Intern Stupid Mistakes

[discodoctor]

There seem to be quite a few soon to be interns here, and like myself are a bit scared. (I am reviewing bates, wash-man internship survival guide etc.) It would be awesome if someone with more wisdom could share a funny-scary-important mistake they or a friend made and how one could avoid it. Any pearls or known pitfalls would be great.

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[cabinbuilder]

Be aware of Potassium levels. There was an intern in my residency who neglected to tell anyone that a patient in ICU was still on fluids with K+ and the K level was over 6.0. It was too late before anyone else caught it and the patient coded and died. The intern was put on probation and was informed that every order he wrote had to be co-signed by an attending or upper level during his probation period. Arrogance got the better of him and he proceeded to continue per his own ideas of patient care. A second patient almost died because of him - he was fired from residency.


Bottom line, even if you were number one in your class, you really know nothing about patient care and hospital medicine. Don't be afraid to ask questions even if you think it sounds stupid. People are trusting you in their care, ask and be safe.

 

[Bartelby]

Be aware of Potassium levels. There was an intern in my residency who neglected to tell anyone that a patient in ICU was still on fluids with K+ and the K level was over 6.0. It was too late before anyone else caught it and the patient coded and died. The intern was put on probation and was informed that every order he wrote had to be co-signed by an attending or upper level during his probation period. Arrogance got the better of him and he proceeded to continue per his own ideas of patient care. A second patient almost died because of him - he was fired from residency.


Bottom line, even if you were number one in your class, you really know nothing about patient care and hospital medicine. Don't be afraid to ask questions even if you think it sounds stupid. People are trusting you in their care, ask and be safe.

Through third year rotations it seems like all interns work directly with an upper level resident who should catch their mistakes, was this guy caring for an ICU patient independently and just reporting? If not shouldn't the resident have been on probation?

Scary stuff though, it's easy to make one wrong step that looks inexcusable to the well-rested armchair quarterback.

 

[cabinbuilder]

Through third year rotations it seems like all interns work directly with an upper level resident who should catch their mistakes, was this guy caring for an ICU patient independently and just reporting? If not shouldn't the resident have been on probation?

Scary stuff though, it's easy to make one wrong step that looks inexcusable to the well-rested armchair quarterback.

We had a very small residency program. You didn't necessarily always have an upper level person to go to do to clinic duties, etc.
DISCLAIMER: This incident happened after I graduated so I don't know all the specifics, just what I heard from the Chief after me. Things happen and my message is that nobody knows everything and if you are flagged as someome who need extra assistance for the patient's safety, don't be arrogant and still think you know it all. Play by the rules, save yourself, save the patient.

 

[Doctor4Life1769]

Be aware of Potassium levels. There was an intern in my residency who neglected to tell anyone that a patient in ICU was still on fluids with K+ and the K level was over 6.0. It was too late before anyone else caught it and the patient coded and died. The intern was put on probation and was informed that every order he wrote had to be co-signed by an attending or upper level during his probation period. Arrogance got the better of him and he proceeded to continue per his own ideas of patient care. A second patient almost died because of him - he was fired from residency.


Bottom line, even if you were number one in your class, you really know nothing about patient care and hospital medicine. Don't be afraid to ask questions even if you think it sounds stupid. People are trusting you in their care, ask and be safe.

I don't know. As a 4th year, I certainly don't know everything.... but it's common sense to stop giving KCl when a patient is hyperkalemic...

 

[smq123]

I don't know. As a 4th year, I certainly don't know everything.... but it's common sense to stop giving KCl when a patient is hyperkalemic...

He probably forgot to list the fluids as another med each morning. Common mistake, but a bad one.

He may have also forgotten to check a BMP regularly.

 

[Doctor4Life1769]

He probably forgot to list the fluids as another med each morning. Common mistake, but a bad one.

He may have also forgotten to check a BMP regularly.

The things I always list on every SOAP:

1. Abx (IV/PO)
2. Pressors (if pt is on it..)
3. IV Fluid + supp (i.e. NS w/ "X" meq KCl.... or D5W and insulin, etc) @ xxx cc/hr
4. anti-HTN meds (not always, but when needed, it's on there...)
5. bowel meds (colace, senna, miralax, etc.)
6. Pain meds
7. ulcer prophylaxis med(s)
8. nausea med(s)

That's off the top of my head at the moment...

I almost always write for daily CBC and BMP unless the attending says otherwise. BMP especially if the pt has electrolyte/renal issues.

So, while I understand that things can be super chaotic as an intern when you're seeing so many patients, and you may forget things.... but, I think being systematic goes a long way towards not missing those important details. Obviously, I may not have listed everything above that may be *important* to note, and if so, feel free to point it out for my own benefit.

 

[smq123]

So, while I understand that things can be super chaotic as an intern when you're seeing so many patients, and you may forget things.... but, I think being systematic goes a long way towards not missing those important details.

I think that it's easy to say this when you haven't been an intern yet.

I certainly thought that "Oh, I'll just be sure to be systematic and I won't miss anything." Yeah, that didn't work out so well for the first few weeks. I think that I imagined that the circumstances would be how it was when I was a med student - i.e. not getting paged constantly, not having 3x the number of patients to see, etc.

I guess that that would be my advice to incoming interns - everything takes significantly longer than you (or your upper levels) think that it will. So build in extra time so that you don't feel so rushed so that you CAN be systematic. Being systematic takes time, and practice, and it's impossible to think clearly and be organized when you're rushed, you're getting bomb paged from 3 different people, etc. So get there earlier than you think you need to be there; you'll probably end up needing the extra time!!

 

[Doctor4Life1769]

I guess that that would be my advice to incoming interns - everything takes significantly longer than you (or your upper levels) think that it will. So build in extra time so that you don't feel so rushed so that you CAN be systematic. Being systematic takes time, and practice, and it's impossible to think clearly and be organized when you're rushed, you're getting bomb paged from 3 different people, etc. So get there earlier than you think you need to be there; you'll probably end up needing the extra time!!

I agree with this (with all your points, but especially this last point). I usually take a look at the census the night before to judge how early I need to come in, especially if there were a lot of overnight admits and the H/P was tabled to the following AM.

I typically have had anywhere from 5-10 patients, of which 1-2 may have been an overnight admit. There were usually 2-3 students (2 4th years, and maybe 1 3rd year), so we would split the census up and give whatever was left to the 3rd year (3-4 at the most). Sometimes we lucked out and had 3-4 per person, but that was a rarity. Depends on the census and how many we cleared out the day before, etc. If there was no 3rd year on the service, we did the H/P's. Of course, this would also mean the attending helped by seeing a few to expedite rounds. If there was, and they weren't terribly busy with their few patients, we had them do the H/P and report to us. Our job was to help in the assessment and plan of the patients. Of course, as MS-4's, our orders had to be checked by the attending. Small, community hospital, brand new FP program, so not many residents at this current time. Thus, we had to be "interns."

I will say this though: THE big differences were we weren't paged AND while we held responsibility, the buck did not stop with us. The attending would be paged. If the resident happened to be on call and we were on call with the resident, then the resident was paged. However, we did address things if personally approached about something (as long as it did not involve narcotics).

What is the typical # of patients we as incoming interns would have to cover? I know it varies based on the program, but ballpark range?

 

[smq123]

What is the typical # of patients we as incoming interns would have to cover? I know it varies based on the program, but ballpark range?

I'd say, worst case scenario, 10-15. It definitely varies by program, as you already said.

I will say this though: THE big differences were we weren't paged AND while we held responsibility, the buck did not stop with us. The attending would be paged. If the resident happened to be on call and we were on call with the resident, then the resident was paged.

I think that this was the part that really surprised me the most - how much longer everything takes when you're being paged constantly. The constant interruption is extremely distracting. Even if you field questions from people who approach you, that's generally not nearly as bad. If you are fielding a question in person, you were usually approached because you didn't look busy. The person paging, however, you has no idea if you're checking email, using the bathroom, entering orders, seeing a patient, or doing chest compressions.

The hardest part for me at my program was that we admit every day (we have to; FM services usually have to admit their practice's patients, regardless of what time or day it is). So, it's not unusual to get paged for two admissions in the middle of rounds; have to stop what you're doing, figure out how you're going to get this all done in a timely manner, etc. And then morning rounds are interrupted by a code, etc.

Like I said, easy to be systematic when you have 2 or 3 things to juggle. Harder when you have more.

 

[Doctor4Life1769]

Thanks for the pointers and a "snap-shot" of intern year.... best of luck the rest of the way.

 

[BrickHouseMD]

Thinking about this makes me want to throw up in my mouth.

 

[eforest]

I'm surprised about this. I guess I'm pretty lucky because if a patient had a potassium of 6, I would be called or paged by the lab. Also, the nurses delivering the fluid with potassium might say something if they noticed that the potassium was elevated, that's another safety net. And, in the ICU usually everone's paying attention to the labs so it's not just the intern.

Be aware of Potassium levels. There was an intern in my residency who neglected to tell anyone that a patient in ICU was still on fluids with K+ and the K level was over 6.0. It was too late before anyone else caught it and the patient coded and died. The intern was put on probation and was informed that every order he wrote had to be co-signed by an attending or upper level during his probation period. Arrogance got the better of him and he proceeded to continue per his own ideas of patient care. A second patient almost died because of him - he was fired from residency.


Bottom line, even if you were number one in your class, you really know nothing about patient care and hospital medicine. Don't be afraid to ask questions even if you think it sounds stupid. People are trusting you in their care, ask and be safe.

 

[MedicineDoc]

I would think there was probably plenty of blame to pass around on that one. The lab for not giving a page on a critical value. The upper level for not scanning the labs assuming they weren't aware of a high potassium. Whoever wrote for iv potassium and didn't stop it when the labs started getting high. The attending who follows behind the resident assuming they had a chance to get there and assess the patient. The upper level for not checking on what the intern was doing. Pharmacy if it was an unusual fluid order.

To new interns I suggest a systematic approach which I started as an intern which some people might think is overkill but for me it's so regimented that it actually makes it faster. One write down the vitals and i's and o's if appropriate. Two. Write all the meds in the left margin with dosing (teaches you the doses and what may be a bogus dose for a med) Three. write phys exam Four. Write labs With little arrows pointing to today's lab from previous days lab (Only if it is changing ie potassium 3.4 yesterday and 3.1 today). Culture results if any in right hand margin. Then radiology reports. Five. Look at h and p or previous days note for problem list. Five. Old plus new problem list with plan after each problem. Six prophylaxis TEDs/SCDs, lovenox 40 mg sub q or heparin 5000 sub q tid if kidney problems ( if indicated not contraindicated). Seven call consultants with questions. Photocopy your note if you can't memorize it or the attending wants micro detail.

 

[MeowMix]

Be nice to EVERY hospital staff member - nurse, custodian, CNA, physician - because they are invariably related to someone who can make your life miserable.

Be nice and respectful to nurses, listen to what they say, be open to feedback. Or your life will become miserable. Especially in community programs, where stories of good and bad behavior spread like wildfire. Women, I know it is unfair, but we are expected to be even nicer. Return pages promptly; go and see patients when they ask you to; take their concerns seriously; be aware that there may be an unspoken concern that you will need to elicit. In the story about hyperkalemia above, most ICU nurses would probably have noticed the problem and helped out an intern IF they liked him/her. If you get the reputation for being nasty to nurses who call you during the night, they will stop calling.

Figure out how to handle multiple simultaneous requests gracefully and quickly. Preferably during your first week. Be aware that in some situations (L&D) you do not have 10 minutes to go and get breakfast before seeing a patient. Figure out how to carry food with you, if you're the kind of person who crashes when you get hungry.

And one medical suggestion: carry the sepsis criteria with you, and use them in evaluating sick medicine patients, especially new admits. It is terrible for patients when we admit someone with lactate 7, 40% bands, fail to recognize that they are in septic shock, undertreat, and they end up with a prolonged hospital course and bad outcome.

 

[peppy]

I would think there was probably plenty of blame to pass around on that one. The lab for not giving a page on a critical value. The upper level for not scanning the labs assuming they weren't aware of a high potassium. Whoever wrote for iv potassium and didn't stop it when the labs started getting high. The attending who follows behind the resident assuming they had a chance to get there and assess the patient. The upper level for not checking on what the intern was doing. Pharmacy if it was an unusual fluid order.

Yeah, while I agree the intern screwed up here, it sounds like a lot of others dropped the ball too and share the blame. Even without a senior on the team, why weren't the attending and nurse paying attention to the labs? While some nurses are better than others, I think just about all the nurses I've worked with (especially in the ICU!) would have said something about a hyperkalemic patient even if they weren't getting extra potassium.

 

[cabinbuilder]

I will re-interate. The intern was not fired for the first patients. He was fired for not heeding the directors rules of having everything double checked and co-signed when he wrote it. He was arrogant and thought he new everything. His attitude cost him his residency. Everyone makes mistakes when they are learning and sometimes patients do die. However, if you are put on probation for some event that may or may not be your fault, just be sure that you cover your bases and accept that you are being monitored closely.

 

[styphon]

My advice is slightly different:

Be aware that not everyone will like you, no matter how you act or how polite you are. Sometimes personalities or character traits clash and there is little you can do to prevent this. In this event, I try to minimize my contact with such person to professional reasons only, which helps limit the amount of conflict present

Make friends with nurses/techs/pharmacists: Said many times before. They will start calling you with questions (which I like), they won't torture you in the OR, and you may learn somethings from them

Be proactive: Lots of times people will not ask you to do a procedure, they will either do it themselves or get a consult to do it so you must be proactive. You have to step in and say "Mind if I attempt doing this?"

Avoid Gossip: Depending on the residency, you may be with the same group for the next 3-5 yrs so a bad relationshipformed in the first year will carry on and likely cause you problems in the later years.

 

[ghost dog]

Be aware of Potassium levels. There was an intern in my residency who neglected to tell anyone that a patient in ICU was still on fluids with K+ and the K level was over 6.0. It was too late before anyone else caught it and the patient coded and died. The intern was put on probation and was informed that every order he wrote had to be co-signed by an attending or upper level during his probation period. Arrogance got the better of him and he proceeded to continue per his own ideas of patient care. A second patient almost died because of him - he was fired from residency.


Bottom line, even if you were number one in your class, you really know nothing about patient care and hospital medicine. Don't be afraid to ask questions even if you think it sounds stupid. People are trusting you in their care, ask and be safe.

This story sounds completely false. BS detector is pinging loudly.

Ghost stories to scare the newbies, anyone?

 

[cbrons]

Any new stories?

 

[cabinbuilder]

This story sounds completely false. BS detector is pinging loudly.

Ghost stories to scare the newbies, anyone?

Why would I lie? What would I gain?

 

[deleted87716]

Why would I lie? What would I gain?

That post is from 2011, just FYI.

 

[SqEdSaint]

Within how many minutes would you say returning a pager is considered timely? Do nurses have a certain expectation of how long it'd take and just wait at the station for x amount of time?

 

[TableMD]

Answer the page immediately so you dont forget about it. Erase the page after you placed the order, answered the question, and put a little blurb on your list so you remember what you did for sign out. Dont let them build up.

Intern year is all about
- knowing the basic care plan for your patient
- placing orders
- answering pages
- getting help from your senior for anything you dont know (we dont write notes so our job is to help YOU)
- if you are not sure, get help!

 

[JonMonkey]

That post is from 2011, just FYI.

- Good thing I saw this....I was about to drop some knowledge.

Within how many minutes would you say returning a pager is considered timely? Do nurses have a certain expectation of how long it'd take and just wait at the station for x amount of time?

- Think of it the otherway around...you page a nurse...how long would you want to wait? Return them as they come. Although I know that this is not always possible but if you are in house and get paged about a patient....go see them, it goes a long way with your nurses, your seniors and your attendings.