1 Scared Intern

[OR 1]

I am going to be an intern in 4 months starting a prelim year in IM and I am really scared. I've done all the usual things in school, H&P's SOAP's tons of proceedures but...Are you guys scared too? What kind of info do you get during orientation? My nightmare is being alone at night and some nurse calls up in the first few months while on wards or ICU and askes for some pain med. I don't know that I know what to give.
Is your resident there with you-how does this work? Are you ever alone?
what is expected of the intern? How many treatment protocols are you supposed to know coming in?

Any interns or residents out there that could answer?

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[deleted109597]

You are alone. You have a senior, but if you call him asking for pain med orders, he/she will hate you. Just ask the nurse if the patient is allergic/sensitive to any meds. Then pull out your pharmacopeia. After a few times of this, you'll get the hand of MSO4 1mg IV q4hrs PRN pain. You'll likely become more familiar with Zofran 4mg IV q6hrs PRN N/V.

 

[Winged Scapula]

You are alone. You have a senior, but if you call him asking for pain med orders, he/she will hate you. Just ask the nurse if the patient is allergic/sensitive to any meds. Then pull out your pharmacopeia. After a few times of this, you'll get the hand of MSO4 1mg IV q4hrs PRN pain. You'll likely become more familiar with Zofran 4mg IV q6hrs PRN N/V.

I am sure my colleague meant, "you are NOT alone"!.

You aren't. Everyone is scared at some times, and everyone was scared all the time when they started internship. You will soon come to see that most of the calls from the nurses are for minor things.

If it doesn't appear to be an emergency, you can ask them if you can call right back - whip out your pharmacopeia/whatever and find something suitable. You can ask the nurse what the patient has used before that has worked (often they know the answer to what they and the patient want, but don't want to tell you what to order). Don't always assume the patient wants or needs narcotics - while IV morphine is fine in most cases, some patients just want Tylenol or Motrin; others may benefit from Percocet, Vicodin or Tylenol with codeine (lasts longer than IV narcs).

There are also lots of pocket books out there to help you, as well as colleagues. Most common calls (which will vary somewhat from rotation to rotation) which may need medication:

Pain - as above assess need/want; what has worked before; patient's age and weight; many young doctors are worried about overdosing patients, you should be just as worried about underdosing and allowing the patient to have unrelieved pain. You will have a choice of everything from Tylenol, Motrin, Toradol, Tylenol with codeine, Darvocet, Percocet, Vicodin, Fentanyl, Morphine, Demerol, Diluadid, etc. oral/rectal/iv/im/patches/pca pump

Nausea - Zofran works well for many; some hospitals restrict it to post-op patients. Consider phenergan or compazine (can have extra-pyramidal or mental status changes with both), Tigan, or some good old crackers and warm soda.

Insomnia - Ambien is probably mostly used; benadryl for kiddies and some elderly (some will go crazy on it); tylenol pm if on your formulary

Tachycarda/Bradycardia or other rhythm disturbance: do not handle this by yourself; call your senior. If a patient is post op tachy with low blood pressure, likely due to volume depletion, but still call for assistance when you first start out. On IM the reasons for these problems can be much more complicated.

Etc. there are entire books written about this stuff. No one expects you to know it all, or not have to look it up. The nurses know and hopefully will be kind and helpful to you as you start out.

 

[Apollyon]

Nausea - Zofran works well for many; some hospitals restrict it to post-op patients. Consider phenergan or compazine (can have extra-pyramidal or mental status changes with both), Tigan, or some good old crackers and warm soda.

As always, opinions differ - I think Phenergan is absolute GARBAGE, and question those who prescribe it. Phenergan has a "black box" warning for kids 12 and under, and I give it about 5 years before it's out for everyone (due to the side effect profile, and abuse potential - the patient who demands "Demerol and Phenergan" is looking for the euphoric effect). I go with Reglan and Zofran first (and always for IV). After the first dose of Reglan, I give some Benadryl, just to offset the chance of extra-pyramidal reactions. The only Phenergan is Rx for suppositories for discharge, and that, still, is rare.

Zofran studies show 8mg is best (for non-chemo n/v - 8 is best result, and more than that isn't better), and that is what I use, because, no matter what the dose, if it doesn't work, more won't work until 8 hours have passed - so, if you give Zofran 4mg, and the patient is still vomiting, you can't give another 4mg (or, otherwise, you can, but it won't do anything) until 8 hours have passed. Then, you've cut down what you can use.

 

[Pox in a box]

You are alone. You have a senior, but if you call him asking for pain med orders, he/she will hate you. Just ask the nurse if the patient is allergic/sensitive to any meds. Then pull out your pharmacopeia. After a few times of this, you'll get the hand of MSO4 1mg IV q4hrs PRN pain. You'll likely become more familiar with Zofran 4mg IV q6hrs PRN N/V.

Don't ever write MSO4 in any hospital chart. If you go to a program where the first night on call, you ask your senior when you are unsure of something and he/she "hates you," maybe you picked the wrong program.

 

[Idiopathic]

Yeaqh, and 1mg q4h? Pretty sure you wont get called back on that one

As far as phenergan goes, I have to disagree apollyon. I know the drug has abuse potential, but so does benadryl. Sure it makes people loopy, but its got antihistaminic properties. The black box warning has to do with dehydration and dystonic reaction in children, and antihistamines typically should not be used in children 2/2 their paradoxical stimulation. Deaths have been reported with mega-ingestion in kids under 2, but thats a totally different patient population anyway.

This drug will NEVER be black-boxed in the adult population.

With that said, sure people seek it, but people seek lots of things (morphine, demerol, dilaudid, stadol, compazine, phenergan...) you certainly cant just rid yourself of entire segments of the pharmacopeia when prescribing because of that.

 

[Idiopathic]

You are alone. You have a senior, but if you call him asking for pain med orders, he/she will hate you. Just ask the nurse if the patient is allergic/sensitive to any meds. Then pull out your pharmacopeia. After a few times of this, you'll get the hand of MSO4 1mg IV q4hrs PRN pain. You'll likely become more familiar with Zofran 4mg IV q6hrs PRN N/V.

Careful giving advice to someone the same level as you

 

[GoodbyeTemecula]

Just remember to never give demoral to anyone over 60. I have seen 2 interns now order a very normal range of dem for most people, except the patients were in their 80s and both went into resp arrest. One died and the other we spent the whole day standing by her bed with resp therapy monitoring her vitals. Stick with morph for the oldies

 

[Apollyon]

With that said, sure people seek it, but people seek lots of things (morphine, demerol, dilaudid, stadol, compazine, phenergan...) you certainly cant just rid yourself of entire segments of the pharmacopeia when prescribing because of that.

Demerol and Phenergan are verboten from my personal prescribing, and anyone who does it (D & P) is either lazy or has been totally suckered. Those are the only two I don't Rx, and, somehow, I have been pretty successful. I'm not "ridding myself of entire segments of the phamacopoeia".

I asked our medical director where I'm at now point-blank when Demerol will be dropped from the formulary, and he said that "there's been a lot of discussion". At Duke, the ONLY indication is for post-op shivering. Otherwise, thank heavens, it's unavailable.

And you say Phenergan will never go away? Ever hear of Cisapride or droperidol?

 

[lowbudget]

I thought The Washington Manual's Intern Survival Guide was pretty good for me as an intern. It took me awhile just to figure out how to manage CONSTIPATION (which is in the guide, btw).

My advice is that you should always see the patient AND look through the chart for every patient they call you about in the first couple of months until you get a feel for how to assess/triage/manage in the middle of the night over the phone. I mean, there are cases where you just *may* consider checking an EKG before you give the pain med order.

 

[Arch Guillotti]

And you say Phenergan will never go away? Ever hear of Cisapride or droperidol?

dude I use droperidol all the time

 

[deleted87716]

Try working in the outpatient (a.k.a. "real") world.

Go ahead...send your patients to the pharmacy with an Rx for Zofran. You'll get sick of the "I can't afford that!" call-backs real quick.

Name another antiemetic that works as well as Phenergan, and is available in both oral and rectal forms, and I'll use it. And don't say "crackers and warm soda," Kim...not that I'd tell a patient to use that rectally, anyway.

Demerol is a different story. I avoid that stuff like the plague.

 

[Pox in a box]

Name another antiemetic that works as well as Phenergan, and is available in both oral and rectal forms, and I'll use it. And don't say "crackers and warm soda," Kim...not that I'd tell a patient to use that rectally, anyway.

Some pharmacies that can do compounding can make it into a gel...I've never figured that one out. Anyone?

 

[Apollyon]

Try working in the outpatient (a.k.a. "real") world.

Umm...I do - and you know that.

I ask the patients if they have a drug plan. That's step one. Also, Reglan is on the Wal-Mart list. Finally, the rarest patient is the one that is intractibly vomiting, yet I'm going to send them home. That is why, if you read the thread, I said that I prescribe it only in suppository form, if it becomes that they can't take PO. Patients get Zofran ODT (insured) or Reglan (uninsured) PO Rx.

 

[Apollyon]

dude I use droperidol all the time

Then you're at one of the fortunate places that has it on formulary. I mean, if it ain't there, you can order all you want, but you won't get it. I am not saying that the black box was warranted, but it's there, and, if you are the unlucky person that has a patient go into cardiac arrest while you're using it (even if they're an ASA 5 and are dying in front of you), some legal eagle (or vulture) will put a picture of you + a picture of Inapsine = $$ in front of a jury, and you're done.

 

[deleted87716]

Reglan is on the Wal-Mart list.

Interesting that you have a problem with Phenergan's SE profile, but not Reglan's.

Whatever you're comfortable with, I guess.

 

[8744]

I am sure my colleague meant, "you are NOT alone"!.

You aren't. Everyone is scared at some times, and everyone was scared all the time when they started internship. You will soon come to see that most of the calls from the nurses are for minor things.

If it doesn't appear to be an emergency, you can ask them if you can call right back - whip out your pharmacopeia/whatever and find something suitable. You can ask the nurse what the patient has used before that has worked (often they know the answer to what they and the patient want, but don't want to tell you what to order). Don't always assume the patient wants or needs narcotics - while IV morphine is fine in most cases, some patients just want Tylenol or Motrin; others may benefit from Percocet, Vicodin or Tylenol with codeine (lasts longer than IV narcs).

There are also lots of pocket books out there to help you, as well as colleagues. Most common calls (which will vary somewhat from rotation to rotation) which may need medication:

Pain - as above assess need/want; what has worked before; patient's age and weight; many young doctors are worried about overdosing patients, you should be just as worried about underdosing and allowing the patient to have unrelieved pain. You will have a choice of everything from Tylenol, Motrin, Toradol, Tylenol with codeine, Darvocet, Percocet, Vicodin, Fentanyl, Morphine, Demerol, Diluadid, etc. oral/rectal/iv/im/patches/pca pump

Nausea - Zofran works well for many; some hospitals restrict it to post-op patients. Consider phenergan or compazine (can have extra-pyramidal or mental status changes with both), Tigan, or some good old crackers and warm soda.

Insomnia - Ambien is probably mostly used; benadryl for kiddies and some elderly (some will go crazy on it); tylenol pm if on your formulary

Tachycarda/Bradycardia or other rhythm disturbance: do not handle this by yourself; call your senior. If a patient is post op tachy with low blood pressure, likely due to volume depletion, but still call for assistance when you first start out. On IM the reasons for these problems can be much more complicated.

Etc. there are entire books written about this stuff. No one expects you to know it all, or not have to look it up. The nurses know and hopefully will be kind and helpful to you as you start out.

No, I think he meant, "you are alone," which is metaphysically true if not actually true. the look of contempt on my senior resident's face when I woke her up was so appalling that I would have almost rather have accidently killed the patient with an overdose of Amiodarone than to wake her up again to ask her about it.

I hate call. With the buring passion of one thousand suns. I always have but a year-and-a-half ago I was also afraid of it and dreaded the pager or the call to a code.

Now I just hate being tired and working at a job where I have the potential to kill and maim (or heal) for less money, per hour, than the guy assembling my Gordito at Taco Bell.

 

[danielmd06]

I am going to be an intern in 4 months starting a prelim year in IM and I am really scared.

Any interns or residents out there that could answer?

Howdy,

I'm rounding the third quarter mark of my intern year as a prelim IM. My advice?

Relax...at least a little bit (sometimes fear is a healthy motivator). If you weren't a little bit scared you would be dangerous. You're not the first person to feel like this, and you certainly won't be the last.

Seniors will be there to help you...or at least should be IMHO. Certainly for your first call.

Often, I've found that the nurses will prove to be a great help to you. The older ones may have tons of experience. Just be careful and think through your decisions. It's your name that goes on the chart underneath an order, not their's.

Some of the above posters have already given you excellent options for the most common problems you're going to get called about: pain, nausea, constipation, diarrhea, and the dreaded bradycardias/tachycardias.

You'll also be called for chest pain, abdominal pain, SOB, and mental disturbances.

Don't be afraid to use your senior, a Medicine Pocket Guide, and your own common sense.

Just remember:

(1) Go physically see the patient if you are in the least bit uncomfortable.

(2) Document in the chart on cross-cover issues.

(3) Always tell the truth about what you see, do, and observe on examination.

(4) Don't be afraid to err on the side of caution. Very few people will criticize you for doing too much when you're on your own in the middle of the night...but you will be blasted every time for ignoring or missing something potentially crucial.

(5) Be professional and courteous to your fellow residents and interns. Always.

You'll be fine.

 

[Faebinder]

No, I think he meant, "you are alone," which is metaphysically true if not actually true. the look of contempt on my senior resident's face when I woke her up was so appalling that I would have almost rather have accidently killed the patient with an overdose of Amiodarone than to wake her up again to ask her about it.

I hate call. With the buring passion of one thousand suns. I always have but a year-and-a-half ago I was also afraid of it and dreaded the pager or the call to a code.

Now I just hate being tired and working at a job where I have the potential to kill and maim (or heal) for less money, per hour, than the guy assembling my Gordito at Taco Bell.

Panda you REALLY need to get your whining language corrected cause you are losing believability..... You are working at a job where you have to potential to kill and maim (or heal) for less money, per hour, than the assistant manager guy of the guy assembling your gordita (not gordito).

The guy assembling the gordita is probably getting $7.5 per hour or $8 if he is closing... I am sure you beat him unless you are working around 108 hours per week (which thank God and the evil lawyers that we have that 80 hour limit which most places try and be around.)

How about from now on we say residents make less money than a cook at chilis?

 

[Winged Scapula]

As always, opinions differ - I think Phenergan is absolute GARBAGE, and question those who prescribe it. Phenergan has a "black box" warning for kids 12 and under, and I give it about 5 years before it's out for everyone (due to the side effect profile, and abuse potential - the patient who demands "Demerol and Phenergan" is looking for the euphoric effect). I go with Reglan and Zofran first (and always for IV). After the first dose of Reglan, I give some Benadryl, just to offset the chance of extra-pyramidal reactions. The only Phenergan is Rx for suppositories for discharge, and that, still, is rare.

Zofran studies show 8mg is best (for non-chemo n/v - 8 is best result, and more than that isn't better), and that is what I use, because, no matter what the dose, if it doesn't work, more won't work until 8 hours have passed - so, if you give Zofran 4mg, and the patient is still vomiting, you can't give another 4mg (or, otherwise, you can, but it won't do anything) until 8 hours have passed. Then, you've cut down what you can use.

I agree that Phenergan has some onerous side effects, but so does Reglan (for that matter, so does Compazine, aspirin and pretty much every medication known to man). A CT surg patient died in our SICU 30 minutes after receiving Phenergan so it was often banned for those patients by the attendings. Some attendings won't let you use Toradol because they've had patients bleed or they believe they will. Everyone has their preferences and experiences. I am leery of Pepcid, Phenergan, Benadryl and narcotics in the elderly because of what I've seen, but that doesn't mean I won't use those medications in other settings or when appropriate, especially if Zofran is unavailable or isn't working (or patient states "it won't work).

The OP was not looking for details on what and when to use something. While I prefer Zofran myself, I have worked in hospitals where it will not be released for patients who are not post-op (and then only for 48 hrs) or receiving chemo. I believe the point of the thread was to give the OP support that he/she wasn't alone and that there are lots of options for common patient complaints. If you have found what works for you, that is fine - she/he may find others and needs to know that there are multiple options for pain meds, nausea, etc.

 

[Winged Scapula]

Name another antiemetic that works as well as Phenergan, and is available in both oral and rectal forms, and I'll use it. And don't say "crackers and warm soda," Kim...not that I'd tell a patient to use that rectally, anyway.

Awww...you're ruining all my fun. As long as the crackers are crushed, I don't see a problem with PR administration!

 

[Winged Scapula]

No, I think he meant, "you are alone," which is metaphysically true if not actually true. the look of contempt on my senior resident's face when I woke her up was so appalling that I would have almost rather have accidently killed the patient with an overdose of Amiodarone than to wake her up again to ask her about it. .

She's obviously the one with the problem. The intern and junior resident's job is to learn and the senior's is to learn and teach. Frankly, she has gall if she's sleeping while you have a patient in distress and you need help.

But I understand. I had a couple of really unpleasant Chiefs when I was an intern. I was afraid to call with a problem because I'd be yelled at and I was afraid not to call because I'd be yelled at. When I was a Chief I had an intern who called ALL THE TIME. She was bright, but lack self-confidence. Once, on a 15 minute drive home, I got 6 pages from her. I figured it was retribution for my not calling as an intern...but I never got mad, never yelled and hopefully, never made them feel bad as an intern. When you do, they stop calling and bad things can/do happen.

Your Chief has/had a lot to learn about being a senior resident.

 

[SLUser11]

Try working in the outpatient (a.k.a. "real") world.

Go ahead...send your patients to the pharmacy with an Rx for Zofran. You'll get sick of the "I can't afford that!" call-backs real quick.

Zofran just went generic, FYI.

I don't want to get involved in this thread because it's nitpicky and way off the OP's topic (e.g. "never put MSO4 in a chart!" and "1mg q4? You idiot ".....please shut up)......

BUT, since it does affect our patients, it's good info.........


Also, I feel that it's not that we don't know how to answer simple nurse calls, but that in the beginning, we question ourselves/are scared of being responsible for a decision.

 

[deleted87716]

Zofran just went generic, FYI.

Yes, but the generic is still $20/pill (at Walgreens). Yes, it's better than the brand-name drug at $30/pill, but it's not exactly a screaming bargain.

 

[Winged Scapula]

Also, I feel that it's not that we don't know how to answer simple nurse calls, but that in the beginning, we question ourselves/are scared of being responsible for a decision.

This is almost always true. Most of the residents I've known who called with a "problem" knew what to do, or at least had a few ideas but were not confident enough to make the decision and of their knowledge, were scared that if they didn't report everything they did they'd get yelled at, or just had trouble transitioning from teflon med student to real doctor.

 

[deleted109597]

Yeah, our formulary won't let us use droperidol due to the black box warning.
Yes, you should always write out "morphine", I just didn't feel like typing it, and I certainly wouldn't say "EM-ESS-OH-four" as a verbal order. But your little personal vendetta with me is fun Pox.

Sub-I is close enough to being on call that you get used to the minor orders. It is weird for the nurses to take my orders, and probably not legal, but if it is anything other than pain, fever or nausea, I go further up the chain of command. Ok, sometimes I give diet and ice chips as well without asking.

I sort of meant the alone part as tongue in cheek, like Panda mentioned. The burn of a thousand suns that is your senior's stare for pedestrian orders isn't worth it. You'll find one of these at pretty much every program. Maybe not after the first call, but certainly after the tenth. However, for anything more than pedestrian, they usually don't mind being called.

 

[Idiopathic]

I don't want to get involved in this thread
.

And yet here you are.

Also, Apollyon I wholeheartedly agree with you on demerol, but it does have its place, just like phenergan. Im sure regional practice dictates a lot of what you do, and you choose not to use phenergan, thats fine, but it is a very valuable antiemetic (and antihistamine) and should not be written off because it causes some euphoria and has abuse potential. I could care less if you use it, but I think lumping it in with QT-prolonging agents is inappropriate.

 

[Green912]

do a Google search for "intern survival guide". Some pretty useful stuff pops up.

 

[Pox in a box]

Yes, you should always write out "morphine", I just didn't feel like typing it, and I certainly wouldn't say "EM-ESS-OH-four" as a verbal order. But your little personal vendetta with me is fun Pox.

I don't know what you mean but I'm glad you already were aware of the need to spell out "morphine." Some people still do not know the inappropriate abbreviations to avoid.

 

[Apollyon]

I believe the point of the thread was to give the OP support that he/she wasn't alone and that there are lots of options for common patient complaints. If you have found what works for you, that is fine - she/he may find others and needs to know that there are multiple options for pain meds, nausea, etc.

...which is why I said, right at the beginning...

As always, opinions differ

...to show that there is not a "cookie-cutter" model to follow, and imply that one needs to form their own style, which takes time.

 

[8744]

Panda you REALLY need to get your whining language corrected cause you are losing believability..... You are working at a job where you have to potential to kill and maim (or heal) for less money, per hour, than the assistant manager guy of the guy assembling your gordita (not gordito).

The guy assembling the gordita is probably getting $7.5 per hour or $8 if he is closing... I am sure you beat him unless you are working around 108 hours per week (which thank God and the evil lawyers that we have that 80 hour limit which most places try and be around.)

How about from now on we say residents make less money than a cook at chilis?

I make about $3250 per month. On my call months (like this month) I probably work 22 out of 28 days or about 70 hours a week for a whopping $11 bucks an hour. I have seen positions at Taco Bell advertised for $10 bucks (in the Northeast). I also want to point out that at Taco bell, everything over 45 is time-and-half. Over 60 is double time.

Here goes:

My monthly salary for 280 hours: $3250

Taco Bell Gordita Jockey working 280 hours per month at $10/hr:

((45x10)+(15x15)+(10x20))x4=$3500

at $7.50/hr: $2625

Net difference between my salary and reasonable Taco Bell hourly wage of $7.50 for the same hours: $625

Value of four years undergraduate, two years of graduate school, four years of medical school, and two years of residency training:

$52/year of higher education per month.

Look on my face when my snotty neighbors accuse me of being a rich doctor:

Priceless

 

[Apollyon]

Interesting that you have a problem with Phenergan's SE profile, but not Reglan's.

Whatever you're comfortable with, I guess.

I don't know if you meant that to sound condescending, but it did.

Reglan - dystonia - Benadryl before second dose.

Phenergan - agitation, profound somnolence - no 'antidote'. Dystonia - Benadryl. Self-selection for the drug-seeker.

Hmm...I'll use the Reglan, as I have, with success.

One note is practice environment, though - I'm in the 'envious' position to be giving IV meds to patients that, mostly, will not be inpatient. As such, I'm riding the fence here. In deference to Idiopathic, your patients are, by and far, peri-procedural, so they're a little more "captive", and have a LOT more individual focus on them. If I was standing continuously at bedside, or I was the one literally administering the Phenergan, it would likely be a different story.

A few weeks back, one of the more senior posting people on the EM forum talked about equivalencies to fentanyl for morphine, Dilaudid, Demerol, and a few other opiates, and he said to look them up, and you might be VERY surprised at an equivalent dose of morphine to, say, 50mcg of fentanyl, or why staff might flip if you order 10mg of morphine, but they don't bat an eye at 2mg of Dilaudid. Interesting stuff.

 

[Idiopathic]

I don't know if you meant that to sound condescending, but it did.

Reglan - dystonia - Benadryl before second dose.

Phenergan - agitation, profound somnolence - no 'antidote'. Dystonia - Benadryl. Self-selection for the drug-seeker.

Hmm...I'll use the Reglan, as I have, with success.

One note is practice environment, though - I'm in the 'envious' position to be giving IV meds to patients that, mostly, will not be inpatient. As such, I'm riding the fence here. In deference to Idiopathic, your patients are, by and far, peri-procedural, so they're a little more "captive", and have a LOT more individual focus on them. If I was standing continuously at bedside, or I was the one literally administering the Phenergan, it would likely be a different story.

A few weeks back, one of the more senior posting people on the EM forum talked about equivalencies to fentanyl for morphine, Dilaudid, Demerol, and a few other opiates, and he said to look them up, and you might be VERY surprised at an equivalent dose of morphine to, say, 50mcg of fentanyl, or why staff might flip if you order 10mg of morphine, but they don't bat an eye at 2mg of Dilaudid. Interesting stuff.

First off, if sleepiness and abuse potential are your main reasons not to use a drug, thats fine. But you shouldnt pretend like a dose of phenergan has any real side effects that would cause you to worry about prescribing it or cause it to be "black boxed".

Second, Im still rotating, so I spend a lot of time in the ER and on the floor, and phenergan is my third choice antiemetic for non post op N/V. Zofrans off formulary until the generic comes in, and Im always willing to try anzemet or compazine, but promethazine is a very valuable drug. Part of the problem with N/V is the inability to sleep. For inpatients or ER patients, helping them get some sleep can be the best thing you do for them.

Just my 2 cents. You do have more experience than me, but this is just what Ive seen in my limited time.

As for opiates, a lot of factors come into play. I never write demerol. I occasionally write dilaudid, and I start my MS dose with 2 mg, which makes plenty of patients unhappy. I only give fentanyl in the ER for things like post dural puncture headache, where you would like the effect to wear off a little quicker than with MS.

 

[dc2md]

Idiopathic, Apollyon, KentW, Kimberli Cox, etc.

To a 4th year med student, this is all pretty daunting...the "variety" of pain meds, antiemetics, etc. Did all your knowledge come with experience or was there/is there a resource that has an unbiased description of all these drugs, when to use them, when to be cautious, MC side effects, best route, etc. As very visible with this tread, the opinions are widespread, but there are basic facts and that's what I'm asking about. Thanks for any feedback.

 

[swpm]

While we're tossing about personal preferences ...

I almost never write for morphine any more, unless a patient is already on it (and doing well). Hydromorphone seems to be a cleaner drug; you just have to adjust the dose (1/5 to 1/7 of what you'd write for morphine). Less nausea, less histamine release and pruritis. Some people say you get a bit more psychomotor goofiness with hydromorphone, but I don't really see that.

So why would one ever choose morphine over hydromorphone? Other than an allergy or "nursing staff comfort" I couldn't come up with anything.

 

[deleted87716]

I don't know if you meant that to sound condescending, but it did.

I didn't.

I didn't think that your intimation that we must be idiots for prescribing Phenergan over Reglan was condescending, either.

 

[deleted87716]

s is all pretty daunting...the "variety" of pain meds, antiemetics, etc. Did all your knowledge come with experience or was there/is there a resource that has an unbiased description of all these drugs, when to use them, when to be cautious, MC side effects, best route, etc. As very visible with this tread, the opinions are widespread, but there are basic facts and that's what I'm asking about. Thanks for any feedback.

I remember liking Internal Medicine On Call when I was an intern.

 

[swpm]

I only give fentanyl in the ER for things like post dural puncture headache

Why not put the patient supine and page anesthesia for a blood patch? If the patient's head still hurts while supine, it's probably not a PDPH. Opiods have a minimal role, if any at all, in the treatment of PDPH.

Otherwise, fentanyl's great for catching up on postop pain if the patient is initially undertreated - which is frequently what the intern gets called for late at night. I'm a big fan of sitting at the bedside with a stick of fentanyl, giving 25-50 mcg hits q5min until they're comfortable ... and then letting the Dilaudid PCA keep them comfortable. Works marvelously, but it's a bit labor intensive.

 

[Apollyon]

I didn't.

I didn't think that your intimation that we must be idiots for prescribing Phenergan over Reglan was condescending, either.

I'm sorry if it came off like that - I really wasn't intending.

 

[Apollyon]

First off, if sleepiness and abuse potential are your main reasons not to use a drug, thats fine. But you shouldnt pretend like a dose of phenergan has any real side effects that would cause you to worry about prescribing it or cause it to be "black boxed".

Second, Im still rotating, so I spend a lot of time in the ER and on the floor, and phenergan is my third choice antiemetic for non post op N/V. Zofrans off formulary until the generic comes in, and Im always willing to try anzemet or compazine, but promethazine is a very valuable drug. Part of the problem with N/V is the inability to sleep. For inpatients or ER patients, helping them get some sleep can be the best thing you do for them.

Just my 2 cents. You do have more experience than me, but this is just what Ive seen in my limited time.

As for opiates, a lot of factors come into play. I never write demerol. I occasionally write dilaudid, and I start my MS dose with 2 mg, which makes plenty of patients unhappy. I only give fentanyl in the ER for things like post dural puncture headache, where you would like the effect to wear off a little quicker than with MS.

I hate to quote the whole post, but it's a good post, and what I wanted to say is that I totally see your point, and, I think, you and I are closer together than further apart as far as n/v and pain in patients goes. The corollary to that is that you will be an EXCELLENT doctor in practice, since I am too (<-- any more sarcasm there, you could put on some bread and make a sandwich).

 

[Apollyon]

To a 4th year med student, this is all pretty daunting...the "variety" of pain meds, antiemetics, etc. Did all your knowledge come with experience or was there/is there a resource that has an unbiased description of all these drugs, when to use them, when to be cautious, MC side effects, best route, etc. As very visible with this tread, the opinions are widespread, but there are basic facts and that's what I'm asking about. Thanks for any feedback.

It will come to you and become second nature. You'll be (like me) fat and happy using one regimen, and, for some anecdotal reason (like me) be averse to another, but, believe me, believe me, you will get it.

As you see, put 5 docs in a room, and you'll get 6 opinions - but we all get to the finish line.

 

[Winged Scapula]

Idiopathic, Apollyon, KentW, Kimberli Cox, etc.

To a 4th year med student, this is all pretty daunting...the "variety" of pain meds, antiemetics, etc. Did all your knowledge come with experience or was there/is there a resource that has an unbiased description of all these drugs, when to use them, when to be cautious, MC side effects, best route, etc. As very visible with this tread, the opinions are widespread, but there are basic facts and that's what I'm asking about. Thanks for any feedback.

Although I can't speak for the others, I'm sure it was the same for them: experience.

The experience came from:

- the long work hours of residency and just doing it over and over

- spending a lot of time with patients and seeing what worked and what didn't

- the above said, there are lots of variables: some patients don't like drug X where others swear by it. It often helps to ask the non-naive patient, what has worked in the past for you?

- since I hang around anesthesiologists a lot, I'll ask them/watch them to see what they use and ask why if I don't understand

- in the case of chronic pain, see above and defer to the experts who chose that as their field

- and ask senior nurses, what they find useful (especially helpful as an intern, getting middle of the night calls, until I developed my own thoughts about each problem. Wasn't allowed/capable of any independent thoughts during junior surgical residency! ).

- learning from attendings; some had certain preferences because of their experience or "that's the way I've always done it" (which is NOT a reason to do something)

I don't know that I found any one book to be of special importance, use. I always had Tarascon's in my pocket (the big one) and used some of those "Intern Survival Books" (I think it was the Washington Manual and Surgery On Call), but also Up to Date was my friend, as were the anesthesiologists and pharmacists. There is no shame in asking for help or just advice.

I generally go with Morphine first, then Dilaudid and then Demerol for post op pain in the NPO patient. I like the Pain-Buster pumps A LOT for those going home or Percocet, PCAs for those staying in house and if the attending has no qualms and the case was dry, Toradol for the first 24-48 hrs. For patients with post-op nausea with narcs, I find the addition of Toradol can really ease the need for narcs. I've used Fentanyl with good success as well and there's something to be said for Benadryl for getting the patient to sleep. I know when I have a migraine, benadryl or phenergan are really key - the pain will go away much faster if I fall asleep than by waiting for the ergotamine to kick in. Reglan does work well for post-op nausea, which is low grade, or the patient who is having trouble advancing their diet post-op. Used it regularly for the post-op gastric bypass patients, as the gastroparesis often made them nauseated. It isn't my first choice, but it certainly ranks up high and may be near the top for certain patients.

 

[Winged Scapula]

I'm sorry if it came off like that - I really wasn't intending.

I have to admit I was thinking about that comment when my I wrote my earlier posts. Perhaps it was because of our previous "history" that I just assumed you were meaning to be insulting when you said those of us who use Phenergan are idiots!

Ehh..we each have our own preferences and different patient populations, formularies. Who cares what each other uses?

 

[swpm]

My nightmare is being alone at night and some nurse calls up [...]

Just remember that you're not there to solve all the problems and cure the patient during the night. Your jobs are to (1) not let them die and (2) not kill them before the primary team arrives the next morning.

Be exceedingly conservative, careful, and have a low threshold for asking the resident on call with you for help. They're not at the hospital to sleep.

Listen to the nurses, and be nice to them ... but never, ever let them talk you into doing something you don't know is correct. Nurses know a lot, but sometimes they know less than they think they do.

Finally, relax a bit. The residents, attendings, and nurses will be acutely aware of the fact that you're a few weeks out of medical school. They're just as afraid of your inexperience as you are ... they won't throw you to the wolves. They will teach you, you will learn, and things will be OK.

 

[Mman]

So why would one ever choose morphine over hydromorphone? Other than an allergy or "nursing staff comfort" I couldn't come up with anything.

Unless a patient can't tolerate morphine because of pruritis or what not, what advantage does hydromorphone have? Not much and it costs more. The chronic pain guru I work with feels there is no reason for somebody to start on a PCA of anything except morphine. If it doesn't work, try something else. Morphine does have the advantage (sometimes disadvantage) of being a little more sedating which isn't necessarily a bad thing in a hospital where patients are severely sleep deprived with q 4 hour vitals and nurses and phlebotomists and RTs and doctors coming and going at all hours.

 

[andros]

There are 2 Washington Manual Internship survival guides -- one called the internship survival guide and the other is the surgery survival guide. Unfortunately, my school's bookstore has neither one so I can't compare them... but I'll (hopefully!) be starting a surgical residency in July so I was thinking of getting the surgery book. Does anyone have any recommendations for one vs the other?

 

[SLUser11]

So why would one ever choose morphine over hydromorphone? Other than an allergy or "nursing staff comfort" I couldn't come up with anything.

Well, I'm convinced. No more morphine, then.........I mean, since you couldn't come up with anything.....

I gotta go....have to change all my patients over to Dilaudid.....lots of phone calls to make......


I didn't want to get involved....and yet, here I am....props, Idiopathic.

 

[dynx]

I am going to be an intern in 4 months starting a prelim year in IM and I am really scared. I've done all the usual things in school, H&P's SOAP's tons of proceedures but...Are you guys scared too? What kind of info do you get during orientation? My nightmare is being alone at night and some nurse calls up in the first few months while on wards or ICU and askes for some pain med. I don't know that I know what to give.
Is your resident there with you-how does this work? Are you ever alone?
what is expected of the intern? How many treatment protocols are you supposed to know coming in?

Any interns or residents out there that could answer?

Strangely enough, I think with all the asides this thread has done a great job of answering your question. Even something as simple as N/V...no matter what you give, you'll f*ck it up in someones opinion. So embrace the inability to make a correct decision and give whatever the f*ck you feel like. You need to know nothing except whats in your pocket pharmacopia.

 

[Idiopathic]

I hate to quote the whole post, but it's a good post, and what I wanted to say is that I totally see your point, and, I think, you and I are closer together than further apart as far as n/v and pain in patients goes. The corollary to that is that you will be an EXCELLENT doctor in practice, since I am too (<-- any more sarcasm there, you could put on some bread and make a sandwich).

Thanks, I think

I wasnt trying to be inflammatory or sarcastic.

 

[Idiopathic]

Why not put the patient supine and page anesthesia for a blood patch? If the patient's head still hurts while supine, it's probably not a PDPH. Opiods have a minimal role, if any at all, in the treatment of PDPH.

Oh, sure. Ill page anesthesia at 2AM for a blood patch. At my major teaching institution, we probably wont be able to easily get one if it isnt 7AM-7PM M-F. I agree with the supine stuff, but if someone has been suffering with PDPH for two days at home, they have probably tried all that. If you cant get a blood patch (or saline patch) then you still need to treat the pain. Caffeine, tordol, etc all have their place, but a little fentanyl goes along way to treating this acute pain, and it doesnt stick around too long.