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Internship survival:What do you wish you'd known

Discussion in 'Clinical Rotations' started by Magree, Apr 19, 2002.

  1. Magree

    Magree Senior Member

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    Hi:

    I thought it would be fun for people who've been through internship or are still in it to give some tips to people who will be starting residency soon. What do you know now that you wish you'd known when you started or what are just some good tips for people starting out. Thankx

    M-
     
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  3. Winged Scapula

    Winged Scapula Cougariffic!
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    If you are old fashioned and don't have a PDA, carry a red pen around with you to write down important things - ie, tasks to do, things the attending/fellow said about a patient. I make boxes next to the tasks on my list and cross them off as I complete them - very satisfying and more organized.

    Keep more patient lists in your pocket than you possibly think you'll need. Besides the more senior team members, the attendings may want one, the social worker, the case manager, the PA, etc. I only used to carry lists when I was on call until I started getting asked for them all the time. Now I waste a lot of trees but its worth it.

    When you round with the team, write down the vitals and any important info on ALL patients - you never know when you might be asked by someone senior or be asked to round with the attending. It was quite a suprise during my first month when the attending paged me to round with him because the Chief was in the OR and no one else senior to me was available - I never expected to have to know the plan on ALL the patients (just the ones I pre-rounded on). This is good practice for when you are Chief and have to know the details of everyone.

    Carry a few essentials with you:
    calculator
    Maxwell's
    small pocket handbook - but pick something useful (you can always keep other books in the call room, put ones in your pocket that actually help you during the day; The Washington Manual Intern Handbook is great and only about 100 pages)
    red pens! and lots of black pens (you'll constantly lose them)

    If on a surgical service, more senior residents (ie, PGY-2 and 3) will transfer their pages to you when they are scrubbed in. A royal pain but now I understand it and learn to live with it.

    Expect to be in the hospital longer than you imagine. If on service which involves trauma response or crashing patients NEVER expect to be home at a certain, preordained time. Patients always wait until 10 minutes before you are planning on going home to try and ruin your day.

    Be friendly with the nurses but don't make friends with them and unless they work on a totally different service, don't date them. Sounds harsh but problems arise when there exists a less professional relationship - orders aren't taken seriously, orders are written which you didn't write (because they thought you wouldn't care), its tough to be the bad guy if something isn't done/done right when you're close friends and if there is romance, imagine the difficulties in working with someone you've been fighting with.

    I'm sure I'll think of more later...
     
  4. Magree

    Magree Senior Member

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    Hi Kim:

    Thanks so much. That was great. Any other info you or others want to add will be greatly appreciated by all.

    M-
     
  5. Winged Scapula

    Winged Scapula Cougariffic!
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    Make sure (to avoid late night phone calls) that your patients have the following written for:

    bowel regime
    anti-emetic
    pain meds
    tylenol (ie, nurses won't want to give Percocet if the patient is only complaining of a headache)

    Make your call orders realistic, ie, don't write "call for SBP > 160" on patients with hypertension or renal disease, or whose baseline SBP is often > 160. You'll be tortured all night with calls.

    PCA boxes are sometimes in shortage. To cover yourself for this, when writing for one, also have some back up intermittent Morphine written for in case you can't get a box.

    If you get a page while on rounds, ask the nurse if its an emergency, otherwise tell her you are rounding and will be there shortly to deal with the issue.

    I'll think of some more later.
     
  6. Docgeorge

    Docgeorge Bent Over and Violated

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    This is interesting....
    BUMP
     
  7. sistermike

    sistermike Senior Member

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    Kimberli Cox: haha.. i like your first response when you said that patients always wait till the last moment to ruin your day. I can just see you saying now "dangit! i was about to leave! couldn't mr. doe have waited till tomorrow to have a heart attack!" <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" />
     
  8. lumbrical

    lumbrical Member

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    This is a helpful thread...

    but,

    1- before everyone starts flaming sistermike for not knowing of which they speak, this person is in high school, so be kind.

    2- sistermike - maybe this isn't the forum for you to be posting things in, since you don't know what we're talking about. Please come back once you're in medical school in several years.

    best wishes,
    lumbrical
     
  9. CUarzt

    CUarzt Member

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    ...do i smell a high horse?
    too stiff for me...
     
  10. Winged Scapula

    Winged Scapula Cougariffic!
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by sistermike:
    <strong>Kimberli Cox: haha.. i like your first response when you said that patients always wait till the last moment to ruin your day. I can just see you saying now "dangit! i was about to leave! couldn't mr. doe have waited till tomorrow to have a heart attack!" <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" /> </strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Sadly enough you are not far off. It was very suprising to me how callous one can become after working so many hours, when each patient becomes a potential problem and time away from home rather than a learning experience.

    I hope I won't get flamed for this, but I am sure once you (and others) have actually experienced the torture firsthand you will agree (or at the very least sympathize) with me.
     
  11. ortho2003

    ortho2003 Senior Member

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    Lumbrical, I think you are the only one that deserves being flamed in this thread. Sistermike was making a joke and you blew it out of proportion. In the future, try to keep the arrogance under control.
     
  12. Pinky

    Pinky and the Brain

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    I just recently finished reading "The House of God" which had some laws/advice for interns. Two of my favorites were 1. Placement comes first. 2. If you don't take a temperature, you can't find a fever.

    Two of these laws were quite appropriate for many MICU patients. One 50 yo lady with endstage everything who was on dialysis and ventilators for 4 months. The patient had no advance directives set. The boyfriend wanted to keep her alive because her social security checks would continue to come to him if she were "alive". I remember how hard we tried to place her in a a long-term care facility that handled vents and dialysis. Twice, when the transfer was imminent, a new intern to the service would order blood cultures which would of course be infected and would delay any transfers. This continued for 2 months. That was painful.
     
  13. Magree

    Magree Senior Member

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    Hi kimberli and pinky:

    Thanks for your input. If you think of any other "survival tips" please post. I think most people, even at 4th year level sympathize with you Kim. Personally, I appreciate your honesty.

    M-
     
  14. CUarzt

    CUarzt Member

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    Pinky--i thoroughly enjoyed that book, it's good to hear someone else has as well.

    most of his "witticisms" or "laws" were excellent.

    this is an interesting thread, so bump bump bump....
     
  15. Winged Scapula

    Winged Scapula Cougariffic!
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by Pinky:
    <strong>I just recently finished reading "The House of God" which had some laws/advice for interns. Two of my favorites were 1. Placement comes first. 2. If you don't take a temperature, you can't find a fever.

    </strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Ughh...placement. A DIRTY word (if my fellow asks me ONE MORE TIME when a certain patient is going to be placed, I'll scream).

    Law #2b: if you D/C the Swan, you can't find a low Cardiac Output! ;)1
     
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  17. Winged Scapula

    Winged Scapula Cougariffic!
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    As a new intern you may not be able to anticipate problems, but you can help head them off or at least control them before getting out of hand (just because someone has a nurse doesn't mean you will be called about problems...you'd be suprised at the things you AREN'T called about).

    So....

    1) before you retire for the evening, make quick rounds on your patients - this is best to do after shift change; ie, a new crew will come on at 11pm ( or whatever time) and the new nurse will have some question which has not been an issue all day but cannot possibly wait until morning, or something that was clarified with day shift but is unclear to night shift. Therefore, seek out the patient's nurse and ask if there are any concerns or problems and try to deal with them rather than get a call at 2:00 am.

    2) when you round look for the patient's nurse - it can be difficult and painful a task, but invariably there will be something they wanted to ask you that they will page you 15 minutes after you've fallen asleep.

    Some of these are probably already evident as medical students...

    If you write notes on rounds in the am, have the charts gathered up and at the bedside, at the ready.

    Interns should always lead the pack - ie, charts should be ready and you should lead the team from bed to bed.

    You do NOT have to wear clogs just because you're a surgical resident. My sneakers are very comfortable, washable and work well with every color scrubs! <img border="0" title="" alt="[Wink]" src="wink.gif" />

    More later...
     
  18. tonem

    tonem Senior Member

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    Kim I sent you a pm

    By the way, I was just noticing the whole clog thing last week. The only people wearing Danskos in the OR at Pitt are the medical students and the residents that graduated from Pitt...everyone else is in sneakers or some other type of clog.
     
  19. droliver

    Moderator Emeritus

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    several observations from my experience

    1) all you need to function effectively are your patient list, a pen, the pocket pharmocopia, and a beeper list for your attendings. Everything else stethoscope, Wash. Manual, etc... just weight you down or get lost. I finally gave in this year & got a PDA which serves as my beeper list/drug book.

    2) tachycardia is an early sign of a problem.

    3) Always start off when you assess someone..."what is the worst possible thing that could be going on" (bleeding, leaking anastamosis, intraabdominal abscess, etc...)

    4) no amount of evening rounds will save you annoying phone calls

    5)nurses can make your life on call worse than you can make theirs so be nice. They will be passive-aggressive against you if you piss them off.

    6) be skeptical of radiologist interpretations- they don't have the benefit of any clinical correlation. You will get burned multiple times if you blindly listen to their reports

    7) expect the wrong diagnosis when you get consulted in the E.D., you'll be less disappointed this way

    8) nobody @ the VA ever has a simple problem, RLQ pain is never appendicitis, its _________ (perforated colon CA, right sided diverticuli, & any # of other rare problems)
     
  20. Winged Scapula

    Winged Scapula Cougariffic!
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    droliver makes a great point which I should have clarified in my earlier post - while I believe rounding or at least checking in on your patients before going to bed can head off *some* calls, he is right in that there is nothing you can do to avoid them all.

    If the nurses like you, they *will* page you less but always, always expect to leave the floor and be paged - wail into the phone, "but I was JUST there!!!!" As a more senior resident he perhaps has the luxury of not carrying a stethoscope, but I often get asked for mine by the fellow or attendings so prefer to have it (plus I can hear better with it over the cheapies hanging by the bedside).
     
  21. Whisker Barrel Cortex

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    DO consult the radiologist about a film when possible and give them the pertinent clinical history. I have heard of 2 cases of residents (both surgical) reading their own films with no help from the radiologist leading to missed diagnosis (complete obstruction in one case went 2 days without being operated on!) which can hurt or kill the patient. Just had to give the plug for the rads. :D
     
  22. surg

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    Here are the tips I give my starting interns (surgery, so we are more than a little compulsive :p )

    1) NEVER EVER LIE! (Sorry for the all caps but this is the most important) You will be tempted to lie about whether something is done, why something didn't happen, or some seemingly inconsequential bit of data that gets asked for. Don't do it. Nothing makes you lose credibility faster and has the potential to hurt patients more than lying.

    2) Write everything down. Don't depend on your memory for anything more important than what you had for dinner that day. At 2AM you will not remember if it was Mr. Jones or Mr. Jonas that needed the chest X-Ray checked.

    3) Check and double check. For example, if you order a radiologic exam, walk the requisition down yourself (or send a trustworthy associate) and get a TIME when it will be done. Make sure the nurse knows when the patient is expected to go so she will keep him on the floor around that time. Call the floor 5 minutes after the appointed time to make sure that he is gone. Check on the films and physically see them with a radiologist if at all possible. This will both ensure the best reading between the two of you since you know the patient best and he (or she) knows the film the best. Also it is a great learning experience.

    4)Help your fellow interns. Your intern class is your new family. If you want any hope of getting out at a reasonable hour, that means you need help. Don't be afraid to ask for help, but also you need to give help when asked.

    5) Be professional to the nurses. They are on your team even when they don't seem like it. Being nice to them yields benefits in lower number of nuisance pages and if they understand your care plan, they will probably carry it out better. (Plus they feed you if they like you!)

    6) Be a professional. Come to work every day ready to work. If you can't do something, say so; someone will teach you how. You are in training and working hard. People know this, but they don't always know if you are in trouble. If you are too tired/sick/toxic to do an adequate job, say so. A competent senior/chief/fellow intern will send you to take a nap if at all possible or even send you home if you aren't needed.

    That's probably the top six that sprung to mind. I know there are more, just can't think of them at the moment.
     
  23. surg

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    Oh, one more. Can't believe I forgot:

    7) In the words of one of my chiefs when I was an intern. "Call me if you need me, need me if you call me." If you are in doubt about a patient or what to do, CALL your senior! That's what they are there for. You are in the 1st year of training. There is no shame in calling for help. You want to learn to do things on your own, but remember, if you don't call and make the wrong decision, it is the patient who suffers. Most seniors/chiefs would rather get called one too many times than one too few.
     
  24. Winged Scapula

    Winged Scapula Cougariffic!
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    In reference to surg's last post - I can't believe he didn't include the phrase, "Calling is a sign of weakness, but if you don't call me when you should, you're deadmeat (or insert some other insult). :D

    Another thing - PLEASE be on time - this goes for fellow interns AND Chiefs. I wasted 18 hours of sleep a few months back because we didn't round until the entire team was present and 1 senior was consistently 45 minutes late each morning. Could I show up 45 minutes late? No...he would have been on time, of course. However, nothing is more frustrating than when you are on service with another intern who cruises in just before rounds, leaving you scrambling to get charts together, collect vital signs, look up labs, etc. Besides being rude, its unprofessional and doesn't look good on an intern level.

    Surg is absolutely right about not leaving anything to chance. I learned that just because I write an order doesn't mean it will be done - we call them "suggestions" here! <img border="0" title="" alt="[Wink]" src="wink.gif" /> If it is imperative that something be done in a timely fashion, check and recheck to make sure it was. You Chief will not accept the answer "I ordered it" if something wasn't done. Its your responsibility to make sure it was done (ie, lab tests, radiological study, PT Consult, etc.) AND to know the results. Before evening rounds, make sure you read the notes of consulting teams/allied health practitioners so you are aware of what's happened with the patient and what others are thinking about him and her.
     
  25. NuMD97

    NuMD97 Senior Member

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    Many of the suggestions noted previously are very helpful. Not only reading what the consultants write, but if you're on a medicine unit (I can't speak for the other specialties), it is IMPERATIVE that you, the intern, carry forth the orders that they suggest. Afterall, it was your team that consulted them in the first place. Nothing irritates these consultants more than being consulted and then not having their orders carried forth. Pre-rounding includes reading these important notes as well as those of the attending(s) assigned to your team. Since they usually round late, after you have already gone for the day, it is important that you check their notes as well, first thing in the morning. Vitals and "eye-balling" the patient before actually examining them, as part of pre-rounding, is important as well. Also check to see what emergencies developed overnight that you must be aware of. Your resident is going to want to know about these cases first as you "set the day" with your resident and team.

    If you are the medical intern, it helps to keep a flow sheet on each patient, which will include all their lab data (this helps if you need to spot trends that need to be brought to the attention of the senior staff), vitals, etc., as well as all orders needed to be carried out daily. This will give you a "thumbnail sketch" of the patient's progress. Everyone uses a different system, find one that works well for you. Organization is key to the first year since you, the intern, are responsible for the minutest of details. Check a small pocket paperback like the "Intern's Survival Guide" which offers a lot of helpful suggestions.

    Good luck. :)
     
  26. surg

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    Hey now Kimberli! "Calling is a sign of weakness" is definitely not the same as "need me if you call me" One implies, never call, the other implies that you should call if when you need help, but you don't have to call if you don't need help. I know you meant it as a joke, but when my chief told me that, I never took it as an insult, but a vote a confidence that I knew enough to do the right thing. Maybe I'll have to stop using the phrase! :( *sigh* and I always liked it so much!
     
  27. Winged Scapula

    Winged Scapula Cougariffic!
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by surg:
    <strong>Hey now Kimberli! "Calling is a sign of weakness" is definitely not the same as "need me if you call me" One implies, never call, the other implies that you should call if when you need help, but you don't have to call if you don't need help. I know you meant it as a joke, but when my chief told me that, I never took it as an insult, but a vote a confidence that I knew enough to do the right thing. Maybe I'll have to stop using the phrase! :( *sigh* and I always liked it so much!</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">I agree - the two phrases are very different in sentiment. While early on, our Chiefs may have checked in frequently, now they expect that we call them if we need them, but need them if we call them. I will admit the phrase "calling is a sign of weakness" has been bandied about here, and perhaps I have occasionally taken it too seriously. Feel free to continue to use your favorite phrase! <img border="0" title="" alt="[Wink]" src="wink.gif" />
     
  28. Devdas

    Devdas Senior Member

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    Folks,

    Just one more advice!
    If you are a surgical intern, please go to restroom before entering the Operating room.
    You will never regret for this.

    Kimberli..How could you forget to give this most important tip? :D
     
  29. Winged Scapula

    Winged Scapula Cougariffic!
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by James Bond 007:
    <strong>Folks,

    Just one more advice!
    If you are a surgical intern, please go to restroom before entering the Operating room.
    You will never regret for this.

    Kimberli..How could you forget to give this most important tip? :D </strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Uhmmm...because I'm so infrequently in the OR that it didn't occur to me?! <img border="0" title="" alt="[Wink]" src="wink.gif" />

    Besides, I figured everyone learned this during medical school.
     
  30. Careofme

    Careofme Senior Member

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    Is it true that a lot of TYPs are both ACGME & AOA approved? I have been noticing this and just wanted to make sure I was making a correct generalization.

    If they are approved by both, then this would probably be the best way for a DO to go if he/she wishes to keep AOA happy while doing an Allopathic residency, right?

    People usually match for their post-TYP program at the same time that they get their TYP (and some dont), right?

    Thanks, (right? )

    Careofme
     
  31. Devdas

    Devdas Senior Member

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    Kimberli said </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif"> Uhmmm..I'm so infrequently in the OR..that it didn't occur to me <img border="0" title="" alt="[Wink]" src="wink.gif" /> </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Are you trying to say that you are an 'OUT'standing surgeon? <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" /> <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" />
     
  32. saori

    saori Senior Member

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    I rarely post in this forum, but I thought that most of these suggestions are wonderful and applicable to the system I'm submitted to.

    I agree wholeheartedly that nurses are allies and also that they should be kept at safe distance (nice, polite, cordial, but not overly friendly).

    As for myself, I am doing my 8 week rotation in Medicine (we'll do 8 weeks of Surgery, 8 weeks Social Clinics, 8 OB/GYN, 8 Pedes, and 4 Trauma and 4 Psych). I know that this system seems odd, but we have to give one year of community service to the Government after graduation, otherwise, we may not work as physicians. This last year (Pasantia) is performed in the most inhumane conditions (think wooden hut in the middle of nowhere) and your skills are the ones that get you through it.

    Some of the things that I've found helpful:

    * Learn how to draw blood. I know it sounds overly simple and even obvious, but when you get used to having nurses and lab techs drawing samples, we tend to get rusty.

    * Practice inserting Foleys. Although nurses are supposed to do this, you never know when they'll rebel and leave you to do it (nurses went on strike a couple of weeks ago, leaving us with all their work and then some - fortunately, they came back the same day...).

    * Because of hospital administration, needles and other materials are not usually kept in the wards and we carry as much stuff as possible in our coat pockets (test tubes, syringes, angiocaths, etc.) This helps prevent a last-minute rush.

    * WRITE EVERYTHING DOWN!

    * Even as you've been asigned the most loathesome of tasks by your senior, don't forget to SMILE at your patient. They are the ones that count!

    * Check the diet orders on each patient. True story (happened to me 2 days ago): Chart reads: "Low-sodium, Low-protein diet" Patient had a spoonful of a hearty chicken soup headed stright toward her mouth (diabetic and with kidney failure to boot) and I almost had to knock the spoon off her hand. Apparently someone had forgotten to tell the patient's relatives of her diet restrictions and they were about to feed her with every single thing she was not allowed to eat. BEWARE OF PATIENT'S RELATIVES SMUGGLING FOOD INTO THE HOSPITAL.

    This is just based on my experience here. I'm sure most of you won't run into any of these situations, but if you ever service an underdeveloped country, these are rules to live by!
     
  33. carddr

    carddr Senior Member

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    <img border="0" title="" alt="[Wink]" src="wink.gif" />
    Saori: you are so right... (interesting how everyone assumes procedures are for only USA hospitals, this is the INTERNET!!)
    I would only add one thing, on your thirdworld OB-GYN rotation be prepared to deliver lots of babies!!!(I had the privilege of bringing 20 newborns into the world on this rotation, not something everyone in the states has an opportunity to do.) Great experience...
     
  34. Wheazer0

    Wheazer0 New Member

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    Just wanted to resurrect a valuable thread.

    Also looking for tips, suggestions, survival skills for EM resident-to-be.

    Any comments on medicine call, trauma and trauma call?

    Must have intern books other than wash manual?

    Here is a link to a post on the EMRA forum:

    <a href="http://www.emra.org/forums/messageview.cfm?catid=8&threadid=54" target="_blank">http://www.emra.org/forums/messageview.cfm?catid=8&threadid=54</a>

    Thanks
    Wheazer
     

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