Intern year starting...first hints

[Apollyon]

Intern year starting up. Depending on your program, you'll have variable amounts of time in the ED.

However, you can hit the ground running. You are now A DOCTOR. You are THE MAN (or WOMAN). Even so, there are some folks above you on the power chart.

So, my first hints that will put you in the lead are as follows:

First, when you present, I want to know in the first 10 seconds why the patient is there: "Mr. Jones is a 55 y/o male complaining of R sided abdominal pain, with nausea and vomiting, and subjective fever". Don't do the IM presentation, where the indication is like the cherry on top - I need the punch-line up front. Second part of that is that this is your chance to grow - if you think the patient is sick, or you're not sure, get help early, but stay with that patient: "I think this guy is bad; I need some help", and you see it and are there. Don't do the med student thing and write up a long-ass thing while the patient circles the drain.

Second, wait your turn for the "good patients". You'll get them, but not at first - but, at the same time, the ones that don't seem so "good" actually turn out to be. And, likewise, if you think you can cherry-pick the good ones by the line written by triage, that will bite you. Trust me.

Third, have a plan. Have a plan. It doesn't stop with the H&P; give me your assessment and plan. Don't just give my your assessment. Have a plan. If you don't have the specifics, go general. "The patient has an objective fever of 102. I've already ordered Zofran, and that has helped the vomiting. I'm worried about his gallbladder, but I didn't order the CT yet."

"Get LFTs, add an NPO order, and what about something for pain? From what you told me, I think an ultrasound might be more in order, but I'll see the patient, and you come with me. You are the face they should see. And you follow up the results."

Oh, and the final thought - you will make mistakes, but don't be the dude/chick that constantly undersells - if you keep wanting to send home the sick, you will occasionally win - and someone will die, and you will hear about it. Know what you don't know - that is what differentiates you from a mid-level.

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[RustedFox]

Interns: your first three words should be the chief complaint.... like this -

"Chest Pain"
"Shortness of Breath"
"Abdominal Pain"
"Lower extremity swelling"
"Altered Mental Status"
"Overdose on ____."
"Polysubstance overdose/abuse."
"MVA, with back pain."
"Victim of assault."

... get it ?

 

[Aesculapius]

Thanks for the advice Apollyon. Any advice on learning/getting good at procedures?

 

[GlutMax]

I think the best advice is to NEVER undersell a patient, it can have the risk of making you look like an idiot (trust me I've been there) or worse kill the patient. Remember you have essentially no experience, you do not have the patient numbers to be jaded yet.

mch

 

[docB]

Thanks for the advice Apollyon. Any advice on learning/getting good at procedures?

Know the procedure before you show up and ask to do it. I can't be teaching you which hand to use to hold the laryngoscope when someone is crumping. Learn that stuff on a dummy.

 

[KarlPilkington]

A few thoughts:

Show up early.
My Program director used to say "If you're early you're on time, and if you're on time you're late."

I always show up 15 minutes early, and start seeing patients.

Nothing is better for the off-going doc than seeing someone show up early and start working.

Very quickly you will come to hate the doc that shows up exactly on time, leaving you to see the crashing 80 year old dialysis patient that comes in with 5 mintues left in your shift.

Don't sign out junk. It takes at least a year to figure out how to give and take an effective sign out. Err on the side of staying to wrap stuff up.

You need read every single day. I mentally added an hour to my shift and would show up to read before I started seeing patients. Find a text that works for you and read it cover to cover. Try to cover all the major topics at least once a year while in residency. You are not going to see it all in residency, you need to read to figure out what you don't know.

Look at all your plain films, base your decisions on your interpretation and then check to see what the radiologist thought. In residency you almost always have a radiologist a few yards away to look your films. Once you're out, a lot of us are on the hook for all of our plain films. If you wanna make enemies as an attending, try calling a radiologist at home to look at a wrist film.

Have a healthy fear of airways. You may think you have it down after a few dozen tubes in the OR on your anesthesia rotation. Dealing with airways is the single most dangerous thing we do. This is not the place to be a cowboy. Get Ron Walls airway book and read it cover to cover. Learn a system to help you predict difficult airways, know how to recognize a failed airway, and know how to do a cric. Practice crics as much as you possibly can, because when you need to do one, its gotta be pretty near perfect on the first try. Treat every airway like it is going to be the most difficult airway you've ever done. Get all your equipment set, do a time-out and make sure everyone in the room understands what you are doing. Don't be afraid to call for help. Never assume that an airway will be easy.

Listen to your nurses, most ED nurses have been in the game for a while, and all of them know a whole lot more about how things run in the ED than the average intern. Be very careful if you ever come up with a plan that the nurse thinks is "a bad idea."

Ask your attendings for feedback on your performance after every shift. My least favorite attending to work with as an intern would always pull me aside and tell me my "areas of weakness." They are now one of my favorite docs in the world, and the majority of the things I know do now are based on their sometimes brutal feedback.

Just my two cents...

 

[VienneseWaltz]

Some advice for the off-service time on the floor or the unit (might be less of an issue with intern work restrictions, though):
1) At night, your job is to keep everyone alive, not to solve everyone's problems. Don't let nurses or other residents bully you into sorting out bullsh*t that can wait until morning.
2) If your patient is in trouble and your chief is not supportive/ignoring pages/MIA, call the ED--we love you and will help you.

 

[Apollyon]

Some advice for the off-service time on the floor or the unit (might be less of an issue with intern work restrictions, though):
1) At night, your job is to keep everyone alive, not to solve everyone's problems. Don't let nurses or other residents bully you into sorting out bullsh*t that can wait until morning.
2) If your patient is in trouble and your chief is not supportive/ignoring pages/MIA, call the ED--we love you and will help you.

True and true - especially the bolded. Remember that, if you are the overnight person, the ED may have the only place that has awake attendings that want to be there, and can help you or tell you something or send someone. The cavalry WILL come over the hill if you call.

 

[alfonzarel]

True and true - especially the bolded. Remember that, if you are the overnight person, the ED may have the only place that has awake attendings that want to be there, and can help you or tell you something or send someone. The cavalry WILL come over the hill if you call.

i'm starting "phase 2" in a couple months. next year will include 2 months of running the ICU, solo, for 24 hour shifts. as in, the only guy in the unit. it's simultaneously awesome and scary. the bolded is reassuring.

 

[b-real]

Great thread and awesome advice, thanks! Keep 'em coming!

 

[Daiphon]

Three most important words as an intern:

I don't know.

We can fix gaps... and appreciate the logic process; but if you don't know something, let us know (and add "but I'll find out." )

*Never* make it up.

-t

Sent from my DROID BIONIC using Tapatalk

 

[Arcan57]

Mentioned previously but worth emphasizing:

HAVE A PLAN!!!

It can be some jackass concoction involving serum porcelain levels and q5min bilateral manual BP checks, but if you have a plan then we have a starting point for a discussion about how to work-up the patient. If you just vomit up the H&P and then stare at me, I can tell you what to do but you're not learning nearly as much and my opinion of you is dropping rapidly.

 

[gman33]

Thanks for the advice.
Any and all suggestions are greatly appreciated.

On off service months, what kind of studying should I be doing?
I figured I should balance reading for the rotation with reading for the workup/management of the related stuff in the ED.

 

[Apollyon]

Thanks for the advice.
Any and all suggestions are greatly appreciated.

On off service months, what kind of studying should I be doing?
I figured I should balance reading for the rotation with reading for the workup/management of the related stuff in the ED.

Optimally, they'll be tailoring the rotation to your needs. Unfortunately, that doesn't happen most frequently. In those cases, review specifically what are the objectives of that rotation? What's written will be clear; if you ask your service attending, they will most likely not know. 10 deliveries? 10 tubes? 10 central lines? Alternately, though, ask the attending how their field can help you as EM. If you make an effort, it hits their ego, and you get more.

 

[OccupyTheED]

Thanks everyone for all the great advice. Keep it coming. Any suggestions on maintaining my health/fitness/sanity/personal relationships during the transition or should I just expect to put most of that on the back burner initially?

 

[Birdstrike]

.

 

[EM2BE]

Thanks everyone for all the great advice. Keep it coming. Any suggestions on maintaining my health/fitness/sanity/personal relationships during the transition or should I just expect to put most of that on the back burner initially?

I will speak to this one. I found that fitness suffered a lot during my intern year (but I also was not an athlete of any sort). I think if you set in your mind you will go to the gym x number of times a week, you will more likely succeed. You have to do something for yourself for your mental health. If you choose the gym, do it. Some focus more on family / relationships on their time off. This is a personal thing.

The health thing can be helped in other ways. If you go to a place that has free food, it almost makes the deal easier. You can eat, but not feel bad about throwing food out when you are done. Also, choose the salad over the greasy main dishes. Simple things will make your life easier. Skip the bag of chips/candy.

Biggest saver for me: I refused to eat anything on the floors/in the ED that anyone brought for people. If they bring in anything, refuse it! It is always something fattening and something you wouldn't have planned to eat on a normal day/night. That was the key to losing weight in intern year (I actually lost 50 pounds that year by changing diet alone).

Don't stress eat either. Stress exercise instead.

 

[StevieStud]

Stairs. Running UP the stairs is good exercise. You can take the elevator going down.

Nurses. New ones know less than you. And are even more dangerous.

Nurses. One day an experienced nurse will save your arse. Remember to thank her.

Review all cases at the end of the shift. Don't wait until the next day.

Don't play the hero. Better to say "I don't know" or "I can't do this" than to flail away without any success.

Learn the strengths and weaknesses of your peers. Working together is better than working against.

 

[StevieStud]

Thanks everyone for all the great advice. Keep it coming. Any suggestions on maintaining my health/fitness/sanity/personal relationships during the transition or should I just expect to put most of that on the back burner initially?

Set aside a defined block of time. Every day/week. for family, friends, relationships, dogs or cats. No matter what, don't skip.

 

[Hamhock]

The following is the best advice I can give and is admittedly a bit of a corollary to the "have a plan" advice above:

Dear EM intern who wants to be a good EM doc:

1. Embarrass yourself. The most memorable learning I have ever had is post-embarrassment. This is the time to admit you don't know or understand something. This is the time to try something. You don't want to be a PGY-4 who can't place a Foley or identify Brugada.

2. Commit. I am not giving relationship advice here; rather, I am paraphrasing my former program director. If you don't commit to a plan based on your assesment, you are just a medical student or advanced NP waiting to be told what to do. It's kind of the same as number 1. There is no learning if you aren't personally involved.

3. Respect invasive procedures. Too many interns are comforted by the attending's experience (even though the knife or needle is in her hands or the attending is posturing) and the comfort of ultrasound. The complications of emergent procedures are tremendous and not to be minimized. Pay attention to all M&Ms about procedures. Focus on the potential complications more than the "how-to" basics. Ask your senior residents if they have seen the vagal-brady arrest from an NG tube or the near-deadly intercostal bleed after non-emergent thoracentesis. That said, go to town: It's your last chance to be free of responsibilty (not really)...and you don't want to be a *****. EM docs are informed cowboys.

4. Codes are the least stressful patients in the ED. They are dead. If you bring them back: you are divine. If you don't, you are the most caring human. Hence: codes are great for residents. No mistakes can be made. This is your chance. Don't be nervous. Slam in the subclavian cordis. Seek the pericardial effusion and know how to place the continuous drain. Carry a knife and cut the chest wall...worry about the chest tube later. Know and consider intralipid appropriately: this is EM, a mix of hard-core surgery and medicine with an anesthesiolgist's skill set and perspective.Visualize daily a thoracotomy or circ. Seek the most important and risky procedures.

5. Listen carefully to the first three-fourths of Scott Weingart's podcasts. Become a resuscitation doc. Know how to set up an A-line. Know how to mix push-dose pressors.

6. Question trauma surgery dogma. Question the dogma of medicine. Plenty is wrong and lots of it doesn't apply to EM.

7. Anticipate board-certification. You will be on your own someday.

HH

 

[8654Marine]

My $0.02.

Agree with the above sentiments.

I and most ED attendings have short attention spans.

KNOW your patients.

Be SUCCINCT in your presentations. I tell my residents to tell me the pertinent info. But anticipate questions I may have.

Have a DISPOSITION. With alternatives if plan A doesn't bear fruit.

Be PREPARED for Emergencies.

For example:

(1). CP , now hypotensive.
(2). HA, now unresponsive or hemiplegic
(3). Vomiting, now torticollis
(4). Febrile now w/ petechia
(5). Sore throat now stridor..

In other words, have some idea/plan for when SHTF.

Be the ultimate "prepper".

 

[AlmostJesus]

Interns-to-be:

If you can place an NG tube squarely down your own esophagus on the first try, I'll overlook everything else, all year. I'll even provide banana flavored hurricane spray.

Extra credit if you don't perforate said esophagus.

Ive dropped a nasal airway without any lido, and a suction catheter down my nose with atomized lidocaine... does that count?

 

[krm232]

Thank you guys so much for responding, I think this is by far the best topic for new interns and I hope it grows. As we all wait to start, we are desperate for tips and really anything to help us through the first few months....

do any of you have any advice on "Things we (senior residents and attendings) expect interns to know"....I know we are interns, and I suspect all of us know to be helpful, respectful, eager to learn and honest, but what I want to know is what are the few things (medically) that if an intern doesnt know, you are thinking, "who the hell hired this kid"....

basically, I know we aren't expected to know EVERYTHING...but what do you expect (in your head perhaps) interns to know....

I think this is what most of us want to know...What should we know (MEDICALLY) before we start, not necessarily what we should learn during the year....Please let us know..

Thanks!!!! I am so excited to be starting in EM, you guys are awesome@

Thanks

 

[Apollyon]

If you are going to be a resident, you might want to change your status from "pre-med".

 

[krm232]

.......................................

 

[Thruster]

... but what I want to know is what are the few things (medically) that if an intern doesnt know, you are thinking, "who the hell hired this kid"....[/B]

basically, I know we aren't expected to know EVERYTHING...but what do you expect (in your head perhaps) interns to know....

I think this is what most of us want to know...What should we know (MEDICALLY) before we start, not necessarily what we should learn during the year....Please let us know..

Thanks!!!! I am so excited to be starting in EM, you guys are awesome@

Thanks

Any takers?

 

[KarlPilkington]

Short list of what I expect an intern to know on Day 1:

-Know how to look at an EKG, don't just tell me it "looks ok." Learn a system, use your system on every EKG, tell me your system.
eg. "The pt has a NSR, no signs of axis deviation, no signs of hypertrophy, I don't see any ST segment abnmls or signs of ischemia."

-Know the doses of all your ACLS/Airway meds

-Know how to figure out what a child weighs based on age.

-Know the basics of chest pain- look for the Slovis article on low risk chest pain.
-Know the basics of PE: Perc, Well's, D-Dimer, CTAngio.
-Know the basics of headache- what do we do about SAH, Meningitis
-Know the basics of pediatric fever- who do we worry about?
-Know the basics of abdominal pain. Appy vs. Chole vs. SBO vs pancreatitis.
-Know the basics of vaginal bleeding/discharge
-Know how to do and describe a detailed head to toe Neuro exam, tell me what you did.

You can get most of this info down cold in under a week of studying, and if you show up with this on day 1, you will be fine.

 

[FSU2013]

Ok, so I'm going to have about 2 and a half months off between now and internship. I have 1 month of a joke class and about 6 weeks between graduation and the start of internship.

As was previously mentioned, I'm going to try to read through Wall's airway book and reread Dubin's EKG book.

What else would you suggest I read? I have a giftcard to lippincott's and I was thinking about getting either Rosen's & Barkin's 5 Minute Emergency Medicine Consult or Pocket Emergency Medicine by Zane et al. Would reading either of these cover to cover before internship be advisable or a waste of my time? Anything else you would suggest reading?

Thanks!

 

[turkeyjerky]

Ok, so I'm going to have about 2 and a half months off between now and internship. I have 1 month of a joke class and about 6 weeks between graduation and the start of internship.

As was previously mentioned, I'm going to try to read through Wall's airway book and reread Dubin's EKG book.

What else would you suggest I read? I have a giftcard to lippincott's and I was thinking about getting either Rosen's & Barkin's 5 Minute Emergency Medicine Consult or Pocket Emergency Medicine by Zane et al. Would reading either of these cover to cover before internship be advisable or a waste of my time? Anything else you would suggest reading?

Thanks!

Honestly, if you're reading dubin as an MS4 you're way behind the curve. Read Garcia and follow some of the good EKG blogs out there. Agree w/ reading the Wall's airway manual. Reading a basic EM book would be a good idea, it prolly doesn't matter which one. If you have time, and haven't read it yet, the ICU book by Marino is quite good and I think it's better to have a good command of critical care earlier than later. As above, try to memorize ACLS drug doses (especially inducton/paralytic doses). Most importantly though, subscribe to and listen to some of the podcasts out there (EMcrit, ERcast, EMRAP, etc) and EM/CC blogs.

 

[dotcb]

No financial interest, but I like EM Secrets. Short, digestible, easy to read for 5 minutes, put down, and pick back up again.

 

[FSU2013]

Honestly, if you're reading dubin as an MS4 you're way behind the curve. Read Garcia and follow some of the good EKG blogs out there. Agree w/ reading the Wall's airway manual. Reading a basic EM book would be a good idea, it prolly doesn't matter which one. If you have time, and haven't read it yet, the ICU book by Marino is quite good and I think it's better to have a good command of critical care earlier than later. As above, try to memorize ACLS drug doses (especially inducton/paralytic doses). Most importantly though, subscribe to and listen to some of the podcasts out there (EMcrit, ERcast, EMRAP, etc) and EM/CC blogs.

Thanks for the vote of confidence, lol.

 

[migm]

this thread is super helpful, please sticky (and keep it going if there is more)

 

[Akail]

Thanks for the vote of confidence, lol.

lol...he's sorta right though. I'm sure with where you're at this point in 4th year, you could scour Dubin and not learn 1 iota. Pick up Garcia...I'm about 1/5 through (senioritis fail) and I've learned quite a bit already.

 

[migm]

Is it worth reading it if one has already gone through "the only ekg book you'll ever need"?

 

[FSU2013]

lol...he's sorta right though. I'm sure with where you're at this point in 4th year, you could scour Dubin and not learn 1 iota. Pick up Garcia...I'm about 1/5 through (senioritis fail) and I've learned quite a bit already.

I just thought it was amusing that I explicitly wrote "reread" Dubin (because it's the only EKG book I have) and was dismissed as a student that should be on the short bus. I thought politely asking people with more experience and knowledge than I have would end with an encouraging "it's great you don't want to slack off senior year like most of your colleagues," not "here's your sign."

 

[RustedFox]

I just thought it was amusing that I explicitly wrote "reread" Dubin (because it's the only EKG book I have) and was dismissed as a student that should be on the short bus. I thought politely asking people with more experience and knowledge than I have would end with an encouraging "it's great you don't want to slack off senior year like most of your colleagues," not "here's your sign."

Instead of RE-(read)ing Dubin; I highly recommend "EKGs for the Emergency Physician" by Mattu. You don't need more "theory" at this point. The book gives you one line of history, and an EKG. That's all you get. Figure it out, then turn to the answer. Damned if it doesn't do a good job of testing you.

 

[Thruster]

thanks! this is great info!! keep it coming

 

[FSU2013]

Instead of RE-(read)ing Dubin; I highly recommend "EKGs for the Emergency Physician" by Mattu. You don't need more "theory" at this point. The book gives you one line of history, and an EKG. That's all you get. Figure it out, then turn to the answer. Damned if it doesn't do a good job of testing you.

Thanks RF! Much appreciated, as always. That sounds exactly like what I should be using.

 

[DreamingTheLive]

lol, I dunno. I still feel like I could learn a lot from some of the more basic EKG books. A lot.

 

[bad virus]

Instead of RE-(read)ing Dubin; I highly recommend "EKGs for the Emergency Physician" by Mattu. You don't need more "theory" at this point. The book gives you one line of history, and an EKG. That's all you get. Figure it out, then turn to the answer. Damned if it doesn't do a good job of testing you.

The Fox strikes again. Man you are so spot on with this book it isn't even funny.

 

[Angry Birds]

Thanks everyone for all the great advice. Keep it coming. Any suggestions on maintaining my health/fitness/sanity/personal relationships during the transition or should I just expect to put most of that on the back burner initially?

You've heard of the "Freshman fifteen" during college?

Residency is way worse. I've packed on tons of blubber (and now just started the long process of losing it).

My advice is: never ever slack off when it comes to diet. When you're at work, make up strict rules, i.e. only eat salad, no snacks, etc.

Honestly, if you have family, it is very hard to find time to go to the gym (at least it was for me), so the only recourse is to rely on diet.