How to Be a Great Intern

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How to Be a Great Intern

• Colleen McEvoy and Farzad Moazed
• Northwestern Internal Medicine
• June, 2009

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Help You will need this!

• You can always get it
• You are expected to ask questions
• Who to ask
• Nurses
• Residents
• Chiefs
• Attendings
• Maija
• Diane

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As an intern, your job is to

• Order labs
• Replete electrolytes
• Schedule tests
• Schedule follow up appointments
• Round with Team
• Write notes
• Write discharge instructions
• Write discharge summaries
• Cross Cover
• Sign out to other interns
• Any/all scut work

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AND GROW a Great STACHE
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First things first.

• Be on time
• Pick up sign-out before 7AM your night float
  interns are counting on you.
• Get labs and vitals from Powerchart
• Replete lytes
• Do NOT need to pre-round, but
• See anyone you are worried about
• SEE THE PATIENT IF ANY CHANGE IN STATUS OVERNIGHT
• Be ready for rounds before 730
• Go to 730 Morning Report

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After Morning Report

• Round with team
• Bring a COW (computer on wheels) enter orders
• Portable phone call consults
• Communicate the plan w/ your medical students
• Attend noon conference - there will be food, some
  of it edible

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During/After Rounds

• Prioritize your work and get started early
• Call consults
• Call consults prior to noon
• Know your question
• Know relevant info
• Understand the urgency
• Follow up the recommendations
• Order important studies, procedures.
• THE OPERATOR IS YOUR FRIEND - as well as the
  Intern Survival Guide full of important numbers!
• Orders for the day, med changes, etc
• Finish notes, teaching, etc
• Sign-out

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How do I do ALL of this in A timely fashion?

• Notes
• Everyday issues
• Sign out
• Cross cover
• Tips

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Notes

• Include update from day before
• Vitals, Exam (updated daily), Labs (can use dot
  phrases)
• MEDS
• Plan should be refreshed daily.
• Be careful with cut and paste

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Ordering Tests

• CTs and General Radiology place order in
  Powerchart. If STAT, call appropriate dept ( in
  blue guide)
• MRIs need
• 1) Order in powerchart
• 2) Fax safety questionnaire to 6-1572
• 3) Call down to 6-4333 to ensure on schedule
• IR - call first thing in AM (730) to get your
  patient on the schedule
• 65200
• Radiology on 4th floor, ER radiology room at
  night

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Transfusion Consents

• Found in nursing station/front desk, just ask!
• Only need one per hospitalization
• Always explain that you feel that the benefits
  outweigh the risks
• Risks include rash, fever, infection, reaction.
• Low risk of infection, but its there.
• HIV 1gt2,000,000
• Hep B 160,000-1200,000
• Hep C 12,000,000
• Theres a lot we dont know about
• Remember risk of sudden deaths increases for all
  comers at a Hgb less than 5.0
• If they refuse document it!

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Procedure Consents

• Also found at front desk
• Always risk of infection and bleeding
• Always think of what you could accidently poke
• Remember anatomy - and inform the patient.
• Make sure the pt is competent
• If patient refuses document it
• Before the procedure, take a time out
• Make sure you document that consent was obtained
  in your procedure note. Also if a follow up CXR
  etc. is needed, order it and document result.
• Surgeons, Interventionalists get their own
  consents

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Powerchartyour friend

• Order Sets
• There is an order set for everything
• Admission Order sets
• Procedure Order sets
• Thoracentesis/paracentesis Labs that need to be
  ordered all in one set
• Pre-formatted Procedure Notes

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Powerchartwhy have you forsaken me??

• Has been known to crash, save your HPs.
• If you cannot find it dont worryask your
  resident, call the pharmacy, call the lab.
• Physician to RN or Miscellaneous Nursing Order
  can cover anything else you need done and dont
  know how to order.
• If you want something done, dont just order it.
  Make the extra phone call. You are the one to
  make sure things get done. The patient is your
  responsibility

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Sign OutS

• CONTINUITY OF CARE ensures patient safety!!
• Quick reference when emergencies arise
• List the acute problems
• Document if DNR/DNI
• Also a way to keep track of ongoing issues, put
  reminders in there for yourself.

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Sign outs

• Electronically generated this is VERY NICE for
  interns.
• Update hospital course, make it brief
• Important to put relevant info, including brief 1
  liner, med probs, code status, POA/contacts
• DONT sign out crashing pts unless youve done
  everything you can within reason.

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What makes a GOOD SIGN-OUT?

• Initial updated one-liner in the sign-out that
  describes the pt is key.
• For example, if a pt presents with SOB but 3 days
  into the hospital admission the pt has been dx'd
  with CAP and ruled out for PE with CT angio, this
  information should be included in the one-liner.
• If something might change overnight, document a
  baseline (mental status, resp status, abdominal
  exam, etc)
• If asking NF to follow up on an imaging study,
  state how the pt presented and exactly what you
  are looking for or trying to rule out.

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• If antibiotics have been recently discontinued or
  changed, add an extra line about these changes in
  the sign-out. (This is key in the neutropenic pt
  on heme/onc).
• Update sign-out with ANY procedures done during
  the day. Even if the procedure went well without
  any complications, unpredictable post-procedure
  complications may occur overnight.
• If a pt has an issue during the day, please state
  the characteristics, work up, diagnosis, what
  NF should do if recurs

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From bowling Night
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PAGer

• Make sure you sign out your pager to on call team
  (make resident show you on day 1)
• If you are not signed out, you are responsible
  for any pages! (NMFF clinic will page you on
  weekends)
• If on consult, can sign out to cell phone
• Make sure you are available during air call

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Cross Covering
OMG!
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First things first

• Patients name and location
• Interns name
• Full set of recent vitals
• Time course of events
• IF YOU SEE A PATIENT or there are active events
  that happen ? DOCUMENT
• THERE ARE NO EXCEPTIONS TO DOCUMENTATION

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Cross Cover

• If patient looks sick- CALL night float
  residents.
• If need to transfer to ICU, you/resident needs to
  call ICU resident, give report, and write a
  transfer note.
• Accompany pt and RNs down to ICU.
• Dont be scaredthis is how you learn.

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codes

• Dont Panic
• ASAP OMIT
• assess (griffin is the pt dead or dying?)
• status (?DNR)
• activate (55555)
• push hard, push fast
• oxygen
• monitor (cardiac)
• IV access
• treat

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Common cross-cover calls

• Insomnia
• Replacing lytes
• The family/patient wants to talk to the doctor
• Pain
• Restarting diets

• Hyper/hypoglycemia
• Hyper/hypotension
• Patient is refusing meds, imaging, etc.
• INFORM THE FAMILY AND ATTENDINGIF THERE IS A
  MAJOR EVENT

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Reasons you must see the patient!

• Chest pain
• Dyspnea/hypoxia
• Uncontrolled bleeding
• Uncontrolled vomiting
• Severe abdominal pain
• Seizures
• Mental Status Change
• Severe Headache
• IF YOU EVER HESITATE AND THINK YOU SHOULDJUST DO
  IT!

• Falls
• New onset pain
• Hypotension
• Arrhythmias
• Fever change in vitals or mental status
• Deaths
• The patient wants you to
• The patient wants to sign out AMA

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Cross Cover

• In beginning, err on side of seeing more patients
  than you think.
• Triaging over the phone is not easy!
• This is where pocket survival guides come in very
  handy.
• Dont forget to write a note on the people you
  see.
• DOCUMENT!!

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Someone wants to see the Doctor

• This is you! (Finally!)
• You must go see them.
• IF you are called to talk to the family of a
  patient you are covering
• See them
• Tell them you are covering for emergencies only,
  here is what I know.
• Ask them how and when their primary team can get
  in touch with them and pass the info along.
• Dont forget HIPPA. (patient confidentiality
  guidelines)
• YOU WOULD WANT TO KNOW IF IT WAS YOUR GRANDMA.

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Patient is refusing meds/tests

• Is it important?
• If not you can hold the vitamin, etc.
• If it is important for the patient to receive
  something than you must go talk to the patient,
  see why they are refusing, talk to them, and
  document that you did.
• As always.DOCUMENT in Powerchart!

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AMA

• If patient wants to leave hospital in middle of
  night and no ones around
• Patient may leave ONLY if they are in your
  judgment
• Alert and oriented x 3
• Capacity to make medical decisions
• Understand consequences of leaving, including
  death
• If so, have to sign AMA form.
• Document whole event clearly in Powerchart
• If not, call security, use meds, call family
  members/resident etc

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Big picture keys to success

• Be an advocate for your patients
• Make the extra phone call
• Take the workup to the next level
• Spend time at the bedside
• Face time increases patient satisfaction
• Work hard
• There is no higher honor than to care for someone
  in their time of need
• If you need to stay later than expected once in a
  while, recognize why You may be saving someones
  life
• Have a good attitude
• Be someone people WANT to work with
• Keep things positive
• Dont complain to Clara over email

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Final Tips of Advice

• You will never forget your intern year you are
  going to learn a TON, you will be tired at times,
  you will make great friends, have fun and have
  the privilege of taking care of people everyday.
• In the words of Dr. Wayne Be where youre
  supposed to be and BE NICE.