Mistakes to avoid as an intern

[Pili]

It seems that the same mistakes are made year after year by interns. It should be easy to warn us so that the wheel does not have to be reinvented each year, but nobody teaches us.
Please share mistakes you have seen made that you yourself would have made had you not been warned beforehand.
I'll start:

1. Making sure the bag is connected to oxygen before bagging a patient (I know I would have been bagging away just like the intern, and was glad was only observing (and taking note) when the intern was ripped to pieces by the attending)
2. Remembering to write prn orders (intern getting calls at 2 am, 3 am for tylenol and such)
3. Making sure that patient that looks sleepy is not actually oversedated and on the verge of death by respiratory depression.

Please share your pearls or we'll all fall in the same traps in a few months.

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[JR]

4. Be nice to nurses- this will go a long way! Remember, they can make your life easier or harder. Also realize most nurses know much more then you do about practical managemant of pts. At times you will get calls at 3 am with dumb questions; don't get mad or scream- it's not worth it. It is also a good excersise of self-restraint.

 

[bigtuna]

#1 Mistake - worrying about your intern year and reading like crazy between now and when your intern year starts.

 

[Spoonman2332]

1. Know the chain of command. If a senior prefers to know about subacute things before you call the attending, respect that rule.
2. Treat med students well. A sub-I who is "with it" can be a godsend to a frazzeled intern.
3. When a patient comes in and you've got to decide what meds to continue and there are 8000 med lists with the patient from nursing homes, outside hospital, home (all having different doses and schedules); check with the patient, if responsive, and call their pharmacy like walgreens to figure out what they are actually on and when they had stuff filled.
4. On that same note, befriend pharmacy and respiratory therapists as often they know quite a bit more about antimicrobials and vent settings than we do.
5. Avoid verbal orders at all costs. It's so much easier to justify the things you do the next morning if you've actually gotten out of bed and assessed the patient yourself.
6. Learn how to call a consult. I was told this by many fellows:
"It's alright to say that you 'don't know.' That's why you're calling the consult. But that doesn't excuse you from completing as much of the work-up as possible; i.e. you probably shouldn't call GI if you haven't done elemenary things like a rectal and FOBT yourself. Get in the habit of determining the clinical question you'd like to be answered and your life becomes easier."
7. Ignore radiology reports and view the films yourself. Go down to radiology and read the films with somebody when you can't figure it out yourself. Just because its transcribed doesn't mean its true.
8. Learn nurses' first names.
9. Do a good job of signing out patients when you leave for the day. How many times have you cursed the intern who signed out "nothing to do" on a patient that ended up crumping and tying up your whole night?
10. Try not to make the same mistake twice.

 

[pretzel]

Mistake I made about meds upon discharge, when they cannot communicate -- find out first which meds they already have filled, so they don't take two doses of the same med from two different bottles, and so they don't keep taking meds from home that you have discontinued.

 

[dcdo]

Regarding consults-

Have a concise 2 or 3 line presentation, and specifically state what the question is for the consult. Fellows will get PO'd if you ramble on and on without getting to the point, then you spend the rest of the year having to prove that you're not a *****.

Of course you will have some sympathetic fellows who remember what it was like to be an intern, so remember to appreciate them.

 

[Kerropi]

3. Making sure that patient that looks sleepy is not actually oversedated and on the verge of death by respiratory depression.

--And make sure to check their blood sugar as well.

 

[Hotsauce21]

-Although this is not my style, I admit that if you can cite some of the most recent literature, it will help your cause. I hate saying this, because patient care comes first, talking to families, etc, but this is something the attg will remember.

-If you do blood draws, remember to take the tourniquet off. =)
-Get into the habit of being able to present by memory as much as you can. Dont memorize, mind you. But your presentation should be familiar enough where you could hit the main points without looking at your card.

-Agreed on following chain of command. Do this.
-Agreed on the consults advice. Dont waffle getting to the point, and do as much research as you can (keep it to 5-10 minutes) beforehand so you know the patient.
-Agreed on treating nurses with respect.

Also, be thorough but not slow. Everyone hates slow people.

###Always present the most important problems FIRST in your assessment and plan. Make sure you have worked out the major issues, before you indulge in the smaller. Even if you have worked out someones b12 deficiency, keep it on #4 on your problem list. Save your "PPI, SCD's for prophy" last, or better yet, dont include it unless they ask.

###Keep your antenna up for subtle findings that in reality, arent that subtle. For instance, someone breathing 30 times a minute is NOT NORMAL. Someone who's crit dropped 6 points (even if its still 33) is NOT NORMAL. Someone who's confused, even slightly, is NOT NORMAL. DON'T disregard slight fevers. You'll need to raise your level of suspicion on some things. It takes experience, but fyi.

Finally, clearly state your problem list and what you are going to do about it.

Oh, and last thing....*trust yourself* if something doesnt seem right, it probably isnt. Trust your instincts, and ask questions until you are satisfied.

 

[irlandesa]

EXCELLENT ADVICE.. Most of the residents I've worked with have said similar things. A few extras:

1)Don't be afraid to ask for help, your junior/senior residents and attendings are there for leadership and support, not to kick you around. If you don't know something or make a mistake, 'fess up and try to fix it as best you can.
2)Can not agree enough about treating med students respectfully. Be clear on what is expected of them, give constructive criticism in person, and if you are teaching them to do a procedure, provide clear instruction so that neither student nor patient is overly nervous/uncomfortable.
3)Agree with the statement regarding radiology reports, and write down the EKG findings as you see them, not as the med student or original admitting team saw them.
4)Even if you plan on specializing or are doing a dual program (Med-Peds, Med-Psych, etc.), keep up with your basic primary care skills. I saw a child psych(triple board) resident once who scared the hell out of a parent and kid b/c she couldn't tell the difference between a big gob of earwax and an inflammed TM.
5)Leave your baggage at the door when you come to work. For example, a single intern who has been on duty for 24+ hours caring for 12 critically ill patients will likely not take kindly to hearing about how stressed out you are about planning your 500 guest wedding on Nantucket. And what's in the past is best left in the past, like some of the crappy things that happened to you in med school (remind me to keep my big mouth shut about this).
6)Try to dictate your d/c summaries on the same day you d/c a patient, or even the night before, otherwise you end up playing catch up and even going to medical records when you could be sleeping or going to noon conference (food!).

 

[VentdependenT]

Bring a tiny violin to play for yourself when you have your 7th admission from overflow onto your packed unit after working all day and being on the 24th hour of your 31 hour on call shift which you've only slept 5 minutes on. Get used to playing it for yourself because nobody else wants to hear it.

Other than that have a blast!

 

[retroviridae]

post-match, this is on my mind. So I am bringing it back up! Any more thoughts?

 

[not-on-fire]

This is in the same vein as one of the OP's points, but is pretty important: if your patient (with baseline hypoxia) starts to have respiratory decompensation and starts to drop his oxygen saturation precipitously and it doesn't move the slightest despite turning the oxygen all the way up (nasal cannula while waiting for face mask), it's a good idea to make sure the nasal cannula tubing is actually connected to the wall. It's even better if you check this before getting your upper level involved and making arrangements to transfer to the ICU. That way, you can avoid the embarassment of greeting the ICU resident outside the patient's door with "Turns out he breathes and sats much better with the oxgen turned ON." Oh dear...
Poor patient: Tachypneic, uncomfortable, being asked whether he would want to be intubated, people running around him - then, after the oxgen was connected, "Hey, I feel so much better!"

 

[lurkerboy]

sometimes you might think that the oxygen is connected, but they are actually hooked up to the "air" nozzle, which is sometimes used for nebs but could easily be mixed up.

This is in the same vein as one of the OP's points, but is pretty important: if your patient (with baseline hypoxia) starts to have respiratory decompensation and starts to drop his oxygen saturation precipitously and it doesn't move the slightest despite turning the oxygen all the way up (nasal cannula while waiting for face mask), it's a good idea to make sure the nasal cannula tubing is actually connected to the wall. It's even better if you check this before getting your upper level involved and making arrangements to transfer to the ICU. That way, you can avoid the embarassment of greeting the ICU resident outside the patient's door with "Turns out he breathes and sats much better with the oxgen turned ON." Oh dear...
Poor patient: Tachypneic, uncomfortable, being asked whether he would want to be intubated, people running around him - then, after the oxgen was connected, "Hey, I feel so much better!"