July 1st!!!

takeurmeds02

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Intern here officially starting tomorrow in the ED.

Looking for sage advice to kick off my career while trying not to freak out about ordering Tylenol haha. What makes a great EM intern??
 
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WilcoWorld

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Intern here officially starting tomorrow in the ED.

Looking for sage advice to kick off my career while trying not to freak out about ordering Tylenol haha. What makes a great EM intern??

Think worst first (e.g.: don't say "It's GERD" say "I've considered MI and AAA, but I think it's GERD because XYZ...").

The best treatment for exsanguination is direct pressure.

Don't try not to freak out, because you're going to freak out. If EM doesn't freak you out occasionally, you're not paying attention.

Also the "answer to the Ultimate Question of Life, the Universe, and Everything" is 42.

Most of all: This too shall pass. The fact that you're worrying means that you're taking it seriously - that's good! You matched, so you've got "what it takes", just treat everyone (especially the patients and the nurses) with respect, and everything else will work out.
 
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First impressions matter. Whatever happens, just be nice to people. ESPECIALLY THE NURSES. I don't know what it is about the nursing profession, they will hold a grudge against you for something you did when you were an intern for your entire residency. It is not worth the misery. I have classmates who experienced this, and they can make your life a living hell.

Agree with ask for help. Saying "I don't know" will keep your patients safer than anything else you can do at this point in your training.

Understand and accept that you are not supposed to know everything. In fact, you are supposed to know ZERO. Everyone else who works with you has accepted that, so don't put unnecessary pressure on yourself. There is nothing more terrifying for your higher ups than an intern who thinks they know all the answers.

Make sure your damn login to the EMR works before you start your shift. Show up early if you have to.

Don't get bogged down writing excessively long notes. This is IMO the number 1 reason for lack of efficiency in interns. Understand what you need for billing, communicate your general thought process in your medical decision making. But let go of the med school H&P, it has no role in the ED.

Shoot for 1 patient an hour during your intern year. On your first day, it'll probably be 1 patient every 2 hours. That's okay, you are not there to move the pod.

You will feel crushed with stress at some point over trivial things. Try to have fun, laugh, enjoy the camaraderie with your fellow residents and your seniors.

COMMIT TO THINGS VERBALLY, even if they are wrong. When you present to your attending, DON'T HEDGE. We are in the business of making decisions. Practice being okay with being uncomfortable, and be okay with being wrong. It will happen a lot this year, and throughout your career.

Develop relationships with the consulting residents. Don't let them push you around, but if you can make their life easier, try to if possible, it will pay dividends throughout your training as you continue to work with them. Some of them will be total d-bags regardless of what you do, don't lose sleep over it.
 
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hoot504

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First impressions do matter, and while that's probably not helping your nerves right now, I would say that it's pretty hard to leave a memorably bad impression as an intern. We're talking only the most arrogant and unpleasant of interns, usually.

I think you should realize, if you haven't already, that you are not going to be good at this job for a goooood long while. It takes literally thousands of patients to start feeling like you even belong at the bedside, let alone the time and experience it takes to gather the requisite knowledge. I think that most residents start to gain a modicum of genuine, earned confidence somewhere around beginning of 3rd year, give or take up to about 6 months depending on who you are.

Until then, you're in for a wild ride. Embrace it.

Edit: Learn people's names. Everyone's. Don't be obnoxious about it, but if you're able to say hello to the custodial services guy at 3am by name, you will generally get some good karma coming your way, and you'll be surprised how few people do this.
 
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CJack

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New attending myself, so take what I say with a grain of salt, obvs. But I too remember the crippling irraitonal anxiety I felt when signing my first official prescription (for tylenol, lol)
1. Be humble. Interns/residents (and hell, attendings for that matter) win me over when they know what they don't know and find answers. I'll take the nervous intern who wants to check the appropriate weight-based motrin dosing for a kido over the arrogant guy who confidently mega-over doses an insulin bolus any day of the week
2. set shift goals- and state these at the beginning of your shift to yr seniors/attendings. can be as broad as "i don't want to kill ppl" or specific like "I want to get better at reading EKGs or "want to get better at flow/efficiency". Sharing these at the outset allows yr supervisors to observe you with that goal in mind and be in a better posiition to offer you concrete suggestions for improvement. At the end of your sift, ask yr senior/attending "what do you think I should work on on my next ****?" so they have awkwardless means to suggest some concrete things you could be working on
3. don't lie or overstate your abilities- this may sound obvious, but we've all been in situation when attending asks something we're pretty sure "has patient had fever" and we didn't ask, and its real tempting to say "no" even though we didn't ask when we think it doesn't reeeeeaaally matter . just say "I'm not sure, but I'll find out". with procedures, you can say (if true), "I've read about this procedure but have never done, can you talk me through it before hand or be with me when I do it?" Bonus is you get points w/attending for self-awareness/scrupulous honesty
4. Try to learn everyone's names, but after introduction totes fair to say "But i'm learning a lot of names these days, so forgive me if I forget it a few more times, you can forget my name too!"
5. try to develop a culture with your co-residents of sharing your f*ck ups. we all make mistakes, and hearing other peoples' normalizes this universal fallibility and mitigates the shame-cycle that can ensue after you invariably make multiple (hopeful minor, but sometimes major!) mistakes
6. your nurses and many techs are your friends and saviors. they know you are green and will save your butts. communicate with them often. say for example, "hey, I was going to order labs and some torodol and if he's still really hurting or there's lab abnormalities, we'll get a CT scan. does that sound reasonable to you?" or "I want to take this guy's complaint seriously but I'm getting a major drug-seeking vibe off this guy, what do you think?" Give them lots of opportunities to share their clinical wisdom, so you can add it to your own
7. take some time before your first shift to learn locations and logistics of frequently requested or potentially time sensitive items, like urinals/blankets and various oxygen delivery devices (NC, ambu bag), telemonitors so that when **** goes down, you don't have to go find someone who knows where/how
8. Charting burden can destroy your life/sanity. invest the time in developing (or stealing) dot phrases
9. Take care of yourself. You, like all of us, will f&ck up, and feel horrible when it results in badness. Clinical situations will be sad and frustrating. Ppl (patients, staff, consultants, attendings) will be jerks. Be kind to yourself
 
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TheSingularity

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1) Don't f****** lie. If you lie I will never trust you again.

2) Don't be lazy. If the Hb is 5, come to me with the rectal exam results, don't make me ask for it.

3) Be receptive to learning.

4) Don't argue over every damn thing. Yes, the 80 yo with abdominal pain and fever needs a CT. Yes, the 50 yo smoker with chest pain needs a rule out.

5) Respect the nurses but don't take crap from them. Stand up for yourself. That goes for you new attendings too. Stand up for your residents!

6) Be able to shoot the s*** and have a conversation about a non medical topic.
 
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Mr. Vandemar

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1) Don't f****** lie. If you lie I will never trust you again.

2) Don't be lazy. If the Hb is 5, come to me with the rectal exam results, don't make me ask for it.

3) Be receptive to learning.

4) Don't argue over every damn thing. Yes, the 80 yo with abdominal pain and fever needs a CT. Yes, the 50 yo smoker with chest pain needs a rule out.

5) Respect the nurses but don't take crap from them. Stand up for yourself. That goes for you new attendings too. Stand up for your residents!

6) Be able to shoot the s*** and have a conversation about a non medical topic.

You seem fun.
 
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cyanide12345678

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1) Don't f****** lie. If you lie I will never trust you again.

2) Don't be lazy. If the Hb is 5, come to me with the rectal exam results, don't make me ask for it.

3) Be receptive to learning.

4) Don't argue over every damn thing. Yes, the 80 yo with abdominal pain and fever needs a CT. Yes, the 50 yo smoker with chest pain needs a rule out.

5) Respect the nurses but don't take crap from them. Stand up for yourself. That goes for you new attendings too. Stand up for your residents!

6) Be able to shoot the s*** and have a conversation about a non medical topic.

Most 80 year old abdominal pains even without a fever should get a CT

Good advice in general though.
 
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bravotwozero

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Most 80 yo olds without abdominal pain and without fever should get a CT.

Nothing good happens when an 80 yo person comes to the ED.

Just remember that. CT is your friend.

I think that's a good thread topic in and of itself. 'Emergent CT findings in old people with vague or nonexistent complaints/exam'.
 
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Birdstrike

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Intern here officially starting tomorrow in the ED.

Looking for sage advice to kick off my career while trying not to freak out about ordering Tylenol haha. What makes a great EM intern??
Just work hard, do your best and you'll be fine. If you had what it takes to get this far, you've got what it takes to get through the rest of your training. Have fun and enjoy the ride!
 
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Regarding all the people who’ve said to pick attendings brains and ask for help - what do y’all do when your attending doesn’t seem to want to teach/want you around?

I’ve had a couple shifts now where the attendings really just seem frustrated with having to supervise a new intern...to the point of just having me follow them around, watch them take a history/examine the patient, then put in the orders, document, and “please Dont bother them when they’re charting.” Asking questions just kinda gets a really frustrated NOT NOW even if I do my best to tactically time my questions to a lull in the flow.

I’m a little worried that I’m so bad they’ve just given up a couple shifts in lol.
 

bravotwozero

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Regarding all the people who’ve said to pick attendings brains and ask for help - what do y’all do when your attending doesn’t seem to want to teach/want you around?

I’ve had a couple shifts now where the attendings really just seem frustrated with having to supervise a new intern...to the point of just having me follow them around, watch them take a history/examine the patient, then put in the orders, document, and “please Dont bother them when they’re charting.” Asking questions just kinda gets a really frustrated NOT NOW even if I do my best to tactically time my questions to a lull in the flow.

I’m a little worried that I’m so bad they’ve just given up a couple shifts in lol.

Don't think that's you that is the problem. Especially if other intern/residents had the same experience. If that turns out to be the case, you should bring that up when you have your quarterly/annual evaluations with your PD/APD.
 
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Buckeye1992

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Regarding all the people who’ve said to pick attendings brains and ask for help - what do y’all do when your attending doesn’t seem to want to teach/want you around?

I’ve had a couple shifts now where the attendings really just seem frustrated with having to supervise a new intern...to the point of just having me follow them around, watch them take a history/examine the patient, then put in the orders, document, and “please Dont bother them when they’re charting.” Asking questions just kinda gets a really frustrated NOT NOW even if I do my best to tactically time my questions to a lull in the flow.

I’m a little worried that I’m so bad they’ve just given up a couple shifts in lol.

Yikes I have never had an experience like that. Granted our first month we pair interns with seniors to ease them in.
 
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Every now and then an attending somehow makes it into academics who has little interest in teaching residents or even practicing medicine.

Sometimes the lesson to learn is who not too emulate.
As I've said many a time, "some animals have to live in the zoo, because they can't exist in the real world". A lazy, ****bag attending is just a leech. They contribute nothing, and are often execrable people. You're absolutely right - sometimes, the lesson is "what NOT to do".
 
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cyanide12345678

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Regarding all the people who’ve said to pick attendings brains and ask for help - what do y’all do when your attending doesn’t seem to want to teach/want you around?

I’ve had a couple shifts now where the attendings really just seem frustrated with having to supervise a new intern...to the point of just having me follow them around, watch them take a history/examine the patient, then put in the orders, document, and “please Dont bother them when they’re charting.” Asking questions just kinda gets a really frustrated NOT NOW even if I do my best to tactically time my questions to a lull in the flow.

I’m a little worried that I’m so bad they’ve just given up a couple shifts in lol.

I had an absentee attending in training in intern year. It would be even a struggle to find this attending to present a patient. Sometimes as an intern I would have seen multiple patients without even having a word with the attending. Normally this particular attending wouldn't care what you did for the non sick patients, but only was available for the sick patients.

Most of the time with this particular attending, I sought advice from my 3rd years, showed them my workup, asked them if they would add anything. The 3rd years should know their stuff by now.
 
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SamtheWise

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Regarding all the people who’ve said to pick attendings brains and ask for help - what do y’all do when your attending doesn’t seem to want to teach/want you around?

I’ve had a couple shifts now where the attendings really just seem frustrated with having to supervise a new intern...to the point of just having me follow them around, watch them take a history/examine the patient, then put in the orders, document, and “please Dont bother them when they’re charting.” Asking questions just kinda gets a really frustrated NOT NOW even if I do my best to tactically time my questions to a lull in the flow.

I’m a little worried that I’m so bad they’ve just given up a couple shifts in lol.

Fill out an evaluation of that attending, and mention all that.

Advice for new interns:

It's ok to be overly conservative, yes not every intoxicated person needs a CTH, but it's ok to want to scan them all when you have no idea. Your seniors and attendings should generally reign in your plans by using their clinical experience and intuition to rule out things rather than imaging - neither of which you have.

You should spend more time with your patients than anyone else - easy to do when seeing 1 per hour, really get to know them, really make them feel listened to.

Jump on the challenging chief complaints in difficult patients, because never in your career will you have more time and more backup when seeing people, i.e. the red painful eye in a Chinese only speaking 80 year old.

If someone asks you if you want to see a new patient, the answer is never 'let me finish this note, then maybe', you drop everything and jump up and go to bedside.

Hang out with the nurses and techs, ask to do peripheral IVs. They'll love feeling like they're teaching you something, and this is a handy skill to have throughout residency.

Most of all, try and have fun. Show up early, stay late, smile often, and never seem bogged down or stressed and people will respond well to you.
 

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Fill out an evaluation of that attending, and mention all that.

Advice for new interns:

It's ok to be overly conservative, yes not every intoxicated person needs a CTH, but it's ok to want to scan them all when you have no idea. Your seniors and attendings should generally reign in your plans by using their clinical experience and intuition to rule out things rather than imaging - neither of which you have.

You should spend more time with your patients than anyone else - easy to do when seeing 1 per hour, really get to know them, really make them feel listened to.

Jump on the challenging chief complaints in difficult patients, because never in your career will you have more time and more backup when seeing people, i.e. the red painful eye in a Chinese only speaking 80 year old.

If someone asks you if you want to see a new patient, the answer is never 'let me finish this note, then maybe', you drop everything and jump up and go to bedside.

Hang out with the nurses and techs, ask to do peripheral IVs. They'll love feeling like they're teaching you something, and this is a handy skill to have throughout residency.

Most of all, try and have fun. Show up early, stay late, smile often, and never seem bogged down or stressed and people will respond well to you.
Agree with all of the above except the peripheral IVs.

Knowing how to do an US guided peripheral is a useful skill as an attending. Placing a regular peripheral IV is something you'll never be doing as an attending, and will only be doing as a resident if you're training in NYC due to the strong nursing unions and generally abysmal nursing there.
 
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Agree with all of the above except the peripheral IVs.

Knowing how to do an US guided peripheral is a useful skill as an attending. Placing a regular peripheral IV is something you'll never be doing as an attending, and will only be doing as a resident if you're training in NYC due to the strong nursing unions and generally abysmal nursing there.

I do put them in a lot. #1 it’s fun to pwn a nurse who sucks at IVs by putting in a blind one yourself after they say the patient is “impossible”, #2 EJ from the head of the bed in a crashing patient can be quite useful, #3 on someone legitimately suffering (kidney stone etc) I’ll tell the nurse to get some pain meds while I start it.

that said it’s something I started doing later my career when I was bored.
 
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SamtheWise

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I do put them in a lot. #1 it’s fun to pwn a nurse who sucks at IVs by putting in a blind one yourself after they say the patient is “impossible”, #2 EJ from the head of the bed in a crashing patient can be quite useful, #3 on someone legitimately suffering (kidney stone etc) I’ll tell the nurse to get some pain meds while I start it.

that said it’s something I started doing later my career when I was bored.


Oh yeah it's so satisfying to put in an EJ when the nurses ask you to do an ultrasound PIV on a patient "THEY'VE ALL STUCK 3 TIMES". Plus getting semi competent at regular PIVs will make your US IVs so much easier, because the muscle memory and feel when you thread the catheter will be burned into your brain.
 
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Thank god I work at a place where I need to put in an IV maybe, at best, once every year.

It's our nurses job to put an IV in, and many are trained to do an US guided PIV too.

eh doesn’t bother me. I do it willingly, many of my partners don’t and that’s fine. When in you are in a freestanding with a small staff and you, sometimes it’s all hands on deck.
 

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Thank god I work at a place where I need to put in an IV maybe, at best, once every year.

It's our nurses job to put an IV in, and many are trained to do an US guided PIV too.
Same. I could get really good/quick at putting in foley catheters too but just like PIVs, that is also thankfully not my job.
 

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EM Doc doing US guided PIV is the same as an EM Doc removing IUDs. Do one and soon you will be asked every shift to do them or a waiting room full of IUD removals.
 
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Thank god I work at a place where I need to put in an IV maybe, at best, once every year.

It's our nurses job to put an IV in, and many are trained to do an US guided PIV too.

God, I so envy you. I'm called to get IV access at least once or twice literally every shift. It's slowly gotten worse over the past couple of years after our director caved to nursing admin pressures (I think?) and sent out an email stating that if we order labs, we are obligated to obtain the blood if nurses attempt 2 IV's and are unable. So, we get inundated with "difficult stick" complaints and are constantly having to drop what we're doing and either get plain IV access or US guided access. It's gotten so old, and I'm so sick of it. The nurses have completely lost their basic IV access skills. Some of these patients have gigantic AC veins and yet I'm still called in because it's a "difficult stick". And if it's peds? Forget about it...
 
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I do a lot of "EZ IJ's" with the US. Takes 2 mins. 1.8" angiocath. I'm pretty facile with US guided peripherals but can do an EZ IJ in half the time.

There was a whole thread about this not long ago. I don't know why this isn't practice-changing for EPs. Do we need a big-OL' study to make it standard of care?
 
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BoardingDoc

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EM Doc doing US guided PIV is the same as an EM Doc removing IUDs. Do one and soon you will be asked every shift to do them or a waiting room full of IUD removals.
I commented on this elsewhere, but your fears are easily avoided in practice. Anytime I'm asked to do an us guided PIV, I just ask that at least 3 nurses have tried to get an IV before I'll take a look and who they are. At this point the nurse either gets the IV, or the patient is clearly a nightmare vasculopath that would need a central line anyway, assuming I can't get my peripheral us guided iv.

My point is that it's a useful skill and that it only becomes a crutch for nurses if you both A: have crappy nurses and B: refuse to tell them to do their damn job before you do it.

As for the IUD thing... Not an emergency. Not my job. No one needs an iud emergently removed by me.
 
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SamtheWise

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EZ IJs are a complete game changer. I have nothing more to add beyond that. They are great lines, easy to place, and hassle free. The only thing I worry about is dropping a lung, I mean I don't worry enough not to do them, and I don't get a post placement CXR on patients with them, but it's always in the back of my mind. I definitely swing by the room and check the pt's HR and pulse ox a couple times later.
 
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