Advice for new interns

[Kpowell14]

Hey Guys!

In less than a month I will be starting an internship at an academic institution and I'm excited, but a bit nervous. I was hoping those of you that have gone through internships could share some insight, encouraging words of wisdom, or just things you wish you would've known going into your intern year. These things could be medical (things you wish you would've reviewed etc.), things to make medical records easier, or just life things. Did you carry around a notebook to keep track of cases similar to when you were a student? Did you create a nerd-book? Did you utilize any cool apps on your phone? Any tips for sleeping better during the day on ER or how to adjust back to days after working nights? Pretty much anything is relevant!

Signed, scared soon-to-be rotating intern

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[SocialStigma]

My intern experience will be different from yours since I did mine at a private practice (where we had no students or residents, so interns did everything), but I think most of this is still applicable. Bringing all of my meals (breakfast, lunch, and dinner + snacks) to work everyday was the best decision I made as an intern because then I could power through all my paperwork at the end of the day without having to leave to get food. You won't be doing much paperwork as an intern at an academic institution except on ER, but I would definitely recommend bringing multiple meals to work when you're rotating through ER. Even if your scheduled shift is 8am-8pm (or whatever), you will often end up staying for hours afterwards rounding your patients off to the next clinician and finishing up paperwork, calling owners back about labwork, etc.

I did have a notebook to put patient stickers in and keep track of things that are pending/still needed to be completed for each one. Makes rounding a lot easier!

Make sure you have earplugs, a sleep mask, and some sort of window covering (blackout curtains would be ideal) for sleeping during the day. Depending on your sensitivity to caffeine (if you drink it at all), don't have caffeine too close to when you're supposed to be sleeping. I would have only 1 coffee at the very beginning of my overnight shift and then no more caffeine for the rest of the night. It made staying awake for 7am rounds hard, but going to bed at 9-10am super easy. Also wearing sunglasses on the way home helps. For the transition from nights to days, I would have a short nap (3 hours max) during the day after my last night shift, and then force myself to stay up until 9-10pm before going to bed again.

Do things to bond with your internmates! Having a cohesive intern group can really make a difference in how much you enjoy your internship.

Enjoy your intern year! It goes by faster than you think and it was honestly one of the best years of my life. I miss it sometimes lol.

 

[JaynaAli]

Know how to do a good neuro exam. Way more ER cases ended up being neuro (like little dogs with neck pain) than I expected.

My internmates kept notebooks. I would make a daily sticky note of the patients I saw and the paperwork I needed to complete for each one. I'd put something like this:
Duffy txsheet [ ] MR [x] discharges [ ] call rdvm [x] sx-report [ ] PM update [ ] tomorrow-txsheet [ ]
Roscoe txsheet [ ] MR [ ] discharges [ ] call rdvm [ ]
Princess txsheet [x] MR [x] discharges [x] call rdvm [x]
...on and on and on and check them off one at a time. Then when I checked off everything for that patient, I'd put a huge line through the entire entry like shown. Made me feel good.


I second the recommendation to bring all your meals. I also kept a secret stash on non-perishable food in my desk. Granola bars, dried fruits, crackers, ramen, etc. Occasionally internmates raided it, but it was nice to have food around for days I forgot or needed to stress eat my feelings really quick.

I have an exceptionally good memory for people/animals names, so I was able to copy and paste a lot of records/discharges. My best hint for that is the minute you paste a template from one animal's record into another's...do control+H, find and replace. Let Word or whatever replace every instance of Fluffy with Princess. You can also change the he/hims to she/hers that way if you make sure to put " she " and " he " with the spaces, but you have to use the spaces or else words like sheltie will turn into ssheltie, hematochezia to shematocshezia, etc.

I used the plumb's app on my phone. Stretched the truth and said I was a student so I could get it free for a year. I also used an anesthesia calculator app I forgot the name of to calculate drops per second (because we didn't have enough MR safe fluid pumps). I started the first month making a quick reference of drugs and the clinician's preferred doses (dr. X prefers 4 mg/kg of drug A, dr. Y prefers 2.5 mg/kg type of thing) but I quickly learned what they liked and made up my own after about a month.
I worked on call for years so sleeping was never a problem for me.

There are ACVIM concensus statements on a lot of internal med/cardio/neuro stuff. Read them at some point. The VIN getting through the night stuff saved my butt a few times. But there are very few instances where you don't have five minutes to go look something up in a book. I even did it with clients in the back watching me look stuff up and call a clinician...they were grateful I was checking with others.
I'm sure I'll think of others later on.

Edit: The ASPCA poision helpline is amazing. They'll tell you exactly what to expect and what to do and you can call them as many times as you want after the first fee is paid. If you tell a client to call them before they arrive to see you, warn them there is a fee but it's legit or else they'll think it's a scam and hang up. Well worth the money.

 

[jmo1012]

• Make time for you and the things that are important, it's easy to spend every last minute of off time sleeping and while some of that is good, spending time on yourself is also necessary
• Vin has a new grad getting through the night emergency rounds during g the summer, good review
• There are many ways to do most things, internship is about trying out everyone's styles and adapting them to make your own
• Some rotations you may only feel like a slave, but it's just a couple of weeks of your life
• Even if you dont feel confident, faking it (not obnoxious or overconfident) will do you a world of good because your clients, techs, and team will trust you, and ultimately eben if you dont know what you are doing, you have the resources to figure it out
• Embrace your mistakes, and learn from those made by others

 

[Kpowell14]

Ah, These are all really good tips!!!

@Rwwilliams do you have any specific questions or heard any good tips lately?

 

[Kpowell14]

@orca2011 and @NStarz , you guys have any suggestions?

 

[orca2011]

- I second the bringing as many meals/stashing snacks in your drawer. Especially anything you can quickly grab and shove in your mouth in between exams on a busy overnight. It will save you.
- Second reading through Vin's "Getting through the Night." I haven't actually made it all the way through it, but it is super helpful. Has a bunch of useful drug dosages.
- I have a clip board with common drug doses written on a sheet. I referenced it a lot initially, but so much of it is by memory now. I also had an old copy of Angel's Intern Manual that I had bound and kept in that clipboard. It was a nice quick reference for a lot of your typical emergencies and I still use it from time to time although I do have the 15-16 edition as well.
- Agree of faking the confidence. It took me a while to get used to doing this but I think it's honestly what has helped me a lot in the second half of my internship or so. At first I was really struggling and now not so much.
- If rounds are like they are here in the mornings, there will be a lot of " Monday morning quarterbacking" which can be annoying when coming off and overnight and you just want to get out of there and go to bed. Majority of the time, it's because of personal preferences and not necessarily anything you did wrong. You're goal is keep patients alive, and just remember that. If you do make a mistake, learn from it. It'll happen, just make sure you grow from it.
- To keep track of my stuff to do, I made a word document with patient name, ID number and location, and boxes for SOAP, PE, owner update, plan, fax rdvm and discharge.
- As for adjusting from days to overnights and vice versa, you just kind of do it. We often only get like 12 hours off after overnight (by the time you get home) and then you're on days for like the next 4 days afterwards. That first day shift is effing rough and you feel drunk most of the time, but you make it through it.
- Make male/female versions of some really common ER cases you can just change the name for the discharges and get them out the door.


And I think reading the consensus statements is a really great idea. I hadn't realized that they were all available until I got to my internship and I've been trying to make my way through them.

 

[Kpowell14]

- I also had an old copy of Angel's Intern Manual that I had bound and kept in that clipboard. It was a nice quick reference for a lot of your typical emergencies and I still use it from time to time although I do have the 15-16 edition as well.
-
it. It'll happen, just make sure you grow from it.
- To keep track of my stuff to do, I made a word document with patient name, ID number and location, and boxes for SOAP, PE, owner update, plan, fax rdvm and discharge.
- As for adjusting from days to overnights and vice versa, you just kind of do it. We often only get like 12 hours off after overnight (by the time you get home) and then you're on days for like the next 4 days afterwards. That first day shift is effing rough and you feel drunk most of the time, but you make it through it.
- Make male/female versions of some really common ER cases you can just change the name for the discharges and get them out the door.

Is the Angell intern manual a doc or PDF that you could share with me- sounds like a great resource!

Yes! I started saving discharges as a student for the common things I saw on ER, hopefully that will come in handy and save me some time!

 

[jmo1012]

Also a big fan of bring the meals. In fact, this year to save even more time, I just bring the weeks worth of whatever in 1 container and dish out every day rather than separating stuff into more dishes to be washed. This means 5 more minutes of sleep and less dishes. I will do just about anything for 5 more minutes of sleep haha

 

[orca2011]

Is the Angell intern manual a doc or PDF that you could share with me- sounds like a great resource!

Yes! I started saving discharges as a student for the common things I saw on ER, hopefully that will come in handy and save me some time!

I'll have to transfer the most recent one I think from work but I can send it your way. Just PM me an email.

 

[deleted498041]

Ah, These are all really good tips!!!

@Rwwilliams do you have any specific questions or heard any good tips lately?

The tip I hear repeated time and time again is to not cry in front of clinicians. I had a couple faculty members tell me that this week lol.

I've come across some advice like, remember that you're just keeping stuff alive when you're on overnights, not necessarily solving every problem. One dose of lasix hardly ever kills anything. It never hurts to intubate or put something in oxygen. Getting a nova is never a bad idea. Unless something is actively dying and you're running a code, you'll have time to consult Google, or Pubmed, or old notes. To anyone starting an internship that hasn't read through Getting Through the Night yet, I think you should. I know I haven't started yet, so my advice isn't worth much, but just reading those transcripts has made me feel a lot more confident to tackle things I'm otherwise unprepared for.

Does anyone have a good way to search the consensus statements? Just go to the college and search for "consensus"? I've found a couple in the last few years that were really helpful, but I never considered reading through all of them.

 

[JaynaAli]

Does anyone have a good way to search the consensus statements? Just go to the college and search for "consensus"? I've found a couple in the last few years that were really helpful, but I never considered reading through all of them.

Journal of Veterinary Internal Medicine - Consensus Statements - Wiley Online Library
I didn't just sit down and read all of them, but if I saw a dog on the schedule with seizures, proteinuria, cushings, etc I made sure to review it.


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[cheathac]

Did any of you want to specialize before starting vet school? My interest in lab animal has increased dramatically, and I'm loving my new job in the field. I'm definitely going to keep an open mind, but there is just this feeling of satisfaction and joy being in the environment that I am in. It just feels "right." And I know I don't have a ton of experience in the area, but it's a different feeling than when I was at a vet clinic or watching large animal clinicians. It fuels my desire to want to study vet med. I just didn't know if wanting to specialize before starting was too premature.

 

[deleted498041]

Journal of Veterinary Internal Medicine - Consensus Statements - Wiley Online Library
I didn't just sit down and read all of them, but if I saw a dog on the schedule with seizures, proteinuria, cushings, etc I made sure to review it.


Sent from my iPhone using SDN mobile

Awesome, thank you so much! I know I've made it through a few while studying in school, but it'll be nice to have them so readily available.

Did any of you want to specialize before starting vet school? My interest in lab animal has increased dramatically, and I'm loving my new job in the field. I'm definitely going to keep an open mind, but there is just this feeling of satisfaction and joy being in the environment that I am in. It just feels "right." And I know I don't have a ton of experience in the area, but it's a different feeling than when I was at a vet clinic or watching large animal clinicians. It fuels my desire to want to study vet med. I just didn't know if wanting to specialize before starting was too premature.

I've wanted to specialize in surgery way before I started vet school. I wouldn't say that your desire is premature, but I would absolutely encourage an open mind. Not only is it possible for you to fall in love with something else, but I think maintaining an open mind makes it that much more pleasurable to study other disciplines as opposed into falling into the "well, I have radiologists/pathologists/food animal vets/etc for that."

 

[SocialStigma]

Did any of you want to specialize before starting vet school? My interest in lab animal has increased dramatically, and I'm loving my new job in the field. I'm definitely going to keep an open mind, but there is just this feeling of satisfaction and joy being in the environment that I am in. It just feels "right." And I know I don't have a ton of experience in the area, but it's a different feeling than when I was at a vet clinic or watching large animal clinicians. It fuels my desire to want to study vet med. I just didn't know if wanting to specialize before starting was too premature.

I've thought about specializing in surgery since I was 16-17 and saw my first orthopedic procedure while shadowing a vet. In my 3rd year of undergrad I decided I wanted to be a surgeon. I still kept an open mind in vet school, though deep down I knew I was never going to be as passionate and excited about any other specialty. I'm entering my second year of my surgery residency now and I am still just as excited by the field as when I was 16. It's okay to know/decide early on what you want to specialize in, just like it's also okay to not figure it out until you graduate vet school.

 

[KCgophervet]

Did any of you want to specialize before starting vet school? My interest in lab animal has increased dramatically, and I'm loving my new job in the field. I'm definitely going to keep an open mind, but there is just this feeling of satisfaction and joy being in the environment that I am in. It just feels "right." And I know I don't have a ton of experience in the area, but it's a different feeling than when I was at a vet clinic or watching large animal clinicians. It fuels my desire to want to study vet med. I just didn't know if wanting to specialize before starting was too premature.

Came into vet school knowing I wanted to do lab animal and will be starting my lab animal residency in July Best thing about knowing what you want to do is you can tailor your experiences to match and really show them that yes, you know what the field is about, and you are dedicated to it. For example I got a part time job working at a medical device company (essentially animal care staff), was on the leadership board of the Research Animal Medicine Club, spent a summer doing an ASLAP summer fellowship, and used all of my elective externships doing lab animal ones at various places. That being said I also did a part time gig at an emergency vet clinic and some shelter work just to check out my options. I think getting experience in the field and making connections really helped my application in the long run, but definitely explore your other interests as well.

 

[deleted387118]

Did any of you want to specialize before starting vet school? My interest in lab animal has increased dramatically, and I'm loving my new job in the field. I'm definitely going to keep an open mind, but there is just this feeling of satisfaction and joy being in the environment that I am in. It just feels "right." And I know I don't have a ton of experience in the area, but it's a different feeling than when I was at a vet clinic or watching large animal clinicians. It fuels my desire to want to study vet med. I just didn't know if wanting to specialize before starting was too premature.

I picked Therio when I was 15. I made sure along the way there wasn't something I wanted to do more but now that I'm in residency I know I made the right choice. It never hurts to plan ahead as long as you don't get so set on the idea that you can't let it go if it's time to let it go.

 

[cheathac]

@jesskb What is meant by knowing it's time to let go? Like if you can't get a residency in that particular area? Thanks for all the replies everyone!

 

[Kpowell14]

I'll have to transfer the most recent one I think from work but I can send it your way. Just PM me an email.

Sent you a PM! Thank You!!

 

[deleted387118]

@jesskb What is meant by knowing it's time to let go? Like if you can't get a residency in that particular area? Thanks for all the replies everyone!

Or if you find something else you like. Seems common about vet school in general. Some people get to the point where they only want to do it because they've planned on it forever even though it's not what they thought or they no longer like it. Be open to changing your mind is I guess what I'm saying.

 

[NStarz]

I'll grab some off the tip of my memory and update later (coming off a long string of tough days and I'm SUPER tired). Some are some weird tidbits that I've picked up unique to where I've worked but may help you in some weird/unique situations along the way that others may not tell you...

1. Kitten maintenance rates are higher than expected - 120 ml/kg/day up to 4-5 months. I've packed kittens with panleuk upwards of 260 ml/kg/day if they've needed it (if they can't handle it, something's usually wrong congenitally, usually. Technically, you can fluid overload a kitten, but it's realllly hard).

2. Rib fractures RARELY occur in motor vehicle accidents. Especially rib fractures at different stages of healing...think non-accidental injury. If you are suspicious of NAI, come up with a reason to take CXR, you'd be surprised how often you'll find rib fx and you have reason, then, to report animal abuse.

3. Don't try to solve all of an animal's problems on ER (still struggling with this one). If an animal comes in in CHF, it's really less of a concern to fix the pododermatitis (maybe at a follow up with the rDVM).

4. Cats can get pyometras. Keep it on your differential list. (This may be a 'duh,' but I was burned my first few times with cat pyos because really, who is silly enough to have an intact female cat in their house?

5. Don't be stingy on the fluids with UOs. Post-obstructive diuresis is a thing.

6. I've gone faster to recommending PUs because of $$ (faster than the theoretical 3 strike rule). If an owner can only afford a one time UO then it will be euthanasia if they obstruct the second time, better to give the cat a chance with a UO --> PU then UO --> UO/euth.

7. Don't judge owners (also struggle with this one, though to a much lesser degree). I have an internmate who not uncommonly tells owners: "we could have saved Fluffy if you brought him/her sooner." NOT COOL, and not the time/place. Sure, if they're bringing in a stable pyo, say "hey next time, spaying will prevent MGTs/pyos/overpopulation, but I am not of the opinion that an appropriate time to do this is when the animal comes in with a BCS 1/9, a sobbing owner, and a creat of 14.5.

8. Learn from EVERYONE. Techs, specialists, assistants, staff doctors. Be humble. Everyone has something to teach you. There's one doctor here who writes horrific SOAPs. We all dread picking up her cases the next day because we don't understand her plan or what was discussed. She knows what she's doing and is incredibly intelligent. But I've learned that I don't want to write my SOAPs like her (ie, SWO - "UO - very sick, may die" is paraphrasing.

9. In our experience, doxycycline IV causes a nasty cellulitis when it extravasates. We love it for our URI kitties, but will only give it PO, or diluted and given over 4 hours.

10. If something's dead, you can't make it deader. Most things will either 1) die or 2) recover without our intervention. It's most important to MAKE A DECISION (learned this the hard way when I ran a code by myself at 1 am).

11. There are certain drug dosages you need to know by heart. These include: valium and calcium gluconate. Others, you have time to look up (and will remember with repeated usages). Know what drug reverses what sedative.

12. Know your shock doses. And get comfortable guesstimating an animal's weight in your head (and confirming with others - ha! Do you guys think this dog looks about 40 lbs? Yeah? Okay, give a bolus...)

13. Stress is a big killer of cats. If a cat can't breathe - hands off. Throw it in oxygen +/- drugs. Agree with someone above that everything should be able to handle one dose of lasix. I like torb as my first go to.

14. Don't be lazy. You're there to learn, and you're only there for a year - make the most of it.

15. The stress of internship isn't that bad, it's all the personal stuff that creeps up during the year that makes it unbearable at times. Have good coping mechanisms in place. You'll need them.

That's all for now. Hope some of this was helpful!!

~N

 

[that redhead]

So I didn't do an internship, but as a general new vet-

* Yes to the notebook - drug doses, basic diagnostic plan for commonly presenting things (GI, skin, etc) but can also jot down things to read up on as time goes on.
* Things to review - clin path (including u/a), basic chest/abd rads
* Have your VIN password memorized

Did any of you want to specialize before starting vet school? My interest in lab animal has increased dramatically, and I'm loving my new job in the field. I'm definitely going to keep an open mind, but there is just this feeling of satisfaction and joy being in the environment that I am in. It just feels "right." And I know I don't have a ton of experience in the area, but it's a different feeling than when I was at a vet clinic or watching large animal clinicians. It fuels my desire to want to study vet med. I just didn't know if wanting to specialize before starting was too premature.

I wanted to specialize in lab animal before I was accepted. I did all the things geared toward lab animal med and had a solid residency application. Applied broadly, rejected everywhere. Working in SA GP now but actively trying to get back to lab animal med. Moral of the story: be prepared for set backs. Have a back up plan. Do NOT gear your entire vet education toward one niche. Hopefully it works out, but if it doesn't, what would your plan be? That sort of thing.

 

[cheathac]

So I didn't do an internship, but as a general new vet-

* Yes to the notebook - drug doses, basic diagnostic plan for commonly presenting things (GI, skin, etc) but can also jot down things to read up on as time goes on.
* Things to review - clin path (including u/a), basic chest/abd rads
* Have your VIN password memorized



I wanted to specialize in lab animal before I was accepted. I did all the things geared toward lab animal med and had a solid residency application. Applied broadly, rejected everywhere. Working in SA GP now but actively trying to get back to lab animal med. Moral of the story: be prepared for set backs. Have a back up plan. Do NOT gear your entire vet education toward one niche. Hopefully it works out, but if it doesn't, what would your plan be? That sort of thing.

Thanks!!! This is very helpful. Is there a reason as to why you didn't get into a residency? I'm hoping me being involved early will help but isn't certain by any means. I can't help but be energized when I work. Today, I saw the heart of a pig beating while in it's chest. Wires/thrombocatheters were being tested. I was in awe and loved it.

 

[that redhead]

Thanks!!! This is very helpful. Is there a reason as to why you didn't get into a residency? I'm hoping me being involved early will help but isn't certain by any means. I can't help but be energized when I work. Today, I saw the heart of a pig beating while in it's chest. Wires/thrombocatheters were being tested. I was in awe and loved it.

I was told by multiple places that a lot of already experienced applicants had applied that year. Another friend applying to LAM residencies was told the same. I had a ton of lab animal experience throughout my undergrad and into vet school, an ASLAP award, rotations in fourth year, good letters...just wasn't meant to work out at that time it seems. It is truly an amazing field Try to go to the AALAS conferences and network or even join the various associations if you're able to- most offer student discounts.

I should add: the vast majority of older vets I know who are specialized (lab animal, path, etc) did some time in GP before moving on. It's okay to go that route!

 

[nyanko]

remember the seizure dose of diazepam or midazolam, please. it's higher than the anesthesia dose, and giving the anesthesia induction dose is like pissing in the ocean of abnormal brain electrical activity

 

[DVMDream]

remember the seizure dose of diazepam or midazolam, please. it's higher than the anesthesia dose, and giving the anesthesia induction dose is like pissing in the ocean of abnormal brain electrical activity

Sometimes, I like pissing in the ocean.

 

[LetItSnow]

remember the seizure dose of diazepam or midazolam, please. it's higher than the anesthesia dose, and giving the anesthesia induction dose is like pissing in the ocean of abnormal brain electrical activity

Do people REALLY come out of 4th year not knowing the anticonvulsant dosing for valium? I mean.... ugh. If so, their ECC rotation isn't doing its job. There are like 3 drugs that you should know in your brain (diazepam, dextrose, calcium gluc) ... everything else you can look up. You don't even need atropine / epi / etc, since you should have a chart on your wall and in your crash cart for those. (If you don't, put one there.)

I know I"m biased as an ER doc, but I really think people should know those three drug doses (for anticonvulsant therapy). At *LEAST* diazepam.

It's not even that hard. Look at the animal, estimate its weight (kgs), move the decimal place over one to get your mL of diazepam. ER is all rough math. 50lb animal = 25kg animal = 2.5ml diazepam. Done. That's plenty accurate enough for a seizuring patient. Unless diazepam comes as anything other than 5mg/ml, but I've never seen that.

Sometimes, I like pissing in the ocean.

I totally peed in the hot tub.

 

[DVMDream]

I totally peed in the hot tub.

You are totally banned from the hot tub...forever.




And yeah, you're definitely a biased ER doc but most interns will be doing ER at some point so they should listen to your drug memorizing suggestions. Now, I'm going to go find the calcium gluconate at work because I'm not sure I've seen it.....

 

[nyanko]

Do people REALLY come out of 4th year not knowing the anticonvulsant dosing for valium? I mean.... ugh. If so, their ECC rotation isn't doing its job. There are like 3 drugs that you should know in your brain (diazepam, dextrose, calcium gluc) ... everything else you can look up. You don't even need atropine / epi / etc, since you should have a chart on your wall and in your crash cart for those. (If you don't, put one there.)

I know I"m biased as an ER doc, but I really think people should know those three drug doses (for anticonvulsant therapy). At *LEAST* diazepam.

It's not even that hard. Look at the animal, estimate its weight (kgs), move the decimal place over one to get your mL of diazepam. ER is all rough math. 50lb animal = 25kg animal = 2.5ml diazepam. Done. That's plenty accurate enough for a seizuring patient. Unless diazepam comes as anything other than 5mg/ml, but I've never seen that.

LIS you'd be surprised at the things that I had to help interns with last year. Of course, for any patient I had that was seizuring I put the midazolam dose in mL in big letters on their cage so it was not ambiguous. And I made sure they knew exactly what to give at all times overnight (if another seizure occurred, or x number in y hours, then give z), and when to call me. I understand that neuro and seizures are not everyone's strong point but it's really quite simple to have a plan of attack for those pets.

 

[LetItSnow]

LIS you'd be surprised at the things that I had to help interns with last year. Of course, for any patient I had that was seizuring I put the midazolam dose in mL in big letters on their cage so it was not ambiguous. And I made sure they knew exactly what to give at all times overnight (if another seizure occurred, or x number in y hours, then give z), and when to call me. I understand that neuro and seizures are not everyone's strong point but it's really quite simple to have a plan of attack for those pets.

Neurology expert to dumb-ass ER doc: Why do you prefer versed to valium for hospitalized patients on a seizure watch? My standard seizure-watch response drug (same as you, I put the dose in mL on the cage) is diazepam. Should I be doing midaz? (If it matters, I always have an IV cath in a hospitalized patient - just one of my rules.)

From an *ER* standpoint, these patients are really pretty simple to deal with. Stop the seizuring, do the baseline lab work, start anticonvulsant therapy if indicated, recommend referral to neurology for further dx like csf/mri/infectious titers/whatever else you cool people do. I used to kinda get nervous about seizure patients, but really .... the baseline work-up and tx is pretty straightforward.

Nowadays, I also talk about MCT diet therapy, too, but....

 

[LetItSnow]

You are totally banned from the hot tub...forever.




And yeah, you're definitely a biased ER doc but most interns will be doing ER at some point so they should listen to your drug memorizing suggestions. Now, I'm going to go find the calcium gluconate at work because I'm not sure I've seen it.....

Yeah, honestly, I can count on one hand the number of times I've had to give CaGluc for seizuring patients (which is when you need it in your head), so that one is probably the least important. Diazepam all the time, Dextrose relatively frequently.

Other than knowing a shock dose of fluids for a patient .... I'm hard-pressed to think of other drugs that I feel an intern has to have <MEMORIZED>. Some people would say your CPR drugs, and it definitely is nice (since when you need it, your staff is looking at you impatiently waiting for a dose) ... but in any well-run ER it's on the wall and in the crash cart, so ... meh.

There are lots of things that are *nice* to have memorized - pain meds like hydro, cerenia, anesthetic drugs, etc. ... but none of them are crucial.

 

[DVMDream]

Yeah, honestly, I can count on one hand the number of times I've had to give CaGluc for seizuring patients (which is when you need it in your head), so that one is probably the least important. Diazepam all the time, Dextrose relatively frequently.

Other than knowing a shock dose of fluids for a patient .... I'm hard-pressed to think of other drugs that I feel an intern has to have <MEMORIZED>. Some people would say your CPR drugs, and it definitely is nice (since when you need it, your staff is looking at you impatiently waiting for a dose) ... but in any well-run ER it's on the wall and in the crash cart, so ... meh.

There are lots of things that are *nice* to have memorized - pain meds like hydro, cerenia, anesthetic drugs, etc. ... but none of them are crucial.

Meh, Colorado drug calculator. Toss in the kgs and it spits out emergency drugs. Takes 2 seconds. No need to memorize those.

 

[nyanko]

Neurology expert to dumb-ass ER doc: Why do you prefer versed to valium for hospitalized patients on a seizure watch? My standard seizure-watch response drug (same as you, I put the dose in mL on the cage) is diazepam. Should I be doing midaz? (If it matters, I always have an IV cath in a hospitalized patient - just one of my rules.)

Nope, no big deal, it's just what we had available at the hospital where I did my neuro internship.

 

[deleted498041]

Do people REALLY come out of 4th year not knowing the anticonvulsant dosing for valium? I mean.... ugh. If so, their ECC rotation isn't doing its job. There are like 3 drugs that you should know in your brain (diazepam, dextrose, calcium gluc) ... everything else you can look up. You don't even need atropine / epi / etc, since you should have a chart on your wall and in your crash cart for those. (If you don't, put one there.)

Yes. I have it memorized because someone in third year told me the quick and dirty way to calculate it, as you described later on instead of actually memorizing a dose. That being said, ECC isn't a required rotation at my school, so yeah, I'm sure tons of us come out not knowing it. I will admit that I do not have the doses for dextrose or calcium gluconate memorized, so I'm glad you said something here brb, putting those numbers in my brain.

 

[deleted498041]

Meh, Colorado drug calculator. Toss in the kgs and it spits out emergency drugs. Takes 2 seconds. No need to memorize those.

Woah. This thing is awesome. How did I never hear about this?

 

[LetItSnow]

Yes. I have it memorized because someone in third year told me the quick and dirty way to calculate it, as you described later on instead of actually memorizing a dose. That being said, ECC isn't a required rotation at my school, so yeah, I'm sure tons of us come out not knowing it. I will admit that I do not have the doses for dextrose or calcium gluconate memorized, so I'm glad you said something here brb, putting those numbers in my brain.

Interesting! I thought ECC was a required rotation everywhere.

It's super easy to remember reasonable doses for Dextrose or Calcium Gluconate: 1ml/kg in an emergency hypoglycemic or hypocalcemic situation where the patient is seizuring (at least, that's what I use).

Just make sure you dilute to appropriate dilutions.... Dextrose commonly comes as 50% and should be given as 25% (or less, but for ease of use I do 25% since that's a simple 50:50 dilution). CaGluconate usually comes as 10% (make sure you check before giving!) and can be given as 10%, but should be done slowly with ECG monitoring. Some places carry Calcium Chloride instead of CaGluc, and the dose is a little different.

Couple addendum things....

-- Midazolam dosing in an emergency can be the same as diazepam; don't memorize another dose. Technically, you can use a lower dose, but I never bother. When I give midaz for a seizuring patient, it's at 0.5mg/kg. I usually reach for diazepam, but if the patient needs a CRI I'll switch to midazolam. But you have time to look that up.

-- Plumbs will tell you to increase the diazepam dose for a patient already on phenobarb, if I remember. I don't find that to be necessary.

 

[JaynaAli]

My practice had 23% calcium gluconate, but we also had a piece of paper taped inside the door of cabinet you took it out of that said how to dilute it to 10% to use.

Edit: I say that to remind people to check the percentage before just assuming it's 10%. I was told that the 10% was harder to get than the 23% more common in large animal so we made do with what we had.

 

[deleted498041]

Interesting! I thought ECC was a required rotation everywhere.

It's super easy to remember reasonable doses for Dextrose or Calcium Gluconate: 1ml/kg in an emergency hypoglycemic or hypocalcemic situation where the patient is seizuring (at least, that's what I use).

Just make sure you dilute to appropriate dilutions.... Dextrose commonly comes as 50% and should be given as 25% (or less, but for ease of use I do 25% since that's a simple 50:50 dilution). CaGluconate usually comes as 10% (make sure you check before giving!) and can be given as 10%, but should be done slowly with ECG monitoring. Some places carry Calcium Chloride instead of CaGluc, and the dose is a little different.

Couple addendum things....

-- Midazolam dosing in an emergency can be the same as diazepam; don't memorize another dose. Technically, you can use a lower dose, but I never bother. When I give midaz for a seizuring patient, it's at 0.5mg/kg. I usually reach for diazepam, but if the patient needs a CRI I'll switch to midazolam. But you have time to look that up.

-- Plumbs will tell you to increase the diazepam dose for a patient already on phenobarb, if I remember. I don't find that to be necessary.

Thank you for all the info I'm starting on CCU in a couple weeks and I'm trying to cram as much in my head now when it comes to knowing what needs to be done asap versus what can be looked up in a couple minutes.

As far as what's required for my school's fourth year rotations... all that's actually required is one medicine and one surgery rotation, and then otherwise you can plan whatever you want but you can't repeat the same discipline more than twice (other than medicine or surgery, because cores don't count towards that), and you can't be at the same practice more than twice. I think that we should have a little more requirements pushed upon us, but I also think that we have a cushy fourth year. Our rotations are 4 weeks long, and we only have eight of them. As much as I loved my four months of vacation/externships, not every student is actually going to work during that time off and I think that we should still be soaking up what we can while we're in the safety of vet school. That being said, I've been off rotations since March and I'm going to have a hard time jumping into an 80-hour work week soon

 

[Coquette22]

Do people REALLY come out of 4th year not knowing the anticonvulsant dosing for valium?.... but I really think people should know those three drug doses (for anticonvulsant therapy).

Yes. Yes I did. I'm a GP and I can count on two hands the number of times I've given diazepam for seizures over the last 2 years*. I didn't have any status epilepticus patients during my rotations and we weren't a big enough school to have a strictly ECC rotation. I've learned the dose, but I certainly didn't come out of school knowing it.
*Not because I didn't want to, just because I've only had a handful of status patients since then.

 

[LetItSnow]

Yes. Yes I did. I'm a GP and I can count on two hands the number of times I've given diazepam for seizures over the last 2 years*. I didn't have any status epilepticus patients during my rotations and we weren't a big enough school to have a strictly ECC rotation. I've learned the dose, but I certainly didn't come out of school knowing it.
*Not because I didn't want to, just because I've only had a handful of status patients since then.

I'm surprised by that (both coming out not having it drilled into you, and counting on two hands). I figured you GP types saw actively seizuring patients at least as often as I did, just given the chances of it happening when you're open and your client coming to you.

In urban areas with ERs, do you feel like your clients just default to the ER for that type of thing even when you're open?

I guess there are more schools that don't have ECC (or ECC-only) rotations than I realized!

That helps me understand why I hear so many people talk about coming out of school and being nervous about dealing with emergencies.

 

[Coquette22]

No ER where I was. We were a very economically depressed area, so maybe that accounts for some people just not seeking vet care period, emergency or otherwise? But yeah, didn't happen that frequently. *shrugs*

 

[Trilt]

I'm surprised by that (both coming out not having it drilled into you, and counting on two hands). I figured you GP types saw actively seizuring patients at least as often as I did, just given the chances of it happening when you're open and your client coming to you.

In urban areas with ERs, do you feel like your clients just default to the ER for that type of thing even when you're open?

I guess there are more schools that don't have ECC (or ECC-only) rotations than I realized!

That helps me understand why I hear so many people talk about coming out of school and being nervous about dealing with emergencies.

I've given diazepam emergently for seizures literally twice in the last eight months as a GP. Calcium once, and I had to convert/dilute our large animal calcium borogluconate for it. And we see a decent amount of emergent patients because we never say no and the nearest ER open during daytime hours is ~1hr away.

And no, I don't know that dose offhand at all. I didn't have a single seizuring patient on ER as a student, and didn't take neuro. I gotta say, with our facilities, if the <30seconds it takes for me to walk over to my open computer with VIN and type "diazepam" in makes or breaks the case... they didn't have much of a chance.

This is nice though:

It's not even that hard. Look at the animal, estimate its weight (kgs), move the decimal place over one to get your mL of diazepam. ER is all rough math. 50lb animal = 25kg animal = 2.5ml diazepam. Done. That's plenty accurate enough for a seizuring patient. Unless diazepam comes as anything other than 5mg/ml, but I've never seen that.

also, man, I forget how different worlds different vets work in, just giggling at this:

(If it matters, I always have an IV cath in a hospitalized patient - just one of my rules.)

 

[Trilt]

I've given diazepam emergently for seizures literally twice in the last eight months as a GP. Calcium once, and I had to convert/dilute our large animal calcium borogluconate for it. And we see a decent amount of emergent patients because we never say no and the nearest ER open during daytime hours is ~1hr away.

And no, I don't know that dose offhand at all. I didn't have a single seizuring patient on ER as a student, and didn't take neuro. I gotta say, with our facilities, if the <30seconds it takes for me to walk over to my open computer with VIN and type "diazepam" in makes or breaks the case... they didn't have much of a chance.

This is nice though:


also, man, I forget how different worlds different vets work in, just giggling at this:

Oh, and not only was our critical care rotation not required, I actually couldn't take it because I was not a small animal focused student. One of the only rotations that was like that.

 

[DVMDream]

I'm surprised by that (both coming out not having it drilled into you, and counting on two hands). I figured you GP types saw actively seizuring patients at least as often as I did, just given the chances of it happening when you're open and your client coming to you.

In urban areas with ERs, do you feel like your clients just default to the ER for that type of thing even when you're open?

I guess there are more schools that don't have ECC (or ECC-only) rotations than I realized!

That helps me understand why I hear so many people talk about coming out of school and being nervous about dealing with emergencies.

I am really not. We did have an ER/CC rotation, total of 4 weeks. They never used diazepam for seizures, they used midazolam (I know, weird). And I don't know the dose off hand and I have had a total of 1 seizuring patient that was not seizuring when it arrived and it ended up being a hypoglycemic diabetic. So.... the diazepam dose wouldn't have mattered. Wait, I lied, recalled one more patient... seizuring stray cat that the good samaritans had brought to us for euthanasia... so I just gave a wee bit of propofol and then euthanzied. I don't really see a lot of actively seizuring patients in GP, at least not so far. Now that I have typed this, I will probably get a string of actively seizuring patients...

 

[jmo1012]

Oh, and not only was our critical care rotation not required, I actually couldn't take it because I was not a small animal focused student. One of the only rotations that was like that.

And it was extremely coveted anyway and tough to get into...

I am really not. We did have an ER/CC rotation, total of 4 weeks. They never used diazepam for seizures, they used midazolam (I know, weird). And I don't know the dose off hand and I have had a total of 1 seizuring patient that was not seizuring when it arrived and it ended up being a hypoglycemic diabetic. So.... the diazepam dose wouldn't have mattered. Wait, I lied, recalled one more patient... seizuring stray cat that the good samaritans had brought to us for euthanasia... so I just gave a wee bit of propofol and then euthanzied. I don't really see a lot of actively seizuring patients in GP, at least not so far. Now that I have typed this, I will probably get a string of actively seizuring patients...

We primarily use midaz here (and at my internship). I think it's just clinician preference. Midaz is great though because you dont have to just give it IV. You can easily give IM and have it work (or IN). Neuro does seem to use more diaz, but our hospital actually doesn't stock much. Midaz for CRIs only because we don't have the stock of diaz in house.

I don't think I graduated knowing the dose for midaz, and I don't remember if I had any seizure patients on ER. Did not take neuro in house. I did however make a list of important emergency doses to keep in my pocket during my first days as an intern.

 

[LetItSnow]

Crazy!

I see seizuring patients all the frickin' time. I saw two on my last shift alone, one that came in actively seizuring, and one that was clustering for the owner, arrived not seizuring, and started seizuring soon after presentation.

Nothing weird about using midazolam. As best I know, the only real advantage over diazepam (given that nyanko says it doesn't matter) is that it's IM absorption is more predictable than diazepam. We stock both in our hospital ... just out of habit I reach for diazepam for actively seizuring patients and switch to a midazolam CRI if I want to go the CRI route. No real logic to it.

I guess my clinicians just hammered those drug doses into me. I remember a big long rounds chat about "what do you have to have memorized," and all the residents and staff looked around at each other and concluded that seizuring drugs are the biggies. Sounds like the other schools don't emphasize it as much.

I'm glad mine did, considering I see it frequently. In the end, it doesn't really matter. You memorize the drugs you use frequently, so in the long run ... who cares.

also, man, I forget how different worlds different vets work in, just giggling at this:

Well, I wouldn't expect it in a GP practice, since there are other reasons to have patients in hospital. But any patient I keep (ok, ALMOST any - occasionally I courtesy hospitalize some laceration repair without charging the owner if I know I can't repair it until 2AM or something and I want to let the owner bail and pick up in the AM) they're sick and I'd be remiss if I didn't have venous access in case they declined. 95% of them are on fluids anyway, and of the remainder that might not be, most of those are CHF cases where I want a catheter for giving lasix and other drugs....

 

[KCgophervet]

I guess my clinicians just hammered those drug doses into me. I remember a big long rounds chat about "what do you have to have memorized," and all the residents and staff looked around at each other and concluded that seizuring drugs are the biggies. Sounds like the other schools don't emphasize it as much.

I'm glad mine did, considering I see it frequently. In the end, it doesn't really matter. You memorize the drugs you use frequently, so in the long run ... who cares.

Went to your school, did/do not have those drug dosages memorized. Never had a seizuring patient on ECC (though had some epilepsy patients on SAM). Clinician dependent learning I guess

 

[DVMDream]

Crazy!

I see seizuring patients all the frickin' time. I saw two on my last shift alone, one that came in actively seizuring, and one that was clustering for the owner, arrived not seizuring, and started seizuring soon after presentation.

Nothing weird about using midazolam. As best I know, the only real advantage over diazepam (given that nyanko says it doesn't matter) is that it's IM absorption is more predictable than diazepam. We stock both in our hospital ... just out of habit I reach for diazepam for actively seizuring patients and switch to a midazolam CRI if I want to go the CRI route. No real logic to it.

I guess my clinicians just hammered those drug doses into me. I remember a big long rounds chat about "what do you have to have memorized," and all the residents and staff looked around at each other and concluded that seizuring drugs are the biggies. Sounds like the other schools don't emphasize it as much.

I'm glad mine did, considering I see it frequently. In the end, it doesn't really matter. You memorize the drugs you use frequently, so in the long run ... who cares.



Well, I wouldn't expect it in a GP practice, since there are other reasons to have patients in hospital. But any patient I keep (ok, ALMOST any - occasionally I courtesy hospitalize some laceration repair without charging the owner if I know I can't repair it until 2AM or something and I want to let the owner bail and pick up in the AM) they're sick and I'd be remiss if I didn't have venous access in case they declined. 95% of them are on fluids anyway, and of the remainder that might not be, most of those are CHF cases where I want a catheter for giving lasix and other drugs....

Drugs I have memorized...

Cerenia, convenia, rimadyl, most of the antibiotics, benadryl, dexsp for allergic reactions, and most of the anesthetic drugs. But this is after a year of repetitive use of these drugs and occasionally I'll not use doxycycline for a while (as an example) and my brain will go was that one 5 or 10mg/kg??? Then I'll have to look it up.

 

[DVMDream]

Also I go through oxytetracycline eye ointment like candy...love that ****. Every corneal ulcer of mine gets that.

 

[Trilt]

Drugs I have memorized...

Cerenia, convenia, rimadyl, most of the antibiotics, benadryl, dexsp for allergic reactions, and most of the anesthetic drugs. But this is after a year of repetitive use of these drugs and occasionally I'll not use doxycycline for a while (as an example) and my brain will go was that one 5 or 10mg/kg??? Then I'll have to look it up.

This is basically an identical list to me, although several of the common abx I have a fridge chart for so I don't have the doses properly memorized.

Also the answer for doxy is both, lol.