[ArcGurren]

I got pimped in the middle of an emergent surgery about the different grades of hemorrhagic shock while trying to tamponade a bleeding artery with both hands and most of my weight. Needless to say, I was gonna have a bad time

 

[sylvanthus]

I got pimped on propofol and succ dosing in a pediatric patient I was about to intubate at 2 am. Yaa, that attending was a douche. We dont freakin learn dosages as students and he knew it. Just wanted to make me look like an idiot in front of the 10+ people in the room.

 

[SLUser11]

I got pimped on propofol and succ dosing in a pediatric patient I was about to intubate at 2 am. Yaa, that attending was a douche. We dont freakin learn dosages as students and he knew it. Just wanted to make me look like an idiot in front of the 10+ people in the room.

...but he let you intubate a child. Can you really be super-mad at him? That's a lot more than most MS3s get to do.

 

[45408]

I got pimped on propofol and succ dosing in a pediatric patient I was about to intubate at 2 am. Yaa, that attending was a douche. We dont freakin learn dosages as students and he knew it. Just wanted to make me look like an idiot in front of the 10+ people in the room.

So as your patient was receiving powerful sedatives and paralytics, you thought your attending was a douche for asking if you knew the doses? Yaaa.

 

[mmmcdowe]

...but he let you intubate a child. Can you really be super-mad at him? That's a lot more than most MS3s get to do.

Get a question wrong and still get to do the procedure? Sounds nice to me...

 

[Dwindlin]

Get a question wrong and still get to do the procedure? Sounds nice to me...

No kidding. We have to know the answers to questions like those before we're allowed to do the procedure. Which frankly I think we should have to know. . .

Not that hard to look up the details of a procedure.

 

[45408]

No kidding. We have to know the answers to questions like those before we're allowed to do the procedure. Which frankly I think we should have to know. . .

Not that hard to look up the details of a procedure.

To be fair, there probably wasn't much time to "prepare for the procedure" when doing a 2am intubation or trauma ex lap.

 

[Dwindlin]

To be fair, there probably wasn't much time to "prepare for the procedure" when doing a 2am intubation or trauma ex lap.

Agree. However if your going to be doing a rotation where you may be in this situation (EM, ICU, Trauma/ACS) it would behoove you to look at things ahead of time (at least have done some reading on airway management/vascular access/basic resuscitation). And fact remains, even in an urgent/emergent situation if I couldn't tell my resident what drugs/dosages/etc. were necessary I wouldn't be doing the procedure.

 

[High Roller]

I got pimped on propofol and succ dosing in a pediatric patient I was about to intubate at 2 am. Yaa, that attending was a douche. We dont freakin learn dosages as students and he knew it. Just wanted to make me look like an idiot in front of the 10+ people in the room.

Your attending was letting you intubate pediatric pts in the ED as a med student????

Doesn't sound too douchey to me....

 

[Localnative]

This happened last night in the ED. I was asked to explain sensitivity and specificity (which I know because I just took step 2, but I got it backwards because I was so tired I couldn't think straight). It was my 3rd midnight to 8am shift in a row, and I haven't been able to sleep much during the day. Hopefully, the attending has mercy on me when he grades me. Anyone have similar stories to share?

waaaaaaaaahhhhhhhhhhhh!!!!!!!!

 

[ucsfstudents]

Happens all of the time. Just know that for some teachers, that is the way they teach because they also learn from being asked questions and recalling the answers. Some people teach by asking questions, while others teach by stating the answer up front. Just keep a positive and interested attitude.

 

[fightingsaint]

We dont freakin learn dosages as students and he knew it.

What does that even mean? No student is capable of learning drug dosages, or it's simply something that you don't think you need to start learning until intern year? Your main responsibilities as a medical student are to show up and read. There's nothing at all wrong with attendings and residents asking you questions to make sure you've been reading. That's the way it works. And if you're performing a procedure, you should know all relevant information...in this case, drug dosages, laryngeal anatomy, ET tube sizing, and vent settings are all subjects you should be very familiar with before being allowed to attempt an intubation.

 

[greatnt249]

This happened last night in the ED. I was asked to explain sensitivity and specificity (which I know because I just took step 2, but I got it backwards because I was so tired I couldn't think straight). It was my 3rd midnight to 8am shift in a row, and I haven't been able to sleep much during the day. Hopefully, the attending has mercy on me when he grades me. Anyone have similar stories to share?

You honestly think that not knowing an answer to a single question is going to torch your grade? Rotations are about learning; you can't possibly know or have the correct answer to everything thrown your way. All you can really do is read about the patients you're seeing and hope for the best.

Some of my best rotation grades came not from being "the genius" on the wards, but from demonstrating to the attendings/residents that I could handle constructive feedback and improve myself from where I was at the beginning of the rotation.

 

[Top Gun]

I got pimped on propofol and succ dosing in a pediatric patient I was about to intubate at 2 am. Yaa, that attending was a douche. We dont freakin learn dosages as students and he knew it. Just wanted to make me look like an idiot in front of the 10+ people in the room.

Its called making sure you're prepared before doing a procedure. If you're going to intubate a kid, you'd damn well better know all of the steps involved before doing it.

 

[sylvanthus]

werfwefsdf

 

[sylvanthus]

scsdfsdfsfsdfsd

 

[genswim24]

Come on people, I don't believe for one minute that everyone of you have known each and every step before all of the procedures you have done (including doses of all of the anesthetics involved) as a student. From aways and rotating at different hospitals, I have seen residents from 6 different programs who have not known every single step/dose of a procedure they get dragged into (they quickly look them up ). These include all tiers of residency programs too. Hell, I have seem some very good attendings have to quickly double check on doses when they are put on the spot. Often times, students and residents get grabbed out of nowhere and asked "hey, do you want to learn how to do ..." and the student/resident just does it. You get walked through it, more so as a student, and do it.

It's so easy to criticize people from your computer and say "you are so unpreppared, etc". I would like these people to sit back and really think about all of their time as a student and I guarantee they were forced into situations that would have been dam near impossible to be 100% prepared for. Now if a person asked to perform a procedure does not know the steps/doses, those in charge have every right to tell them to step back, read about the procedure, and be ready to do it next time. Just because you are an expert on your field now, does not mean you always were.

 

[Dwindlin]

Come on people, I don't believe for one minute that everyone of you have known each and every step before all of the procedures you have done (including doses of all of the anesthetics involved) as a student. From aways and rotating at different hospitals, I have seen residents from 6 different programs who have not known every single step/dose of a procedure they get dragged into (they quickly look them up ). These include all tiers of residency programs too. Hell, I have seem some very good attendings have to quickly double check on doses when they are put on the spot. Often times, students and residents get grabbed out of nowhere and asked "hey, do you want to learn how to do ..." and the student/resident just does it. You get walked through it, more so as a student, and do it.

It's so easy to criticize people from your computer and say "you are so unpreppared, etc". I would like these people to sit back and really think about all of their time as a student and I guarantee they were forced into situations that would have been dam near impossible to be 100% prepared for. Now if a person asked to perform a procedure does not know the steps/doses, those in charge have every right to tell them to step back, read about the procedure, and be ready to do it next time. Just because you are an expert on your field now, does not mean you always were.

I haven't seen anyone claim to have known everything, but I can tell you on occasions I wasn't able to answer all the residents/attendings questions (no matter what time it was) I wasn't allowed to do the procedure, I got to "watch this one, and read up for the next one." So, I learned quickly that if there is a procedure that I may have an opportunity to do I damn well read up on it before the rotation started (though obviously things were forgotten even after reading up). I am surprised people find this an unreasonable expectation.

To come on here and call the attending a "douche" for asking a question they couldn't answer, but still getting to do the procedure is asking for the reaction they got.

 

[genswim24]

I haven't seen anyone claim to have known everything, but I can tell you on occasions I wasn't able to answer all the residents/attendings questions (no matter what time it was) I wasn't allowed to do the procedure, I got to "watch this one, and read up for the next one." So, I learned quickly that if there is a procedure that I may have an opportunity to do I damn well read up on it before the rotation started (though obviously things were forgotten even after reading up). I am surprised people find this an unreasonable expectation.

To come on here and call the attending a "douche" for asking a question they couldn't answer, but still getting to do the procedure is asking for the reaction they got.

Like I said in my post, I think it's a completely fair for your upper level to not let you do a procedure if you don't know every step of a procedure. I do think the douche response was a little much, but people were overly critical of the guy as well. No matter how much one prepares as a med student, our lack of experience will allow any upper level to ask enough questions for us to screw up. I bet every one of us could think of a time we were in a procedure (whether we were doing it or watching it) thinking I hope they don't ask question x, because I just can't seem to remember it right now.

The first time I intubated a patient was doing a surgical rotation. I had no idea that intubating a patient was even a possibility. The anesthesiologist asked if I had done one, I said no, and he pulled me over. He walked me through each step and it was a great learning experience. I really don't think there is anything wrong with learning in this manner, but it appears others might. I could be mistaken in this feeling, but it's tough to read through the lines sometimes on internet forums.

 

[SLUser11]

Come on people, I don't believe for one minute that everyone of you have known each and every step before all of the procedures you have done (including doses of all of the anesthetics involved) as a student. From aways and rotating at different hospitals, I have seen residents from 6 different programs who have not known every single step/dose of a procedure they get dragged into (they quickly look them up ). These include all tiers of residency programs too. Hell, I have seem some very good attendings have to quickly double check on doses when they are put on the spot. Often times, students and residents get grabbed out of nowhere and asked "hey, do you want to learn how to do ..." and the student/resident just does it. You get walked through it, more so as a student, and do it.

It's so easy to criticize people from your computer and say "you are so unpreppared, etc". I would like these people to sit back and really think about all of their time as a student and I guarantee they were forced into situations that would have been dam near impossible to be 100% prepared for. Now if a person asked to perform a procedure does not know the steps/doses, those in charge have every right to tell them to step back, read about the procedure, and be ready to do it next time. Just because you are an expert on your field now, does not mean you always were.

Agree 100%. There's a lot of armchair quarterbacks in here....but it doesn't take away from the main point that the student should be grateful instead of pissed for his "3am pimping."

 

[Caesar]

Was he asking about a D-dimer?

If so, what you should take from the conversation is it is a terrible test that is almost never reasonable to order in an ED.

Also, to me that's not pimping.... They test it on step 1 and 2. You should know Spin and snout. To me unreasonable information is pimping, asking a basic question is making sure you know something important.

/soapbox

 

[greatnt249]

Was he asking about a D-dimer?

If so, what you should take from the conversation is it is a terrible test that is almost never reasonable to order in an ED.

Also, to me that's not pimping.... They test it on step 1 and 2. You should know Spin and snout. To me unreasonable information is pimping, asking a basic question is making sure you know something important.

/soapbox

I see a D-dimer as being as useful as a V/Q scan...if it's negative, you can be pretty sure nothing serious is going on.

 

[MeRLin443]

I see a D-dimer as being as useful as a V/Q scan...if it's negative, you can be pretty sure nothing serious is going on.

Then you should probably read more about the utility of D-dimer in a patient with high pretest probability.

 

[greatnt249]

Then you should probably read more about the utility of D-dimer in a patient with high pretest probability.

If the patient already has a high pre-test probability, I probably wouldn't even bother with the D-dimer, as it wouldn't give me any information essential to making the diagnosis or setting up a treatment plan.

I suppose I should have clarified myself earlier, but the person I replied to hadn't mentioned pre-test probabilities when talking about ordering D-dimers.

Then again, by the time we get called to do an admission on such a patient at our hospital, a D-dimer and CT-PE have usually already been ordered by the ED staff, and the results are usually back before we even get to see the patient, regardless of pre-test probability.

 

[Caesar]

If the patient already has a high pre-test probability, I probably wouldn't even bother with the D-dimer, as it wouldn't give me any information essential to making the diagnosis or setting up a treatment plan.

I suppose I should have clarified myself earlier, but the person I replied to hadn't mentioned pre-test probabilities when talking about ordering D-dimers.

Then again, by the time we get called to do an admission on such a patient at our hospital, a D-dimer and CT-PE have usually already been ordered by the ED staff, and the results are usually back before we even get to see the patient, regardless of pre-test probability.

In the ED you usually only order things with high pre-test probability.

I brought up D-dimer because its sensitive and not specific, and they ask about it all the time in the ED. And if you know it, you know Sensitivity and Specificity.

 

[drizzt3117]

In the ED you usually only order things with high pre-test probability.

Lmao.

Like pan-ct on every patient?

 

[Laryngophed]

Lmao.

Like pan-ct on every patient?

Oh dear...

 

[greatnt249]

Oh dear...

You laugh, but it happens.

In the ED you usually only order things with high pre-test probability.

Many times, this is not the case at my hospital's ED; most of them seem to be sieves.

 

[SLUser11]

You laugh, but it happens.



Many times, this is not the case at my hospital's ED; most of them seem to be sieves.

Are they?

Are you sure you're not just regurgitating the "facts" and insults that your surgery and medicine residents told you?

Have you ever done a rotation in the ER?

 

[45408]

Lmao.

Like pan-ct on every patient?

Other than a trauma patient, I've never seen more than a chest + abd/pelvis on a single patient in the ED, and even that's pretty uncommon.

In the ED you usually only order things with high pre-test probability.

I brought up D-dimer because its sensitive and not specific, and they ask about it all the time in the ED. And if you know it, you know Sensitivity and Specificity.

Um, no. You also order tests to rule things out that you really wouldn't want to miss. They order EKGs and troponins on everyone with chest pain, but the pre-test probability is pretty low.

 

[drizzt3117]

Other than a trauma patient, I've never seen more than a chest + abd/pelvis on a single patient in the ED, and even that's pretty uncommon.

I saw chest abd pelvis head yesterday on a pt with chest pain; it didn't end up coming to me so I didn't really investigate it further.

 

[greatnt249]

Are they?

Are you sure you're not just regurgitating the "facts" and insults that your surgery and medicine residents told you?

Have you ever done a rotation in the ER?

Did I strike a wrong chord with you? We were recently forced to admit a transfer pt with DM-I with hyperglycemia who, get this, wasn't even in DKA. No anion gap whatsoever. Maybe mildly elevated lactate. Transfer was for "diabetes education." You CANNOT sit there and tell me that isn't a weak admission, especially when we had to deal with this guy (who happened to be a chronic narcotics user) for at least 2 days.

I'm not saying that ED docs are stupid or unnecessary. I'm telling you how it is at MY HOSPITAL alone. At MY hospital, D-dimers get ordered regardless of pre-test probability and more people get CTs than is probably necessary. If you're not guilty of this behavior, then more power to you; you don't fall into the category of medical practice that I'm talking about. Why you're getting so worked up about my commentary on a place you most likely do not work at is beyond me.

 

[SLUser11]

Did I strike a wrong chord with you? We were recently forced to admit a transfer pt with DM-I with hyperglycemia who, get this, wasn't even in DKA. No anion gap whatsoever. Maybe mildly elevated lactate. Transfer was for "diabetes education." You CANNOT sit there and tell me that isn't a weak admission, especially when we had to deal with this guy (who happened to be a chronic narcotics user) for at least 2 days.

I'm not saying that ED docs are stupid or unnecessary. I'm telling you how it is at MY HOSPITAL alone. At MY hospital, D-dimers get ordered regardless of pre-test probability and more people get CTs than is probably necessary. If you're not guilty of this behavior, then more power to you; you don't fall into the category of medical practice that I'm talking about. Why you're getting so worked up about my commentary on a place you most likely do not work at is beyond me.

Oh, I'm not too worked up about it. It seems like written-out questions on the internet can be interpreted as more aggressive than I intend.

I'm genuinely curious, and they were real questions, not attacks. The truth is that medical students are exposed to a lot of s#@t-talk about the ER without any real experience on the matter, and they often take some of these things at face value. Since I was a surgery resident for 5 years, I saw plenty of bad behavior from my co-residents, and I feel like we sort of lead by example, and we create bad behavior in our medical students. I'm certainly guilty of talking crap about the ER, so hopefully I don't seem like I'm preaching from a pedestal.

I believe that emergency physicians often get misunderstood, and since they are in the business of creating more work for residents in other specialties, they are often resented. When I spent a month in the ER as a MS4, I got some much-needed perspective from the other side of the argument:

1. I saw how many things they don't call us about.
2. I saw how the inability to rule something out puts them in a precarious spot.....send the patient home, and shoulder a large amount of liability, or arrange for a "weak admit."

It's easy for a medicine resident to say, "this patient is not having an MI!!" But the ER doc's response is usually, "Oh, I agree. I don't think they are having an MI, either...but I can't prove it."

 

[colbgw02]

Other than a trauma patient, I've never seen more than a chest + abd/pelvis on a single patient in the ED, and even that's pretty uncommon.

I'm not sure how we're defining "pan-scan", but I agree that non-trauma patients don't tend to get pan-scanned out out of the ER in the same way that, oh, a FUO patient in the ICU will. At worst, I see too many r/o PE chest CTs combined with r/o appendicitis CTs.

Um, no. You also order tests to rule things out that you really wouldn't want to miss. They order EKGs and troponins on everyone with chest pain, but the pre-test probability is pretty low.

And just to reinforce the above quote and reference back to the original statement that started this series of posts - the idea that the ED is ordering tests with a high pre-test probability is laughable. EDs aren't designed to do that, and that's not meant as a knock on EDs or EM physicians. That's just the way they're set-up: exclude life-threatening conditions and move the meat.

 

[greatnt249]

Oh, I'm not too worked up about it. It seems like written-out questions on the internet can be interpreted as more aggressive than I intend.

I'm genuinely curious, and they were real questions, not attacks. The truth is that medical students are exposed to a lot of s#@t-talk about the ER without any real experience on the matter, and they often take some of these things at face value. Since I was a surgery resident for 5 years, I saw plenty of bad behavior from my co-residents, and I feel like we sort of lead by example, and we create bad behavior in our medical students. I'm certainly guilty of talking crap about the ER, so hopefully I don't seem like I'm preaching from a pedestal.

I believe that emergency physicians often get misunderstood, and since they are in the business of creating more work for residents in other specialties, they are often resented. When I spent a month in the ER as a MS4, I got some much-needed perspective from the other side of the argument:

1. I saw how many things they don't call us about.
2. I saw how the inability to rule something out puts them in a precarious spot.....send the patient home, and shoulder a large amount of liability, or arrange for a "weak admit."

It's easy for a medicine resident to say, "this patient is not having an MI!!" But the ER doc's response is usually, "Oh, I agree. I don't think they are having an MI, either...but I can't prove it."

Fair enough; I know I wouldn't want to face the burden of having to decide daily who is truly sick enough to be admitted.

 

[TallScrubs]

Was he asking about a D-dimer?

If so, what you should take from the conversation is it is a terrible test that is almost never reasonable to order in an ED.

/soapbox

Not according to the attendings in the EM forum.

 

[High Roller]

Was he asking about a D-dimer?

If so, what you should take from the conversation is it is a terrible test that is almost never reasonable to order in an ED.

Also, to me that's not pimping.... They test it on step 1 and 2. You should know Spin and snout. To me unreasonable information is pimping, asking a basic question is making sure you know something important.

/soapbox

Whats wrong with a D-Dimer?

Maybe I'm learning voodoo medicine at my program, but its very reasonable to order that test under the right circumstances (low pretest probability, non-PERCable pt, hx of negative D-dimers, low clinical suspicion, etc.).

 

[High Roller]

In the ED you usually only order things with high pre-test probability.

I brought up D-dimer because its sensitive and not specific, and they ask about it all the time in the ED. And if you know it, you know Sensitivity and Specificity.

Not true at all, and you'll get burned if you practice like that.

 

[sylvanthus]

I haven't seen anyone claim to have known everything, but I can tell you on occasions I wasn't able to answer all the residents/attendings questions (no matter what time it was) I wasn't allowed to do the procedure, I got to "watch this one, and read up for the next one." So, I learned quickly that if there is a procedure that I may have an opportunity to do I damn well read up on it before the rotation started (though obviously things were forgotten even after reading up). I am surprised people find this an unreasonable expectation.

To come on here and call the attending a "douche" for asking a question they couldn't answer, but still getting to do the procedure is asking for the reaction they got.

Ehhh it was more the manner in which the pimping was done but not going to get into it as who really cares? The point of the thread imo was to vent and not judge others venting but whatevs.

 

[Caesar]

Whats wrong with a D-Dimer?

Maybe I'm learning voodoo medicine at my program, but its very reasonable to order that test under the right circumstances (low pretest probability, non-PERCable pt, hx of negative D-dimers, low clinical suspicion, etc.).

The number of Pts that fit PERC with the complaints that elicit PE as a DDX are few and far between which was more of my point.

There is often no reason to order the D-dimer unless you want to be convinced of a negative.

 

[Caesar]

actually at the risk of breaking the internet I am going to admit I was wrong when I said the high pre-test probability thing.

I'm not really sure what I meant by it. I think the point I was making was more of a student/testing aspect and not a clinical practice aspect, but I can't be sure anymore.

Whoever said the bit about ruling out big bad stuff, I agree with, but I also don't think EDs are ordering confirmatory tests often anyway. At least at my hospital(s) there is a low threshold for admit and the medicine service works a lot of things up.

In summary, I was wrong. Hope the internet survives.

Oh and I still hate D-dimers for anything except in the one circumstance above.