OnlineMedEd-Intern-Guide-Preview.pdf

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Prologue a. Introduction and disclaimer b. OnlineMedEd Story c. ier 1 Knowled Knowledge ge = opics or intern year d. On Call Pearls

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Philosophy and Bureaucracy  a. Philosophy b. Stages o Death and Dying in Residency c. Duty Hours d. Te eam Cap Explain Explained ed e. Morning Inter Interdisciplinary disciplinary Rounds (IDR) . Stress g. Clinical Reasoning h. Errors in Clinical Reasoning i. Finite and Infinite Games  j. Patientt Satisaction Patien

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Surviva l echniqu Survival echniques es a. ime Management: Data racking b. ime Management: o Do Lists / Scut Lists c. Surviva Survivall Skills: Morning Workflow d. Survival Skills: Urg Urgent ent and Important e. ime Management: urkeys and Windows . People Management: Relationships g. Peop People le Managem Management: ent: Being Effective h. People Management: Arguments i. Lie Management: In Your Box  j. Doing Questions k. Studying Resources

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Rounding and Documentation a. H&P: Spoken Presentation b. Daily Rounds: Spoken Presentatio Presentation n c. Documentation: Saying it Right (or CMS) d. H&P: Written emplate e. D/C Summar Summary: y: Written emplate . Ideal Admit Order Set g. Procedure Notes h. ranser o Care / Step Down: Written emplate

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Medications a. Meds: op 50 b. Common Meds: Heart Related c. Common Meds: Lung Related d. Common Medications: Pain e. Common Meds: Poop and Vomit . Common Medications: Psych Meds g. Antibiotics

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Methods a. Chest Pain b. Shortness o Breath c. Abdominal Pain d. Syncope e. Weakness . Fluid Where Fluid Shouldn’t Be (Swelling) g. Delirium h. Hemoptysis i. Fever  j. AKI k. Bleeding l. Dysphagia m. Back Pain n. Headache o. Joint Pain p. Diarrhea q. Pulmonary Hypertension r. ECG Interpretation s. Cough t. Acid Base and the Chamber o Secrets

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Common Medical Problems a. Cardiac Chest Pain b. So you admitted that chest pain c. Heart Failure In the Clinic – Outpatient d. Heart Failure In the Hospital – Inpatient e. Afib . COPD Exacerbation g. Pulmonary Embolism h. Sepsis i. Principles o Antibiotic Management  j. Pneumonia k. Electrolytes - Sodium l. Electrolytes - Potassium m. Cirrhosis n. GI Bleed

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Approach to LFs Inpatient Diabetes Diabetic Ketoacidosis Outpatient Diabetes Stroke

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Intern Notes a. Cardiology b. Pulmonary c. Renal Nephrology Kidney d. GI and Liver e. Heme Onc . Inectious Disease g. Endocrinology h. Rheumatology i. Neuro

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ICU a. Sick, Not Sick, On the Fence b. Who Goes to the Unit? c. ARDS - Lung Protective Strategy d. Ventilator Strategy e. Common Medications in the ICU: Sedation and Paralysis . In the ICU: Approach to Shock g. In the ICU: Pressors h. In the ICU: Septic Shock i. In the ICU: Running a Code  j. In the ICU: Running a Rapid

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H I    L   O  S   O P  H Y

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Finite and Infinite Games In your career to date you’ve been playing finite games. Tey have a start time, a stop time, rules on how to play, and rules on how to win. Tat was the shel, the USMLE Step 2, the grade, and graduation. When playing finite games you have a role and see others as playing their role. But people are not roles. Tey are people. Tey have eelings, emotions, and souls. Finite games crush people, and your "win" is ofen someone else's loss. Hopeully you developed survival skills. You might have “beaten the game” by figuring out what had to be done to get the A, the honors. And that’s great, because you survived. But now, more importantly than any point in your career, it’s time stop playing finite games and start playing infinite ones. Te grade doesn't matter. People matter. Yes, residency has a start and end point, a set o rules, and a test to wrap it up - JUS LIKE WHA YOU’VE DONE YOUR WHOLE LIFE. Yes, you can continue to play a finite game and “win.” Pass the test, get through residency, and check the box. You’ll see people still in that mindset. Tey’re the ones avoiding consults, writing crap notes, and treating people poorly. Tey’ll do the bare minimum to “win.” Tey’ll ocus on MKSAP17 and only care about what’s “on the boards.” You don’t want to be this person. Tey WON’ be effective. And they will be miserable. In infinite games there are no end points, no winners, and no losers. Tese games don’t have roles – they have people. It’s the game you must now learn to play. I you haven’t played this way beore, yes it will be challenging. But, it’s a transition you must make. Never again will you have as much support, supervision, and eedback as in residency. You will develop more in these three years than you have in your entire lie so ar. Never again will you grow this much. You get a taste o autonomy. Your signature matures. Your notes carry weight. YOU matter. You will be orced to learn things you never wanted to learn. You will take care o people you don’t want to take care o. But you’ll grow. HIS IS HE IME O LEARN  and become EFFECIVE. Tis game lasts the rest o your lie. Now can’t be a time in lie that you, “just get through to see the other side.”

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See people as people with emotions, souls, egos, and ears. You’ll be effective. See patients as people with emotions, souls, egos, and ears. You’ll be effective. See learners as people with emotions, souls, egos, and ears. You’ll be effective.

Te more effective you become during training, the more effective you will be in lie. You won’t rise to some superhuman ability upon graduation; you’ll be reduced to your basest orm o training. Te urther you rise, the more you learn, the better you are and the more effective you become now, the better you’ll be or the rest o your lie. Tere is no winning or losing in residency– there’s only effectiveness in patient care. 23

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ime Management: Data racking Te Data racker is a means o taking every new patient rom the ED to discharge. It makes daily rounding super easy. It lets H&Ps and Discharge Summaries flow. No more clicking through 15 tabs while sitting there on the phone all conused. Move on rom empty Epic templates with meaningless inormation that no one wants or cares to see. Look like AND know what you’re doing. Find ours on the resources tab o the dashboard at onlinemeded.org (ree, just register).

ypes of Data Tere are two things you want on your data tracker: the static and the daily. Te static data is the inormation that won’t change. Some o it should be obvious (name, date o birth, MRN, acct number, PmHx, PsHx, Soc Hx, All, FamHx, Home Meds), but some may not. Te major categories in the H&P orm should go in the static data. But you also want to include the big tests: major diagnostics, procedures, and past inormation. Tat’s going to change depending said diagnosis. Tis is where culture data, C scans / MRIs, echo results, cath results, etc. are going to go. It’s NO part o the daily data (it will be or one day) but you want it easily accessible at all times. You put the surgeries and procedures here too. Finally, the day of presentation  goes in the static data (the vitals, labs, and pertinent physical exam). Tis static data is the important ino or the H&P and Discharge Summary . Te daily data are the points you want to track: vitals, labs, meds etc. You want to be able to track trends. It’ll let you see what happened day to day, better or worse. Tis is where you’re going to present from daily . Literally. On rounds, you will tell your story ; you know what the subjective and what the plan is... but how do you remember all those labs and vitals? You don't. Since you know the gist o what’s going on, you tell the story, then you look down at this tracker and read off the details, then continue the story. Tis is just to have the details written down to reer to later. Whatever you choose, ideally static data is on one side while daily data is on the other . An example, “the notecard” is shown on the next page. For meds you best get yoursel a pencil. Tey change all the time. Every day you’re going to sit in ront o a computer. Every day you will run through the meds. Whatever you pick (I always liked separating scheduled rom prn) the meds will be displayed in the same order every day. You just quickly go through and mark changes. And because medications change daily, you will either want to leave space and/or be able to erase meds or dosages.

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 S   U R  V I     V A L 

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S������� S�����: M������ W������� It’s an awesome time saver to let autopopulating notes just autopopulate. Tey look stupid, which makes you look stupid. But it’s ok to do it, because it does save time. Still, do this sparingly. Make your stuff look good. For billing, for communication. Make it look like you actually wrote it and didn’t let a computer write it for you.  S 

SAMPLE DAY 6:30am

arrive at the hospital and sit down at a computer terminal. Fill out data tracker.

7:00am

morning report.

8:00am

see patients. – Dying: barring a crashing patient or someone you identified to be in trouble based on labs and vitals, you should be able to round reely and geographically. It’s about obtaining inormation at this point. I someone is in trouble, call your upper level immediately.

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the "other D’s"  – Diagnosis: put in orders NOW... aka early. Get ahead o the other resident teams who will wait until afer attending rounds to put their orders in. – Discharge: inorm social workers, nurses, and patient amilies that the person might go home. I the plan yesterday was to discharge them today, activate that discharge. – Discuss: talk to your upper level resident about the plan or the day. Make sure you’re ready or rounds and that a plan has been developed AND enacted.

10:00am  Attending Rounds – Te attending comes through and sees patients with you. – Coaching happens. – Plans are critiqued and uncertainties are laid to rest. 12:00pm Work ime – Do what came up on Attending Rounds. – Save lunch or when the lines are short and the space abundant (go at 1, not 12). 1:00 – 3:00pm Procedures and Meetings – Set amily discussions, paracenteses, thoracenteses, etc. or this time block. – Use this time to start writing notes i there’s nothing else to do. 3:00pm – 5:00pm Notes and New Patients – Finish your notes by 4:00pm. Te o-Do list should be mostly checked off. – I you’re on Short or Long call, here’s where you’ll start to pick up new patients rom the ED. Tis time (1:00 – 5:00) can be sort o a jumble, depending on when patients come in. 5:00pm – 7:00pm Go home or finish off your call. 35

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H&P: Spoken Presentation First Line: State the name, age, gender, and the chie complaint. • LEAVE OU past medical history  • Do include radicals and game changers (HIV, ransplant) First Paragraph: FAR COLDER  • Frequency, Associated Symptoms, Radiation, Character, Onset, Location, Duration, Exacerbating Factors, Relieving Factors • ell the attending the timing and characterization exactly as you have it. Give it unadulterated. Let the attending take a second crack at the complaint. Second Paragraph: Tis is, by ar, the hardest concept to master. Say only what’s relevant. Tird Paragraph: What the ED did and what response it had. You may not need this, but i it helps with the differential diagnosis or the understanding o the treatment course, say it. Review of systems: DO NO say the words, “review o systems.” DO NO list anything in the review o systems. Anything you thought relevant rom the review o systems goes in the second paragraph. Te other stuff: • PMHx, PSHx, Meds, Allergies, Social, Family  • Get through this as ast as possible; we can look it up later. Reer to it when i asked • SOMEIMES stuff in here is relevant (debility now, unctional status, or you think colon cancer and they had a colonoscopy), but most o the time it’s useless. Don’t say it. Physical Exam • Vitals: Say the numbers. Not, “stable,” or, “within normal limits.” • I they changed, say what they were on presentation ollowed by what they were when you saw them. • I no change, just say what they were at the time you saw them. Again, no ranges during the H&P. • Physical: • Go top down, BU • Say only the things that alter the differential. • POSIIVE i there and should be. • NEGAIVE i not there and should be. • LEAVE OU the diatribe o normal findings. • DO a thorough exam. • DOCUMEN said thorough exam. • SAY a relevant exam.

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Documentation: Saying it Right (or CMS) What you mean to say

What you should write down

Tere’s an inection

Sepsis

Urosepsis

Sepsis secondary to urinary tract inection

Altered Mental Status

Acute Encephalopathy  

AKI

Acute Renal Failure

Nausea and Vomiting

Intractable nausea and vomiting

Pain

Intractable pain

Failure o outpatient therapy

Failure o outpatient therapy  

Te patient’s getting better

Resolving

Te patient’s better

Resolved

Te patient’s getting worse

Worsening

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 O  U  N D I     N  G

Te patient’s probably going to die Grim prognosis Any reason that they might need oxygen, in any way, at any time, or any reason. Nasal cannula, CPAP, Intubation, whatever Acute hypoxemic respiratory ailure Acute (or chronic) Hypercapnic respiraRetaining CO2 tory ailure Tey have a low albumin ( 30 seconds to recover

PRESYNCOPE = SYNCOPE

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Joint Pain

Determining the diagnosis o joint pain is multi-aceted. Te first consideration is the number of joints involved ; it’s the basis or the organizer. Not that inectious arthropathies or crystal arthropathis CAN’ be monoarticular, it’s  just that they’re likely to present with multiple joints. I it’s not multiple joints at HIS presentation, it eventually will be over the course o the patient’s disease and show in more than one joint. Te second is toxicity and acuity , which parallel each other. Te more toxic a disease, the more acute it will be. oxic and acute diseases cause loss o unction, painul swollen  joints with deormity, and a high ever. Te patient will seek your attention. Te less toxic disease (and the more insidious ones) will present with weight loss, night sweats, low grade evers, and possibly a barely problematic joint. Knowing which diseases present in which way can help you separate them. Te third is which joint is involved. Tis helps the least, but there are some diseases that have a prediliction or certain joints. For example, RA attacks little joints like the hands and eet, OA affects the large weight bearing joints, and Ank Spond attacks the spine. You have to know the details o each disease to use this inormation, which is why it’s the least useul o the three.

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Pulmonary Embolism Making the Diagnosis

reating a PE

Patients with PEs that matter will have either achycardia or Hypoxemia. Te absence o both rules out an acute (but not chronic) Pulmonary Embolism.

Warfarin should be started the day o diagnosis. It must be bridged with heparin. Goal is INR 2-3. Tey must be on it or 5 days or when the INR is 2-3, whichever is LAER.

Well’s Criteria and Diagnostic Decisions Well’s Criteria – Calculating Te Score ZOMFG I DON KNOW 3 DV 3 HR > 100 1.5 Immobilization (Leg Fx, ravel) 1.5 Surgery w/i 4 weeks 1.5 h/o DV or PE 1.5 Hemoptysis 1 Malignancy 1 V/Q And D-Dimer Interpretation

Score < 2 Low Prob D-Dimer VQ OK

Score 2-6 Med Prob V/Q Useless

Score > 6 High Prob V/Q OK

LMWH (Fragmin, Lovenox, Arixtra) is  just as good as Unractionated heparin, but more convenient (can be done at home,

with ↓ length o stays); they don’t mandate requent P checking. But, they all have a longer half-life and, being smaller, can’t be reversed with protamine. Unfractionated Heparin is the “heparin drip,” a weight based dose o about 80units/ kg with a protocol or adjusting the drip based on the P every 6 hours OR the Xa levels. It’s easily reversed with protamine. It’s indicated in submassive PE. tPA is indicated in massive PE. Tere’s a high bleeding risk.

Do I Do A C Scan?

Score < 4Don’t Do it

Score > 4Do it

C PE Protocol when you want a confirmatory answer and the kidneys are good. V/Q scan when you can’t do a C PE protocol AND the lungs are normal. Tis is also useul in the “rule out” category. D-Dimer never inpatient. It’s used in the outpatient setting to rule out a PE. Don’t do a C scan or a positive D-Dimer.

Te 3 points on the top o the chart really mean, “I have no idea why they have shortness o breath. Just scan them to find out.” 108

Trombectomy is considered only in Chronic Tromboembolic Pulmonary Hypertension. Specifically, in the chronic condition and never in the acute setting. Vena Cava Filter. I the patient 1) has a DV, 2) can’t be anticoagulated, and 3) the next PE will kill them... then, and only then is it ok.

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Cardiology  Coronary Artery Disease See Common Medical Problems 1.

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Diamond Classification a. Exertional b. Lef sided, substernal c. Relieved with nitro Associated Symptoms a. (Pre)Syncope b. Diaphoresis c. Dyspnea Risk Factors a. HN b. DM c. HLD d. Obesity  e. Smoking Diagnosis a. ECG changes, 12-lead q6H � SEMI b. roponins q6 H � NSEMI (above 1.0 “counts”) c. Stress test d. Cath reatment a. Every patient: ASA, Statin, BB, Ace-inhibitor b. Every true MI: Morphine, Oxygen, Nitrates, Aspirin, Beta-Blocker, Ace-I, Statin, Heparin i. Full dose Lovenox or Heparin gtt ii. Plavix load 300mg x1 then 75 daily  c. Call cards

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Blood Products Product

Indications

Blood

Low Hemoglobin, Symptomatic Anemia

Platelets

Trombocytopenia