Have any tips for presenting train-wreck pt's that are new to you?

[IJL]

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I'm still a very new intern, but I've noticed a common trend that has been happening to me over the past few weeks.

Show up in the morning with plenty of time to pre-round on my patients, oh but wait, overnight admitting intern got slammed here are 1, 2, maybe 3 more new patients you need to present on rounds - but don't worry, only 2 of them are train wrecks and the other is an MICU transfer that has been in the hospital for 26 days.

I always feel extremely unprepared when it comes time to go through the H&P

I wanted to complain at first, but I've come to the realization that this is just the norm and I'll just have to get better at it.

So, does it just get easier with practice?

 

[Leo Spaceman]

Start with...Mr X is a new patient who was admitted last night/ I just picked up from intern X who was been here for 26 days. From his chart/sign-out, briefly this is a 89 y o male who was admitted for blah, blah, blah. Present what you know, and at the end it's probably safe to say that you will look into the patient's chart in more detail later that day. If the overnight intern/resident /RN is present, you can always ask at the end..." Did I miss anything else pertinent/important?" (of course the RN will ALWAYS have something to add 😉, and always ask the RN before rounds about any issues (s)he's concerned about.
Also, even if you don't know all the nitty-gritty, make sure you've done as good of a physical exam as you possibly can and looked through abnormal labs/radiology.

GL!

P.S.: If you're really pressed for time, sometime, the latest consultant's not might be helpful in giving you an overview of the hospital course.

 

[disorder]

the overnight train wreck patients will get easier with time mainly because you'll just understand medicine better.

the ICU transfers will always be challenging given their extended hospital course and you won't be able to read every single progress note. i would ask the ICU resident/intern to give you a quick 1-2 two minute sign out about the hospital course highlights and the CURRENT active issues. that way, when you present, you can say "admitted for X, hospital course complicated by Y, Z, A, and active issues are currently B, C, A" and support this presentation with whatever has been going on. For example, Y was dx by *** and Z was treated by ***.

presenting complicated patients is hard and challenging. i have issues with this and still do, but rest assured that presenting patients is something that takes practice and that you perfect over time.

 

[Lazarius]

My program (and many others) have done a few things to fix that. patients admitted by the night float team have to be presented to the attending and the team by the night float person at 8 am to reduce handovers. As for MICU transfers, the are not allowed after 5 pm. If the MICU happens to get full and they need to kick relatively stable people out to the floor in the middle of the night, the patient remains under the care of the MICU team till the morning when he/she gets called out to the accepting team directly. Also to reduce unnecessary handovers.
I think this not only saves interns the hassle of doing what you mentioned in your post, it is also safer for patients.
And just FYI, even as a PGY-3, quickly wrapping my thoughts around a patient who has been sick in the MICU for 26 days and trying to present him is still considered somewhat challenging if I have very little time to do it.