question for the interns, from a measly 4th year

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kat82

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hey all! i am a 4th year applying in EM, just had a couple of questions- my sub-i experience so far has been pretty easy- aka i was not really functioning like a true intern. i worked in the ICU where i followed about 2 patients, wrote notes, followed up on labs and stuff, but i really didnt have to do much scut work (which was great- trust me, i LOVE 4th year and i am not complaining)

i just talked to a friend who did a sub-i at an away hospital and she told me that she had a REALLY challenging month- carrying 6 patients, drawing her own blood, doing her own ekgs, basically doing "everything" for the patient. she was at a hospital in nyc which supposedly has terrible ancillary services which is why she claims she did so much

i feel like i am going to be a total idiot when i start internship. i dont know how to draw blood (im pretty bad at it) and i wouldnt know how to set up an ekg if my patients life depended on it (literally) she made me feel like maybe i am totally unprepared! i do have one more sub-i to go and it should be a little bit harder (or so i've heard) but i just dont want to completely die when i start internship

also i dont know if this is a REALLY dumb question- but when i was a sub-i, i basically did everything the resident told me to do, or asked before i did anything. when you are an intern, what sorts of things do you decide and do on your own (in terms of orders and stuff) and when do you ask the resident or wait for rounds to discuss? i know this should be pretty obvious to me but i've had such a sheltered experience and i'm just wondering for next year.

any advice from the newly minted interns out there?
thanks!
-kat
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I came from a pretty cush place to train, from a medical student perspective (I never drew labs, never did EKG's, etc). As an intern, I rarely have to do those things, but when I have had to, I've always found someone to ask for help. For questions that there was no one to ask, I looked up how to do it and did it.

Everyone feels like a total idiot when they start. My first week or two was a total uncertain blur, and I found it funny that nurses who had more experience than me were asking for my guidance on how to treat patients. If I didn't know something, I looked it up. If I didn't know how to do something, I found someone to show me. And quickly, I got confident in my decisions. Four months in, there are fewer things I have to look up, but they still exist. It helps that I'm at a very friendly program where my upper levels are happy to help me out.

As far as knowing what to do yourself and knowing what to save for discussion, that will come. At first you will do very little without confirmation, but over time that will change. Early in internship, you can't go wrong if you ask. Its always better to ask than to assume and do the wrong thing. You can practice now by coming up with a complete plan for your patient before asking your resident what to do. If their decision differs from what your own plan was, ask for their thought process on it. If you get in the habit of writing down exactly what you'd do (ordering of tests, dosages of meds, etc.) then that transition to the intern who's writing those orders becomes easier.
 
kat82 said:
i feel like i am going to be a total idiot when i start internship. i dont know how to draw blood (im pretty bad at it) and i wouldnt know how to set up an ekg if my patients life depended on it (literally) she made me feel like maybe i am totally unprepared!
Click to expand...

You will be a total idiot, just like everyone who came before you.

But to be clear, you won't be an idiot because you can't draw blood or do EKGs. That's why we have techs and nurses. If you really want to learn these things, learn from them. If you don't, big deal. I can count on one hand the number of patients I've tried to stick in the last 4 months, and I haven't done a single EKG. At this point, I'm better at LPs than blood draws. So what.

The learning curve is steep, and the hardest thing to learn is when to make an independent decision. Some of my fellow interns still call the resident for every stupid little thing ("Is it okay if I give a fluid bolus?"). Others of us have more of a reputation for maybe doing more than we should and calling later to report (better to ask forgiveness than permission).

Either way, you'll find your own path, and it will be fine.
 
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as others have mentioned above, you'll learn on the fly like many before you. I've never draw blood (unless doing a radial stick for an ABG counts) and wouldn't have a clue how to set up an EKG machine. Hopefully you'll end up at a hospital where you won't have to do that stuff. Plus, each hospital is different. Where I went to med school, the nurses placed an NGT, where I did internship we placed them. Where I went to med school RT drew ABG's. Where I did internship, we drew them. So it's variable and you'll work out the details as you go.

Tired's discussion of autonomy is spot on. Early on you'll ask more but as you progress your decision making will become much more independent. By the end of the year you'll let your seniors know as more of an FYI and less of a "hope this was OK to do"...


Good luck and don't sweat it.
 
Tired said:
You will be a total idiot, just like everyone who came before you.

But to be clear, you won't be an idiot because you can't draw blood or do EKGs. That's why we have techs and nurses. If you really want to learn these things, learn from them. If you don't, big deal. I can count on one hand the number of patients I've tried to stick in the last 4 months, and I haven't done a single EKG. At this point, I'm better at LPs than blood draws. So what.

The learning curve is steep, and the hardest thing to learn is when to make an independent decision. Some of my fellow interns still call the resident for every stupid little thing ("Is it okay if I give a fluid bolus?"). Others of us have more of a reputation for maybe doing more than we should and calling later to report (better to ask forgiveness than permission).

Either way, you'll find your own path, and it will be fine.
Click to expand...

Very Very dangerous, especially if you are not the senior... can be a recipe for disaster if your senior is one of those control freaks.
 
Faebinder said:
Very Very dangerous, especially if you are not the senior... can be a recipe of disaster if your senior is one of those control freaks.
Click to expand...

Yep, I learned the hard way that being the cowboy/girl isn't always appreciated by the seniors!

It came back to bite me as a Chief with interns that would do the same thing and drive me crazy!!!:laugh:
 
drawing blood and ecg set ups come with experience...everybody feels stupid doing it for the first time +/- 1 year...then it becomes routine...then if you dont practice, the skill also tends to rust...but it's like riding a bike, and it becomes easier to get the hang of it again.

it's a skill that you won't really be needing as much as an attending, so you'll be fine even if you dont master it. But in our hospital where you don't get to go home if you dont fiish all your IV line insertions and extractions, it's a "necessary" skill, so much so that we usually joke that we are being trained as phlebotomists...hahaha

I hope these can help...

1. Listen to the patient -- many patients who are hard to extract blood from or insert an IV line (think cancer patients on chemo drugs), usually know their "best" places. They will point it out to you. Even if it doesn't make sense, listen to them because it helps them feel comfortable, so you are also comfortable doing the procedure.

Choose your veins wisely--this is actually I think the most important step. The "intern's vein" is on your wrist, thumb side. Definitely the easiest place to insert an IV line in majority of people. For extractions, go for the antecubital area. If you have difficulty seeing it, even with a tourniquet, you can feel for it by locating the biceps tendon. This takes practice. I am pretty skinny--my co-interns joke that they dont need a tourniquet to line me, so they always practice for the feel of the vein on me. I suggest you do the same. There IS a big difference to the ballotement of a vein. Sometimes before lining or extracting blood from a particularly obese or edematous patient, I use my own arm as guide.

2. Ask the patient to do some hand and arm exercises before tying the tourniquet to really pump up those veins. Sometimes, flicking on veins (just enough pressure so as not to be painful to the patient) also helps.

3. Drown the area in alcohol, you'll see the vein much better. But dry it with a sterile gauze just before you insert the needle so it's not slippery.

4. For blood extractions using plain syringe, pump the syringe first then leave just a very small amount of air. So when you puncture the vein, it's sort of a vaccuum. If you need lots of blood, do it in one puncture by using a 10 ml syringe. For desperate measures or if we need an ABG anyway with the cbc and the bmp, we do an ABG with a 5 cc syringe, draw the needed ABG blood with the tuberculin needle from the 5 cc syringe, and divide the rest to the other blood works.

5. For IV line insertions in very fragile veins or in babies, this is a wonderful trick: attach it to a tuberculin syringe with sterile NSS. Once you nick the vein, pull out the needle asap (so you dont get through and through) and push the sterile NSS so you can guide the catheter in place.

6. Brands do matter (???) Well, at least for the super difficult patients anyway. I dont have any stocks on these places ok, but really, check out the test tubes and get the ones with the minimum amount of blood needed. (Yes, they differ). As for IV lines, we have our favorites. Some do well with Cathula, others swear by Braun. Always, if you can, get the one with the "wings" which are really important because they allow better control so your thumb is on the base and the index and the middle finger are on each wing of the insyte.

7. Best place to learn IV line insertion is in OB! Those preggy women have veins that are the med students' equivalent of training veins.

8. Relax. You will get better with practice. I was a dumb clerk myself, and by mid internship I was inserting lines on premies. I don't know how to say this without coming off as a religous nut, but really, sometimes when I have a difficult case, just before I insert the needle, I say a little prayer in my head. Something like, "Lord, my patient needs this. Guide my hands..." It helps me a lot.

Good luck!
 
As for ECG set ups, know your machine and memorize the colors. I dont dare even rival the speed that ecg technicians have. I'm still terrible at it and I fumble a lot. I think it's okay...
 
Add...

If it's an elderly with very loose skin, make sure your other hand pulls the skin taut so the vein doesn't move a lot.


Hope that will help you out.
Im ok with blood, but still get freaked out with intubation. That is a much harder skill to master for me. ANy one out there who has tips for endotracheal intubation? :)
 
buckley said:
As for ECG set ups, know your machine and memorize the colors. I dont dare even rival the speed that ecg technicians have. I'm still terrible at it and I fumble a lot. I think it's okay...
Click to expand...

"White on right, smoke over fire" (i.e. black at upper left chest, red at lower left chest).
 
thanks for the link!
thanks for the mnemonic!...some machines have green and brown though...

someone PMed me about whether the vein is lateral or medial to the biceps tendon, MOST of the time it is medial, just above the tendon. Hook your hand over a table edge and make the effort of lifting the table up--this will bring out your biceps tendon. feel how hard and gritty it is compared to the vein which has a rather "bouncy" feel.
in line with this, when you need to do an abg on the antecubital area, you go lateral so you don't get venous blood.

i hope we can get more intern survival tips going...good luck to us!
 
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buckley said:
thanks for the link!
thanks for the mnemonic!...some machines have green and brown though...

someone PMed me about whether the vein is lateral or medial to the biceps tendon, MOST of the time it is medial, just above the tendon. Hook your hand over a table edge and make the effort of lifting the table up--this will bring out your biceps tendon. feel how hard and gritty it is compared to the vein which has a rather "bouncy" feel.
in line with this, when you need to do an abg on the antecubital area, you go lateral so you don't get venous blood.

i hope we can get more intern survival tips going...good luck to us!
Click to expand...

There are usually veins on both sides of the biceps tendon, and they can vary in position.

MainArmVeins.gif
 
Yup, variations are a lot. MOST of the time, the better vein is MEDIAL. If I would guess in an obese edematous patient, I would go medial.
 
Blade28 said:
"White on right, smoke over fire" (i.e. black at upper left chest, red at lower left chest).
Click to expand...
1. clouds over grass-- RIGHT CHEST with white on upper left chest and green on lower chest.

2. smoke over fire on the LEFT but the brown lead is a little more medial and superior to the red lead...so it is black on upper left chest, then brown and red on lower left chest, with brown being a bit more medial and superior.
 
AWESOME help guys! Thanks :)
 
nykka3 said:
1. clouds over grass-- RIGHT CHEST with white on upper left chest and green on lower chest.

2. smoke over fire on the LEFT
Click to expand...

But then how do you remember which leads go on which side of the chest? Or do you have to remember "clouds over grass, white on right, smoke over fire"?

Yikes!
 
wow, thanks for all the great tips, esp the blood draw stuff:). i need to vent however--- my friend that i mentioned in my original post is driving me NUTS!! we just spoke last night and she literally said


"unless you just did the sub-i that i did last month, you will be totally unprepared for intern year. my sub-i was arguably the toughest sub-i in the country"

how could she say that??? she wont stop talking about how she was so amazing (for carrying 6 patients- NOT 12!!) and how she NEVER called her resident before writing any orders (i think thats ridiculous as a 4th year). shes trying to give me "tips" on how to be a good intern (who does she think she is!!!???) am i wrong for being totally irritated? i feel like shes TRYING to make me feel inadequate and pumping herself up. grrr!
 
Blade28 said:
But then how do you remember which leads go on which side of the chest? Or do you have to remember "clouds over grass, white on right, smoke over fire"?

Yikes!
Click to expand...

You just look at the little diagram on the box. All of the tele leads I've seen have that...makes it even fellow proof.
 
kat82 said:
wow, thanks for all the great tips, esp the blood draw stuff:). i need to vent however--- my friend that i mentioned in my original post is driving me NUTS!! we just spoke last night and she literally said


"unless you just did the sub-i that i did last month, you will be totally unprepared for intern year. my sub-i was arguably the toughest sub-i in the country"

how could she say that??? she wont stop talking about how she was so amazing (for carrying 6 patients- NOT 12!!) and how she NEVER called her resident before writing any orders (i think thats ridiculous as a 4th year). shes trying to give me "tips" on how to be a good intern (who does she think she is!!!???) am i wrong for being totally irritated? i feel like shes TRYING to make me feel inadequate and pumping herself up. grrr!
Click to expand...

Yep, sounds like it.

You are not wrong. I'm irritated with her just by reading your post. Maybe she won't match and we'll all have an evil laugh about it.:smuggrin:
 
kat82 said:
"unless you just did the sub-i that i did last month, you will be totally unprepared for intern year. my sub-i was arguably the toughest sub-i in the country"
Click to expand...

Let me reiterate. EVERYONE is unprepared and overwhelmed when they start residency. EVERYONE. Doesn't matter which med school you went to, what electives you took in your MS-IV year, how much you studied between med school graduation and residency orientation. Doesn't matter what field you're going into.

Happens to EVERYONE.
 
On any given day, I think I would rather have a "dumb" intern who makes easy referrals to me than a "genius" intern who thinks he can and ends up screwing the patient and me twice over...:thumbdown:

Dr. Cox, if I don't match, I think I will change my name just so I dont hear your evil laugh :scared: Getting scared of that one...
 
I am now a 3rd year EM resident. I was in your shoes (size 10 right?) not long ago. If you are not scared and worried about internship there is something wrong with you. My 1st rotation was CCU, I survived and so will you. My advise for 4th year is have fun, learn some stuff, don't stress about next year .... and have fun. If you start your year in the ED the expectation is that your plans for the patient will be wrong. There would be no need for residency if you already know everything. Feel free to PM me. Good luck
 
hi everyone, thanks for the support. i think my friends recent burst of "confidence" really caught me off guard and got me nervous. part of me hopes that she has a major wakeup call next year! i seriously am still shocked at the fact that she wrote most of her orders as a sub-i without asking or getting them cosigned right away.

im glad to know that everyone feels totally nervous at the beginning of internship. i know that mine is still months away and i should be enjoying 4th year (and trust me, i am, i am LOVING it) but i just wanted to make sure that i wasnt alone out there!

thanks again
kat

ps- i really enjoyed dr. cox's response, hahahah
 
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