Most important/useful tidbits to know when starting Peds internship...

[StringBean]

Hey everyone.

First off, congrats to those (like me) who will be starting internship in Peds this June/July. I was thinking we could start a thread where those who have gone before us (or if you've been provided one of those GREAT little pices of info) could share some "must know" tidbits/pearls for internship. You know... just some things that we could use to make the transition a little easier... and perhaps a tad bit less scary

Thanks & good luck to all my fellow Pediatricians!

~Bean

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[Empedocles]

This is interesting, please share people!!

 

[Homunculus]

1) Befriend the nurses
2) Sepsis, Sepsis, Sepsis
3) All that wheezes is not asthma
4) Bag UA's are worthless
5) Bolus NS only
6) Abx within an hour
7) Oders before notes
8) Patients come first
9) Things change
10) Oxygen is good
11) ABC, ABC, ABC
12) Volume is your friend
13) Even the dumbest kidneys are usually smarter than the brightest doctor
14) Referring docs have altered perceptions of reality
15) Act quick, think slowly
16) Patients do not suddenly deteriorate, healthcare professionals suddenly notice

(some of these stolen from other sources)

--your friendly neighborhood sage caveman

 

[mr.annoying]

1) Befriend the nurses
2) Sepsis, Sepsis, Sepsis
3) All that wheezes is not asthma
4) Bag UA's are worthless
5) Bolus NS only
6) Abx within an hour
7) Oders before notes
8) Patients come first
9) Things change
10) Oxygen is good
11) ABC, ABC, ABC
12) Volume is your friend
13) Even the dumbest kidneys are usually smarter than the brightest doctor
14) Referring docs have altered perceptions of reality
15) Act quick, think slowly
16) Patients do not suddenly deteriorate, healthcare professionals suddenly notice

(some of these stolen from other sources)

--your friendly neighborhood sage caveman

wow those are good! I think I'll just skip intern year!

 

[Empedocles]

1) Befriend the nurses
2) Sepsis, Sepsis, Sepsis
3) All that wheezes is not asthma
4) Bag UA's are worthless
5) Bolus NS only
6) Abx within an hour
7) Oders before notes
8) Patients come first
9) Things change
10) Oxygen is good
11) ABC, ABC, ABC
12) Volume is your friend
13) Even the dumbest kidneys are usually smarter than the brightest doctor
14) Referring docs have altered perceptions of reality
15) Act quick, think slowly
16) Patients do not suddenly deteriorate, healthcare professionals suddenly notice

(some of these stolen from other sources)

--your friendly neighborhood sage caveman

Awesome
Great stuff

 

[Bernardo_11]

Good stuff there Homonculus!

Here's more....

1)CSF orders (after you do those spinal taps for your Fever r/o sepsis patients)
Tube 1- culture and gram stain
tube 2- protein and glucose
tube 3- cell count and diff
ALWAYS try to get a 4th tube for storage.. you never know when you might need an HSV or enterovirus PCR

2)In the NICU- any baby that's tubed needs anti-biotics

 

[arydolphin]

Nurses place bets on which intern will be the first one to write an order for IV Tylenol, so don't be that guy. More to come later...

 

[KidDr]

Good stuff there Homonculus!

Here's more....

1)CSF orders (after you do those spinal taps for your Fever r/o sepsis patients)
Tube 1- culture and gram stain
tube 2- protein and glucose
tube 3- cell count and diff
ALWAYS try to get a 4th tube for storage.. you never know when you might need an HSV or enterovirus PCR

Definitely always get that 4th tube, and put an extra mL in it if you can. And most importantly, never tube your CSF to the lab, always make sure it's carried there in person (having someone say that your CSF specimens were somehow "lost" in the tube system is the worst...)

2)In the NICU- any baby that's tubed needs anti-biotics

not sure what you mean by this, just because a baby's intubated doesn't mean they need abx...

 

[fourthyearmed]

not sure what you mean by this, just because a baby's intubated doesn't mean they need abx...

Agree, not all intubated babies are on antibiotics.

 

[Bernardo_11]

Ah... I see what you mean. Not al of them were on antibitotics at a given point in time. But if a baby is tubed and brought to the NICU at birth for any reason, usually a 3 day course of amp/gent is done as a sepsis r/o (at least at the unit here). That's what I meant. Sorry.

 

[doctawife]

Make sure every admitted baby has some kind of diaper ointment - otherwise you will get paged. Likewise for Tylenol, just make sure they don't have liver disease.

Never mess the cards or liver transplant service patients until after you call the fellow. (Although this might be a Baylor thing.) But do have a plan when you call.

Always read the EKG (including QTc), get a CXR and do 4 extremity bp's before consulting cardiologist for that murmur.

If the baby that was born pink is now blue, and you don't know why, get someone to write for PGE and call for help.

Vaccines are good. Try to insist on them. (BTW - there was a case of measles in Houston this year. I'm fairly sure my success rate for getting parents to give the damn MMR has gone up since I've become aware of this fact.)

Look at your own x-rays.

You are never alone - always call for help if perplexed. That is what upper levels are for!

 

[StringBean]

Here's a little one that a great attending shared w/ me...

When on call, just b/f you attempt to get that all-so-needed shut eye.. round on your pts and decided what you would want to do if thier IV falls out (i.e. they need an immediate replacement or they can wait til morning for fliuds) that way when you get paged in the middle of the night to be told that they lost the IV you don't have to go back to the floor & check out the chart to see if they can wait til morning for a replacement.

 

[KidDr]

Here's a little one that a great attending shared w/ me...

When on call, just b/f you attempt to get that all-so-needed shut eye.. round on your pts and decided what you would want to do if thier IV falls out (i.e. they need an immediate replacement or they can wait til morning for fliuds) that way when you get paged in the middle of the night to be told that they lost the IV you don't have to go back to the floor & check out the chart to see if they can wait til morning for a replacement.

Along these lines, when I was an intern one of my seniors on my general peds rotations would walk around with me from room to room at about 2 in the morning on call nights and we'd go through the "worst case scenarios" for each kid, or other potential things I was likely to be called about. It was always really helpful, and as a senior I try to do similar things for the interns on my teams now, if there's time. If this sounds helpful try to convince your seniors to do this for you. Or at the very least definitely utilize your seniors, I can't emphasize enough that I would so much rather be called if you're unsure about something, than have to fix a bad situation later.

 

[RuralMedicine]

Along these lines, when I was an intern one of my seniors on my general peds rotations would walk around with me from room to room at about 2 in the morning on call nights and we'd go through the "worst case scenarios" for each kid, or other potential things I was likely to be called about. It was always really helpful, and as a senior I try to do similar things for the interns on my teams now, if there's time. If this sounds helpful try to convince your seniors to do this for you. Or at the very least definitely utilize your seniors, I can't emphasize enough that I would so much rather be called if you're unsure about something, than have to fix a bad situation later.

Very good point--one I now stress to the nurses here (they don't call the intern in the middle of the night they call the attending on call and we're often at home so if you need us you might need to give us 5-10 minutes to get there). Call me early and I promise to not yell or complain (even if I don't in retrospect think you really needed to call me). [I make it a point not to yell in general and I try not to complain (adressing problems constructively is not complaining it's being proactive) is good advice as well]

 

[RuralMedicine]

Definitely always get that 4th tube, and put an extra mL in it if you can. And most importantly, never tube your CSF to the lab, always make sure it's carried there in person (having someone say that your CSF specimens were somehow "lost" in the tube system is the worst...)

Or in a bigger kid even an extra 2-3 mL--notoriously you end up needing to send viral PCRs or your attending decides they "must have" something you didn't order. Also think about doing opening and closing (if your opening pressure is elevated) pressures if you are tapping for something other than the neonate with fever obligatory sepsis rule out.

 

[RuralMedicine]

1) Befriend the nurses
2) Sepsis, Sepsis, Sepsis
3) All that wheezes is not asthma
4) Bag UA's are worthless
5) Bolus NS only
6) Abx within an hour
7) Oders before notes
8) Patients come first
9) Things change
10) Oxygen is good
11) ABC, ABC, ABC
12) Volume is your friend
13) Even the dumbest kidneys are usually smarter than the brightest doctor
14) Referring docs have altered perceptions of reality
15) Act quick, think slowly
16) Patients do not suddenly deteriorate, healthcare professionals suddenly notice

(some of these stolen from other sources)

--your friendly neighborhood sage caveman

Nice [Although I might have to take offense with 14 as a pediatrician at a small rural hospital with no in hospital subspecialists. After spending 4 years on the other side at an academic children's hospital I've learned that early transfer/ referral can be lifesaving. Sometimes you need to stabilize them and get them out (and if you get mocked by PGY2 residents for transferring because they ended up doing so well just be glad they did so well)]

As a caveat to 10--Goal oxygen saturations may vary depending on comorbidities and patient status, achieving this is good. Supplemental O2 is not always good, it could be quite bad for infant with hypoplastic left ventricle who was actually achieving sats in the low 80s anyway before you decided to "help him".

As a caveat to 16--Blood pressure is a poor indicator of hemodynamic status in children as hypotension is a late and ominous sign. Dynamap blood pressures tend to overestimate in sepsis in general but especially in children as well. Perfusion, heart rate, respiratory rate and effort, and urine output are always important data to have.

Good luck to our future Peds (or Med-Peds ) residents!

 

[arydolphin]

Here's some things that have come to my head, some are peds-specific, others are more things for internship in general:

*Along the lines of going around on your patients in the middle of the night and looking at fluid status before you go to bed (as was posted earlier), I like to go around to the nurses' stations of all of the units I'm covering and ask if they have any questions before I try to lay down to get some sleep. I can't begin to tell you how frustrating it is to try to lay down and then get paged for something 2 minutes after you lay down. Doing this before going to bed takes maybe 10 minutes at the most, but it can save you some small calls late in the night.

*Listen to nurses and parents, no matter if something they say sounds like the silliest thing in the world. As an intern, nurses usually have the experience advantage on you, especially in the subspecialty fields (think Heme-Onc, Cardiology, NICU, etc.) and will know when a kid needs your attention. Also, lots of parents seemingly have a sixth sense for when their kid is just "not right", and even if you don't think it's particularly bad, show the parents that you are taking their concerns seriously.

*It's a great release, but overall, don't bitch and moan about how your schedule sucks or how you got screwed over on something schedule-wise, it happens to everyone and all you do by complaining is waste energy.

*Communication is the key to everything. This means between you and parents as well as anyone involved with patient care (attending, fellows, other residents, students, etc.). The more you communicate, the less likely something unforseen is likely to arise. Just like another poster said, use your upper levels for guidance, and if you're ever unsure about something, let them know because it's much easier for them to give you advice then instead of later on when all hell is breaking loose. Also, don't be afraid to say "I don't know", you'll be much safer if you accept this and look for advice from the people above you.

*Whenever you are getting a consult, have a plan in mind in terms of what made you get the consult and what information you would like to get out of the consulting service. Example: don't just page the cardiology fellow and say "I need a consult because I hear a murmur", explain to them how you have interpreted the murmur (location, grade, pitch, etc.) and how getting a consult will add to the management plan (i.e. an echo will not only tell you the etiology, but help guide your decision on follow-up).

*Remember that most of your patients are going to be young children, and when they come into the hospital, they are often nervous and so are the parents or other family members. It goes along with the communication point I made above, but talking your way through a physical exam and explaining why you're going to do labs or other tests on a child goes a long way towards building trust between yourself and your patient as well as the family.

*Finally, you're going to work a lot of hours in your intern year, but make sure you take some time for yourself to enjoy things in your life outside of medicine. For me, these things include going out to dinner with my girlfriend at least once a week, keeping up with 24 and the Amazing Race on my Tivo, and playing golf as much as possible. While you may feel that your entire life is focused on residency, having this actually occur is not healthy at all, so learn to keep other activities in your life and you'll be a happier person, and probably a better resident at the same time. Hope this helps some people out.

 

[Homunculus]

Nice [Although I might have to take offense with 14 as a pediatrician at a small rural hospital with no in hospital subspecialists. After spending 4 years on the other side at an academic children's hospital I've learned that early transfer/ referral can be lifesaving. Sometimes you need to stabilize them and get them out (and if you get mocked by PGY2 residents for transferring because they ended up doing so well just be glad they did so well)]!

true. though the point of that tip was more toward the *other* end of the spectrum-- ie the "oh the kid is very stable" and they show up on a non-rebreather on coninuous nebs, lol.

:As a caveat to 10--Goal oxygen saturations may vary depending on comorbidities and patient status, achieving this is good. Supplemental O2 is not always good, it could be quite bad for infant with hypoplastic left ventricle who was actually achieving sats in the low 80s anyway before you decided to "help him".

as a general rule of thumb, O2 is good. there are exceptions for everything. like fluid boluses in heart failure. but that's why we're the pediatricians, 'casue we notice things like that

:As a caveat to 16--Blood pressure is a poor indicator of hemodynamic status in children as hypotension is a late and ominous sign. Dynamap blood pressures tend to overestimate in sepsis in general but especially in children as well. Perfusion, heart rate, respiratory rate and effort, and urine output are always important data to have.

yup. all the points you mentioned do not suddenly happen at once. as a general rule, kids don't suddenly crump. you'll notice all the things you mention (or fail to notice those things) when the nurse pages you with "xxx is a sick as snot".

: Good luck to our future Peds (or Med-Peds ) residents!

amen. good luck to them all. and may their immune systems be robust, lol.

--your friendly neighborhood hyperactive immune system caveman

 

[earmuffs]

Excellent thread. Thanks for all the tidbits everyone!

Can we consider this one worthy of a sticky?

 

[Homunculus]

done

-your friendly neighborhood sticky-ing caveman

 

[notstudying]

These are some great ideas! I'll especially second checking in with nurses before you go to bed, and trouble shooting what calls you might get with the senior or attending-this has saved me lots of grief, and some needed minutes of sleep.

Other thoughts...
1. The learning curve is huge, especially in NICU. You will probably feel like the most clueless person in the world after your first day-by the end of the 3rd you'll be an old pro. Just hang in there, and resist the urge to run away to the bahamas and open a bar.

2. Know how to bag/mask ventilate a patient-it's not too difficult, and you can bag a crumping patient/newborn for a long time (with the exception of mec deliveries and CHD, but even those if you can't intubate, you can still ventilate). Intubation can usually wait.

3. Patients on IVF need to have electrolytes checked periodically (learned this one the hard way .

4. Good signout technique is important-if people are asking lots of questions, you probably aren't giving enough detail; if they are yawning and falling asleep, it's probably too much. Ask a senior for tips on your style.

5. In an emergency, take your own pulse first. Or at least take a deep breath to collect yourself-the patient won't be any worse off 5 seconds later if you can now think things through better.

6. Crazy people get sick too-i.e. just because someone has an underlying psychiatric/emotional problem doesn't mean they can't also have a medical one.

7. Every day assess whether your patients have things you can stop-IVF, drugs, frequent vital signs. It's easier to keep adding orders than to take some away.

8. Patients are a lot harder to kill than you think when you start internship year-and it's probably not going to be the tylenol order that does it . So try to relax, learn, and enjoy being a real doctor!

 

[ekydrd]

...

4. Good signout technique is important-...

It's also a good idea to prepare any discharge paperwork ahead of time, short of signing them, if a particular patient might be able to go home any time in the next two days. This saves the cross-cover team the hassle of filling out the forms... and the breath they would otherwise be wasting cursing you under their breath for having to do the paperwork in the first place. It's really annoying when a team checks out that patients X, Y and Z might be going home, then get the call that they are ALL going home and the orders and forms needs to be done... and you still have three more admissions to see within the next 30 minutes. Having been the recipient of such a scenario I plead with you to prevent it if at all possible as it really sucks!!!

 

[KidDr]

4. Good signout technique is important-if people are asking lots of questions, you probably aren't giving enough detail; if they are yawning and falling asleep, it's probably too much. Ask a senior for tips on your style.

Along these lines, do not let people sign out ambigious things to you, because it can be a real pain to try and figure things out later if you don't get the details you need. For example, if people sign out "check so-and-so's labs at 6 pm," make sure they tell you what they want you to DO with the labs. It sounds like it's a basic thing, but it happens quite a bit, and it's not fun to deal with.

 

[butterflies06]

Hey everyone,

Just wanted to say that this is a great thread and the advice from all of you is wonderful.keep it coming!! I do have a question however...are there any quick pediatric references (i.e. pocket texts or PDA downloads) that we should be carrying around as pediatric interns? I have the huge Nelson's Text and Harriet Lane, are there any others out there?? Just wondering. Thanks everyone!!

 

[medfred]

1. you can give tylenol to liver kids, but never motrin as it causes bleeds!
2. watch giving NS boluses to kids with ascites even if they have low Na; their total body Na tends to be high.
3. know what prns your kids got overnight and what might have recently fell off the MAR

 

[Daddy-O]

never trust a premie. ever.

 

[Homunculus]

never trust a premie. ever.

lol. that one is definitely worth repeating. a hearty "ditto" from me.

--your friendly neighborhood doesn't trust a preemie farther than he can throw . . well, farther than they can throw him caveman

 

[abs]

The things I learned during internship...

1) Sleep when you can!

2) Make sure you have a good support system (who are willing to deal with your sleep deprived crankiness)!

Best of luck!

 

[KidDoc29]

1) Befriend the nurses
2) Sepsis, Sepsis, Sepsis
3) All that wheezes is not asthma
4) Bag UA's are worthless
5) Bolus NS only
6) Abx within an hour
7) Oders before notes
8) Patients come first
9) Things change
10) Oxygen is good
11) ABC, ABC, ABC
12) Volume is your friend
13) Even the dumbest kidneys are usually smarter than the brightest doctor
14) Referring docs have altered perceptions of reality
15) Act quick, think slowly
16) Patients do not suddenly deteriorate, healthcare professionals suddenly notice

(some of these stolen from other sources)

--your friendly neighborhood sage caveman

1. Or sleep with them
2. it's usually RULE-OUT sepsis; hardly ever the real deal
3. true, but it's usually asthma
4. not worthless at all - you can get a spec grav, look for ketones, lots of other useful stuff
5. unless they're hypoglycemic and need D25, hypoproteinemic and need 25%Albumin, etc
6. what happens in an hour and a half?
7. fair enough
8. no, their parents do
9. really?
10. well, not for certain congenital heart lesions
11. DEFGHIJKLMNOPQRSTUVWXYZ
12. true, but only with adequate contractility and appropriate afterload
13. and yet most interns cannot interpret a UA - learn this before you start
14. but still now vastly more than you do
15. success as an intern is really more about THINKING quickly on your feet, but then taking the time to ACT slowly and methodically to avoid mistakes
16. spend some time in the Delivery Room or the NICU - quick downward spirals are the norm

 

[kristing]

1. Do not use the terms *LETHARGIC* or *IRRITABLE* unless you are going to do a full sepsis work up and start antibiotics.

2. Vaccinate every child in your clinic as if it's the last time you will see them.

3. Listen to the moms who won't vaccinate. Do not treat them as crazy. Try to figure out what their reasoning is and discuss with them based on their reasoning. Be gentle and describe each disease slowly and carefully if the mom doesn't want to vaccinate. I only have had one mom turn me down so far after I have used this method.

4. Besides the horrible abuse you will see (yes you will see it, it is awful), realize that most parents LOVE their children and try to do best by them. Even if it is illogical and even if they drive you bonkers. When I have stepped back and repeated this little ditty in my head, it has made me be able to deal with things a lot better.

5. When you are going to talk to a patient and the family,
SHAKE PEOPLE'S HANDS
SIT DOWN
KEEP AN OPEN POSTURE (do not cross anything)
HAVE GOOD EYE CONTACT
ADMIT IF YOU DON'T KNOW
SAY THINGS LIKE "I am sorry that happened" if something bad happened

Seriously - #5 was taught to us in our residency orientation by a fabulous doctor and it has helped me over and over again.

 

[J-Rad]

1. Speak Human Being-ese. Yeah, you just spent 4 years learning "Medical-speak" but in the end you are a douche bag if the parents don't understand what is happening to [what hopefully is] the most precious thing in their universe because your too busy trying to impress upon them your mastery of this new language. I think it's okay to use the language with parents as long as you serve as their interpreter as well (ex. My common intro to murmurs: "A murmur is just a sound created by turbulence in the blood-like how the white waters of the river makes a lot of noise but the smooth stream is quiet. The reason we concern ourselves with them is that congenital heart disease-meaning a defect in the heart that someone is born with often creates a murmur; but very few murmurs represent congenital heart disease-and many children have what are called benign-or harmless-murmurs of childhood that we can hear well because their chest walls are so thin...) We should all be intelligent enough and respectful enough to approach parents in this way. Just imagine if it was your child.

2. If you are going to make an intervention with a child at any time of day, talk to the parents and tell them why. For me, the easiest place to forget this was on the newborn nursery when a baby had a high bili. It was easy to just telephone order the bili lights (esp when things got busy with other things) and not talk to the parents. But to them just the fact that you did something may scare the bejesus out of em. Just imagine if it was your child.

3. Have a grasp on acid-base disorders, and realize that you can have a normal pH, pCO2, Bicarb and still have an acid-base disorder occuring, and that calculating the anion gap can be useful, even without a gas, in telling you if there is a metabolic acidosis going on (>20 AG: there is a metabolic acidosis). I am an acolyte of the Haber approach outlined in "A Practical Approach to Acid-Base Disorders" Richard Haber; West. J. of Med. 1991 Aug 155: 146-151. You can adjust normal Bicarb levels for age.

4. Realize that hypotonic maintenance IVF are not necessarily a benign drug and that it is more convention than evidence as the reason for putting kids on hypotonic saline MIVF routinely (certain exceptions noted). There is some emerging data that, overall, more harm than good can come of it and Normal Saline (with glucose if needed) is more often the appropriate choice (that being said I don't see it being done at my institution that much currently). Remember that not only damaged noggins like to secrete ADH inappropriately; so do damaged lungs; and damaged and massively pained bodies. Yes, you may cause a hyperchloremic non-gap metabolic acidosis with NS, but my [initial, not in-depth] readings so far indicate that this is not associated with increased mortality.

5. Just imagine it was your child.

 

[KidDr]

4. Realize that hypotonic maintenance IVF are not necessarily a benign drug and that it is more convention than evidence as the reason for putting kids on hypotonic saline MIVF routinely (certain exceptions noted). There is some emerging data that, overall, more harm than good can come of it and Normal Saline (with glucose if needed) is more often the appropriate choice (that being said I don't see it being done at my institution that much currently). Remember that not only damaged noggins like to secrete ADH inappropriately; so do damaged lungs; and damaged and massively pained bodies. Yes, you may cause a hyperchloremic non-gap metabolic acidosis with NS, but my [initial, not in-depth] readings so far indicate that this is not associated with increased mortality.

SO true. I didn't really learn this until the end of my intern year, but ever since then I've been very cognizant of exactly what you said above, and it's made a difference for my patients. I think part of the problem is that in med school, the way we're taught about SIADH makes you think it's a rare/weird condition (at least that how's it was for me), but in reality ADH secretion is on a continuum, and many, many conditions in kids will raise ADH secretion above a normal level, potentially leading to hyponatremia, especially if the kid's being given hypotonic fluids. Of course there are notable exceptions, but in general this is a good bit of info to remember on the wards.

 

[ramonaquimby]

what you said is SO true, but i'd have to break this...

A murmur is just a sound created by turbulence in the blood-like how the white waters of the river makes a lot of noise but the smooth stream is quiet. The reason we concern ourselves with them is that congenital heart disease-meaning a defect in the heart that someone is born with often creates a murmur; but very few murmurs represent congenital heart disease-and many children have what are called benign-or harmless-murmurs of childhood that we can hear well because their chest walls are so thin...

...down even further for my patients. i lvoe 'em to death, but they don't understand 'turbulence', nor do they understannd 'defect' or 'benign', lol...

i say keep it even SIMPLER!

 

[KidDoc29]

Actually that is incorrect. Maintenance IVFs given to pediatric patients are rarely hypotonic, assuming dextrose is added, which is virtually always. To be specific, 1/4 NS is 77 mOsm/L, and 1/2 NS is 154 mOsm/L (both HYPOtonic to plasma), BUT D5 1/4 NS is 329 mOsm/L which is actually HYPERtonic to plasma. In other words, routine MIVFs are not hypotonic. They may however be inappropriate in the volume contracted patient, who is maximally secreting ADH, and will therefore become hyponatremic if supported with 1/4 NS due to avid retention of free water.

 

[KidDr]

hey!
This may have already been mentioned--
Whenever you have really interesting cases, be sure to at least jot down their medical record number, or even better, print off a copy of their discharge summary and start keeping a file of them. This way, when you need cases to present for morning report cases, M&M, or even possibly for case write-ups, you'll have lots of interesting ones to choose from. I only started doing this about the middle of my 2nd year, and I have several good ones to choose from when I need them. But I still really wish I'd started at the beginning of my intern year, because there's many patients (whose names I can't remember at all!!) I wish I could look up, but I can't.

 

[Frankie.A]

Hey! Great thread! I have a question as someone who wants to do pediatric infectious disease in developing countries... would I do a peds residency first followed by an ID fellowship?

Thanks!!

 

[chhsu]

Yup, 3 years peds+3 years ID fellowship. That's exactly how you'd do it! If you have a lot of research under your belt, you can fast track it and subtract 1 year thus spend only a total of 5 years in training.

There is also another way which is not commonly done. You can also go work in public health with the CDC. They have a program called the Epidemiologic Investigative Services (EIS) which trains physicians to conduct epidemiologic investigations. I have a few colleagues who trained in the program without doing fellowship but were sent overseas to investigate and treat ID outbreaks. It's less of an individual patient treatment and more of treatiing at the population level.

 

[blanche]

would love to revive this thread! good lord, internship is going to be here in no time

 

[coldflare]

This was a great thread last year when I was staring down the barrel of internship, so I thought I'd add a few I've picked up this year.

1. When writing prescriptions for home meds, rounding is usually ok. Don't prescribe 4.5ml BID of Orapred - 5 ml BID is fine. Caveat: meds with low therapeutic index, to avoid toxicity. Also consider compliance when assigning a dosage schedule - q6h is great for serum levels, but you are more likely to get all of the antibiotics into the patient if you dose at q8 or q12. Even the best parents are likely to sleep through an early-morning dose, night after night.

2. Nurses will call you while you are sleeping with a problem AND a plan, which is tempting because they are usually right, but go examine the patient anyway. Telephone orders are for keeping the patient safe until you can get there, not for keeping you in bed until morning. Example: "My kid in 16 started vomiting again, do you want to change his formula from 24cal back to 22cal?" Makes sense, but go check for abdominal distension. Is he stooling? Etc.

3. When you admit a patient with a common disorder for the first time, work out the admission orders with your senior resident or attending, and then photocopy them and save them as a reference for the next time. This is especially handy when you are admitting patients for a subspecialty (i.e. CF patients for Pulm or Crohn's patients for GI), which most of us didn't do much in med school.

 

[Thewrongstuff]

SO true. I didn't really learn this until the end of my intern year, but ever since then I've been very cognizant of exactly what you said above, and it's made a difference for my patients. I think part of the problem is that in med school, the way we're taught about SIADH makes you think it's a rare/weird condition (at least that how's it was for me), but in reality ADH secretion is on a continuum, and many, many conditions in kids will raise ADH secretion above a normal level, potentially leading to hyponatremia, especially if the kid's being given hypotonic fluids. Of course there are notable exceptions, but in general this is a good bit of info to remember on the wards.

I am still a premed but I want to go into peds. and ADH always fascinated me for whatever reason. SIADH results in keeping fluids in the body by creating aquaporins in the kidney right? So SIADH basically dilutes NA levels to the point where the descending loop in the kidney has trouble w/ reabsorption and a hypo solution will only worsen the problem (more dilution) and cause hyponatremia?

But...what do lungs have to do with ADH secretion? I thought it was only an endocrine pathway thing?

 

[spacewoman spif]

Hypotjetically, would you rank the Peds program at Mich state uni (E. Lansing) higher or Maimonides Peds (NYC) higher on the ROL?
Thanks much!
spiff

 

[coldflare]

But...what do lungs have to do with ADH secretion? I thought it was only an endocrine pathway thing?

About 40% of small cell lung cancers are associated with SIADH. The tumor cells actually secrete ADH, and they are unregulated by the normal endocrine pathway. It's called a paraneoplastic syndrome.

 

[Medica2010]

so here's a thought that comes into my head, usually at 2 in the morning... What is your life like when you go home? what do your husbands/wives/families/friends think? especially in the first year! thanks... i always wonder about this, but i feel like it must vary alot by specialty

 

[J123]

Lots of good stuff on this list...
One thing that comes to mind is DOCUMENTATION. Please, please, please, when you are called to see a patient document what you did (exam, labs, talked with parents, etc). Believe me, the nursing staff will be documenting that you were notified of 'xyz'. Not only is it CYA for you, but it is important for the ongoing care of the patient -- you may not be there to explain what you did and why -- so help yourself from getting paged when you're home post call and asleep, and help keep your colleagues 'in the know' so to speak.
Best of luck to all of you!
J

 

[drpediatrician]

a lots of good text here.. but following is worth reading and posting again n again.

These are some great ideas! I'll especially second checking in with nurses before you go to bed, and trouble shooting what calls you might get with the senior or attending-this has saved me lots of grief, and some needed minutes of sleep.

Other thoughts...
1. The learning curve is huge, especially in NICU. You will probably feel like the most clueless person in the world after your first day-by the end of the 3rd you'll be an old pro. Just hang in there, and resist the urge to run away to the bahamas and open a bar.

2. Know how to bag/mask ventilate a patient-it's not too difficult, and you can bag a crumping patient/newborn for a long time (with the exception of mec deliveries and CHD, but even those if you can't intubate, you can still ventilate). Intubation can usually wait.

3. Patients on IVF need to have electrolytes checked periodically (learned this one the hard way .

4. Good signout technique is important-if people are asking lots of questions, you probably aren't giving enough detail; if they are yawning and falling asleep, it's probably too much. Ask a senior for tips on your style.

5. In an emergency, take your own pulse first. Or at least take a deep breath to collect yourself-the patient won't be any worse off 5 seconds later if you can now think things through better.

6. Crazy people get sick too-i.e. just because someone has an underlying psychiatric/emotional problem doesn't mean they can't also have a medical one.

7. Every day assess whether your patients have things you can stop-IVF, drugs, frequent vital signs. It's easier to keep adding orders than to take some away.

8. Patients are a lot harder to kill than you think when you start internship year-and it's probably not going to be the tylenol order that does it . So try to relax, learn, and enjoy being a real doctor!

www.pediatricianonline.in

 

[arlsoonDO]

Hi everyone,

don't let this thread to die out. 2.5 wks until orientation

any more advice before internship year?
books, topics to look at, etc.
thanks

 

[BigRedBeta]

About that time to resurrect this thread - and since the NICU is pretty damn boring at the moment, I might as well be the one to do it.

1) Ask for help - from your other interns, your upper level, the fellow, the nurses, or the attending - it's a millions time better for you to feel dumb than for you to get a patient into trouble (in which case you'll be asking for help anyways).

2) If you just write "bolus" on your order, it's going in over an hour, if you want it in faster, write it that way.

3) know that 2 out of 4 SIRS criteria and presumed infection = Sepsis...NOT bacteremia, NOT shock, NOT what ever other kind of definition you can come up with. All you have to do is look at the vital signs.

4)If you have sepsis and poor cap refill (>3 secs), BOLUS, BOLUS, BOLUS. Give fluids until the cap refill is 3 secs or less, your goal being 60ml/kg in the first 15 minutes if necessary. If a nurse tells you the IV is going to blow and can't handle that amount of fluid, you have to at least attempt giving the fluid.

5) Be nice to the nurses, but don't let them walk all over you. They know what to do, you know why to do it.

6) If you have kids or plan on having kids (or even just imagine what having kids might be like), our job can be incredibly scary. For all the badness we see, remember that ~75% of kids leave the hospital as newborns and never spend another night in the hospital until after the age of 18. Even though it may not seem like it at times, the overwhelming majority of kids are normal and healthy.

7) Talk with parents and explain why you're doing what you're doing (or not doing). It amazes me how many extremely angry parents I've managed to calm down just by going through my thought process with them. On the other hand though, if you can't explain, don't bull**** them, just stand your ground.

8) At some point, you will make some parent or nurse cry, often when you least expect and with absolutely no intent or malice on your part.

9) Mental status changes are bad - whether it's an infant who can't be calmed down, or an 8 year old who is combatitive or the teenager who is suddenly talking strangely. Figure out why.

10) If you have a sick patient who you are checking on frequently, even if things seemed to have stabilized, take time to document it.

11) Relieving symptoms is not the same as fixing the problem. Giving the kid who is throwing up a bunch zofran and making sure he can keep fluids down is nothing but a bandaid if you have something other than gastroenteritis causing the vomiting. The same thing with opioids - they cover up the pain, not get rid of it (although sometimes that's the only thing to be done).

12) In the complex chronic care kids, listen to the parents - they absolutely know their kids. If they say something's not right, even if you can't really tell, then do your best to figure it out. Once you have a stack of lab results back that are all normal, you can present the information and reassure them that you haven't been dismissive of their concerns. And ask them if they're comfortable leaving before you send them out. Almost all of them are surprisingly reasonable and just want to have someone make sure things are okay.

 

[natashana]

I'm so nervous!!!!

 

[kissachka]

So i've recently matched into my top choice peds program and after a day of euphoria the fear came rushing at me lol. Is there anything you wish you would've done before starting residency? Sharpen up on a few things or just take the few weeks off to relax before the stress and sleepless nights begin? I know it's very normal to be nervous and probably feel a bit inadequate but should I be doing something for it??? BTW the advice here as definitely great please keep it coming!!!

 

[Socrates25]

Nurses place bets on which intern will be the first one to write an order for IV Tylenol, so don't be that guy. More to come later...

For the record (I know most of you know this already), IV tylenol (brand name ofirmev) is now available for use. Anecdotally a lot of nurses will tell you that the pain-relief effect is superior to PO tylenol, even with equivalent dosing.

One thing that new interns will get baited by the nurses into is giving tylenol for every temp > 100.4. Given that tylenol is not an entirely benign drug (there appears to be some correlation between tylenol and asthma) I think you should only treat fevers in certain circumstances. If the kid is eating/playing/sleeping normally, there's no need for antipyretics unless the temp is dangerously high. On the other hand if the kid is miserable then by all means give it. But it shouldnt be just a reflex reaction.