Friday: Ten Random Things I asked My Interns to do Today

Poor Intern. As Stated previously, said intern commited Cardinal sin #1 (The absolute worst violation) and is now in the dog house. Poor Intern (From here on designated PI) had an eventful Friday. I should procrastinate no longer and hereby list for you the Ten Random Things I asked My Interns to do Today: (Things PI had to do are *)

1. Discuss with the nurse if she can place a foley.
2. Place IV lines in three nursing home patients who have the most horrible, edematoud arms I've ever seen. *
3. Follow up blood test results.
4. Personally administer an enema. If that doesn't work...well...I'll let you know if it worked. Otherwise, poor intern. *
5. Confirm the size, shape and stage of the decubitus ulcers on the sacrum of said nursing home residents. They are quiet obese patients.*
6. Three rectal exams. *
7. Put together a good lecture on hyponatremia and the many causes of it. Make it a Powerpoint presentation.*
8. Review literature on Loss of conscience and come to a conclusion on whether this is an emergent situation.*
9. Insert a foley in a patient, himself!*
10. The enema didn't work...Poor Intern*

I wonder if he figured out what I was upset about?

Noah Got Upset

As a reponse to my previous Comical post about how I joke with my interns and students. Noah wrote the following:

"Just jump on the orthopods. The IM docs are always claiming their intellectual superiority. Would love to compare the average board scores of medicine residents versus ortho residents. I'd bet we beat the meds by a standard deviation, honestly.And internal medicine is far more rote memorization than thinking. 90% of what you need to know you could look up in the Sabatine pocket medicine manual, and the other 10% you read before rounds on up-to-date. Evidence-based medicine nearly gets you off the decision-making hook in most circumstances. All you need to do is look it up.I guarantee that the orthopod's functional application of anatomy and biomechanics is on par with any internal medicine doc's application of physiology, immunology, or pharmacology to pathological situations.And kudos to ER docs, who can not only understand the important aspects of every field within medicine and surgery, but, unlike meds, don't shit themselves when a situation gets hairy".

Noah at vertical mattress

Rare as it is that I get a negative reaction like this, I took the oppurtunity to explain to Noah just what I meant:

"Oops I've managed to upset someone. We're all just joking around and this definitely shouldn't be taken too seriously Noah.I know that Ortho residents do better on their boards. I always feel bad because I feel that an ortho resident is like taking a new mercedes and driving it off-road. it doesn't make sense that they take the brightest minds for the job when I feel we can put their minds to better use. But I do believe you may have just taken me joking around with my interns a LITTLE TOO SERIOUSLY! I really don't think of Orthopods that badly"

On another note, evidence based medicine VERY RARELY gets us off the hook. There are studies to support maybe 40% of everything we do. The rest is all thinking and rationalization.

And, one more sidenote. I've been on the medicine floors for three years now, in the ICU for two, in the CCU for two and did four one month ER shifts. Not once "When the situation got hairy" (and it does often, believe me) did I pass any form of stool on myself. Like the post I wrote, this is also just hospital humor!

Update to Readers

In light of recent events I thought I would update my readers on an upcoming attraction in the Mad House.

This morning, my intern commited cardinal sin #1. While in the middle of ATTENDING rounds he bursts out with "I don't know what's wrong with Ms. Simon, she's become unresponsive". The resident (a.k.a: Me) was not made aware of this earlier on RESIDENT rounds thus making RESIDENT look very BAD in front of ATTENDING! I mean "Unresponsive" tends to carry a 'bad' prognosis and really should and would have been looked into.

All this, and right before Friday's "Ten Random Things I asked my Intern To Do Today". I would call that...bad timing.

May god have pity on his soul this Friday. Because I won't!

Spectrum

“Well, the thing is that I don’t expect you to do this well, I mean, you’re going to be an ER resident. You’re actually supposed to learn to do this wrong”
“Shut up you sarcastic dork”
“Just kidding! You’re not supposed to learn to do this wrong but just wrong enough”
“You act so high and mighty about your internal medicine”
“Well, I mean, internal medicine requires thinking”
“Oh and ER doesn’t?”
“Yes it does, don’t get me wrong. It’s just that as an ER resident you’re trained to come to the wrong conclusion. At least that’s my experience”
“Ohhhhh….I am so gonna kick your ass”
“Look, you should be happy. At least you’re not going to be an Orthopod like the Sub-I”
“Oh yeah…Where on your spectrum of intelligence does Orthopedics lie”
“Well, if I had to place Emergency it would somewhere in the middle, you know, does everything, just not so well. Maybe slightly above Rehab Medicine”
“Ohhhhh….”
“And Ortho. Well, I guess I would place Ortho slightly above…..Housekeeping”
“Oh, I am on service next month and you are so not getting a consult” Says the Sub-I.
“What do you mean, what if my car breaks down? We always need Orthopods to repair the cars out in the parking lot”
“OH! You are sooooo not getting a consult”

White Team.

PTT

“What do you mean a PTT made you anxious?”
“Well, I just never had to face that kind of pressure before”
“That kind of pressure? Wait until it’s your post-call day and you’re exhausted and the admission from last night is going down the tubes and you can’t even remember your own name”
“That’s too much for me”
“THAT’S TOO MUCH? But you’re going into Emergency Medicine”

The look on the face of my intern made me realize just how innocent she really was, how little she knew and how little she worried. Still, no battle scars. The reason for my anxiety is that I realize things can get out of hand rather quickly. When complications happen they usually happen suddenly and only experience reveals the warning signs. The eye cannot see what they brain does not know. My intern has seen nothing yet.

I left her there on our post-call day after I saw all our patients. Helped her with a few notes and then I decided that my dues were already paid and that staying late on a post-call day is an intern’s job. I have no right to rob her of this experience.

On my way home the pager went off. It was the fourth floor and the lack of typical warning signs on the face of the beeper caused me to believe it was another nurse trying to reach me when she should be calling my intern. I had no way of calling back now and so I continued home. After arriving at home I found out that the patient from last night decompensated. I hear it was quick and chaotic. I also heard that my intern panicked. That she wasn’t ready for this and that the patient was rushed to the unit and later died.

The news didn’t surprise me. It was a patient who was really sick and it was certainly a possibility that she would crash. Somehow though, I don’t think my intern realized what I meant. Tomorrow she will.

At home I played with Jordan after not having seen her awake for nearly a week. And when the time came to bath her, feed her and put her to sleep I jumped at the opportunity. It was Jordan and I sitting in the spark of the nightlight in her bouncer. She was clean and sucking on her bottle and my thoughts waned and I remembered my intern. She is home now and she’s tired and her new life just smacked her in the face.

She’s wondering if this is really what she wants to do with her life now. Can she endure like this? Can she be a witness to such tragedy and be critical at critical situations. She is double-guessing everything she did today and likely herself.

As I sat there feeding Jordan I thought of my tortured intern. She must be going through shock but it will eventually make her stronger. But its misery now and it’s something she must experience. My intern was in hell and I looked down at Jordan and thought about the patient from the fourth floor. We were both in Heaven.

The Skeptic's Circle

Check out the Skeptic's Circle over at Orac. Sad news, Nate no longer blogging.

Friday: Ten Random Things I asked my Interns to Do Today

I'm back, rotation almost over.

1. Take a STAT PTT.
2. Grease the Radiology tech.
3. Draw various other bloods.
4. Transfer a patient to the unit.
5. Do an EKG.
6. Walk some patients around the hall.
7. Attempt to give her first patient the horrible news that he has lung cancer with metastasis to the brain.
8. Call for old records from another hospital.
9. Give me a massage. (a bonus)
10. Do a rectal!

Friday: 10 Random Things I asked My Interns To Do Today

First, I intended to apologize for the very light posting on this blog as of late. I have some planned posts that I really want to write but this rotation is so brutal that if I get home early all I want to do is hang out with Jordan (Future Intern).

As I said, I 'intended' on apologizing but then I thought to check out some of the bloggers I love to read, as I haven't checked in for a while. I noticed Dr. Charles is on his little break, so is Orac. Maybe...maybe it's Summer, finally, and whatever time I do get I like to spend outdoors. So I will give a pseudo-apology for the light blogging. I will return when I get inspired or when I get enough rest, whichever comes first.

Of course, no Friday would be complete without the Ten things I asked my Interns to do today. So here goes:

1. I sent my female Intern with the big boobs to ask the interventional Radiologists to do a STAT PICC line. I apologize for my male shovenism to my readers. The PICC line was placed, STAT.
2. Go take a detailed history on a patient that I was supposed to present at a conference later in the day.
3. Discharge a patient.
4. Gave an assignment to do a future presentation on Hyponatremia.
5. Asked for a PTT on a patient every 6 hours. A very very hard to stick patient.
6. Transferred a patient to Surgery.
7. Push Social Work for placement.
8. Increased the dosage on a few meds.
9. Sent my student to get us breakfast.
10. A rectal exam.

Friday: 10 Random Things I Asked My Interns to Do Today

1. Take a history on a patient he will not admit. (Made him quite angry)
2. reinsert an IV port.
3. Beg Bedboard to allow us to transfer a patient to another floor. (I sent chocolate)
4. Page surgery and pretend to be very upset about a patient on our service who's been awaiting surgery for a week now.
5. Discuss giving meds correctly with the nurse.
6. Order an Echocardiogram.
7. Order a Renal Ultrasound.
8. Call three atendings to inquire about their desired work-up.
9. medical student to draw blood on a patient.
10. A rectal exam. (My day is never complete without asking for at-least one rectal exam)

BTW, I neglected to mention that it seems my disciples are now spreading the madness. Look out for some more Madness coming to a hospital near you.

Poor Guinea Pig

“So why do you keep drinking?”
“They keep opening liquor stores where I hang out”

That was a gem and it didn’t take long. It was only the second patient I saw since returning but I nearly lost my balance. I swear I could hear glass break. I bit my lips to prevent myself from laughing.

Then, another grenade:

“I once ate a battery”
“Why did you do that? Were you trying to commit suicide?”
“No. There were just all these batteries on the floor”

Yes, I know you’re expecting more of the answer but that was it. He stopped talking after that. There were just all these batteries, on the floor…

One day after returning from Israel I was asked to take over my team, learn all my new patients and be on call (ie: admit some more). My new interns are just so ‘Internish’. This could not have been me two years ago, no, no, it couldn’t be. The highlight of Saturday was trying to explain to my intern and my annoying third year student how to draw blood. Excruciating as it must have been to the patient who we were punishing for coming to the hospital in July. I was wholly taken back when the patient signed out a few minutes later, poor guinea pig.

Please don’t misunderstand, I have nothing against students, I even like them, a little. But there are a certain few who feel that they should pretend to know more than they do. This is a beneficial quality if it motivates the student in question to do research and to inquire, but it can also have the opposite effect. Specifically, if they finish off your sentences to prove they know the answer.

More often than not, they’re wrong. I understand that they want to impress me with how much they know but it has the opposite effect and just makes them look as if they’re unwilling to listen to a teacher. I have no expectations of third year students except that they remember what I’ve taught them and that they listen. This usually means that I expect them not to know anything, the first time. But that once I’ve taught them then they should know the answer. If you cut me off every time I’m trying to teach then I’ll simply stop teaching.

Overall, my team is pretty descent. I know a little something and my interns know nothing, yet. By the time I’m done with them they’ll know all the wrong things. Like how to pretend you’re working when you’re really not and Rule number 13.

It should be an interesting month.

Now, if you’ll excuse me there are these things all over the floor, what do you call them? Oh yeah, sharp razors…

Jetlag

Stepped off the plane last night. Back in the Mad House today for a call. Nice to know life is just as hectic and irrational as when I left.

I have to say I actually did miss this place. This feeling of joy at returning will probably last until I meet my first patient.