Intern Survival Guide


Tips on surviving floor rotations

1) Be organized AND always write things down! You need to develop a good system to keep track of your patients’ information/daily labs/ ‘to do’ list. Some suggestions:

a. Copy your dictated H/P, fold it in half and write your daily vitals, labs, studies and ‘to do’ list on the back. You can also have a separate ‘to do’ list (examples on page 31.32).
b. There are pre-printed H/P and daily sheets you can use but many find them too time consuming. (http://www.medfools.com/downloads/medicine)
c. Copy every pt’s H&P, daily progress note and put it in a folder. Just don’t lose your folder. You may want to put your contact information so that they can page you if it is found.
d. Use your daily sign-out sheet and put whatever important information on the sign-out sheet during the day.


2) Pre-round: 6:30-9:00AM (You have to pick up your sign-out sheet by 7:00AM)

a. Get to work early and get your notes started or finished before rounds. It really helps to have your notes done before rounds so you can work on other things after rounds.

b. Many people pre-write or pre-type their progress notes. This makes a lot of sense particularly for chronic patients where the plan does not change very much. If you do this, leave some room under the active issues so that you can hand-write additional thoughts based on that morning’s labs. You don’t have to have the perfect plan or have all the labs in the morning. You can add addendum to your notes later if the plan changes during rounds.

c. Correct abnormal electrolytes early. At the beginning of the year you may feel a little uncomfortable so call your resident. Below are some recommendations.

i. Potassium: Each 10 mEq is equivalent to 0.1 increase on the lab level.
1. Supplement all potassium below 3.8-4.0 unless pt has renal failure (3.0-3.4 may be acceptable, check with resident)
2. KCl 10mEq IV (run over one hour)
a. If pt has a central line you can run IV per protocol
b. Can give 1ml of 1% lidocaine with each 10mEq bag if it’s painful: be careful with pts with cardiac conditions
3. K-Dur 10mEq PO (tablet)
4. K-Lyte 25mEq PO (liquid)
a. Has a lot of bicarb so if pt is alkolotic give KCl
5. K-Phos 2 tabs PO
6. K-Phos 10mmol IV (run over one hour)
7. Give 10mEq for every 0.1 below 4.0
8. Watch potassium closely in pts on lasix.
9. You can also add 20mEq KCl to each 1L bag of IV fluid
10. Remember K+ will not correct unless you replace Mg
11. Make sure to correct potassium cautiously in patients with renal disease, particularly those with end-stage renal disease.

ii. Magnesium
1. Supplement all Mg below 2.0 unless pt has renal failure (around 1.6 is fine, check with resident)
2. For every 0.5 deficit, give 1 g of Mg
3. Magnesium Sulfate 1 g IV (run over 1 hour) or 400mEq MgOxide po BID or TID

iii. Phosphorous
1. Consider supplement if less than 2.0
2. Particularly important for patients in respiratory distress (ATP).
3. K-Phos 2 tabs PO q daily
4. Neutra-Phos 2 packs PO q daily
a. only helps pts taking po
b. give it with meals
c. K-phos 10mmol IV
5. Na-phos 10mmol IV
iv. Calcium
1. check albumin to correct level
2. calcium carbonate
a. Tums: 500mg tab = 25 mEq cal
b. Os-Cal: 650mg = 13 mEq cal


3) Progress Notes: (sample on page 31)

a. SOAP note
i. S: what happened overnight (start with telemetry events or acute events)
ii. O: vital signs (include finger stick glucose checks, I/O, weight if applicable)
iii. A/P: Assessment of pt and your plan for the day
iv. Code status
v. Social (update family), disposition plan


4) Rounds: Time for rounding is usually between 9:30-11:30 but can vary. Rounding is a time to present your pts and also for learning and teaching.
a. Presentation: Concise and relevant information only. Always get the most recent lab data and look at all micro, radiology studies (listen to all reports before rounds)
b. Teaching: Interns are not expected to read all the time but you should read on topics related to your patients. It’s always good to bring in articles. You can access KP on-line library (http://cl.kp.org ) or use Up-to-date for information.


5) After Rounds: You need to prioritize your “to do” list. Call consults, put in e-consults for studies and replace electrolytes early. Always take care of your sickest patients first.


6) Always ask for help when you need it. Your team should work together. If you are overwhelmed tell your resident. There are usually two interns on a team, so help each other. Sometimes the patient load is very uneven, and it is the resident’s responsibility to redistribute.


7) Take care of your patients as you would your family members. Remember to keep your patients and their family members updated. You may not always see family around so ask the nurse to call you when they are there. Trust me, it will save you a lot of time at discharge and will also help avoid angry family members and patients.


8) Dealing with patient’s family:
a. Large family: You don’t have time to explain everything to everyone. The best thing to do is ask family members to designate a spokesperson to contact for updates.
b. Angry patient or family: Don’t try to handle the situation yourself. Tell the pt/family member you see that they are upset/angry and that you need to call your resident/attending to be present.


9) Be nice to nurses, clerks, PT, OT, RT and all other medical staff because they can make your life a lot easier. Interns are sleep-deprived and stressed, but remember to keep your cool. If you run into problems with a staff member call your resident/attending.


10) Verbal Orders: It is a privilege and can be taken away if we abuse it. All verbal orders must be signed within 24 hours. You can sign someone else’s verbal order. If you disagree with the order you can write on the order that you are signing for “Dr.X”, but you should still sign it. For all verbal orders remember to have the nurse read it back to you and double-check the name of the patient.
__________________Scientific I'll add a few things that I've learned so far...(this goes for inpatient issues). The nurse pages you and says:
1. Pt having Chest Pain- #1- Ask nurse for their vitals, if on monitor, ask if they are having EKG changes. Order Stat Cardiac enzymes, EKG, tell nurse to give pt Morphine, NTG, O2. #2- GO SEE THE PATIENT NOW!
2. Pt Aggitated/Mental status change- #1- Ask the nurse for vitals, Find out if this is baseline, or if this is new, #2-Go see the patient, Check their meds and see if something you are giving might have caused it, #3- Check UA (especially in older pts), ABG, Chem 7, #4- Haldol 5mg IV x1 if needed.

Personally, I don't prescribe narcotics for long term pain control unless the patient has cancer or some sort of SERIOUS problem. Here are some alternatives.
- Motrin 600mg po QID prn, or Naproxen (but these can cause ulcers if used for too long),
- Gabapentin or Amitriptyline(for fibromyalgia and neurologic pain),
- Tylenol(but remember liver toxicity!!)- use for single headache, etc
- Ultram is in fact very addictive!! It's supposed to be less addictive than opiates but I hear it is the #5 most abused pain med! Don't overprescribe!
- Meloxicam is a great antiinflammatory
- Don't forget about physical therapy!
- For patients with more severe pain, if you need a narcotic, another alternative is Methadone. It's good for long term pain control and it is pretty inexpensive as well.

Will post more later...

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