1 Scared Intern

[Tired]

Am I the only one that thinks one troll account is responding to another with that part there?

The OP (who apparently can't read a pharmacopeia) asks a general question. You offer basic advice so fang (another MS4 apparently) rips you a new one. The OP chimes in that, actually, he/she didn't want to hear from MS4s. Then fang accuses you of an "inflated ego" for trying to be helpful, and proceeds (in the very same post!) to offer the same advice you did. Meanwhile assorted random posters accuse you of generating a "pissing contest" for relating your own experiences on sub-i's.

Yeah, it looks like the trolls have come to the General Residency issues forum, and we got sucked right in.

Perhaps in the future the OP should use PMs to get his/her questions answered, since there are only limited people who are "qualified" to answer their silly questions

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[mytirf]

1.) If you get called for something during the first few months of residency, always go see the patient, no matter how big or small, unless timing or circumstances does not permit you.

I really think this is the more important thing you can train yourself to do. Even if the nurse, says "Patient X has a rash on his/her butt" go take a look if you have the time. Most of the time it will be nothing, but that one time will bit you in the you know what if you don't take it seriously.

3.) As time passes you will learn through experience what is serious and what is not and you will be able to triage your time better and also able to take care alot of the problems over the phone.

Also great advice. I would also suggest developing a sense of which are the experienced nurses and really learn to listen to them. If there are worried about a patient, YOU should be worried about that patient.

My two cents about pain meds....Start in the middle or on the low end of the dosing range (especially in opiate naive patients) and then titrate to effect, within a short period of time. You can always give more, but you really can't go backwards too easily. And yes, the PCA is your friend.

BTW, not to get the middle of this but I think co-signing is necessary, especially for drugs that have potentially serious side effects (really any drug). This is why computerized order entry can be helpful in these situations, because the orders needing to be co-signed are queued to the apparent resident. We currently still have paper orders, and I have run into a few problems with very well-intentioned medical students who mis-wrote orders and no surprise the supervising intern was the one who got yelled at. Oh Well....

 

[fang]

The OP (who apparently can't read a pharmacopeia) asks a general question. You offer basic advice so fang (another MS4 apparently) rips you a new one. The OP chimes in that, actually, he/she didn't want to hear from MS4s. Then fang accuses you of an "inflated ego" for trying to be helpful, and proceeds (in the very same post!) to offer the same advice you did. Meanwhile assorted random posters accuse you of generating a "pissing contest" for relating your own experiences on sub-i's.

Yeah, it looks like the trolls have come to the General Residency issues forum, and we got sucked right in.

Perhaps in the future the OP should use PMs to get his/her questions answered, since there are only limited people who are "qualified" to answer their silly questions

No no no, you misunderstand completely. My view of mcninja's inflated ego was due to his offering advice about some specific issues (pain management) which I felt he was unqualified to dispense without a little qualification. I questioned his authority. I proceeded to offer some unrelated opinions (clearly identifying where I was coming from as an MS4) about what it will be like to be a new intern... very different than telling someone how to prescribe morphine for pain in a style that suggests a level of experience over and above reality.

Yes, my inital post was inflammatory (and could have been worded in a much more diplomatic manner), and I apologize for that.

Can we now get back to the original topic? I think OR1 is actually asking some useful questions, and some people have offered some useful advice.

 

[lucky_deadman]

No no no, you misunderstand completely. My view of mcninja's inflated ego was due to his offering advice about some specific issues (pain management) which I felt he was unqualified to dispense without a little qualification. I questioned his authority. I proceeded to offer some unrelated opinions (clearly identifying where I was coming from as an MS4) about what it will be like to be a new intern... very different than telling someone how to prescribe morphine for pain in a style that suggests a level of experience over and above reality.

Yes, my inital post was inflammatory (and could have been worded in a much more diplomatic manner), and I apologize for that.

Can we now get back to the original topic? I think OR1 is actually asking some useful questions, and some people have offered some useful advice.

Interesting that you apologize for your initial post being inflammatory, but don't stop to think twice about taking this opportunity to get in one final jab on mcninja.

How can you say he has an inflated ego if you know him no more than some posts here. I'm sure you take issue to people making judgments about you and your personality disorders/flaws from what little we've read about and from you. Hipocracy anyone?

Advice is just one's opinion. And as the old saying goes "opinions are like dinguses, everyone has one and most of them stink". So the OP should be more than qualified to sort through the advice and choose for themselves what they wish to take away. Talk about an inflated ego, thinking you must decide who's advice is and is not acceptable for the entire rest of the forum.

You don't like someone's advice, then simple don't take it. No need to tell them they are wrong as they are intitled to their own opinion.

As far as the original questions go, there are some many pain meds and anti-emetics available as well as combinations that the OP and everyone must come up with their own solution for each unique situation.

 

[lucky_deadman]

The OP (who apparently can't read a pharmacopeia) asks a general question. You offer basic advice so fang (another MS4 apparently) rips you a new one. The OP chimes in that, actually, he/she didn't want to hear from MS4s. Then fang accuses you of an "inflated ego" for trying to be helpful, and proceeds (in the very same post!) to offer the same advice you did. Meanwhile assorted random posters accuse you of generating a "pissing contest" for relating your own experiences on sub-i's.

Yeah, it looks like the trolls have come to the General Residency issues forum, and we got sucked right in.

Perhaps in the future the OP should use PMs to get his/her questions answered, since there are only limited people who are "qualified" to answer their silly questions

I was not accusing any one person of starting the pissing contest. I was merely pointing out it had turned into one and that both parties involved seemed pretty adament to not let things be and get in the last word. Because one person pissing is a show, it takes two or more for it to become a contest.

If I want to see that kind of mudslinging and name calling, I can turn on C-Span or some news channel and watch the professionals (politicians) go at each others throats.

 

[fang]

Interesting that you apologize for your initial post being inflammatory, but don't stop to think twice about taking this opportunity to get in one final jab on mcninja.

How can you say he has an inflated ego if you know him no more than some posts here. I'm sure you take issue to people making judgments about you and your personality disorders/flaws from what little we've read about and from you. Hipocracy anyone?

Advice is just one's opinion. And as the old saying goes "opinions are like dinguses, everyone has one and most of them stink". So the OP should be more than qualified to sort through the advice and choose for themselves what they wish to take away. Talk about an inflated ego, thinking you must decide who's advice is and is not acceptable for the entire rest of the forum.

You don't like someone's advice, then simple don't take it. No need to tell them they are wrong as they are intitled to their own opinion.

As far as the original questions go, there are some many pain meds and anti-emetics available as well as combinations that the OP and everyone must come up with their own solution for each unique situation.

I actually agree with most of this. To be precise, I thought what he did represented an "inflated ego", but I make no judgements about what he's like overall as a person. And I meant what I said that I'm sure he's a good student. However, I don't agree that everyone is always entitled to their own opinion-- everyone is entitled to their own opinion only if they make it clear where that opinion is coming from. That's my main "beef" with all of this. I'm sure everyone on this forum can decide for themselves what to beleive or not, but it's not inappropriate to question someone's authority about a subject. I didn't do it in a nice way, but his replies to me were not exactly pleasant conversation either.

 

[8744]

To the OP, Here is what I Rec:

1.) If you get called for something during the first few months of residency, always go see the patient, no matter how big or small, unless timing or circumstances does not permit you.

2.) After seeing the patient, if you are comfortable with the situation deal with it, if not, then always call your senior to ask for advice, they would be more appreciative if you call to tell them something is up with the patient than to find out on round that one of the patients had an MI overnight or clotted off their new graft but you forgot to mention it because it was 3am. The attending will have your senior and you for breakfast. Plus it is just good patient care to ask for help when you need it, don't assume anything..... I am sure you heard the saying "Assumption is the mother of all F#$% ups".

3.) As time passes you will learn through experience what is serious and what is not and you will be able to triage your time better and also able to take care alot of the problems over the phone.

4.) As one of my Spine Attending tells it " TRUST NO ONE. THERE IS ASSASSINS EVERYWHERE!" You will learn the meaning of that sentence as you go through residency. And if you ever want to make sure something is done, do it your self.
Here is a book that I would highly recommend, "On Call, Principles and Protocals"

http://www.amazon.com/Call-Principles-Protocols-Shane-Marshall/dp/0721650791

http://www.harcourt-international.com/catalogue/title.cfm?ISBN=072163902X

Both are the same book except one is the 4th edition. It teaches you how to deal with the most common problems overnight as a Intern. Even though I am in Ortho, I read this book front to back and it has taugh me a ton on medical management, which will last me a long time. If you want a book for surgery, there is an on call surgery book that is very good as well.

Hope this helps.

Impossible for me. I am cross-covering 160 patients tonight and as the pager goes off every five minutes plus I have been doing admissions until just a half hour ago when things slowed down most of the calls sound like this:

"Sure, go ahead and give Mr. Smith, who I have never heard of and know nothing about, some ativan. 1 mg IV sounds fine. Thanks. Bye."

I really only go up to the floor for chest pain, respiratory distress, and codes.

And you have to trust people. I trust the nurses to take verbal orders. I trust my friends who say they will handle something for me to do it. I trust the pharmacy when they tell me the renal dose for a medication. You can't do it all yourself.

 

[kylek044]

I'm not sure if there was actually an answer among the bickering over which drug to prescribe.
IN THE INTERN YEAR, IS THERE ANYONE ELSE WHO YOU CAN TALK TO OR ASK ABOUT YOUR ACTIONS? IS THERE ANY SYSTEM OF CHECKS AND BALANCES?

 

[Winged Scapula]

I'm not sure if there was actually an answer among the bickering over which drug to prescribe.
IN THE INTERN YEAR, IS THERE ANYONE ELSE WHO YOU CAN TALK TO OR ASK ABOUT YOUR ACTIONS? IS THERE ANY SYSTEM OF CHECKS AND BALANCES?

Every resident should have someone senior to them to talk to.

This may be an in-house senior, a Chief at home or even the attending. There are allied health professionals who can assist as well - a pharmacist, a senior nurse, a physical therapist, depending on the question.

Now, this should not be taken to mean that one's questions/calls will be well received (coming from someone who was yelled at a lot as an intern) nor that you should make a call without having put some thought into what you might do/plan of action.

 

[SLUser11]

And as the old saying goes "opinions are like dinguses, everyone has one and most of them stink".

I'm pretty sure that excuses are like a-holes.

Opinions are like vaginas.

 

[lucky_deadman]

I'm pretty sure that excuses are like a-holes.

Opinions are like vaginas.

That one could go way too many places on a thread like this. You might want to clarify.

BTW: Does that mean I don't have an opinion?

 

[SLUser11]

BTW: Does that mean I don't have an opinion?

You certainly post like you do.








zing.

Sorry, couldn't help it after that setup.......I don't have a problem with you.....

 

[jonnylingo]

Not only does Medicare pay substantially more to the hospital than I recieve for a salary but I do real, necessary, and billable work for the various services to which I am a chattel slave.




From USA Today front page: The government (Medicare, and to some extent Medicaid) spends about $11 billion annually on 100,000 medical residents, or roughly $110,000 per resident.

Panda, well said. Where is all this funding going!!!????!!!??? No doubt some of the $110,000 goes to cover liability insurance, but c'mon! We get a mere 35-50K of this 110K, and on top of that, like you said, we are doing billable work for the hospitals to which we are "slaves". Does anyone have insight as to WHERE the vacuum is into which all the surplus Medicare funding (the ~60-75K/resident after salary) as well as the endless cash flow from resident billings go? Someone's cashing in, and it's not the resident for sure.

 

[Wahoos]

Panda Bear, I agree with you that you can not see everything that comes up, but the point is that as a intern starting, you should try to see as many of thr e problems that come up overnight. I got called for a patient that was "seems a little out of it, can you come and see this guy when you get a chance" by the nurse. I said yes, but didn't get a chance to see him until the morning because I was covering 100+ patients in Trauma surg, plastics, neurosurg floor and ICU, urology, and also the level I truama pager over night, plus the trauma consults. Anyways, the patient ended up having a massive MI with troponin in the 20s, had to get a Bypass. I learned my lesson, sure I was busy, but I should have seen this patient in between things. Like I said, big things on the phone can turn out to be small things and small things can turn out to be big, so it is good form to try to see all the problems that arise overnight. I am sure no matter how busy you are, you can always pull a few minutes to pop your head into the room.

The Saying "Trust no one" is a saying, but i agree with you that you have to trust people or your job as an resident will be hell. But you will learn who you can trust more or less over time.

 

[GrandMasterB]

i will avoid getting involved in the personal disputes on this thread, but I wanted to chime in on the cross coverage stuff. i had a tough first few weeks of residency- i had done a masters the year before and hadnt been in the hospital for a while. my first rotation involved cross covering about 100-150 patients a night and admitting 5 patients. i had a cointern doing the same and a resident admitting ten. was pretty hectic, but i think i got through it without killing anyone or doing anything blatantly negligent. how did i do this? by trying to see everything that sounded important, asking for help when i needed it and never being lazy. since then i have had my share of experiences like wahoos and most of those times related to my being too busy to see someone or blowing something off because i know that nurse to be a worrier or whatever. the lesson is to take everything seriously. getting a call for back pain in a patient with arthritis on pain meds should at least cause you to take a second and read the sign out, make sure there is nothing else going on, ask for vitals etc. OP, it is a good sign that you are worried and humble- this will make you a better doctor. that doesnt mean confidence will make you a worse doctor- it just can place more demands on your personal skills and knowledge.

 

[OR 1]

Panda Bear-I bought ON Call -good stuff. Tired- To the OP "who can't read a pharmacopeia"-you may not want to make that assumption. I did whip out my pharmacopeia and tried to look for the correct drug, but the patient had a bowel abcess and my resident wasn't around. So I checked with the pharmacy and it turned out I didn't have the correct drug. I didn't want to make this guy's bowel problem worse, you are a little cavalier with another man's bowel!


Question – Should you just look up the drug and write for it??? Tired states- just whip out the pharmacopoeia and write for the drug, that makes me nervous as a new intern. I feel ok with writing for drugs that I know and have worked with like potassium, mag, calcium etc. I'm trying to get a sense of things, maybe I'm just scared and maybe this is where I should be -whipping out my pharmacopoeia and just writing for the drug that I have not had any experience with or the dosages. I s that what you guys do just look it up and write for it even when you don't have experience with the drug and hope the nothing bad happens to the patient? I fully realize as a R2 and certainly R3 R4 that I will feel comfortable with writing for drugs as I will have had experience with these drugs and done this a thousand times. Maybe I'm overly cautious and should just go with looking it up and stop worring about it? Or do you write for drugs you have worked with and the other drugs call your resident????

 

[megacolon]

It is unlikely that you will be alone as a fresh intern. I know that when I started, my residents expected me to call them because they remembered exactly what I was feeling a year ago. My residents told me in the beginning that they would be very concerned if I DIDN'T call them for things because it would make them more concerned because they don't know if you really know what you're doing yet.

Relax and enjoy the last months of paradise known as 4th year because it will all be over soon enough and you will have plenty of time to worry.

Go and see the patients you get called on at night. Over time, you will learn that you don't have to go see every patient because unfortunately you don't just get called for patients not doing well. You will get the call at 0230 to "help clean up the orders, or be notified that so and so's DNR order expired, or get called about someone's diet at 0300"

 

[grumbo]

While not very practical, I found the poem below to be interesting and applies to the OP's original sentiment.


It is amazing.
Fear, excitement, worry, and wonder
It’s like I’m on a first date, but I’m not.
It’s my very first patient as a doctor.
I need help to steady my shaking knees.

I try to calm myself, but
An uninvited guest storms in and makes camp: Doubt
Questions fly: Am I smart enough? Did I learn enough?
Will the patient listen to me? Can he see my fear?
Where do I turn if I need help?

The patient is waiting – hurry.
But what if I can’t help? What if I misdiagnose? Or mistreat?
The patient trusts me with his life; can I be trusted?
What if….. Doubt is beginning to win this battle.
I have to fight back, but I need help.

Fortunately, I have an ally,
A white shield that hangs on my shoulders.
I can stand behind the coat and let “M.D.” fortify my name.
I do not need my own authority, I can borrow.
The profession will help me.

It’s time to go in.
I have to be confident and in control.
I have to listen to the patient; I have to be thorough.
I have to be friendly but professional.
God please help me.

I walk into the room.
A middle-aged man sits in the chair waiting for me.
His face is worried and his eyes are scared.
“Don’t worry,” I say,
“I’ll be your doctor. I’m here to help.”

 

[jennyboo]

Are you guys scared too?

Hmmm, for some reason it didn't really occur to me to be scared (ha!) -- but I think your feelings are pretty normal.

What kind of info do you get during orientation?

Not much useful.

At our orientation, they repeated many times, "Fill out death certificates correctly or security will page you back to correct them!" Fortunately, the instructions for filling them out are available in the "death certificate binder" we have, which they take out EVERY time you pronounce someone. With directions right in front of your nose, you can't mess that up too easily. And no biggie if you do.

ACLS was "useful" from an educational perspective but, being a PGY-1, I have never actually run a code so right now it's more for my own education. Pay attention to it, but don't beat yourself up for not learning it by rote right away.

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.

Micromedex (or whatever PDA or pocket drug guide) is your friend. In general, if you look up the medication of choice and dose it on the lower end of their standard dosing, it won't go wrong. Nobody expects you to know medications off the top of your head -- you'll learn a few standard ones within a couple of weeks, but I still look stuff up all the time. Also, sometimes the nurses know the dose if you don't, and sometimes they also know what they want and will ask you, "How about Tylenol 650mg po q6hrs prn pain?" If it sounds reasonable you can just say, "Sounds good to me!" I did that a lot in my first month -- and they know what new interns are like in the first couple months.

UpToDate is also your friend. Don't know what to use to treat symptoms of conjunctivitis when asked to fix someone's itchy eyes at 3am? I looked it up on UpToDate and then promptly went to Micromedex to get the right dose.

Is your resident there with you-how does this work? Are you ever alone?

Usually not alone, but it depends on the hospital.

what is expected of the intern? How many treatment protocols are you supposed to know coming in?

You are expected to know NOTHING on July 1.

 

[jennyboo]

Also, now that you've got me thinking on the subject, here are the most common things I've gotten calls for at 3am, and the solutions which go down well in my hospital. I'm sure it varies for many other people in different hospitals.

Insomnia - "_____ wants to know if he can have something for sleep."
1. Cirrhosis patient on the transplant list: "No"
2. Old, frail, has dementia, or easily gets mental status change: "trazodone 50mg po qHS prn sleep"
3. Standard patient: "Ambien 5-10mg po qHS prn sleep"
4. Alternatives that have some drawbacks in various situations: Benadryl; oxazepam; Ativan (alprazolam/lorazepam) in some patients with anxiety or withdrawal issues

Agitation/Sundowning in Dementia Patients- "_____ is 92, demented, and screaming at 3am, can we have an order?"
1. "One-to-one sitter" - Conservative management, and drug-free.
2. "Move her to a high traffic bed"
3. "Have her sit in a chair and fold towels in front of nursing station"
4. "trazodone 50mg po x1" "50mg po qhs standing" and can even be given around the clock.
5. Atypical antipsychotic - "Zyprexa 2.5mg po x1" or "Seroquel 12.5mg po x1"
6. Last resorts: Haldol 1-10mg po/iv/im x1 (repeat as needed, not to exceed max recommended daily dose), restraints
7. Ativan ok for anxiety, but not good in easily unhinged patients.

Aches and pains (not chest pain, worst headache of life or other potentially life-threatening pain)
1. General minor aches and pains - "Tylenol 650mg po/pr q4-6hrs prn pain" (to max 4 grams in normal patients, 2 grams in liver patients)
2. "Toradol 15-30mg iv x1" (repeat as needed to max recommended dose), use caution in renal failure
3. Back pain/muscle spasm - "Tramadol 50mg po q6hrs prn back pain", Flexeril, Skelaxin (I'd have to look up the doses of those last two).
4. Oral, controlled substances - "Percocet 325/5 1tab po q4-6hr prn pain"
5. Patches - "Lidocaine patch, 1-3 patches topically to affected area daily, on for 12hrs off for 12hrs." Fentanyl patches if they need long term management -- usually not at 3am.
6. IV opioids - Morphine 2-4mg iv at a time (timing varies by patient) for standard patients, but can give as little as 0.5mg for sensitive patients.

Hypertension - "_____'s blood pressure is 195/98, do you want to give him something?"
- Consider restarting any BP meds that were held on admission for hypovolemia.
- "nitropaste 1/2 - 1 inch topically x1, leave on for 12hrs"
- "metoprolol 5mg iv x1" if tolerated by heart rate
- Oral hydralazine, labetalol, "Norvasc 5mg po x1" (makes nurse happy at 3am, probably won't fix it right away but she won't call you back)
- We have to move patients to the step-down units to give some of the other iv stuff for real hypertensive urgencies, so the drips, etc are a different issue altogether.

Hypotension - "_____'s BP is 88/56"
It makes a difference whether this is baseline or not (88/56 is often patient's normal baseline but triggers the RN's protocols for calling you, whereas 70/40 or any deviation from patient's baseline is usually concerning and merits seeing the patient)
1. "Please check a manual pressure" (often higher than the stupid nursing assistant's vitals machine)
2. "normal saline 250cc iv x1" (500cc if patient doesn't have low ejection fraction, renal failure or other reason to be cautious about fluid overload), repeat as needed -- While you're on your way to see patient.
3. See patient, unless you know why patient's hypotensive and aren't concerned.

Fever
1. Certain populations -- neutropenic, potentially septic, transplant patients -- you need to see and write a short "PGY-1 event note." If on the other hand the patient is young and stable, sometimes you can get away with verbally ordering cultures.
2. "Blood cultures x2, urinalysis & urine culture" - Also consider "portable chest xray, sputum gram stain & culture, diarrhea for Cdif" & other pertinent tests based on history.

Chest pain - "Do an ekg now while I'm on my way to see the patient." Once you figure out what you think is causing it, decide what to do afterward. Your first few chest pains, you will probably find yourself calling your senior resident to ask what to do. After the first months of internship (okay, I was in the cardiac care unit in July), I was handling most of these by myself and just occasionally calling to run an EKG, chest xray or management plan with the senior resident by phone.

Another intern's patient's family wants to ask the doctor about the management of his cancer. "____'s daughter wants to talk to a doctor, can you come by?" At 3am.
1. "_____'s doctor has gone home and is only here during the day. Please tell the family to ask the daytime medical team, since I do not know this patient and am only cross-covering."
2. Sometimes you have to tell the patient's family the above yourself. My first few months, I was walking to the patient's room to do this. Now, I just ask the nurse to put the family member on the phone so I can explain it to them from the call room.

Shortness of breath - These, also, you will have to see yourself. Some useful things include:
- Stat portable chest x-ray
- Nebulizers. In our hospital, it's "Duonebs x1" or "Xopenex/Atrovent neb x1" or albuterol.
- Blood gas if patient gets sick. In our hospital, it's "Stat ABG" but in many places you have to draw it yourself.
- Turn up the oxygen (nasal cannula --> open face mask --> venti-mask --> non-rebreather mask --> bipap). Keeping in mind that COPDers and other carbon dioxide retainers should have sats in the low 90's or high 80's ("titrate oxygen saturation to 88-93%) and no higher, and do best with venti-mask or bipap.
- Lasix 40-80mg iv x1 or Bumex 2mg iv x1 if concerned for pulmonary edema

-------------------------------------------------

Meh. I'm tired of typing. But you get the picture -- you will develop a repertoire of tools like these during your first two months of internship and use them repeatedly for the rest of it. You will also call your senior resident to ask about these situations a few times during your first couple months, and by the middle or end of the year you will be handling most of these things by yourself without much trouble, and calling only for the sickest patients (mainly so the resident will call the ICU fellow for a transfer and save you from getting barked at for waking them up from their sleep).

 

[LovelyRita]

I think that list is pretty good. Things that would not go over well at my hospital would be the ambien for the average patient since our average patient has COPD and our attendings would say that it depresses respiratory drive. Next, interesting about the use of Nitropaste....it's never really been considered as an option, but maybe one night I'll try it.

Most of my attendings flip out if you order toradol on anyone who doesn't fall within some parameters. I forgot to mention that not only does our average patient have COPD, but they have renal insuffieciency as well. I swear people's creatinine's go up 0.5 when they walk in the door. I had an ER attending last month who hated toradol unless they were having a kidney stone (I know....) he said it was expensive and other drugs could do just as good a job, blah blah blah. I personally think it's a great drug. I've gotten phone calls from the pharmacy "the patient is 65, do you still want it?" uh huh.

I like the idea of putting the old lady at the desk to fold towels. Don't forget about her helmet, though because she will find a way to throw her non-ambulating body on the floor and hit her head.

 

[GrandMasterB]

that list is pretty good- but some stuff is different hospital to hospital:

chest pain:

nurse: this guy has chest pain
me: what are his vitals, has he complained before?
nurse: the vitals from the shift are in the computer, i dont know
me: can you get a set of vitals and do an ekg?
nurse: i am busy, we dont do stat ekgs, what is your name doctor?
me: ....

5 minutes later:

patient: doctor i have been short of breath and having chest pain for 30 minutes
me: how do you use the ekg machine?
patient: can you find a doctor that knows something?
me: they arent in the hospital right now


fever:

nurse: this patient's temperature is 105
me: ok, give him a cooling blanket, some tylenol and collect urine
nurse: we dont have cooling blankets, what is your name doctor?
me: bah more blood cultures to draw

pain:

nurse: this patient has severe pain you havent addressed
me: i have never me that patient before, where is his pain
nurse: i dont know
me: what are his vitals
nurse: i dont know, they are in the computer, what is your name doctor?

 

[GrandMasterB]

oh and one of my personal favorites:

heparin drip:

nurse: doctor this patient's ptt is 40, what rate should i change the drip to?
me: use the weight adjusted protocol
nurse: we dont use those on this floor
me: how much does he weigh
nurse: i dont know
me: isnt this ptt from 10 hours ago?
nurse: i dont know
me: they are supposed to be q6, can you do one now?
nurse: we dont do stat ptts
me: there was one scheduled for 4 hours ago
nurse: but it is past that time
me: can you draw the one you were supposed to now?
nurse: we dont do stat ptts

or

nurse: i wasnt here 4 hours ago, i have never met this patient before
me: can you draw it now?
nurse: no, he is a hard stick


also works for troponins

 

[Auscultate]

oh and one of my personal favorites:

heparin drip:

nurse: doctor this patient's ptt is 40, what rate should i change the drip to?
me: use the weight adjusted protocol
nurse: we dont use those on this floor
me: how much does he weigh
nurse: i dont know
me: isnt this ptt from 10 hours ago?
nurse: i dont know
me: they are supposed to be q6, can you do one now?
nurse: we dont do stat ptts
me: there was one scheduled for 4 hours ago
nurse: but it is past that time
me: can you draw the one you were supposed to now?
nurse: we dont do stat ptts

or

nurse: i wasnt here 4 hours ago, i have never met this patient before
me: can you draw it now?
nurse: no, he is a hard stick


also works for troponins

LOL ..Grandmaster, do you work at the VA ??

 

[Mman]

Helpful tidbit...7.5 mg of Toradol is as effective as 15 or 30 mg for pain, but less renal impairment. Stop the pain, save the kidneys, just use the smaller dose.