The Washington Manual Internship Survival Guide (2 page)

Acknowledgments

We wish to thank the Washington University residents and faculty for their enthusiastic support of this project, and even more importantly, their ongoing contributions that have served to make this guide immeasurably better.

We would also like to extend our thanks to Melvin Blanchard, MD, and Vicky Fraser, MD, whose leadership and support have been vital to the continued success of this book. We appreciate the tremendous support of Thomas De Fer, MD, and Katie Sharp in their coordination of our efforts. From Wolters Kluwer/Lippincott Williams & Wilkins, we are indebted to Sonya Seigafuse, Leanne Vandetty, and Kimberly Schonberger.

E.M.K.

G.N.L.

H.F.S.

Contents

Contributing Authors

Preface

Acknowledgments

Abbreviations List

  
1.
  Objectives

  
2.
  Keys to Survival

  
3.
  ACLS Algorithms

  
4.
  Books, Web Sites, and Other Resources

  
5.
  Useful Formulae

  
6.
  Patient and Staff Relations

  
7.
  Patient Safety

  
8.
  Risk Management

  
9.
  Triage

10.
  Admissions

11.
  Daily Assessments

12.
  Discharges

13.
  Cross-Coverage

14.
  Other Notes of Importance

15.
  Top Ten Workups

16.
  Pain Control

17.
  Fluids and Electrolytes

18.
  Acid–Base Disorders

19.
  ECG and Radiography

20.
  Therapeutic Dosing

21.
  Approach to Consultation

22.
  ABCs of Critical Care

23.
  Guide to Procedures

24.
  Final Touches

Index

Abbreviations List

Objectives

1

As an intern you will encounter many new challenges. These will range from very simple to most complex. Please remember that you have acquired the tools to address this adversity. And, even when you feel most overwhelmed, you are undoubtedly surrounded by a wealth of available resources that include ancillary and nursing staff, fellow interns, senior residents, and attending physicians.

Although the year ahead of you may now seem long and daunting, your tasks (other than survival) are quite achievable. The following competencies/milestones were copied from the curriculum for the inpatient general medicine rotation for the internship program at Washington University School of Medicine and Barnes-Jewish Hospital. You can see that not only are the objectives quite simple, but your rigorous work in medical school has well prepared you to master many of your goals. Throughout the year, use these objectives as a checklist to remind yourself of your accomplishments and to guide your learning in potential areas of weakness.

•
  Patient care:

•  Gather accurate information about patients, including performing a thorough history and physical examination.

•  Synthesize data into a prioritized problem list and differential diagnosis, and then formulate diagnostic and therapeutic plans.

•  Prioritize each day’s work.

•  Know the indications, contraindications, and risks of some invasive procedures and competently perform some invasive procedures.

•
  Medical knowledge:

•  Demonstrate an increasing fund of knowledge in the range of common problems encountered in inpatient internal medicine and utilize this knowledge in clinical reasoning.

•  Become familiar with the diagnostic and therapeutic approach to patients with chest pain, shortness of breath, fever, mental status changes, abdominal pain, GI bleeding,
syncope and lightheadedness, renal failure (acute and/or chronic), cirrhosis, congestive heart failure, anemia, hypertension, diabetes mellitus, pneumonia, chronic obstructive pulmonary disease, urinary tract infection, soft tissue infections, and alcohol withdrawal.

•
  Practice-based learning and improvement:

•  Understand your limitations of knowledge and judgment; ask for help when needed; be self-motivated to acquire knowledge.

•  Accept feedback, learn from your own errors, and develop self-improvement plans.

•  Use information technology to manage patient data and access online medical information.

•
  Interpersonal and communication skills:

•  Demonstrate caring and respectful behaviors with patients, families, including those who are angry and frustrated, and all members of the healthcare team.

•  Counsel and educate patients and their families.

•  Conduct supportive and respectful discussions of code status and advanced directives.

•  Facilitate the learning of students and other healthcare professionals.

•  Demonstrate the ability to convey clinical information accurately and concisely in oral presentations and in chart notes.

•
  Professionalism:

•  Demonstrate respect, compassion, and integrity.

•  Demonstrate a commitment to excellence and on-going professional development.

•  Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and other aspects of clinical care.

•  Develop an appreciation for the ethical, cultural and socioeconomic dimensions of illness, demonstrating sensitivity and responsiveness to patients’ culture, age, gender, and disabilities.

•
  Systems-based practice:

•  Work efficiently with others as a member of the healthcare team.

•  Advocate for quality patient care and assist patients in dealing with system complexities.

•  Understand and appreciate the importance of contacting the patient’s primary care provider at the time of admission or soon thereafter.

•  Learn the cost-effective use of diagnostic and therapeutic technologies.

Keys to Survival

2

1.
  Don’t panic, and keep your sense of humor.

2.
  Take care of your patients. You are finally using your education and training.

3.
  Work hard, stay enthusiastic, and maintain interest.

4.
  Be organized and prioritize your tasks.

5.
  Verify everything yourself (e.g., labs, X-rays, ECGs).

6.
  Ask questions and
ask for help!
Believe it or not, you are not expected to know everything.

7.
  Be kind to the nurses and other ancillary staff. They can make your life much better … or much worse.

8.
  Choose your battles carefully. Even in the name of patient care, ugly behavior is ugly. Don’t get a reputation.

9.
  Sleep when you can, remember to eat, and be mindful of your own health.

10.
  Don’t forget your family and friends.

11.
  Call for consultations on your patients early in the day and have a specific question you want answered from the consultant.

12.
  Start thinking about discharge/disposition planning from day one.

13.
  Dictate discharge summaries the day the patient leaves.

14.
  When generating a differential diagnosis, look for an etiology in VITAMIN E:
V
ascular,
I
nfection/
I
nflammatory,
T
rauma,
A
cquired/
A
utoimmune,
M
etabolic/
M
edications,
I
nherited/
I
atrogenic/
I
diopathic,
N
eoplastic,
E
nvironmental.