Is there a thread for people who are terrified?

[gutonc]

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Best rotations for a 4th year student before internship? I have an ICU scheduled and some more medicine auditions. Haven't scheduled anything for blocks in jan-april.

What specialty?

A good rads elective is helpful for most specialties. Besides that and ICU I'd spend the rest of my time sleeping and drinking.

 

[Trogghunter]

Cardiology, but I want to learn some things that I can't read about---see an interesting mix. I've done a cardio consult and have cardiothoracic coming up.

 

[Buzz Me]

-Never lie (and never document something you didn't actually do).

I will reiterate this. No one goes into residency thinking they're going to lie, and for the most part, no one tells big lies.

But those little ones can add up.

For example, when documenting the physical exam, please remember you're no longer being "graded" (in the same way you were in med school) and it's more important to be accurate and truthful than complete. I don't know how many times I've seen the following on the daily physical exam in SOAP notes:

A&O x3 (really? every day you ask the patient what year it is, and where they're located? I think not)

CN II - XII intact (NO ONE, outside of maybe neurology, checks 11 cranial nerves daily)

Strength 5/5 UE/LE, etc. - don't document that you checked 16 muscle groups if you didn't

Wound - please look at the wound if you're going to describe it. Same goes for the dressing. Many people barely lift the sheets off the patient, let alone look under their gown. I've seen primary teams write "dressing C/D/I" on patients that we've examined and have bloody, saturated dressings, or "wound C/D/I" on patients with pussed-out wound infections

 

[Perrotfish]

I will reiterate this. No one goes into residency thinking they're going to lie, and for the most part, no one tells big lies.

But those little ones can add up.

For example, when documenting the physical exam, please remember you're no longer being "graded" (in the same way you were in med school) and it's more important to be accurate and truthful than complete. I don't know how many times I've seen the following on the daily physical exam in SOAP notes:

A&O x3 (really? every day you ask the patient what year it is, and where they're located? I think not)

CN II - XII intact (NO ONE, outside of maybe neurology, checks 11 cranial nerves daily)

Strength 5/5 UE/LE, etc. - don't document that you checked 16 muscle groups if you didn't

Wound - please look at the wound if you're going to describe it. Same goes for the dressing. Many people barely lift the sheets off the patient, let alone look under their gown. I've seen primary teams write "dressing C/D/I" on patients that we've examined and have bloody, saturated dressings, or "wound C/D/I" on patients with pussed-out wound infections

I check CN III-XII on most patients daily. H movement of the eyes, shine a light in the eyes, touch both sides of the face (same on both sides?), smile, stick your tongue out and say ah, and shrug. It take less than 30 seconds

 

[Stellar Clouds]

Best rotations for a 4th year student before internship? I have an ICU scheduled and some more medicine auditions. Haven't scheduled anything for blocks in jan-april.

Vacation.

 

[gutonc]

Cardiology, but I want to learn some things that I can't read about---see an interesting mix. I've done a cardio consult and have cardiothoracic coming up.

I assume you mean IM unless you've gotten into one of those super rare Cardiology residencies.

Anyhoo...do your ICU month and then take a 4 month nap. Done and done.

 

[Buzz Me]

I check CN III-XII on most patients daily. H movement of the eyes, shine a light in the eyes, touch both sides of the face (same on both sides?), smile, stick your tongue out and say ah, and shrug. It take less than 30 seconds

That's good - keep it up!

Many people don't do this. I've seen people write "CN II-XII intact" yet when I ask them for a penlight they look embarrassed and walk away. Or they document it on the intubated and sedated patient.

 

[45408]

Strength 5/5 UE/LE, etc. - don't document that you checked 16 muscle groups if you didn't

Wound - please look at the wound if you're going to describe it. Same goes for the dressing. Many people barely lift the sheets off the patient, let alone look under their gown. I've seen primary teams write "dressing C/D/I" on patients that we've examined and have bloody, saturated dressings, or "wound C/D/I" on patients with pussed-out wound infections

For upper/lower extremity strength, unless you say "biceps, triceps, pronation, supination, intrinsic digits" etc, most people will assume you did a pretty brief exam. I'm just making sure they're not stroking out....

And to be fair, you can have a raging wound infection with an incision that is c/d/i 😀 now, if there's pus dripping out, then that's neither clean nor dry...

I check CN III-XII on most patients daily. H movement of the eyes, shine a light in the eyes, touch both sides of the face (same on both sides?), smile, stick your tongue out and say ah, and shrug. It take less than 30 seconds

why do you check them daily? just curious. Most people aren't going to develop a brainstem lesion in isolation during their admission.

 

[Bacchus]

For upper/lower extremity strength, unless you say "biceps, triceps, pronation, supination, intrinsic digits" etc, most people will assume you did a pretty brief exam. I'm just making sure they're not stroking out....

And to be fair, you can have a raging wound infection with an incision that is c/d/i 😀 now, if there's pus dripping out, then that's neither clean nor dry...


why do you check them daily? just curious. Most people aren't going to develop a brainstem lesion in isolation during their admission.

I can't believe I'm asking this, but I should because either no one actually read notes I put this in or its accepted (which I think is not the case).

For the MSK strength testing is it appropriate to put gross motor function and strength intact?

As in the patient can lift their legs against my resistance and are able to move them.

 

[singinfifi]

You are not alone. I'm pretty sure that anyone who tells you they weren't scared was either lying to you or not paying attention.

This is heavy stuff. This is people's lives, their families. It's good to be scared, caution can help you stay sharp and that's fine, you just have to learn not to let it control you.

Senior residents are great assets. Honestly, so are attendings. Don't be afraid to ask questions and above all, don't be afraid to say "I don't know". Be "that guy" who is always willing to help out your seniors and fellow interns. Don't be the jerk who always has to be the first one out the door. If you feel overwhelmed, say so. Tell a trusted mentor or an advisor. It's ok, we've all been there.

• *Don't be late
• *Don't ask when you can leave.
• * If your'e in a regular internship year with electives in sub specialties treat every one of them like that is YOUR specialty. Go to clinic, get interested.
• * Don't lie. Please, don't lie. I'm lucky, none of my co-interns in my program do this, but I've seen residents do it. "The troponins are negative" (read: they weren't ordered or I didn't check them). It's bad for your team, it's bad for you, it's bad for your attending and most importantly, it's bad for your patients.
• * Patient care comes first. Always.
• * When you place a line check the x-ray yourself. Every time. Even if you don't know what your looking at (get a senior to help you). Do not place a central line and sign it out for the night team to "follow up on"
• * Always give "if then" statements in your sign out "If the potassium is above 6 then give glucose, D5W, Kayexylate 60, Calcium and get an EKG" Don't say/write things like "f/u PM Potassium level".
• * Stop and remember why you went into medicine in the first place. Yeah, it's hard to think about when it's 3am and your'e in the ICU and alarms are beeping and nurses are bringing things to your attention that have been EXACTLY THE SAME all day but for some reason at 3am they decide to ask you if you want to bolus the patient because she's tachycardic at 104, and it's been worked up...extensively...(this may have happened to me last night lol) but even at that moment, when you can't imagine why in the world you've landed where you landed, if you take a step back and think about it, you'll realize you're exactly where you want to be and it feels pretty amazing (that works for me anyway, I hope it does for you too 🙂 ).
• * Take time for yourself. Guard your free time. It's OK to say no to social outings and stay in once in a while.
• * Don't lose sight of yourself. This goes with the last one. Make time for your hobbies, your interests.
• * Don't doubt that you belong where you are. You've worked hard, you're going to continue to work hard, but your job? It's amazing. Enjoy it. Be confident that eventhough you don't know everything (and no, you don't) you have the capacity to learn.
• * Stand up for yourself, when appropriate. You don't think a patient is ready to be discharged and case management is on your case (ha! see what I did there?). Say something. You disagree with a treatment plan? Ok maybe don't "stand up for yourself" to your attending, but it is ABSOLUTELY appropriate to ask why an attending is doing something if you don't understand (NOT in an accusatory way, in a "I want to learn your thought process way).
• * Be nice to nurses. Even the ones at 3am who suddenly notice the tachycardia that's been there for 2 days. They will save you. They will support you, they will fight for you and they will ALWAYS be your first line of information about your patient. Trust them, be good to them. Chances are they know more than you do right now. Don't take them for granted and don't snap at them. If you do snap, apologize (we all get a bit edgy sometimes).

I hope all of you love your intern years as much as I did. If I can ever help any of you with anything, please. Drop me a note 🙂

-C

 

[danielmd06]

I can't believe I'm asking this, but I should because either no one actually read notes I put this in or its accepted (which I think is not the case).

For the MSK strength testing is it appropriate to put gross motor function and strength intact?

As in the patient can lift their legs against my resistance and are able to move them.

For the neurological exam, it's best just to write in plain English exactly what you did or observed. Avoid abbreviations and acronyms. This goes for the cranial nerves, too.

In your case, just write that the patient could lift his/her legs off the bed without resistance or with you giving slight/moderate/heavy resistance. As a pearl, it's always easy to use gravity rather than your own strength to oppose the patient's muscles. You'll pick up subtle drift that way. And your (and the patient's) strength can be a variable quantity anyway. If you want to check specific muscle groups, I would write the muscle and the 0/5 up to 5/5 strength score that you get.

 

[Dejavu]

SinginFiFi said...

"•* Be nice to nurses. Even the ones at 3am who suddenly notice the tachycardia that's been there for 2 days. They will save you. They will support you, they will fight for you and they will ALWAYS be your first line of information about your patient. Trust them, be good to them. Chances are they know more than you do right now. Don't take them for granted and don't snap at them. If you do snap, apologize (we all get a bit edgy sometimes). "

I cannot agree more. One of the smartest things I ever did was to figure out where the dictation secretaries' offices were and I took them some lemon bars early in my internship year. Boy, I was gold with them forever more. No-one had ever done that, ever.

The same is true for nurses. Take them some homemade treats or something while doing early rounding or the evening shift or both.

Of course, chocolate chip cookies won't make up for being a jerk.

They will remember who took the time to think of them, when it comes time to decide "should I wake him up for the Tylenol order or just wait til morning".

Plus, they do have a feel for when a pt just doesn't seem right. Listen to that. Even if they cannot explain it, it is worth looking into.

 

[Mr hawkings]

SinginFiFi said...
"

I cannot agree more. One of the smartest things I ever did was to figure out where the dictation secretaries' offices were and I took them some lemon bars early in my internship year. Boy, I was gold with them forever more. No-one had ever done that, ever.

The same is true for nurses. Take them some homemade treats or something while doing early rounding or the evening shift or both.

Of course, chocolate chip cookies won't make up for being a jerk.

They will remember who took the time to think of them, when it comes time to decide "should I wake him up for the Tylenol order or just wait til morning".

.

Can someone also tell them to have some patience for us dumb interns in July and August since we would only have been doctors for weeks at that point.
Can we all just be nice to each other?

 

[gutonc]

Can someone also tell them to have some patience for us dumb interns in July and August since we would only have been doctors for weeks at that point.
Can we all just be nice to each other?

The good ones will be. The bad ones will make your life suck next May just as much as they will this July.

 

[Buzz Me]

Can we all just be nice to each other?

If only it were that easy!...