Monday was my first day in ICU. I was assigned to 2 patients and then went on my own to do the H&P/SOAP note. I was excited about the cases, but as soon as I looked at the charts and the labs and all the caution signs on the patient's door, I started to feel very lost & overwhelmed. A lot of the patient's are on drips or ventilators. My first patient has been in the ICU for a while and just returned from surgery for debridement of large hemorrhagic bullae on both arms (final dx - necrotizing cellulitis and fasciitis) due to an infection from eating raw oysters. btw, can you guess which bug would cause this?
hint: the patient has liver disease which makes him more likely to get infected. He also went into septic shock and developed acute renal failure from hypoperfusion of the kidneys.
As interesting as it sounds, I was like, how am I suppose to come up with a plan for this patient?
My 2nd patient was actually in the CCU (cardiac care unit) which was on the same floor. That patient was more straightforward and only had atrial fibrillation (with a hx of a. fib), but he became bradycardic from taking beta blockers (used to control his heart rate). They just took him off the BB and observed him to see if it helped improve his HR. And it did. He was transferred to the "floor" the next day since he was doing fine.
Rounds was at 11 am and I was worried about how to present these patients since I didn't have time to talk to the residents about them. I spent a lot of time on the first patient and too little time on the second patient. They were busy also because the ICU was full. It turned out that I didn't have to present them and the residents went ahead and did it.
Later, that afternoon, they went to the patients I saw and explained what was going on and what they were planning to do each patient and teaching me about the ICU. They even read my SOAP note! I never really had someone critique it and felt a little nervous for a moment while watching them analyze it. But it turned out to be a good thing because the resident showed me what things to add and how to write the A/P part for each patient. The residents were very good about asking me what labs to order in certain patients and why (just to make sure I understand everything). They are very nice about it too.
The ICU is definitely a lot more challenging and it's all about getting the patients stable so that they can be moved to the "floor". Any patient who has to be on a ventilator has to go to ICU. Also, every patient who presents to the ER with DKA goes straight to the ICU. The rooms are less private with one wall being made of glass so that the nurse can see you more easily. There's a cabinet on the bottom of the wall which, when you pull one of the cabinet doors down, it's a toilet. This is so that they can keep track of your output.
So far, all the residents are very nice and helpful and so are the nurses. The nurses will usually inform me of any changes about the patient. Also, they don't mind if I ask them about stuff like "what's that tube? or what does this say/mean?"
Btw, the director will regularly meet with us to make sure that we are treated okay, if we have a problem with other students/residents/attendings, and if we are getting a good learning experience. She also asks if we are having any car trouble or problems with housing. They try to help us out as much as possible since we have busy schedules.
As far as the residency program goes, something I learned about this program is that it's family-oriented friendly. Many female residents are pregnant (or male resident's wife) because the hospital insurance is really good and they have 24 hour daycare in the hospital. Something to consider when looking at residency programs.
book recommendation: The ICU Book by Marino. very easy to read, a couple of residents recommended it, I would just read it at the library.
Thursday, July 26, 2007
Friday, July 20, 2007
Week 2
Can't believe how fast the week flew by. Although, I still have Saturday morning rounds tomorrow. This week was a continue of "floor" medicine. IM is definitely more about thinking rather than doing ("procedures"). I spend half the time with the patient and the rest of the time looking at labs, consultation reports, and writing a SOAP note. I rely heavily on my PDA. It seems that there's a lot more types of procedures and a lot more abbreviations than what we learned from school.
One lunch meeting, they had a procedures session. They had a brief lecture on how to do certain techniques (like punch biopsy) and the rest of the time we spent practicing those techniques on cows tongue, raw chicken, or an orange. It was cool except I had to leave early for afternoon report. I had a chance to learn how to do an actual punch biopsy the correct way.
1. Stretch the skin with one hand where you plan on doing the biopsy. This is so that the hole will become more elliptical shape once you let go of the skin.
2. Push in the punch straight down with a slow back and forth twisting motion.
3. Remove the punch biopsy tool and get a pair of tweezers and grab the "skin sample". Then, with a pair of scissors, cut the "sample" off from the bottom.
4. Then put in one suture to close the wound.
They also had a cryotherapy spray can to practice freezing, a cauterizing tool for burning, suture stuff, and how to shave a small, flat skin lesion superficially to send off for biopsy.
Today, there was a diabetes clinic that I had to go to. I got to learn from an endocrinologist about how he approaches patients. He saids that he and the patient are a team and they have to work together to get better (especially with diabetes). The patients really like the doctor. I got a better idea on how some of the oral hypoglycemic drugs and insulin works. He also explained the important things one should do on a physical exam for a patient with diabetes. Here it is:
1. Check the eyes (retinopathy)
2. Check for carotid bruits (diabetes = heart disease)
3. Listen to heart and lungs.
4. Check the abodomen.
5. Check the feet (dorsal pedalis pulse, posterior tibialis pulse, and popliteal pulse; also, do the microfilament test or sharp/dull sensation on the feet (neuropathy); inspect the feet for callouses, ulcers, claw toe deformity, swelling, muscle strength & ROM of feet, and ingrown toe nails).
Another thing about diabetes that, so far, 2 doctors have already mentioned to me (which means it's probably important to know): Diabetes is a macrovascular dz and a microvascular dz. Macrovascular is the heart and brain. Microvascular is the eyes (retinopathy), kidneys (nephropathy), and amputations/feet (neuropathy).
Macrovascular dz requires atleast 2 drugs (like glucophage & TZD) for treatment whereas microvascular dz requires one drug for treatment. Actually, any person who diabetic must be started on a minimum of 2 drugs (maximum is triple therapy). Also, a blood glucose of >200 at any time automatically means they are diabetic.
A side note about TSH levels. Normal is actually 2-3. The doctor learned this when he was an intern and the attending was the one who discovered TSH (I think that's what he said?).
Next week: I get to work in the ICU !
One lunch meeting, they had a procedures session. They had a brief lecture on how to do certain techniques (like punch biopsy) and the rest of the time we spent practicing those techniques on cows tongue, raw chicken, or an orange. It was cool except I had to leave early for afternoon report. I had a chance to learn how to do an actual punch biopsy the correct way.
1. Stretch the skin with one hand where you plan on doing the biopsy. This is so that the hole will become more elliptical shape once you let go of the skin.
2. Push in the punch straight down with a slow back and forth twisting motion.
3. Remove the punch biopsy tool and get a pair of tweezers and grab the "skin sample". Then, with a pair of scissors, cut the "sample" off from the bottom.
4. Then put in one suture to close the wound.
They also had a cryotherapy spray can to practice freezing, a cauterizing tool for burning, suture stuff, and how to shave a small, flat skin lesion superficially to send off for biopsy.
Today, there was a diabetes clinic that I had to go to. I got to learn from an endocrinologist about how he approaches patients. He saids that he and the patient are a team and they have to work together to get better (especially with diabetes). The patients really like the doctor. I got a better idea on how some of the oral hypoglycemic drugs and insulin works. He also explained the important things one should do on a physical exam for a patient with diabetes. Here it is:
1. Check the eyes (retinopathy)
2. Check for carotid bruits (diabetes = heart disease)
3. Listen to heart and lungs.
4. Check the abodomen.
5. Check the feet (dorsal pedalis pulse, posterior tibialis pulse, and popliteal pulse; also, do the microfilament test or sharp/dull sensation on the feet (neuropathy); inspect the feet for callouses, ulcers, claw toe deformity, swelling, muscle strength & ROM of feet, and ingrown toe nails).
Another thing about diabetes that, so far, 2 doctors have already mentioned to me (which means it's probably important to know): Diabetes is a macrovascular dz and a microvascular dz. Macrovascular is the heart and brain. Microvascular is the eyes (retinopathy), kidneys (nephropathy), and amputations/feet (neuropathy).
Macrovascular dz requires atleast 2 drugs (like glucophage & TZD) for treatment whereas microvascular dz requires one drug for treatment. Actually, any person who diabetic must be started on a minimum of 2 drugs (maximum is triple therapy). Also, a blood glucose of >200 at any time automatically means they are diabetic.
A side note about TSH levels. Normal is actually 2-3. The doctor learned this when he was an intern and the attending was the one who discovered TSH (I think that's what he said?).
Next week: I get to work in the ICU !
Sunday, July 15, 2007
Week one Part two
At first, I liked the idea of being on my own finally when I see patients. Of course, as soon as I got to the ER, I realized, what/where do I write my SOAP note on? I later learned, it goes on a progress note sheet.
I entered the room and introduced myself as "student doctor Jennfer". I interviewed the patient and was surprised at how receptive they were, even though I was just a student. I later learned that patients actually see me as a doctor and assume that as well. kinda scary since I'm new at this. btw, I failed to mention to the patient that he's my very first real patient. :P well, after a thorough interview and a semi-decent physical exam, I went to an empty counter to write a SOAP note. Then I suddenly remembered a few more questions to ask the patient. So I went back in the room, and asked more questions. I only did this about 3-4 times. :)
After completing my SOAP note, I looked at it, noticing how disorganized and crappy it looked squeezing in additional info on the side. Oh well, I figured I'd do a better job on the second one.
Tuesday - Saturday, I managed to get to morning report as early as 6:59 and 30 sec. I've learned a few things and started to improve on my interviewing skills. Presenting cases is still something I need to work on. Let's see, some obvious interview questions I failed to ask a patient.
1. after reviewing labs of extremely high BUN & creat, I forgot to ask the patient, " have you pee'd lately?" (it turns out that the patient hasn't urinated for the last 3 weeks!)
2. after reviewing labs of anemia in a female patient, I forgot to ask "do you have heavy periods?"
3. after asking a patient, "do you smoke/drink alcohol/do drugs?" The response was a no. Then after looking the patient's toxicology report + for marijuana, the resident told me that some cultures don't consider marijuana to be a drug.
4. After asking a patient "do you smoke cigarettes?" The patient replied "no." But later learned that she didn't "currently" smoke, but did in the past. (she has COPD, which makes more since now that I know she had a Hx of smoking).
I entered the room and introduced myself as "student doctor Jennfer". I interviewed the patient and was surprised at how receptive they were, even though I was just a student. I later learned that patients actually see me as a doctor and assume that as well. kinda scary since I'm new at this. btw, I failed to mention to the patient that he's my very first real patient. :P well, after a thorough interview and a semi-decent physical exam, I went to an empty counter to write a SOAP note. Then I suddenly remembered a few more questions to ask the patient. So I went back in the room, and asked more questions. I only did this about 3-4 times. :)
After completing my SOAP note, I looked at it, noticing how disorganized and crappy it looked squeezing in additional info on the side. Oh well, I figured I'd do a better job on the second one.
Tuesday - Saturday, I managed to get to morning report as early as 6:59 and 30 sec. I've learned a few things and started to improve on my interviewing skills. Presenting cases is still something I need to work on. Let's see, some obvious interview questions I failed to ask a patient.
1. after reviewing labs of extremely high BUN & creat, I forgot to ask the patient, " have you pee'd lately?" (it turns out that the patient hasn't urinated for the last 3 weeks!)
2. after reviewing labs of anemia in a female patient, I forgot to ask "do you have heavy periods?"
3. after asking a patient, "do you smoke/drink alcohol/do drugs?" The response was a no. Then after looking the patient's toxicology report + for marijuana, the resident told me that some cultures don't consider marijuana to be a drug.
4. After asking a patient "do you smoke cigarettes?" The patient replied "no." But later learned that she didn't "currently" smoke, but did in the past. (she has COPD, which makes more since now that I know she had a Hx of smoking).
Saturday, July 14, 2007
Week One part one
After orientation (Thursday & Friday), I spent the entire weekend moving and unpacking. Also, I went to a baseball game on Sunday night hosted by the Dr. E for all the medical students and a few attendings. It was a nice set up. We had a shaded tent area reserved with a private swimming pool and hot tub (I never imagined that a baseball field would ever have a swimming pool.) We had hamburgers, hot dogs, soda, and unlimited beer (but, of course, I can't stand the taste of beer). I was surprised at how laid back everyone was, especially in front of the attendings.
Monday arrived sooner than I wanted it to. Getting up at 5:30 am was really hard. So I got up at 5:45 instead. I'm supposed to arrive at the hospital at 7 am for morning report, so I left semi-early. I drive to the employee parking lot to discover that it's completely full. Now I only have 4 minutes to get to the conference room before I'm late. So I hurry up and park at the visitor parking lot (actually, I didn't know where I was parking. I just parked at the first empty lot I found). I rushed to the elevator (btw, I didn't exactly know where the conference rm was exactly except that it was on the 5th floor) and I notice a couple of interns/residents in the elevator also going up to the 5th, one of whom would be the resident I follow because I recognized his name on his white coat. So when we all got off the elevator, I just followed them and arrived at morning report with, literally, a few seconds to spare.
Morning report, I learned, was basically presenting new admits that came in last night in the emergency room. Whoever had night call (6pm-7am) would report their findings (SOAP note) to everyone at morning report (7-8 am). They discuss their plan with the attending and the attending gives feedback and also pimps the presenter about the case. Then they can go home and go to sleep. The residents & students who work in the day would follow up on the patients. I find morning report to be most intimidating because it's a large group of 20 physicians & students. When I say intimidating, I mean I won't look forward too much to presenting the case when I have my week of night call.
My first assignment was to check up on 2 patients. Dr. R (who is a 3rd year resident, was an orthopedic surgeon in another country for many years before deciding to come here which requires doing residency) is very knowledgeable & laid back and basically said "see patient A in room 100 and patient B in the ER, and write a SOAP note with updated labs and page me when you're done."
Monday arrived sooner than I wanted it to. Getting up at 5:30 am was really hard. So I got up at 5:45 instead. I'm supposed to arrive at the hospital at 7 am for morning report, so I left semi-early. I drive to the employee parking lot to discover that it's completely full. Now I only have 4 minutes to get to the conference room before I'm late. So I hurry up and park at the visitor parking lot (actually, I didn't know where I was parking. I just parked at the first empty lot I found). I rushed to the elevator (btw, I didn't exactly know where the conference rm was exactly except that it was on the 5th floor) and I notice a couple of interns/residents in the elevator also going up to the 5th, one of whom would be the resident I follow because I recognized his name on his white coat. So when we all got off the elevator, I just followed them and arrived at morning report with, literally, a few seconds to spare.
Morning report, I learned, was basically presenting new admits that came in last night in the emergency room. Whoever had night call (6pm-7am) would report their findings (SOAP note) to everyone at morning report (7-8 am). They discuss their plan with the attending and the attending gives feedback and also pimps the presenter about the case. Then they can go home and go to sleep. The residents & students who work in the day would follow up on the patients. I find morning report to be most intimidating because it's a large group of 20 physicians & students. When I say intimidating, I mean I won't look forward too much to presenting the case when I have my week of night call.
My first assignment was to check up on 2 patients. Dr. R (who is a 3rd year resident, was an orthopedic surgeon in another country for many years before deciding to come here which requires doing residency) is very knowledgeable & laid back and basically said "see patient A in room 100 and patient B in the ER, and write a SOAP note with updated labs and page me when you're done."
Thursday, July 5, 2007
Orientation - July 5th
Finally, I get to start rotations! well...atleast the orientation part of it. It was pretty laid back. The first thing I saw was a lot of breakfast food (didn't know they would provide breakfast for us). They had eggs (which I, of course, don't like), bacon, biscuits, hashbrown, juice, and coffee. I got a tour of the hospital and met some of the doctors and staff in charge. Don't ask me about my schedule, won't know til tomorrow. They gave us a syllabus of what to expect from IM rotation which basically saids that they are going to teach us how to get better and better at writing SOAP notes (which is great since I don't feel like I know how to write one because of the lack of feedback last year). They gave us a packet to read over the weekend which is just some basic info on how to write a SOAP note, admit orders, and other stuff. The syllabus says we'll be assigned 4 patients a day and also admitting patients from the ER. They'll also have some hands-on type sessions for just the students on how to suture and do other procedures.
So far, I don't feel intimidated (only b/c I haven't actually started yet) and the 4th years say that I shouldn't be. Everyone's been very friendly.
One 4th year gave us a tip for rotations that was said by a professor at their medical school like a hundred times during their second year. She saids that the rules are great. Just say them before each day of rotation to remind yourself of them. Here they are:
1. Arrive on time.
2. Be nice.
3. Work hard.
4. Don't leave until your attending/resident/intern is done for the day.
Other interesting info: one student is already going to start the night float shift - next week!
So far, I don't feel intimidated (only b/c I haven't actually started yet) and the 4th years say that I shouldn't be. Everyone's been very friendly.
One 4th year gave us a tip for rotations that was said by a professor at their medical school like a hundred times during their second year. She saids that the rules are great. Just say them before each day of rotation to remind yourself of them. Here they are:
1. Arrive on time.
2. Be nice.
3. Work hard.
4. Don't leave until your attending/resident/intern is done for the day.
Other interesting info: one student is already going to start the night float shift - next week!
Subscribe to:
Posts (Atom)