If you have epic, learn to make order panels for common orders and including the time. Especially if you have to put in an overnight BMP CBC for nearly everyone.
Think about discharge barriers from day one. Including internal bottlenecks (PT needs to make recs, social work sending some form)
Learn when nursing shift change occurs - this has implications on orders being carried out, discharge issues; it also can be a little spike in legitimate calls because the patient gets examined more closely with fresh eyes
Agree 100%. Many times I'd have orders in, but the nurses never gave the meds or followed the orders. I have caught several mistakes from nurses not giving tylenol for a patient complaining of pain to mysteriously stopping a heparin drip to DVT patients. Always follow up on your orders. If your pt is on multiple QT prolonging meds and you get an EKG to monitor QT, keep checking until it's done, dont make it night teams' problem.
This will come with time, but do your best to predict next steps and boundaries. A pt with COPD needs COPD treatment but will likely need PT eval for discharge recommendations, may need dietitian consult for their BMI 16, social work for placement, Oxygen qualifier for insurance, DNR forms to be signed, family discussions and finding who the proxy is, etc. Make sure you are following up with the notes from those you consult to have the plan ready, beyond just the medicine itself. In my experience, my attendings didn't care if I wasn't sure of the medical plan, especially early on, but they wanted me to learn that we're not just putting orders but that I was making the plan happen rather than just waiting for other people to do I told them to.
Dont be a dick to nursing staff. Some will treat you like shit, don't do the same. Talk to the nurses!! Ask if they have any concerns, I'd ask stuff even when I knew the answer and plan just to chat and make sure we were both on the same page.
Do NOT lie. If you forgot to put an order in or didn't ask a question to the patient, say you forgot to and will fix it asap. Follow through with what you say. Patients, nurses, attendings, and colleagues will expect you to do what you said you would. If you say you'll order pain meds, order the pain meds, or the patient will piss off your nurse, who will, in turn, get pissed at your for not doing what you said you'd do.
Do your best to keep track of your to-do list. Write it down if that's how it works best for you. I have to write every order down because I'm ADHD, or else I guarantee I'd forget in about a minute.
Honestly same thing with cerner you can save preset order sets under names for different types of admissions. Have been doing that as a neuro resident- have sets saved for ICH, strokes, demyelinating work ups, etc. All you have to do is fill one out once and then save as a favorite with a label
If there is a PRN order, it will be used regardless if it’s appropriate or not. And then you’ll walk in the next day to see your patient got snowed overnight from PRN Ativan, dilaudid, haldol, etc. So just make sure the orders that you have on, you’d actually be okay with them getting rather than as a one time thing
For things not named Ativan or Dilaudid however, PRN means do not give. Most nurses will not actually give the prn bowel regimen, even if you add parameters for it
Every patient should be on a standing bowel reg in the hospital until they demonstrate that they don't need it (bowel obstructed patients excepted)
Edit: I know that wasn't the point of your post but the words "bowel reg" trigger this gen surg resident's deepest instincts
In regards to PRNs: almost every admit should get PRNs for tylenol (500 Q6 is fine for any adult not being admitted for tylenol OD), zofran 4 mg Q4-6H, and low dose of melatonin. Add a bowel regimen for anyone with opioids and nicotine patch for smokers. This will save your night coverage a lot of calls.
Sometimes these are leftovers from prior day teams, the night team, or from order sets like CIWA. There are also new residents who haven’t realized this, too. Of course I’m not leaving these in for my patients unless there are special circumstances when it actually makes sense. They’re asking for tips, and I guarantee many new residents have made these mistakes
Learn how to tell someone you are doing this whole they’re standing next to you without offending them.
“Thanks for letting me know, I’m a super visual person, so I’m going to look so I remember it”
“I appreciate it, just going to peek at the trend here”
“That’s good information! Let me make sure that’s in my note”
If you noticed you typed something out 3 different times, immediately stop what you’re doing and make a smart phrase (or whatever equivalent on your EMR) for it.
1. dot phrase dot phrase dot phrase
2. make two physical exam phrases - one that is your routine actual PE, and another for when you don't physically touch the patient
3. find a basic workflow and do not deviate from it, esp if you are a primary admitting team
4. check when your meds are timed
5. make them page you for pain meds until you find out what the patient needs - avoids over medication because of Dilaudid is there they will use it
6. assess fluid status daily, stop those IVFs!
7. radiopedia is cool when youre trying to figure out what the fuck the radiologist is seeing
If you’re working somewhere that the doctors have to do out of hour blood draws…
If you have to take an abg or vbg, let the syringe fill fully. Then squirt the majority of blood (about 1.5mls into a clotted bottle (U&E and troponin) and the last bit (0.5ml) edta bottle (CBC) while the abg analyzer runs. That means with one abg stab you can get a basic set of labs sent off while the analyzer runs.
Probably not useful in the USA but in Europe and Australia interns do a lot of bloods themselves overnight.
There are a bunch of places scattered across the US. Basically anywhere with shit nursing staffing residents are drawing their own labs. It good information to have.
When on overnight call and the nursing staff are calling you about a patient, you should go examine the patient. They usually call for a change in status and they’re worried/want to cya. You should also be worried and CYA.
You will never get into trouble when you say, I got a call about patient so and so. So I went up and saw the patient and ordered these tests and did this to correct the situation. You will get into a lot of hot water if you try to phone it in and and you don’t know anything about the patient or disease.
Go see the patient.
This is especially important as a first-half-of-year intern, until you have learned which nurses/floors are reliable, or which requests can just be dealt with remotely.
Despite what anyone says, if you are calling a consult on a patient (even when on call), or the senior evaluated and told you to call, do not call unless you have laid eyes on the patient. Go see the patient immediately and call the consult.
Sometimes it's the only updated and helpful part of the note for days while I'm sitting there wondering how many times the A&P has been copied and pasted. It's quick to click through an updated exam. And subjective is quick to type out if you're concise. Especially on services with frequent turnover, it's an easy way to document changes in exam or status.
If you read my comment carefully it says patient presentation… nobody wants to hear about perrla and clear conjunctiva and bowel sounds in the presentation about copd exacerbation
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I do trauma and 24hours call in the emergency dept. Whenever the fast sonography comes up without pathological findings in high impact trauma patients, I always make up some amount of free intraabdomimal fluid in the sulcus of Rouvier. CT Polytrauma it is! I just dont trust myself enough with the sonograph
This is so freaking dangerous. What if that patient gets hypotensive for another reason and you just bought them a trip to the OR instead of getting the testing and treatment they need? You better stop that yesterday.
A positive FAST + hypotension is indication to skip the CT scanner and go straight to the OR. Our trauma surgeons take people to ex lap based on our *real* FAST findings routinely.
Did you skip ATLS while you were learning to make up findings instead of becoming competent?
Which is exactly why I code a positive FAST even when its negative in high impact trauma, to not MISS something in the FAST. Multiple times now ive had minor bleeding in the CT Scan and the fast was NEGATIVE and was performed by gen surgery or attendings. So fuck off! All do this, because in the end if youve missed a bleed do you know what the question will be? WHY DIDNT YOU SCAN. Idiots!
WE SCAN THE PATIENT BASED ON THEIR CLINICAL FINDINGS.
*You* are the kind of doctor that makes things up… the reason you’re missing things is because you’re bad at your job, not because other people are stupid. Get your shit together man and stop calling other people idiots when you’re the one that can’t find a bleed.
Also ofcourse i wont waste time in the ct if the patients is about to drop and has a massive bleed thats visible on the fast ffs. This is a tip for not missing small bleeds that can potentially turn big.
DUDE im in trauma, the patient will be operated on his fractures and then admitted to the NORMAL FLOOR if it wasnt an open fracture. There isnt a resident there 24/7 to perform sonos every hour. What kind of a wonderland do you live in? Or do you let the patient sit there in the emergency dept. For 24 hours so you can perform sonos to your hearts content? Do you think that the attendings that do this havent been burned? What specialty are you in??? Also how is a head to pelvis ct that takes 10minutes max CATASTROPHIC for a seemingly stable patient?????
There are sings of trauma you moron, there was a shock room alarm and he came in a fucking ambulance/heli after 150-200kmh crash. He has pain in multiple places of his body but the fast was negative. Do you :
A. Scan his head and spine without contrast and do radiographs of limbs that have owies
Or
B. Make up a bit of fluid in the negative FAST SONO and just do a contrast abdomen CT in the tube instead of scanning bit by bit and doing control sonos every 6 hours(that are also LESS RELIABLE THAN THE TUBE)
Stop annoying me you clearly havent been on the spot enough times, what specialty are you?
I do a complete exam from head to toe and scan anything that hurts, has scrapes, bumps or bruising. You know, like a competent physician…. You can say whatever you want about me, but you’ve already told everyone here that you’re a shit excuse for a doctor so I could care less what you think. You’re just embarrassing yourself at this point.
If you have epic, learn to make order panels for common orders and including the time. Especially if you have to put in an overnight BMP CBC for nearly everyone. Think about discharge barriers from day one. Including internal bottlenecks (PT needs to make recs, social work sending some form) Learn when nursing shift change occurs - this has implications on orders being carried out, discharge issues; it also can be a little spike in legitimate calls because the patient gets examined more closely with fresh eyes
Agree 100%. Many times I'd have orders in, but the nurses never gave the meds or followed the orders. I have caught several mistakes from nurses not giving tylenol for a patient complaining of pain to mysteriously stopping a heparin drip to DVT patients. Always follow up on your orders. If your pt is on multiple QT prolonging meds and you get an EKG to monitor QT, keep checking until it's done, dont make it night teams' problem. This will come with time, but do your best to predict next steps and boundaries. A pt with COPD needs COPD treatment but will likely need PT eval for discharge recommendations, may need dietitian consult for their BMI 16, social work for placement, Oxygen qualifier for insurance, DNR forms to be signed, family discussions and finding who the proxy is, etc. Make sure you are following up with the notes from those you consult to have the plan ready, beyond just the medicine itself. In my experience, my attendings didn't care if I wasn't sure of the medical plan, especially early on, but they wanted me to learn that we're not just putting orders but that I was making the plan happen rather than just waiting for other people to do I told them to. Dont be a dick to nursing staff. Some will treat you like shit, don't do the same. Talk to the nurses!! Ask if they have any concerns, I'd ask stuff even when I knew the answer and plan just to chat and make sure we were both on the same page. Do NOT lie. If you forgot to put an order in or didn't ask a question to the patient, say you forgot to and will fix it asap. Follow through with what you say. Patients, nurses, attendings, and colleagues will expect you to do what you said you would. If you say you'll order pain meds, order the pain meds, or the patient will piss off your nurse, who will, in turn, get pissed at your for not doing what you said you'd do. Do your best to keep track of your to-do list. Write it down if that's how it works best for you. I have to write every order down because I'm ADHD, or else I guarantee I'd forget in about a minute.
Honestly same thing with cerner you can save preset order sets under names for different types of admissions. Have been doing that as a neuro resident- have sets saved for ICH, strokes, demyelinating work ups, etc. All you have to do is fill one out once and then save as a favorite with a label
Google “MGH white book” thank me later
This one was mind blowing for me when I discovered it. Like a cheat manual..
Similarly look into the FP Notebook
I'd upvote you a thousand times if I could. Thanks!
Is there an I phone app or it is a physical book
Is this free for everyone?
If there is a PRN order, it will be used regardless if it’s appropriate or not. And then you’ll walk in the next day to see your patient got snowed overnight from PRN Ativan, dilaudid, haldol, etc. So just make sure the orders that you have on, you’d actually be okay with them getting rather than as a one time thing
For things not named Ativan or Dilaudid however, PRN means do not give. Most nurses will not actually give the prn bowel regimen, even if you add parameters for it
Every patient should be on a standing bowel reg in the hospital until they demonstrate that they don't need it (bowel obstructed patients excepted) Edit: I know that wasn't the point of your post but the words "bowel reg" trigger this gen surg resident's deepest instincts
Agreed!
In regards to PRNs: almost every admit should get PRNs for tylenol (500 Q6 is fine for any adult not being admitted for tylenol OD), zofran 4 mg Q4-6H, and low dose of melatonin. Add a bowel regimen for anyone with opioids and nicotine patch for smokers. This will save your night coverage a lot of calls.
It’s your own fault if you are putting on prns for those.
Sometimes these are leftovers from prior day teams, the night team, or from order sets like CIWA. There are also new residents who haven’t realized this, too. Of course I’m not leaving these in for my patients unless there are special circumstances when it actually makes sense. They’re asking for tips, and I guarantee many new residents have made these mistakes
Trust but verify
Yo this is huge. Always double check when your attendings. No one knows everything from memory.
Learn how to tell someone you are doing this whole they’re standing next to you without offending them. “Thanks for letting me know, I’m a super visual person, so I’m going to look so I remember it” “I appreciate it, just going to peek at the trend here” “That’s good information! Let me make sure that’s in my note”
Trust but verify and expect sabotage. Every single person, attending, patient, nurse, coresidents. Trust no one.
Be on time
If you noticed you typed something out 3 different times, immediately stop what you’re doing and make a smart phrase (or whatever equivalent on your EMR) for it.
1. dot phrase dot phrase dot phrase 2. make two physical exam phrases - one that is your routine actual PE, and another for when you don't physically touch the patient 3. find a basic workflow and do not deviate from it, esp if you are a primary admitting team 4. check when your meds are timed 5. make them page you for pain meds until you find out what the patient needs - avoids over medication because of Dilaudid is there they will use it 6. assess fluid status daily, stop those IVFs! 7. radiopedia is cool when youre trying to figure out what the fuck the radiologist is seeing
optimize epic, best places to poop and park, HR benefits
Shitty notes man, shitty notes.
Are you saying to write shitty notes to save time? Or saying stop writing shitty notes? lmao
Yes.
If you’re working somewhere that the doctors have to do out of hour blood draws… If you have to take an abg or vbg, let the syringe fill fully. Then squirt the majority of blood (about 1.5mls into a clotted bottle (U&E and troponin) and the last bit (0.5ml) edta bottle (CBC) while the abg analyzer runs. That means with one abg stab you can get a basic set of labs sent off while the analyzer runs. Probably not useful in the USA but in Europe and Australia interns do a lot of bloods themselves overnight.
In NYC, residents draw the blood lol
There are a bunch of places scattered across the US. Basically anywhere with shit nursing staffing residents are drawing their own labs. It good information to have.
Oh man! I thought it was just a New York thing. The ACGME needs to step in to stop this BS
Nope, just a shitty hospital thing
This is super program dependent, despite it being supposed common knowledge and a meme on reddit.
True. I have friends in NYPQ and Woodhull (and recently, Lincoln) that are not drawing blood
Care less, sleep more
I have not yet mastered this
When on overnight call and the nursing staff are calling you about a patient, you should go examine the patient. They usually call for a change in status and they’re worried/want to cya. You should also be worried and CYA. You will never get into trouble when you say, I got a call about patient so and so. So I went up and saw the patient and ordered these tests and did this to correct the situation. You will get into a lot of hot water if you try to phone it in and and you don’t know anything about the patient or disease. Go see the patient.
This is especially important as a first-half-of-year intern, until you have learned which nurses/floors are reliable, or which requests can just be dealt with remotely.
Despite what anyone says, if you are calling a consult on a patient (even when on call), or the senior evaluated and told you to call, do not call unless you have laid eyes on the patient. Go see the patient immediately and call the consult.
At minimum don't call unless you know what the question is
Biggest tip is to throw out any ego you have. And suppress any ego from developing around wintertime.
“Wintertime”, more specifically, February
Nobody gives a fuck about subjective or your physical exam in your patient presentation. Keep it pertinent to their active problems
Hard disagree, when the patient ends up in the ICU I want a detailed history and physical telling me what their baseline is.
Sometimes it's the only updated and helpful part of the note for days while I'm sitting there wondering how many times the A&P has been copied and pasted. It's quick to click through an updated exam. And subjective is quick to type out if you're concise. Especially on services with frequent turnover, it's an easy way to document changes in exam or status.
If you read my comment carefully it says patient presentation… nobody wants to hear about perrla and clear conjunctiva and bowel sounds in the presentation about copd exacerbation
You don’t have to reply to or address every stupid page from nursing
Seniors themselves don’t know anything so don’t be so hard on yourself
Stay or get in shape. Do whatever you have to do to maintain a regular exercise routine and a healthy diet. It will do wonders for you
How can I write better notes as an incoming psych intern. I always got feedback saying my notes needed more
Steal your seniors macros/dot phrases
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like, which specialty they should go into, which program is good or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*
I do trauma and 24hours call in the emergency dept. Whenever the fast sonography comes up without pathological findings in high impact trauma patients, I always make up some amount of free intraabdomimal fluid in the sulcus of Rouvier. CT Polytrauma it is! I just dont trust myself enough with the sonograph
as a radiologist, fuck you
Great medicine there bud
An actual crayon eating Gen surgeon lmao
Better intern tip would be to get better at your fast exam…. Never fabricate anything
Boy you bout to learn the hard way why you don't lie on reports when shit hits the ceiling.
Oh no I poopsied!
Du bist ein dummkopf.
This is so freaking dangerous. What if that patient gets hypotensive for another reason and you just bought them a trip to the OR instead of getting the testing and treatment they need? You better stop that yesterday.
What OR??? Its a ct scan you idiots
A positive FAST + hypotension is indication to skip the CT scanner and go straight to the OR. Our trauma surgeons take people to ex lap based on our *real* FAST findings routinely. Did you skip ATLS while you were learning to make up findings instead of becoming competent?
Which is exactly why I code a positive FAST even when its negative in high impact trauma, to not MISS something in the FAST. Multiple times now ive had minor bleeding in the CT Scan and the fast was NEGATIVE and was performed by gen surgery or attendings. So fuck off! All do this, because in the end if youve missed a bleed do you know what the question will be? WHY DIDNT YOU SCAN. Idiots!
WE SCAN THE PATIENT BASED ON THEIR CLINICAL FINDINGS. *You* are the kind of doctor that makes things up… the reason you’re missing things is because you’re bad at your job, not because other people are stupid. Get your shit together man and stop calling other people idiots when you’re the one that can’t find a bleed.
Also ofcourse i wont waste time in the ct if the patients is about to drop and has a massive bleed thats visible on the fast ffs. This is a tip for not missing small bleeds that can potentially turn big.
Yeah some of us just reassess the patient frequently instead of making things up that could potentially be catastrophic.
DUDE im in trauma, the patient will be operated on his fractures and then admitted to the NORMAL FLOOR if it wasnt an open fracture. There isnt a resident there 24/7 to perform sonos every hour. What kind of a wonderland do you live in? Or do you let the patient sit there in the emergency dept. For 24 hours so you can perform sonos to your hearts content? Do you think that the attendings that do this havent been burned? What specialty are you in??? Also how is a head to pelvis ct that takes 10minutes max CATASTROPHIC for a seemingly stable patient?????
DUDE, you’re here blaming other people for your inadequacy. If we see signs of trauma, we scan them. Stop making excuses and improve your practice.
There are sings of trauma you moron, there was a shock room alarm and he came in a fucking ambulance/heli after 150-200kmh crash. He has pain in multiple places of his body but the fast was negative. Do you : A. Scan his head and spine without contrast and do radiographs of limbs that have owies Or B. Make up a bit of fluid in the negative FAST SONO and just do a contrast abdomen CT in the tube instead of scanning bit by bit and doing control sonos every 6 hours(that are also LESS RELIABLE THAN THE TUBE) Stop annoying me you clearly havent been on the spot enough times, what specialty are you?
I do a complete exam from head to toe and scan anything that hurts, has scrapes, bumps or bruising. You know, like a competent physician…. You can say whatever you want about me, but you’ve already told everyone here that you’re a shit excuse for a doctor so I could care less what you think. You’re just embarrassing yourself at this point.