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Discussion in 'Internship' started by turkleton, Mar 26, 2007.
does anyone have anything similar to this for Peds? it would be very helpful.
Since the thread is basically getting hijacked anyway:
The problem here was that, had the RNs not jumped in, everyone would have just read the comment made by tibor, rolled their eyes, and moved on. Instead, the nursing set has made it a habit to track all the premed/MS/resident forums, looking for fights. Now this excellent sticky is filled with crap (like the post I'm writing right now), all because someone dared to say something negative about the RNs.
They're turning otherwise informative threads into repetitive arguments, and for what? This isn't a nursing forum, and last I checked there was no rule that says "All references to nursing must demonstrate reverence and love."
Uugh, as much as I HATE to contribute to this, and continue to this topic I feel compelled:
Seriously? How is the above thread "a child throwing sand"? This is one of the more intelligent and positively worded posts I've read on this website in a while. S/he was complimentary and thankful; acknowledged certain nurses shortcomings, and called for mutual respect. This post was responded not a half hour later by one of our "colleagues" who posted "Don't argue w/ nurses, unless it's patient care that's involved. They are not worth it. It's like arguing with a 7 year old. You have better things to do, and talking to a nurse just drains about 10 brain cells per minute."
This statement, particularly in the wording and posted RIGHT after a nurse leaves a comment is obviously meant to be nothing but inflammatory and insulting and offers nothing constructive to the original thread. When the nurses respond, then others jump on them for defending themselves--WTF?? I have been in the Clinician's forums, and I see MD/DO/med students (some of who posted here) always jumping to the defense of docs there--if you can "troll" their forum, who are you to tell them to stay out of ours?
The hijak of this useful thread was NOT from nurses, it was from our immature, disrespectful and arrogant physician colleages. If someone wants to know what to expect as a PGY-1, you better believe nurses are going to have some useful advice! So are social workers, PAs, physical & occupational therapists, nutritionists, etc. We should welcome their input, read it carefully and take (or quitely discard) what we can from it, just like we should do from the residents and attendings who posted here. If these doctors did a little more listening before discarding what someone has to offer just because of the letters after their name they might actually learn something, streamline their workload and provide superior patient care.
I apologize for this long post and continued hijak, but I have not been so appalled and ashamed of my fellow physicians in a long time after seeing the responses here. C'mon everyone--we can do better than this.
whoa , i think he wasn't being insulting and i agree most people aren't worth arguing over trivial stuff ,unless it is about someone who could sue or die from not listing or the nurses not listing
Agreed. Like I said, arguing with nurses just isn't worth it.
Nothing to be gained by yelling at them 'calling them stupid' or whatever.
It amazes me how many housestaff don't do this and end up getting written up by nurses. Then again, the physician profession is one of the most arrogant around (and a lack of people skills to boot).
You don't think calling nurses "dumb" or "clueless" or stating that talking with them is like "losing 100 brain cells per minute" is insulting? Wow...you have a really high tolerance for insults, I guess.
It may not be worth arguing over but I frankly am sick and tired of the arrogant attitude amongst physicians, especially those in the SDN forums. Am you wonder why the nurses feel they have to defend themselves with attitudes like those expressed here.
Almost as tiring as people who get all bent out of shape over an internet message board. No doubt these are the same that can't criticism in "real life"
Most useful post EVER on SDN. Made sifting though the playground name-calling BS (does every thread about being a new resident HAVE to degnerate into a nurse vs doctor shouting match? ) actually worth it to find this.
Thanks so much.
More of the same, please!!
Wasn't throwing sand...My first post was clearly thanking the docs on this particular thread...The sand was from a fellow...Reread my 1st post here. If anything, I admitted flaws from my nursing peers...
I dunno, I've been in nursing almost 13 years...I've made many mistakes, and pissed many people off...Hopefully all while trying to help ensure better outcomes for the patients. I tend to think opening the lines of communication between ALL areas of medicine best serves the patients...That is why I enjoy reading what the docs are talking about...
We should learn from each other.
Thanks for the kinds words from KC and Bitsy...
We expect professional behavior in the Moderated Forums and have higher standards than perhaps you do in your personal life.
Therefore, comments which are derogatory toward members of our community are not allowed in the Moderated Forums and would best be kept to yourself or posted in The Lounge. This is made clear in the SDN Terms of Service agreement which you signed when you registered.
As for writing the actual orders, I doubt anyone is allowed to write ranges. For example, you can't order Morphine 1-5mg iv prn whatever. The nurse isn't allowed to use discretion. You can write morphine 5 mg prn pain >7/10, 2 mg prn pain > 4/10, etc.
As for phenergan, I'd start with 6.25 mg. It works just fine for nausea and won't knock people out as much or make the older folks nearly as loopy as giving 25.
With good reason
In most hospitals that I've worked, range orders are absolutely allowed (as you described - the range on the dose) and have been the standard since, always - However, the range for the frequency is being phased out. It's led to many problems. Some pharmacists don't even like the range for the dose, as pt gets 2 mg from one nurse all shift, and then 4 mg from the next nurse. the nice thing about the range on the dose, is that it's situational. Pt comes back from PT, is really hurting, we can give 4mg. But at bedtime, he hurts only "a little" so you can give 1mg.
The number 1 rule of residency:
Trust no one ...
The number 2 rule of residency:
Feed the nurses ...
The number 3 rule of residency:
Love your pharmacist
UCSF's hospitalist handbook has useful appendices like this (S/S for insulin, Heparin scales, Nitropaste dosing, K/Mg repletion), similar to excellent post above. Also section on "Night Calls" walking you through common calls (bradycardia, fever, low urine output, confused patient). Most program's have their handbook, but not all are online--it's good stuff for us interns-to-be!
Lets start this argument again.
Only give Phenergan IV if the nurses at your institution are comfortable giving it. They pump it in undiluted and fast because they ussually don't use it IV and it will be noticed.
Not being a pediatrician I can't be too helpful. Hopefully some peds folks will chime in or you could start a similar thread on the Peds forum.
I will say that many peds orders are a lot more house dependent. For example where I did residency all peds drips had to be calculated on these special forms. There was one for dopamine, insulin, phenobarbital and so on. Find out from your seniors if something like this exists at your house.
Some places want orders in mg/kg and others demand that you calculate it out and order in straight mgs. JCAHO is leaning toward the straight mg way. Find out what's expected for you.
Most peds places now generate code sheets with the code drug doses already calculated out for the patient's weight. Find out if your house has these and where to find them. If you have them they should the 5th thing you ask when you hit the door in a code. If you're interested the first 3 are #1 What's going on? #2 Is there an airway #3 Is the kid breathing #4 Is there a pulse.
Another good tip, especially for ICU rotations, is to round on all your patients at midnight or so, ask all the nurses if they have any questions or need orders for anything and tell them that you're going to try to get some sleep. If you're nice to the nurses they'll take care of as much as possible then and then leave you alone for a few hours. Another reason to be nice to the nurses is that they'll batch their calls. You'd much rather get one call and talk to three nurses than get three seperate pages 20 min apart.
but don't nurses destroy brain cells when you talk to them?
and I heard that they have no discretionary skills in discerning appropriate dosing determination...
has anyone seen those white hats and white stockings??
When IS my tee time??
Chimi, don't start that crap all over again. Let the thread go back to its original intent, please?
We tend to use fewer of the standing orders in pedi than are used in adults. On the floor, some hospitals may allow a few things like tylenol, others won't. In special care units, there will usually be standing orders that are already in place.
Increasingly, we are having doses for drips written as "Dopamine 5 micrograms/kg" and then the nursing staff will go to preset calculation pages to determine dilution protocols. There are obvious benefits to this in an NICU where we want to use minimal dilutions and have very tiny babies. For things like indomethicin, it is generally a good idea to be very specific. For example, "give 0.1 mg/kg = 0.08 mg IV over one hour for PDA" is best as we can use indocin in various doses for various purposes.
I've agreed with some of your points in previous posts but this is counterproductive. As a friendly neighborhood Advisor, I'll remind you to keep on topic.
Just frustrated these days, another EMTALA violation yesterday by a doc.
I'm a small town now, with 2 sister hospitals, one old, one new. Some docs at old (and nurses) speak poorly of us, and were against us opening. I Just came from the big city, where medicine was run by all of its inhabitants, not just docs. A great environment.
Here, (and this is not an embittered nurse talking), patients are suffering at the hands of the "good 'ole boy" network of docs, when it comes to taking call (signing up for it, and not answering), and many other games being played. Our admin is laying down and allowing it. We have violated EMTALA at least 20 times in the last year, due to doc games.
"The title of the thread is things I wish I knew as a PGY-1"
Please check yourself, always. Learn now to do the right thing, and point out crap (from anyone) when it is affecting patient care. Do your best by the patient.
1. Stay humble. You're just a doctor. Outside of the hospital, you stand in line just like everyone else does. You still need a colonoscopy at 50 just like everyone else. Your wife /husband is still not impressed--you've still got to change the diapers, wash the dishes, and take out the trash.
2. Your learning is only beginning and will never stop (true in life, but esp. true in this job).
3. Learn to try your best and accept the results, even if your best turns out not to be the best.
Using sliding scale insulin for controlling inpatient hyperglycemia is bad medicine (or good general surgery, I suppose). Some places you don't have a choice because there are no protocols or because (like the VA) rapid-acting insulins are non-formulary. Sliding scale is merely a tool to help you establish a good basal plus qAC regimen.
I would be exceedingly cautious about throwing restoril at everyone. Benzos and old people don't mix.
Your PRN orders should reflect a thought process and anticipation of patient-specific issues. They are not a "one size fits all" protocol to toss around indiscriminantly unless you are willing to cause morbidity from under- and over-treatment. I would encourage you to minimize PRNs at the start of the internship because with calls from nursing you will learn what kinds of issues specific patients present with overnight. I have seen significant overnight events totally missed because there were inappropriate PRN orders (so the MD never got called) and the MD never checked in with nursing in the morning (at the risk of losing brain cells, I suppose).
>>>>Morphine 1-5 mg IV q 4 hours PRN pain
>>>>Dilaudid 1-2 mg IV q 4 hours PRN pain
These are significantly different equianalgeisic dosages. I encourage folks to look up morphine-dilaudid conversions and reconsider this recommendation.
I read an interesting ER paper that suggested that dilaudid was a better analgesic: the thesis -- the nurses didn't understand how much of an equianalgesic morphine dose they were administering in their PRN order and, therefore, the patient received relatively more opiate.
Ugh. I re-refer everyone to the last paragraph of my original post.
Now we can quibble 'til the cows come home about which antiemetic or sleeper to use and what dose of what will do what. Here are a few of the cruel facts that future interns should be aware of. What meds you can give and in what dosages will be determined a lot more by your hospital's formulary and your nursing staff's comfort level with certain drugs than your medical judgement. Good luck writing for Ambien if your house gets a deal on Restoril. They will change it without your OK. That goes double for antibiotics. See what happens the first time you try to order Zyvox.
As for sliding scale insulin of course it's not for long term use. Sorry I didn't specifically state that. However the patient's ultimate long term diabetic regimen doesn't need to be determined at 2am by the cross covering tern, hence the slide.
As for narco equivalents I can tell you from years of experience that titrating the dose to the actual patient and giving the nurse who's at the bedside all night the latitude to cover the pain is way better than memorizing an equivalent table.
The bottom line on this stuff again is that you must know your patients and thin before you write. Talk to your seniors and follow their lead. You will get plenty of experience at dealing with overnight issues without getting a call every time any of your 60 cross cover patients needs a tylenol.
Regarding potency/narcotic equivs...
It is my hope and recommendation that NO ONE, especially a new inter, automatically right orders for narcs and many other meds, without specifically checking their pharmacopeia. Especially late at night, especially when you are tired, especially when you are busy. That's when mistakes happen. And while you might expect that the nurses will call or pharmacy will call about your mistake, they may not and its your fault of you overdose the patient. No one else's if you wrote the order.
So, for those who are quibbling about what narcotic or antiemetic to give, it really doesn't matter. Give what works best for THAT patient and always recheck your oders, doses and dosing equivalents.
q4 dosing interval for fentanyl is too long. q2 is about the most you can do without a lot of breakthrough pain.
That is quite a dose of fentanyl. I'm not sure you need to bother dosing it Qanything, since most patients won't be breathing after the first dose. Consider stepping it back to micrograms.
And just remember that fentanyl accumulates with a fairly long half life and initially has a short duration of action, so is a poor choice for chronic pain.
Mick's post has some bad HTML in it quoting you, thus the quote from his post gets attribed to you. I fixed it.
1. Comfortable shoes are a must!
2. Meals and sleep help. It seems like you don't have time but try to make time before you collapse.
That's all folks!
Here's something I did know as a resident (because a wise attending told me) and it helped a lot.
Sometime toward the middle of your residency you should be able to tell which of your attendings are the most competent and who you respect and want to be like. Once you identify them stick to them as much as possible and really learn how they do what they do. Do this well and you'll become the kind of doctor you want to be.
The addendum to this is that as you watch a particular attending you will likely see them make mistakes. Don't let this disappoint you. Everyone makes mistakes. If you're really good you can learn from their mistakes and become an ever stronger doc.
A surgeon at my hospital told me that in surgery, you find the most competent attendings and stick to them for the first couple years so you learn the right way to do things. Then, in the last couple years, you stick with the incompetent and insecure ones because they'll let you do all their cases.
Interesting, because while I agree with the first part (learn from the most competent) I would actually venture that the most secure and competent attendings are likely to allow you to do more. They realize that they can get you out of whatever mess you create - the insecure ones are not comfortable with their own skills and resources when you F-up.
1. Show respect and gain respect - This will serve you very well when interacting with all health care professionals. Having a genuine interest and learning the names of the nurses, physical therapists, dietitians, pharmacologists, etc will benefit you greatly when you need their assistance. It benefits you in ways you'd never know b/c others wind up going the extra distance for you i.e. IV placement, transport, seeing someone first thing in the a.m. for you, etc.
2. Don't try and cover your ass with a bunch of PRN orders - I have seen lots of errors committed because of this. Yes, PRN bowel regimen on the patient with standing pain meds makes sense. No, PRN tylenol for fever in anyone who you are anticipating an infectious w/u in does not. You PRN orders should be based on the individualized plan for your patient. I had a crosscover intern order restoril 30mg on my ESLD patient who had insomnia b/c of hepatic encephalopathy just so she wouldn't get called at night. She looked like an idiot on rounds. When thinking of PRNs - consider bowel regimens for most people bed bound and on pain meds, but I would discourage using PRN ativan, pain medicines, sleeping aids (except maybe trazodone 25mg) or benadryl. Drug companies already get paid too much, why add to their profit margin by prescribing unneeded medicines.
3. Stay on top of your medication list - We have a system that automatically imports our medication list on our computer based sign on into our daily progress notes. Some people don't pay enough attention to keeping their med list up to date - which can really hurt your crosscover and is generally poor form.
4. Think of discharge planning issues early. When considering your plan for your newly admitted patient, you should think about dispo. Will they likely need PT/OT eval while in house? Will they need a PICC line for home abx? Will they need home nursing or wound care? Nothing is worse (for both you or the patient) than resolving their inpatient needs but then having the patient have to stay the weekend b/c you slacked on dispo stuff. Social Workers can be immensely helpful in this regard.
5. Be proactive - Ask your senior resident early on if you can take the lead in rapid response calls or codes. If a patient is crumping, call the resident for assistance but ask the resident if you can assume the lead. Midway through intern year, this can be very helpful and will prepare you for the next stage of training.
6. Read about one thing per day - You don't have to read an hour, but try reading about one topic for 15 minutes per day. Preferably, something related to your patient. UptoDate is great for this sort of thing, but it is also great to make use of review articles. People who just study the Pocket Medicine book are handicapped.
7. When things get tough, seek your friends and family - Internship is a marathon. Aspects of internship can be difficult and your work starts to become your life at times. When a patient dies or when things don't go well, try to remember the bigger picture. It can also help to seek the solace of an aged physician. This doesn't necessarily have to be in person. Jerome Groopman has a great collection of essays on his website that always help me remember the reasons why I chose this profession.
8. Be a team player - Nothing is more frustrating than getting a crappy sign out from your colleague b/c they "can't wait to get outside and enjoy the nice weather". Your co-interns will really appreciate it when you tuck your patients in.
9. Don't be afraid to pick the brains of the attendings consulting on your patient. If you just follow up the consult note, you won't learn that much. If you take part in the discussion of the consult service rounding on your patient you can come away learning a great deal.
10. Don't stop doing what made you happy before internship.
This is great advice for the upcoming year. Thank you.
That's what I thought. Apparently, there was a not-so-competent attending in his program that he hooked up with in his senior years that let him do just about every case. Obviously, his one experience can't be applied universally.
There is that expression 'the longer you stay, the longer you stay'
There a caveat to this that I don't think can be appreciated until you do cross-cover. The amount of work on cross-cover with new admits and honey-dos can rapidly snowball and if you stay an extra hour to take care of things yourself, you can buy cross-cover an hour of sleep (maybe the only hour they'll get that night) while you get 8 either way.
look I finished my residency and I'm all for helping out your buddies. But it is true that the longer you stay the longer you stay. Things always come up.
You will bond with your co-interns, you will cover for each other- not just in terms of patients scut wise but many ways-
things are much better now with this 80 hour work week and no 36 hour shifts (except surgery I think).
The (traditional) residency rules of the road:
1 - Eat when you can
2 - Sleep when you can
3 - Sh*t when you can
4 - Screw when you can
5 - NEVER EVER f--- with the pancreas (for our surgery folks)!
the longer you stay the longer you stay!!!!
get in, and get out.
sh*t hits the fan in a heartbeat (pun intended)...
LOL and when you get called to GI rounds at 11pm don't panic, it's your MAR feeding you
Post some book recommendations..
That would vary by specialty and rotation...
washington manual intern survival guide is AWESOME!
get it for sure...