It's almost July and many med school graduates are getting ready to be interns.
They will be making a lot of decisions they haven't made before, and many decisions can hurt patients.
A lot of the time you'll be rushed and pressed for time in making critical decisions, and other times you'll be making a decision which has ramifications that might not be noticed for some time.
Basics:
1. Read up on things you're weak on. A lot of people say you can't study for intern year, but you actually can. The logistics of placing orders and the way the unit works is something you'll learn on the job, but there are essentials you need to carry with you into intern year.
2. Go see the patient. Even if you get called for a fever, don't just say "Yea give some tylenol." They could be tachycardic or hypotensive by the time you get to the room and you don't want to miss anything.
3. Always go talk to the patient or family when you're asked to unless you're managing an emergency. A hospital is a strange and foreign place to many people other than you, they don't know how it works. You might be the only sense of comfort and familiarity they have.
4. Have a To Do list and write everything down. You'll constantly be called and paged and interrupted while hungry, tired, and dehydrated and you'll lose track of things.
5. Call consults on rounds, place orders early. Inpatient medicine is incredibly slow so you need to get the wheels turning early.
6. Learn from your consultants. If someone has a heart rate of 55 and they're sitting up talking to you, texting on their phone, walking around and have no symptoms and no cardiac history, and a normal EKG, it doesn't merit a cardiology consult unless there's something worrying you. Feel free to ask them questions about management and make it a part of your practice.
7. Work for the interns next to you. You are a unit and a team. Build morale and the rotation will be better.
8. Don't rock the boat..I hate having to say this but as an intern you have to follow orders and march. People who oppose their superiors will often find themselves treated differently. Maybe you'll have an attending or fellow who is open-minded, but especially early in your training, do what you're told unless it will harm the patient. Don't argue on rounds and don't burn bridges. Your contract isn't guaranteed to be renewed each year.
9. Bring food from home, play music in the team room. Residency can be a long, joyless and oppressive march. Make it as good as you can.
Patient Care
1. Make the habit of finding the patient's first medical H&P and find out what problems they've had at that time. As time passes, a lot of things don't get charted and you can potentially miss a lot of information. Someone in 2016 might not have charted that the patient has a drinking problem, but maybe from 2010-2014 they had been drinking a liter of vodka a day, and so on.
2. Always compare prior imaging/EKGs to the new ones. This ties into my next point.
3. Baseline, baseline, baseline. I vomit every time I hear "What's the patient's baseline?" So now I give the baseline creatinine, exercise tolerance, hemoglobin, etc.
4. Know your hospital's antibiogram (what germs are resistant/susceptible to what antibiotics)
5. If you have someone in the ICU and you don't know if they'll be fluid responsive for resuscitation, you can lift their legs up and take their BP. It'll take some help, but the fluid shift will tell you how some extra fluid will help.
6. Always know your patient's ejection fraction and renal status because this ties into fluid resuscitation. You might kill someone if you bolus them with fluid when their EF is 15% and they've already gotten fluid. Always ask the patient's cardiac status/renal status when you're getting sign out.
7. Don't copy-paste your physical exam in the EMR. I've seen consultants/other teams keep on writing a patient was intubated when they were extubated for 3 days in another unit. Don't embarrass yourself.
8. Don't take criticism personally. You will be criticized and corrected all the time. You are a learner. A lot of people have bristly personalities or will be rude, and that's their problem.
9. Take medical students under your wing. Like you, they were used, disrespected, ignored, and bossed around. Be an educator and mentor.
10. Don't do maintenance fluids in sepsis. The pathophysiology is that vessels have poor tone and leak in sepsis. Bolus and pressors as indicated.
11. Know everyone's drug allergies. Ask them, even if there are already some that are documented. They might have tried a new medicine that gave them a new allergy.
12. Bladder pressures if you think someone has abdominal compartment syndrome (trauma,bad ascites)
13. Know side effects of what you're prescribing. Iatrogenic harm is real
14. Calcium channel blockers are contraindicated in patient's with afib-rvr in heart failure
15. Don't forget to place patients on IV fluids if they're NPO for a procedure or imaging, preferably with dextrose in there.
16. Update your nurses and treat them right. Some will be difficult to work with no matter what, but if you make their lives easier and treat them like a team member, they will help you more. They're at the patient's bedside more often than you, and they will often relay information from consult services to you.
17. No potassium repletion for ESRD patients. Renal should always be notified immediately when a dialysis patient comes in anyway and they'll give you a hand.
18. Make sure all your patients on ventilators have orders for suctioning and n-acetylcysteine as needed.
19. Don't miss the MI because you're so set on working up abdominal pain.
20. Neutropenic fever patients need 2g of cefepime instead of lower doses. Always get b-galactomannan as part of your work up.
21. No DREs on neutropenic patients. Don't introduce GI germs into their bloodstream
22. Do everything you can to prevent intubation on an asthmatic patient. If it absolutely has to happen, make sure there's a fluid bolus and pressure bag ready, that people have atropine and epinephrine at bedside.
23. Don't hesitate to call the code. You'll be inexperienced but the nurses and residents will come in quickly and run the code and help.
24. Get the lactate and VBG in patients who roll in tachycardic and hypotensive. Draw blood cultures before antibiotics
25. People post-PCI or cardiac surgery will have elevated cardiac troponins and a scary looking EKG with ST elevations that take some time to die down. If you get called about an EKG with ST elevations, go see their previous EKGs and see the patient first.
26. When you get called with a set of abnormal vitals, tell nursing you'll be there and for them to have a repeat set as you walk over there and any necessary labs.
27. If someone comes in with chest pain, ask what their exercise tolerance is and how it has changed, their pillow orthopnoea, if they have enough energy and strength to do their ADLs without getting short of breath, and if they've missed any doses of their medicines, including aspirin/plavix for people with stents.
28. Know your GI prophylaxis indications. Examples are steroids, coagulopathy, intubated on a vent, etc. The typical patient just hanging out in the hospital doesn't need it.
29. If someone's platelets have tanked in the ICU, it could be due to sepsis, antibiotics like vancomycin, or heparin-induced thrombocytopenia.
30. Expect hypoglycemia if someone's getting steroids. Manage it accordingly
31. Expect transient bacteremias after ERCP
more to come
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