Help! ASAP!!! I'm drowning over here

[SomethingFishy]

OK..new intern obviously..call has been tough, I knew it wouldn't be easy, but I don't have a lot of back up support and I'm in dire need of help from anyone willing to offer advice.
Here are my issues:
1-When I get called or paged to see a pt or called about a pt, I freak out, lose all grip on what I am supposed to do and what I know and just kind of stand there for a long time, then eventually I ask someone for help. I know I'm not stupid, but I can't seem to get that whole autonomy thing going. Anyone had this happen and know what to do about it?
2-I feel like I did better with H&Ps in medical school. Kinda sad. I know "you will never know as much as you did 3rd yr of medical school" and all of that, but wow I can't seem to string up a good H&P to save my life. I keep leaving major things out. Also, I feel like my physical exam skills went to ****. I can't seem to correlate anything anymore--is that a murmur? umm crackles mean...?
3-I don't really know how to formulate a good assessment and plan..any help is appreciated--I especially am not sure of how to address things, like do I say, I think that the dx is most likely ___; less likely dx but considered in the differential are__ and they are ruled out b/c ___? then where should I put my plan? Help help help
..and the biggest of all...**4**--when I don't know something, like if a CT read comes back and I don't know what the interpretation means, I don't know where to look for help on how to figure it out. Or for instance, if a lab result is abnormal, I have a hard time finding how to look it up. And the worst of all, if I'm having trouble formulating a diff dx/assessment/plan, I have absolutely no idea how to find help and look things up.
As you can see, I'm a mess and I'm getting crushed right now b/c of it. I really thought I was smart coming out of med school, but I've realized that I don't know which pts shouldn't get heparin prophylaxis and I don't know what to do with pneumonia. Someone help!!

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[Top Gun]

Relax. You're new. It will get easier once you get more experience. When you get called about a patient, don't panic. Just review the chart and go see the patient. That should give you a better idea of what's going on, so that you'll know how to manage the patient. Let's say you get called to see a patient whose blood pressure is 80/56. Go review the chart. What's his/her history? Does the patient have CHF, some sort of GI bleed, or is he/she septic? Many times if they're septic and already getting antibiotics, they just need a fluid bolus or an increase in IV fluids. If the patient has a history of peptic ulcer disease, go examine the patient, including heart, lungs, abdomen, and do a stool guaiac. Then do a CBC. It could be that the patient is actively bleeding and needs to be transfused a few units. You can also give some normal saline. Above all, SEE THE PATIENT. Look at his/her general appearance, including color and whether he or she is in any distress, and then do a quick but careful exam. Once you've seen the patient and started the initial management, if the patient looks critical and you're not sure what to do, call your senior! But do this only after you've seen the patient and reviewed the chart. That way the senior has a better idea how to help you. Also, check your signout list and see what particular issues are going on with that patient.

 

[bluesdude]

Great advice from top gun and i'll add a little.
1.When you goto see a sick pateint go through the ABC systematically.Is she/he breathing? can they finish a sentence? eyes open? BP not danegerousely low? If they're hooked to a monitor have a look at it to get the current vitals and/or check the chart.If the there's any problem with the ABC's you shouldn't hesitate to shout for help.Even the most senior doctor can not and shouldn't manage a sick patient on their own.
2. If the patient's reasonably stable ,then you'll have time to go through the notes.You should be able to find why patient's admitted and what his other active problem and relevent past illnesses are.
3. Always check the drug chart.Have they missed a dose or double dosed by mistake? any new medications started that might've caused the problem?
4.
About formulating an asessment:I don't think there's one single format that would suit every patient and every situation.
Genrally I start with patient's gender and age and i proceed to the presenting complaint,relevent past hx and then the working diagnosis and after that comes the plan."This 65 year old,previousely well, lady has presented with severe frontal headache and fever.She had slight neck stiffness but no neurological symptoms.The most likely diagnosis is meningitis so we're planning to do a septic screen,CT scan and lumbar puncture and start IV antibiotics"
5.Do you have access to any online resources at hospital? We have uptodate access in our hospital and there is also a set of national guidelines here in Australia called "therapeutic guidelines" which is very helpful.Even if you don't have any of these you can find a lot just by googling.Emedicine is another good online resource which is free.If you don't have access to internet carry a handbook.
6.I believe learning how to apply knowlege in medicine takes longer than obtaing that knowlege.As an intern you shouldnt feel bad about not knowing everything.
7.try to develop some hobby.Something to help you get through. your life shouldn't be all about hospital.
8.You ARE smart coming out of medical school.Don't doubt that.
Just out of curiousity:What sort od senior support do you have?

 

[Top Gun]

Oh, here's some further answers to your questions about heparin prophylaxis and pneumonia. Cases in which you want to avoid subcu heparin include anyone with low platelets or a drop in platelets (as heparin can induce thrombocytopenia), and obviously anyone who is actively bleeding (i.e. melena, intracranial bleed, etc...). In cases like these, you can give bilateral venodyne boots for DVT prophylaxis. As for pneumonia, the workup is pretty straightforward. Once you've done your H&P, and your findings suggest pneumonia, get a CBC, blood cultures X 2, chest X-ray. Also, send urine for Legionella and Strep antigen just in case. And a lot of times we send sputum for gram stain and culture, although I'm not sure how diagnostically effective this particular test really is. For antibiotic coverage, we tend to favor IV Rocephin and Zithromax. Zithromax provides good coverage for atypicals.

 

[Top Gun]

But, for pneumonia, when you order blood cultures, make sure you get sensitivities as well so you find out not only what type of bug it is, but also what antibiotic works well for it.

 

[Vader]

Your job when cross-covering patients is to keep them alive. You are not expected to do major diagnostic workups, but just rule-out the immediately life-threatening things (i.e. MI, PE, sepsis, etc). Common calls are for hypotension, chest pain, shortness of breath, hypoxia, fever, altered mental status, hyperkalemia, and low urine output. You should have a quick differential for each of these presentations, know what are the main tests you would order to rule-out life-threatening conditions, and how you would initiate management. For example, for chest pain, a short ddx might be: MI, PE, PTX. An EKG and chest X-ray would be a good start for a workup, depending on the history and physical exam.

There are various resources you can use to help guide you. Our program gives us an "intern survival guide" which has quick work-ups for common problems encountered. Over time, you develop a sense of what needs to happen when presented with a specific problem. The most important thing though is to remain calm and collected.