This rotation just dosn't get any better :(

[ocean11]

I don't know man! my luck this past month + has been just so bad.... so today was an utter disaster. first of all, I come in in the morning, a little late, but you know what... I like sleeping in... so anyways... my intern told me that one of the patient's I signed out last night, was bleeding heavily over the night and her CT showed 3 retroperitoneal bleeds. She was not my initial patient but was 'handed over to me' by my senior who told me to sign them out for her. Our sign outs are ONLY Supposed to be done by residents or interns and NEVER by the students, especially 3rd years....... anyhow, the intern was pissed when i signed out and I guess I didn't mention that the patient's INR was 10 (yeah high I know....)... he freaked out at midnight when he got the CT scan results back..... and called the other intern at midnight... he was pissed at the senior for not signing out herself. Honestly, I didn't even know to look for the INR...> I feel like a total *****..... but I know its not totally my fault.

Then I had a presentation infront of my attending (who thankthfully) already evaluated me, because the presentation sucked.... it was another patient who had a high INR and he was like "did you do a hemocult test" I thought someone else did it in the ER?!?!..... so I said it was negative.... (I confused him with another patient) then instead of letting it go, my senior was like NO he didn't have the exam and told the attending he was admitted directly NOT via the ER... she could have just kept her mouth shut and said nothing b/c it wasn't the attendings patient, and it was an honest mistake on my part.... evne the intern who was SUPPOSED to present knew NOTHING about the patient and told me to do it...... so now I look like a liar or incompetent or perhaps both..... there is NO way I'm going to ask for a reference letter from him now..... arghghghghg

Honestly this sucks..... why is my end of my third year so sucky...... perhaps I am making mistakes now so in the future I won't screw up and kill someone....

INR INR INR... VERY IMPORTANT! lesson of the day! an INR of 10 is important....

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[ericdamiansean]

Honestly this sucks.....

Fortunately, I didn't learn it the hard way, other than a snide remark because when you lie about a lab, or whether you ausculated the lungs etc, very senior people can catch you instantly by asking you a few more questions before telling you that "Please do your work properly the next time" in comparison to some of my colleagues who got heavy firing. So, the next time you didn't do something, just admit it. Unless you're in psy where what the patient says may change from time to time or you can always say "He said that when I asked him"

INR INR INR... VERY IMPORTANT! lesson of the day! an INR of 10 is important....

That's not the only one...you've got to learn who needs what as well

 

[Medpilot]

Saying "no" and "I don't know" are two of the hardest things to have to say to a senior res or an attending, but I've learned that it's not the end of your career if you do.

And as for rotations that seem to last forever... I hear you.

 

[jdh71]

There is no way you can be expected to know what is important on every single patient - YOU - ARE - LEARNING - at the end of the day it's not being a genius and remembering every but being experienced that makes the difference. There was a bad outcome, and like the emotional midgets that surgeons are your intern displaced his/her anger onto you - WHATEVER - let it run off your back - be a duck. The good news is you learned a valuable experience lesson, you will never let an INR like past you again (anything over 3 should be reported for future reference). I've fseen some of your posting around here these last few months and I think you're doing fine. As perfectionist personalities, medical students tend to be very hard on ourselves, but stop. You made a mistake, learn, live, and don't do it again. Tommarrow's a new day . . .

 

[colbgw02]

This isn't particularly relevant to the OP's story, but sometimes a senior resident or attending will ask you some ridiculous piece of information that there's no way you should have been expected to pick up. A subtle "trick" I learned is to say, "the patient did not give me that history, but I did not specifically ask." You'd be surprised how disalarming that can be. More often than not, they realize that it was a ridiculous question in the first place.

 

[ChildNeuro]

After third year you will be able to pick up on important things, i.e. grossly abnormal lab results or what have you, that make you immediately concerned. I had a patient who had a quite serious problem in the ED, and we needed to do a Stat procedure, I knew how serious it was and got everything all setup, a third year who didn't seem to know what was going on just stood there and asked me a couple of questions, and then tried to get one of the residents to see their patients with a sprained ankle or something because they didn't know how serious the issue was we were working on even though I told them. The attending got very upset with the student, tell her that how she should have waited rather than try to divert the resident's time to her patient just so she could end her shift. Morale of the story is that third years don't know how to recognize life-threatening conditions. There was a recent article in New England Journal of Medicine about superwarfarins, which can also produced markedly abnormal coags. Bottom-line err on the side of caution, if you don't something then ask someone who does, and just report everything you see with accuraccy. Alot of times when presenting the ED physician asked me did you ask X, I just say, "No, I didn't think to ask that." 100% of the time the ED physician doesn't ask about X either because I know what to ask about, and I got an excellent ED evaluation. Residents and fourth years often forget that third years are still going up on the learning curve. If you told me that a patient had a INR of 10 I would freak out and say if medicine or admitting service knows, have they ordered the fresh frozen plasma yet, how much etc . . . I would want to examine the patient, are they bleeding inside their head? This is a panic lab value that the lab would call the resident directly, and they would probably have it repeated STAT. I would never admit a patient directly to the medicine floor in the middle of the night, bypassing the ED department, I would have them go there first. In the end the resident who got called with the INR of 10 had a responsibility to manage the problem and then inform the incoming team i.e. resident to resident what was going on, how it was being treated, i.e. the patient had an INR of 10 at 2:00 am, we gave so many units of fresh frozen plasma, ordered a head CT, and are following the coags with serial PT/PTT/INR q 4 hours, . . . this is a medical emergency and a fourth year would not be expected to be the sole link of information about the patient to an incoming team. The system didn't work because the intern or resident FAILED to inform the incoming team, bottom line, very poor work. I would expect the supervising resident to know about this patient and inform the incoming team, it is unlikely that only the intern knew about a problem of this magnitude, so they should and will be asked to account for their failure to inform the incoming team. A student student shouldn't be expected to know that an INR of 10 is the same thing as saying a patient is at a high risk of spontaneously bleeding into GI, cranium, etc. . . and need urgent treatment. Too often, those attendings and residents who don't take responsibility for their patients pass this on to the students, and yell at them when they make a mistake or ask a question.

 

[ocean11]

A student student shouldn't be expected to know that an INR of 10 is the same thing as saying a patient is at a high risk of spontaneously bleeding into GI, cranium, etc. . . and need urgent treatment. Too often, those attendings and residents who don't take responsibility for their patients pass this on to the students, and yell at them when they make a mistake or ask a question.

true true.... well the intern was not the only one that knew, the senior resident knew and SHE was the one that was supposed to sign out BUT she couldn't be bothered b/c she wanted to go home early and then passed it to me. The interns had left for the day earlier b/c they were post call and they thought she would sign out, but she didn't. She's pulled this kind of stuff before, she dosn't even round with the team very often. The interns are the ones left to make decisions most of the time! man...... I can't wait until this is over with this team.....

Today I saw a patient and my intern asked me about him, the intern didn't even check up on him the ENTIRE day! he was like "how was his heart/lungs... sounded good" ok..... and then went on his buisness eventually going home without seeing the patient at all!

My team also makes me present ALL THE TIME infront of the attending b/c they can't be bothered to (or even show up to teaching rounds sometimes). I present patients that are not my own all the time... arghghggh well the silver lining is that the attending knows me well and likes me, he gave me a good midterm eval.....

 

[arthrodisiac]

the resident should be put on probation for telling you to sign out, thats no joke.

 

[Tiki]

A student student shouldn't be expected to know that an INR of 10 is the same thing as saying a patient is at a high risk of spontaneously bleeding into GI, cranium, etc. . . and need urgent treatment.

Yes we should. It's the end of third year, of course we should know that an INR of 10 is not a good thing. We should also know how to reverse it, not that it is our job to do so. That being said, this clearly is the fault of the resident because they are the ones responsible for their patients, NOT the student.

Ocean, you sure do seem to have a new crisis every week. Hope the rest of third year goes alright for you.

 

[ocean11]

the resident should be put on probation for telling you to sign out, thats no joke.

Do you guys want to hear something REALLY REALLY funny , well lets first start with the good news... my team loves me, they are happy with me today, my senior (who I'm sure feels guilty) told me to.... wait for it.... sign out TODAY AGAIN! LOL.... isn't it hilarious on the SAME patient.... THE GOOD news is that this time I'm know not only WHAT to look for BUT will report EVERYTHING! she's on her way to getting in some serious Shait... I don't get it....

lets keep our fingers crossed that all goes well tonight!

 

[andros]

first of all, I come in in the morning, a little late, but you know what... I like sleeping in

INR INR INR... VERY IMPORTANT! lesson of the day! an INR of 10 is important....

I know there are issues with having a med 3 do sign out, but... come on. I can understand the resident being p!issed off with that stuff happening and then you strolling in late because you like sleeping in.

And I agree with the above poster. By the end third year you should know an INR of 10 is important (and should mention it in any presentation... especially sign over!)

 

[justwondering]

our residents and attendings have told us over and over that the worst thing we can do give them false info. of course, it sounds like u made an honest mistake (info on the rectal in the ER) which we ALL make, but this is actually not something to brush off. especially since students may not always make the connections necessary to see WHY a question the attending asked was relevant (ie sometimes they ask seemingly obscure things that actually are really related). had i been ur resident, i would have corrected you on the FOBT but maybe not the direct admit thing. maybe the guys had a GI bleed. i say "i dont know" all the time. i dont care if i look dumb, at least they wont work with the wrong info (especially since they wont try to verify ur info).

 

[ChildNeuro]

We *should* know by the end of third year that an INR of greater than 10 is a big deal, some of us knew this the first day of third year, some of would look it up if we didn't know how abnormal it is. However, just because there is a good chance (75%?!?) that a finishing third year med student does know that the INR of 10 is significant it is wrong to have third year medical students be the sole sign-out to the next team of residents, what this resident did was negligent. We, as students, try our best to help in patient care in as many ways possible, but we should never be the sole person signing out patient. The resident of the old team should have made sure that this patient with the INR of 10 was being taken care of medically. There might be communication going on that the student is not aware of in this case, i.e. chief residents, and residents and interns can and do meet behind our backs and discuss "our" patients without us. When you are a resident or intern, the patient becomes much more "your" patient and you are responsible for coordinating care, not so with the medical student (although we try to take care of them as our patients). Residents and attendings can manipulate a situation to make a student feel bad about their care of the patient when in the end they were not trained to care for the patient in the manner requested by the resident or attending. If a lawsuit was filed in this case, I doubt that the medical student would be rightly held responsible, it would be the resident's fault who did not make sure that it was communicated properly to the next team. Sometimes I take on too much responsibility for patients and communicate directly to consulting attendings, order blood work and radiology studies myself, and talk directly to the patient about what will be done, but this is when the residents are swamped and the intern is swamped, and I have the permission of the attending and tell them what I have done.

 

[ocean11]

I know there are issues with having a med 3 do sign out, but... come on. I can understand the resident being p!issed off with that stuff happening and then you strolling in late because you like sleeping in.

And I agree with the above poster. By the end third year you should know an INR of 10 is important (and should mention it in any presentation... especially sign over!)

My resident wasn't pissed about me coming in late... it was only 5 minutes. As for the INR of 10, I knew it is a horrible number BUT didn't know the patient had that number because I wasn't really looking at the labs... yeah I missed it, b/c I had no reason to believe that this patient had coagulopathy. ACTUALLY I didn't know ANYTHIGN about the patient at all... I was instructed to 'give thsi sign out paper' to the intern and read it, there were NO labs on there.... I quickly wrote down lab numbers from the computer but didn't go over them.... a mistake I'll NEVER make again (like today when I'm signing out again b/c my senior wanted to go home early)!! my other two patients I knew WELL and knew what to look for.

 

[arthrodisiac]

u should report your resident. i know you want a good evaluation, but it is grossly irresponsible what is being done. the resident isnt being paid to go home early because she is feeling tired.

 

[ChildNeuro]

This would be a good issue to bring up with an attending at the end of the rotation if not sooner because it is a systemic error, i.e. the system is not setup properly and it can easily be seen how another student could get into the same difficulty position again and negatively affect patient care. If there was a rule that students don't sign out patients then this rule was not followed properly, and the residents and interns need to learn/be told to follow the system.

Medical students should just be given tasks that are within their realm of expertise to handle, i.e. look-up these lab values and report back to me, discuss this with the patient, take this patient to radiology and report back what the radiologist said to me. It doesn't make sense to expect a med student to comprehend the overall care of a patient and condense this and report it during sign-out rounds, this is an intern or resident job, as students are still filling in the blanks.

 

[MediCane2006]

Should you have picked up on the INR and recognized its importance? Absolutely. Yes, you're "only" an MS-3 but the reality is that internship is going to come around a whole lot faster than you think, and at some point in your clinical med school training you need to start trying to think about a patient as a whole rather than a random set of lab values to remember. This is by no means easy - heck, I'm still training myself to think that way - and doesn't happen overnight. But I'll bet from now on you watch every patient's coags like a hawk. And that's the important thing to take away from this. You screwed up. Admit it, learn from it, and move on.

Having said that, though, anything you did absolutely PALES in comparison to what your resident pulled. Having an MS-3 sign out patients - especially patients who aren't even yours - is under no circumstances acceptable or even defensible and that resident should be put on probation or fired. As residents on a busy service sometimes it's tempting to have an especially motivated MS act like a junior intern, and I'm all for med students taking on responsibility and feeling like an essential part of the team. But having an MS do signout is just crap and flat-out should never happen. So while it's okay to be disappointed in yourself for missing a lab value, any adverse outcome resulting from it rests squarely on the shoulders of your idiotic resident.

 

[ChildNeuro]

It can be hard having lazy residents or interns on a rotation, because when they start messing up and breaking protocol then as a med student I would usually be scratching my head and become frustrated with such an intern or resident who often spend a large amount of our time talking about personal issues when I would have to cut in and say, "Don't we need to go check on our patient's lab results or work on this?" Seriously, I was on a very inefficient medicine service a while ago, and one patient the team skipped, i.e. talked about for a couple of minutes, and didn't see that day. The patient complained because I was the only "doctor" who say him that day. Anyway, I learned that you can learn from inefficient residents and interns as well because you can take their work away from them, and help the patient, and speed things up at the same time. I had a very inefficient resident, and I was sort of the med student leader for the rotation, a very big attending called down to the call room and wanted to know what was be doing with Patient X. Well, I had paged inefficient intern, who did not return my calls, what did I do? I order the blood work, UA, pancultures and radiology work, and was forcing the patient to walk around halls. So, when the attending called I just managed the patient via the attending. The inefficient intern & junior resident were a little peaved saying "when were you going to tell us?!" And I told them that I had talked directly to the atteding, told them what I did, and that I was personally taking care of the situation. Needless to say, I got alot more to do on the rotation, and great evals to boot. When an intern or resident is screwing up this is big red warning light as it WILL negatively affect a patient or less severely just get the whole team in trouble, it is the perfect opportunity for you to take control of situation and do what needs to be done. The senior residents or attendings won't fault you. In your case, if you knew what an INR of 10 meant (and you unfortunately you didn't) I would have paged the senior i.e. chief resident or attending and have said, "Hey, I just got signed out a patient with an INR of 10, my resident/intern left for the night, what is the game plan with this patient?" They then would have sent down the chief resident to order treatment, etc . . . What I learned is that no one will blame you for being diligent, and if you don't do anything it will make you very very frustrated. Bottom-line residents and interns make mistakes too, and we need to help catch them and correct the problem.

 

[Hard24Get]

I agree with everyone - the story is weird. I am doing my Sub-I now, and at least where I am, we hand the crosscover typed sign-out sheets we worked on during the day, and have "to do" lists for the. So even if you had forgotten to mention the INR, the sheet would say, "supratherapeutic INR - 10mg vitamin K given, recheck INR at am labs, f/u q12 CBC". If there is no such list you should work on one. I don't think there is anything wrong with 3rd years giving sign-out, although here only Sub-Is can work on the document and sign over the pt. Have you tried to tell your resident you are uncomfortable doing the sign-out, or at least run the list with him or her?

 

[ChildNeuro]

Most modern supermarkets and banks have better communications and computer systems than todays hospitals. I have been on many rotations that used computer programs and variations of Word to print up lists for the residents. We would get a crash course in the list, usually working with the intern who would fret about the list and talk about the abusive nature of the surgery resident, and need to figure out the different notations that the resident wanted, and often have to re-print the same information in a different manner several times because the list didn't look right.

It would be so nice if the list for a rotation could be seen on multiple computers and handheld devices, so that it could be updated, and so we wouldn't have to waste ALOT of paper printing out the list each morning. It is a good way to track patients, but if people could modify the same document at the same time from different computers, then one person would not have to be saddled with the responsibility of updating the list.

Now, I realize the advantage of the list, but on every rotation that I was required to maintain the list the students were treated very poorly, had much less patient contact, and basically the residents would only look at the list and refuse to communicate with us like human beings about the patients that we were supposedly taking care of as a team. In the end, the list dehumanizes students in a way as we are forced into a role where we have to create a perfect document, which is impossible and we are inevitably yelled at about, and residents don't talk to us like human beings. I think that there is alot of poor communication in medicine and dehumanization in medicine such that doctors treat patients very antiseptically and coldly, and likewise students are treated very coldly as well. Very little technologic know-how is being utilized to make hospitals run better, because those in control, the attendings, don't see how this paperwork and poor use of computers is bogging down students, interns, and occassionally residents. One of the worst jobs, IMHO is getting vitals on a disorganized medicine floor, sometimes it took me 1.5 hours just to get all the vitals, alot of the time they weren't done and I had to do them, but this is hard when you have to get vitals for 30 patients or more, . . . if only vitals were entered electronically to a computer this would save so much wear and tear on students.

 

[chrisisinnocent]

if only vitals were entered electronically to a computer this would save so much wear and tear on students.

What is worse at our hospital is that it's only half converted. There is a computer system and a paper chart at the same time. On top of it there is a soft chart for nursing. Depending on the patient or the service the information is scattered among 4 different sources. I spend most of my time hunting down the different charts with different ways of organizing and recording the information. It's like having the worst of all worlds.

 

[Hard24Get]

It would be so nice if the list for a rotation could be seen on multiple computers and handheld devices, so that it could be updated, and so we wouldn't have to waste ALOT of paper printing out the list each morning. It is a good way to track patients, but if people could modify the same document at the same time from different computers, then one person would not have to be saddled with the responsibility of updating the list.
. . . if only vitals were entered electronically to a computer this would save so much wear and tear on students.

Wow, didn't realize how good I have it. My hospital has a centralized signout sheet system (although the surgeons don't use it for unknown reasons). I can edit from any computer, certain handheld brands, and even from home. The program also imports the medications from your sign-out sheet into your notes, which you can also edit from anywhere.

Only our ICU has electonic vitals, I agree we really need it everywhere.
Wow, I am going to ask about these things when interviewing for residency!

 

[ChildNeuro]

wow, I knew that someone somewhere would put the technology of the 1990s to work in hospitals today! (Note the sarcasm ;-). I think that some hospitals have patient name tags with bar codes, so when the patient care tech taks the vitals, they are zapped into computer memory, and available to everyone, makes it probably 20 times more efficient to review trends, maybe even make some of those neat graphs that rest of the world uses! I think this would save the nurses aides alot of time if they didn't need to scrawl down number every few seconds and leave more time for patient care. But I guess I have learned how to decipher enough poor handwriting that I could make it doing clinical work in a developing country, where such uses of resources would currently be at the bottom of a long list. It makes sense though in hospitals where technology is employed for accurately stocking the caferteria, that this same technology be used to be more efficient on the wards. If everyone could type we could have truly total electronic medical charts, that would be sooo nice

 

[Bubb Rubb]

Wow, didn't realize how good I have it. My hospital has a centralized signout sheet system (although the surgeons don't use it for unknown reasons). I can edit from any computer, certain handheld brands, and even from home. The program also imports the medications from your sign-out sheet into your notes, which you can also edit from anywhere.

Only our ICU has electonic vitals, I agree we really need it everywhere.
Wow, I am going to ask about these things when interviewing for residency!

we have a centralized signout system, too, but it doesn't pull meds electronically since the MAR is still paper for some reason unbenownst to me. :bangsheadontable: and the vitals are electronic, albeit in a computer system seemingly straight from the early 80s... aaaaaaaaah. at least they're pulled automagically into the signout.

anyway, back to the OP's topic: doing signout on patients that aren't yours is quite ridiculous. MS3s at my school aren't expected to sign out even their patients to the crosscover team, although it happened more than a couple of times.