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Discussion in 'Emergency Medicine' started by David Mitchell, Mar 19, 2017.
Asking for a friend. JK. Asking for me.
No dumber than I was. That's it. If you're dumber than I was, you're right out.
Did you remember how to use a stethoscope?
The best ones realize how dumb they are, the worst think they know what they are doing.
Thank you for this post. All I think about post match is a) awesome I love my program b) I'm a complete moron, MS2s studying for boards know more than me.
haha, yea but for realz.
True story, i probably was a half decent "intern" on my subi, but after 6 months of doing nothing i honestly have forgotten which side the heart is on.
If the rotating students arent much much better than me in July there is a problem.
It's going to be a s**t show.
I have absolutely no idea how to actually be a physician. The thought of an attorney looking at one of my notes makes my stomach churn. I tell myself that it's good that I'm scared, but I'm still terrified.
Remember when PERC, PECARN, TIMI, and HEART were like actual things and not jumbles of letter? Those were the days.
The July rotation as a SubI felt great at the start because I felt like a genius. By the end of the month, it was obvious how much growth the interns all had. I suspect all of us will come in setting the bar pretty low, but with hard work will get back to SubI levels (LOL ) quickly.
Absolutely. It's for checking reflexes in back pain patients.
Its not the medicine that is going to be the biggest hurdle. It's switching from being a student (H+P machine) to someone that now has to document correctly, order tests (if your hospital does physician order entry), recheck your patients, disposition them, call the consultants or get their discharge instructions/Rx's done. Seeing a patient an hour as a medical student is very, very simple. Doing so as a new intern, with all of the extra stuff that students usually don't do makes it a really tough transition.
I'm almost done with intern year, and they're still allowing me to be pretty dumb.
A 1st month intern that checks reflexes on back pain patients is at the top of her class.
Recognize abnormal vitals signs.
Always examine the part of the patient that hurts (look under their clothes).
Communicate a reliable H&P.
Know how to use the EMR/Order entry system.
See how patients respond to treatments in the ED.
If you can do all of the above for at least one patient per hour (to start), than we can teach you Emergency Medicine.
Transitioning from med student to intern was one of the hardest transitions I've had in training. In hindsight I'm like how was I that dumb.. but at the time it was tough as ****. You will all feel the same way eventually
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working in a level 1 academic center as a nurse in June and July can be interesting. They are the months of inefficiency and incorrect orders. Some new interns are good, others, we wonder how the hell they figure out how to put their clothes on in the morning.
But they all come around eventually.
Wait...we are going to have to put in orders???
Just remember, if anyone asks why you're listening on the wrong side, just point out that it's the aortic valve sound zone.
I've gotten really angry at interns in their first month only twice in my career, all of this was a decade or so ago.
The first was when one told me I was committing malpractice by not immediately intubating a sick pulmonary edema patient. Worse, they started telling the family about how terrible my decision was and that they should request immediate transfer to another facility lest I assassinate Grandpa (found that out part after the fact). Naturally after 30 minutes of BiPap and high dose nitro they looked fantastic, and I'm all "see, it turns out I actually kinda DO know what I'm doing". Sadly this person came from a top medical school, had awesome scores and everybody loved them when they came to interview. The moral of the story is you just never know how people are going to be until they show up and start working in the trenches.
The second was when we asked a first month ED intern if they'd like to drain an abscess on a senior resident's patient. Mind you, this is at a center that would never be considered a procedural hotbed. Granted, it was just a simple I&D, but we did not expect to hear "nah, I did plenty of those in medical school, I'm good".
W. T. F.
OK, just remembered another funny one. Long time ago some of the off service surgical interns were having fun one day with some our nurses. They would write witty free text nursing orders like "hugs q1 hour, PRN sadness". We all (including the nurses) thought it was hilarious, but as part of the EMR that **** was there forever. The administrators were not amused.
I was always checking for dextrocardia.
Is that JHCAO mandate starting in 2017, or 2018?
That was good, need more of those stories. Wonder how those guys turned out
The "smart" ones in month 1 are the scary ones. The dumb ones (the ones without their heads up their arses) are who residency is for.
Almost done with intern year now. I remember being scared ****less ordering Dilaudid for the 1st time...on a sickle cell pt who states that they normally get 4mg at a time
I love this thread
OMG. I was the dumbest.
Literally almost every sub-I knew way more than I did.
Sickle cell asking for dilaudid? Did they ask for the benadryl chaser too? (yes, real sickle cell/chest crisis patients exist, and they get what ever they want, but most of the time...)
Don't worry, they get worse every year. You'll be shocked how bad the next class is when you're a second year.
Who cares just have a good attitude. Work hard. Show up 5+ minutes early. Take sign out like a champ. Don't argue with attendings about stupid **** that doesn't matter. Work harder. Don't ask stupid questions you can look up. Be eager to do crap and don't piss off the nurses. Work hardest. Don't forget to eat, pee and poop somewhere in there. Viola, you are now an amazing intern. You're welcome.
Dilaudid? I was terrified I would kill somebody with a tylenol order if I didn't take a history and scroll their labs for signs of liver disfunction first.
I love this thread and I know this is not what it's about.... but are you serious? I trained with a hematologist who would flat out ream you out for this comment. If the patient is a documented to have sickle cell and says they are in pain, they are in pain, and who in the world are you to suggest otherwise. I'm all about exercising caution when prescribing opiates but I don't think this is an appropriate setting for that.
More in line with the discussion... forget dilaudid, I feel like I'm going to be sweating bullets ordering Tylenol on the off chance my patient has covert liver failure.
...Tylenol is bad for the liver, right??
EDIT: Hahah, did not read the post right above mine, glad I'm not the only one
Do you want to know how I know you didn't read my entire post? Like the parenthetical statement at the end? Go ahead... guess how I know that you didn't read the full post.
I did read it, I guess it wasn't clear to me how you're making the distinction. Not trying to start a fight, my friend, just passing on the teaching from someone who knows a lot more about it than I do.
Most "sickle cell" patients have sickle cell trait and are drug seeking (yes, I'm looking at you, mister "abuse the nurses and was at our sister hospital 12 hours ago which you completely forgot to mention even after I asked you multiple times when the last time you were at a hospital... of which the last time you actually admitted you were tested for sickle cell and it came up with trait... oh, and your extensive list of allergies that don't include dilaudid is amazing).
Now yes, someone with confirmed sickle cell disease or an actual description of the disease that makes sense in any way that doesn't scream "drug seeker" gets fluids, pain meds, and oxygen. If they know what works for them... they get what works for them.
We had one individual who wanted his diluadid and benedryl mixed and pushed at the lower port while his bolus ran. Turns out they are mixable in syringe.
I felt like a drug dealer giving "him what he wanted." - like I need a tip or something.
Well this thread has taken an interesting turn, and it leads me to another intern tip:
Do not worry about diagnosing drug seeking behavior as an intern. Worry about diagnosing life and limb threatening conditions.
On a side note - when it comes to SS pain crises, I'm about as generous with the dilaudid as anyone I've known, but I see NO reason to give diphenhydramine IV. Why can't it be given PO?
It's in the middle, with the lungs.
We expect you to be worse than fourth year medical students
Eh some people are taking this clueless intern thing a little too far...
At my program you better damn well know more than a 4th year medical student and you're expected to be at the head of the bed for that GSW chest that just rolled in the trauma bay on July 1st. Now I'll be there right by your side helping you if needed but its your airway and your patient. Sure you'll be scared ****less for the first month but by the end of the year you'll be more than capable of handing that patient's airway like a ****ing boss.
That being said the above is very program dependent. We don't baby our interns or have graduated responsibility like most programs.
you're a med student. get out of here.
Most of them aren't actually in pain. They're in it for the drugs. How do I know? Because they were just at sister hospital yesterday and they told me that their last ed visit was 2 weeks ago. They have sickle cell trait, not the disease. And they're sitting there in no distress playing with their phone. And they ask for iv everything. Yawn.
I can smell the bull**** coming a mile away.
Yep. I definitely subscribe to the "throw them to the wolves" philosophy, with appropriate backup. Put in a chest tube with a PGY1 on one of their first shifts in July. Tubes, lines, etc. If its your patient, its your procedure. And many of the upper levels seek out the interns in the first few months to let them have their intubations, etc as well. 3 years is not a long time. No point in dancing around it, gotta grow up in a hurry IMO.
The logic of "they have sickle cell disease, so they can't be faking pain and can't be abusing narcotics" is just stupid. Patients with chronic pain syndromes are much more likely to become addicted to narcotics and abuse them as they are exposed to them much more than other patients. Sickle cell patients are no different in their ability to abuse narcotics than the chronic renal stone patient or chronic stomach pain patient or chronic back pain patient who has learned to abuse the system to get medicines. Who is to say that the chronic back pain patient shouldn't be believed? I once worked with a chiropractor who would ream you out for this comment. Who are you to suggest otherwise that this chronic back pain patient isn't having 12/10 pain and doesn't need dilaudid?
Most often, I do give the patient the benefit of the doubt, but when you work in one ER long enough, develop a good gestalt, and if you have a good EMR and access to other local EMRs, you will quickly learn which patients are drug seeking and which patients aren't.
And as far as the acute management of sickle cell pain and hematologists being superior at managing this, I have never seen a hematologist in all of my time in the ER for a sickle cell pain crisis and have also never admitted a patient to a hematologist for a sickle cell pain crisis. Please do tell me though your rainbow and unicorn hospital where you work where hematologists are coming down to the ER to acutely manage sickle cell pain and admitting them to the hospital at all hours of the day. Most encounters would go like this:
Me: "Hi this is Doctor TecmoBowl and I would like to admit a patient for a sickle cell pain crisis."
Hematologist: "Are they in acute chest syndrome?"
Hematologist: "Are they having an aplastic crisis?"
Hematologist: "Are they having splenic sequestration?"
Hematologist: "I'm confused, why are you calling me?"
Me: "I have a patient I would like to admit for a sickle cell pain crisis."
Hematologist: "Oh, I see. Can you just admit to the hospitalist."
My program is the same. No graduated responsibility, first Years sweating as they try to run codes, etc. I still keep a very very very close eye on them. Nobody should expect you to know everything. The 4th year med school brain drain is very real, but by the end of the first month they are all usually up and up. Obviously the worse than 4th year med students thing was a joke but they are still barely not med students.
Not knowing what to do on day 1 = okay.
Thinking you know what to do on day 1 when you have abso****inglutely no clue = not okay.
One group is teachable. The other is not.
I have seen a number of intern classes come and go and have had the true honor of being there for the first moments of doctor-hood for quite a number of people. It's one of my true joys as a teacher.
I can only speak for me, and somewhat for our ED philosophy though even within our group there are differences...
I ask only that the learner be eager and honest. I am there to teach them and if they bring these two things I bring the rest.
I truly love working with the intern class. It's the baseline from which we appreciate the great successes they have along the way and after training.
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I don't want to sidetrack the whole thread with talk of sickle cell pain management.
I do think there is a good learning point for interns.
Learn from your consultants, but don't defer to their judgment. Especially not in a teaching hospital where the consultants are other trainees.
EM physicians are the ones who deal with most acute presentations. You need to learn how to deal with these complaints and make your own management plans.
When I talk to a consultant it is for a few reasons.
To get someone admitted.
To get a procedure done I cannot perform.
To arrange for follow up.
Rarely I will get a consult to buff the chart.
And the rarest of all reasons for a consult is to ask for advice with management.
Always remember that you are the one seeing the patient and that you need to make decisions.
Consultants will recommend all sorts of nonsense.
I can't believe I just found this thread. I've been anxious lately because I feel like I forgot medicine, and with a little senioritis coming on, have very little motivation to study (but excited to start intern year). I'm glad I'm not the only one in this boat, because I agree that people studying for step 1 or 2 know more medicine then I do right know.
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and if they perform a bulbocavernosus reflex they should get a f*cking medal!