MD on Call

Tips for new docs (Twitter)

Thu, 29 Jun 2017 12:03:11 +0000

This is a summary of tweets I came across by people that have “been there” or have something to recommend to junior residents. These are popular around July 1st for some reason… Have a look at some of those people’s profiles; some of them are rock stars!

Don’t make up exam or history findings. Ever. Simply say, “I didn’t ask” or “I didn’t do that” and then go back and do it. @EMSwami

The nurses can smell your fear. Bring chocolate, not attitude @rfdsdoc

Stay fed and hydrated, read - listen, and ketamine @embasic

“He did earlier” is not an appropriate response to the question “Does the patient have a pulse? @bungeechump

You want to save lives? Wash hands @rfdsdoc

You will feel stupid all the time and that never really goes away. Don’t worry though, everyone else feels the same way. @dr_ashwitt

“I don’t know” is sometimes a perfectly acceptable answer @DavidJuurlink

Always say “hello” and introduce yourself, before you start poking at people! @dancingfish

Don’t be a dick to the nurses @NandySelson

If asked by colleagues to treat or perform a procedure, make your own decision if it’s indicated or contraindicated. @HildenLA

Don’t confabulate; Pay attention to the little details @docsuzy

Above all, avoid diagnostic momentum. Make your own assessment - diagnosis regardless of whoever did it before. @cabreraERDR

Blood stains come out with peroxide @SJA_TM

Don’t immediately add the title “Dr.” to everything with your name on it. It just makes you look like a douche. @DrCouz

Don’t take off your clothes in call rooms. Regardless of how awesome it looks on Grey’s Anatomy. @DrCrouz

Take up running. Even if you hate it, it’s the best workout you can fit in whenever, wherever. @DrCrouz

It’s ok to hate residency. It doesn’t mean you’ll hate your career. @DrCrouz

Introduce yourself to the nurses, they will really help you. @McWhirterEmily

The magnesium - calcium - phosphate replacement guidelines are the most used document on my phone. AntiBs protocol comes 2nd. @fakethom

Ask your ward pharmacist - we’re here to help! @PlaceboJo

Learn to know when to do nothing @malcolm1771

Always say please on an X-ray request form! @dramandam1

Realize there’s more than one way to do many things in medicine. Different from how you trained may be ok. @Doctor5and2

Share every mistake with your fellow new docs to help avoid them @macfining

Your own clinical judgement is an essential part of any evidence-based assessment - treatment plan @AntifragileDoc

Trust your first impression and follow your instinct @macfining

Always have a plan B @macfining

Trust, but verify @BBMD10

Don’t be afraid to have a go at formulating a management plan for a patient. We learn by having a go and getting it wrong. @DrJHurley

Make sure you take your breaks, even if the department is busy. A rested doctor = a safer doctor @DrHurley

Count the respiratory rate yourself. It matters! (and it’s not always 20) @umanamd

Working hard and honesty will get you far - already knowing (or pretending to know) all the answers won’t @chartierlucas

When called to a convulsion, if the patient is still texting - tweeting, it’s a pseudoseizure. @drlfarrell

Respect the knowledge of the nurses. Especially in the ICU. And always treat them with respect. @doc_swallow

If you don’t know what you are doing, do nothing. Good advice given during my own training. Applies elsewhere in life too. @AntifragileDoc

Welcome to the world of grey zones, where art and science exist in glorious tension @amy_a_neilson

Uncertainty is not an ignoble state @drlfarrell

Never ever wear suede shoes @drlfarrell

Watch the “Empathy” video from the Cleveland Clinic @couragesings

Pull up a chair, sit down, & really listen. Let people tell you their story. It is a worthy 10 mins. Plus you get to sit! @amy_a_neilson

Learn early on to think of the ringing phone as a background music. Don’t answer it! @amy_a_neilson

Run to the code, but walk into the room. @JCBeausoleilMD

Work hard to maintain friendship outside of medicine, avoid losing perspective on life beyond your bubble @ashley_miller

Don’t piss off the nurses. Everyone in the hospital has more experience than you at this point. @EMurgentologist

Good luck to all who now have bigger shoes to fill. Accept the challenge. Rise to the occasion! Be well. Be smart. Be save @ERmentor

You can call them “legs” and “arms”. You’ll still be a doctor @ZackBergerMDPhD

Sometimes the single best thing you can do for a patient is to do nothing. Wait for more data before you jump the gun. @cheeler

Renal dosing for 99.9% of drugs are based on creatinine clearance. Never say “GFR” to your clinical pharmacist. @shery1santos

Never condone medical mistakes. @drlfarrell

It’s NEVER lupus!!! @BadGluteus

That hot surgeon you see, don’t hit on him, he’s already married. @BadGluteus

Get a mentor. @cabreraERDR

Ask about what the patient enjoys. Or what they are reading. What music they listen to. @ZackBergerMDPhD

Improve your handwriting @SaifAhmedKhan97

Try to get the most out of you off-service rotations, even if you don’t think it’s useful! @ER_Swan

Discipline yourself to do medical readin every week. It will pay off in the long run. @WMedAdmissions

Some people ARE going to die today. Some may make it JUST long enough to get to you. This is not your fault. @CaseyClmnts

The only difference between a drug and a poison is dose @EMEducation

Remember to check the medlist on D/C; look for critical interactions before adding a new med. @EMEducation

When you write orders review them with a nurse and ask if you have missed anything. Say thank you. @dboyceMD

Know what you know. But if you don’t know, get the consult. @TheWellnessLife

Take the time to really listen to your patients - medical history and the people behind the illness. @DRjhopkins

Your librarian especially likes a “thank you” every now and then @hammerslibrary

Don’t steal cookies from the nurses! @socalexmd

Please learn about Harm Reduction & understand that patients don’t always do what you want - but we care for them regardless @NurseNerdy

Welcome to the team! Remember it takes a metropolitan to care for a patient and we do it better as a team! @NurseNerdy

When increasing or decreasing a dose, write up or down error to let us know the change is intentional @CommPharm

Keep hand written order legible and provide contact info. Please print name. @TDaungst

One may not be the smartest, so do everything to not be the dumbest! @DanielVelaMD

Don’t be afraid to ask for help. Competence includes knowing your own limitations @TChanMD

Before leaving the patient’s room, say “Have I answered all of your questions?” @drjfrank

Write legibly, fill out your med charts properly & be kind to the patients & other staff. Healthcare is a team sport @Nurse_Sibs

C’est la vie “That’s life”. Some people get hurt, some people get sick. Majority get better, some don’t. Don’t blame yourself! @W40SYM

You will be judged by the quality and legibility of your documentation and notes. Write NEATLY and fill in form COMPLETELY. @mjslabbert

Don’t drive tired. Get a taxi or even power nap in your car. It’s a mistake you can’t un-make. Loof after yourself (please!) @_NMay

Sit DOWN when you talk with patients and encourage them to be educated en empowered. @MeridithGould

Bring fruits and healthy snacks to the night shift. @HildenLA

Do what’s best for the patient not the administrator. @Want2BeMD

If med is not for you, that’s OK. You haven’t failed. Your life isn’t over. Get help. The “outside” world will welcome you. @JenWords

If a nurse, janitor, or any other member of the team mentions you haven’t washed your hands, be thankful & wash those hands! @couragesigns

Surgery for you might be mechanical & routine; for the patient, it is terrifying. @couragesigns

Discipline yourself to do medical reading every week. It will pay off in the long run. @drjfrank

It’s never too early to make a personal financial plan. Yes, really. @drjfrank

Don’t commit yourself before presenting to an attending. Always leave yourself an out. @abbashu

Don’t forget to take care of yourself. You are a new doc, but you are far more than just a doc @CareyCuprisin

How to be a good medical student in the clinic

Tue, 09 Aug 2016 14:31:07 +0000

This post is an expansion on an answer I wrote on Quora on what makes a great medical student in the clinic. It’s very similar for interns and junior residents so I thought I’d share it here.

Be motivated, but not too much. We’re aware that our specialty is probably not the one you want to do and that’s fine. Just don’t try to fake a special interest in what we do. It’s obvious. It’s best to clarify your interests at the beginning of the rotation so we can tailor the rotation accordingly.

You can ask questions (obviously), but not too many. Don’t fake an interest by asking questions. It gets annoying and slows down the clinic.

Never make up a clinical finding. When you didn’t do something on an exam, just say you didn’t do it. Same goes for history, but we’re well aware of the “patient say something to the med student and a totally different story to the attending” phenomenon.

Write clear, concise notes. Seems obvious, but it’s more difficult than it seems. It’s often an overlooked aspect of pre-clinical years. I assume it’s because schools assume this will get taught during clinical rotations and clinicians think this has been taught during the pre-clinical years…

Show up on time. Leave when the work is done. Sounds obvious but I’ve seen people try to get away with it. Ward and clinic = team work. If you slack others will have to pick up the slack and they’ll remember.

Do what you’ve been asked to do. No hiding in the library.

If you’re asked to do a presentation, make sure you don’t go over the allotted time. I know your topic is super interesting, but it’s probably something I know very well already… Think about those classes when the prof would go over the allotted time…

“Pure medical knowledge” is not as important as most students think. Knowing how to get access to that information is way more important, especially now that we have a world of knowledge available at our fingertips.

Keep an open mind. It’s easy to start a rotation thinking “there’s no way I’ll ever enjoy doing this”, but it’s a trap. I never for a second thought I’d enjoy my psychiatry rotation but I really did. I even got a good reference letter out of it!

When you sit down and think about it, it’s easy to be a top med student - intern - resident. Be a good team player and do the best you can. You’ll get rewarded with a good evaluation plus you’ll have someone to call when you need a favour — or a reference letter!

Learn

Tue, 29 Mar 2016 10:41:07 +0000

It’s been said before, and I’ll say it again. The learning curve, when you’re alone to take care of around a hundred patients, is steep. Learning by doing is even truer than ever. Making the best of it is very important.

Reflective Practice

While you walk to your next challenge, take a second to reflect on how you managed your last patient.

What did you do that made the encounter positive?
How could you improve?

More technical

Does a new differential diagnosis come to mind?
Is your plan clear enough for everyone involved? (nurses, other residents/attending doctors)

I know, I know. We’re always told to “reflect” on our performance and hearing this gets tiring after a while. What I’m suggesting is easy and quick. No writing involved.

How about everything else?

That steep learning curve applies not only to the medical aspects of patient care but also to everything else that may be involved - the “extras”.

You learn to manage teams.
You learn to communicate with colleagues and other professionals efficiently.
You learn to teach.

After a few months of doing calls, you’ll realize how important those “extras” really are.

Staying Healthy While On Call

Sat, 10 Oct 2015 21:15:03 +0000

Every once in a while, we must be reminded of what health is exactly. As you probably know by now, health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO definition). As a resident, your job is to make people healthy. Unfortunately, because of many contributing factors, residency can be a very unhealthy part of a physician’s life. We must be careful not to let it get out of hand.

Eating

Let’s face it. Hospital food tends to be on the tasteless end of the taste spectrum. If it’s tasty, it probably spent some time in the deep fryer and we all know how healthy that is. I personally have never been the guy bringing lunches from home when on call. However, I will make a conscious decision about the quality of the food that’s offered by the cafeteria. That’s easier said than done. For one thing, we tend to associate food with reward: “I’m on call and I’ll work hard tonight, therefore I deserve french fries”. That’s a bad habit we should try to eliminate. However, that’s easier said than done. As you will quickly learn, food tastes SO much better at 3AM. Chips? Chocolate bars? They are tasty to begin with, but in the middle of the night, they could replace sleeping.

After a few years of hard work, what that can lead to is a nice little belly. You don’t want to have to calculate a Framingham score on yourself do you?

I recommend bringing easy-to-carry food with you in your “on call bag”, such as

almonds / trail mix
apple
banana
baby carrots

There’s a lot more good choices to include and you should create your own solution. Just knowing about the problem is a good first step.

Move!

Many people think that since they’re running all over the hospital, that must be good enough to qualify as the minimum recommended daily activity. It is common knowledge that what is considered the “recommended daily activity” changes every other week, but we rarely do that. If you doubt my last statement, just get a pedometer or one of the wearables (Fitbit, Nike FuelBand, Polar Loop, Apple Watch…) and see for yourself.

During residency, I started running more regularly. I’m not a big runner - maybe 30 min. 2-3 times a week, but it’s better than nothing! I like running because you can easily bring your equipment with you and you can do it almost anywhere. Running is not for everyone, I know, but I strongly encourage you to find a sport that will help keep your heart and mind in great shape.

Sleep

“Sleep when you can” is one of the rules of residency. If you can nap, nap. Even during the day, if you can spare half an hour, try to go to your call room for a power nap. No one will beg you to go to bed in the middle of the night, but the rule still applies.

The day after being on call, I always try to get a few hours of sleep, but I will set my alarm for a few hours later so I have time for dinner and then exercise a little before going back to bed to get ready for the next day. With the new duty hour rules, this may change, but the gestalt remains the same.

Having a social life during residency can be a foreign concept for many, but it’s important! When a group of residents organise an evening out, join them, even if you’d rather stay home and watch TV. Besides clearing your mind, you will get to know your colleagues differently. This special rapport will carry over to the hospital and will make your job easier as well. It is a win-win situation.

Mind

Unfortunately, the “social well-being” part of the WHO health definition is often overlooked. Residency is notorious for sleep deprivation and difficult working conditions. High expectations we set for ourselves are another source of worries. That can lead to important mental health issues.

About six month into my first year of residency, I had had enough. I just finished two blocks of general internal medicine and was now on gen surg with 1 in 4 calls. On top of that, it was Christmas and the medical students were away. I was covering for all three gen surg teams and doing floor and emerge consults. (I had good help from my seniors though, I must say. I’ll always remember the night Dave Robertson brought me a Starbucks coffee. I almost cried with joy). Anyway, I realized I was becoming mentally tired. I just couldn’t give anymore. Fortunately, I had a few days off over New Year to recharge the batteries, but they were really low and it took me a while before I felt “normal”. I often wondered if I was clinically depressed at that time, but I don’t think so. However, that episode made me realize how dangerous work can be for our mental health.

I personally find sports to be of a great help for my mental well-being. Others find that practicing mindfulness is best for them. Mindfulness has gained momentum over the last few years, especially in medical schools. Many offer free classes and I recommend attending them. A good tip is to practice mindfulness when your pager beeps.

If you ask an older attending what makes a good resident, they will likely tell you “someone who knows when to ask for help”. I believe that applies to everything in residency, including yourself. Even if you’re feeling fine right now, I recommend at least knowing what resources are available in your centre.

Online depression screening test

Suicide

Suicide is the number one killer of young physicians. Here’s a very good list of the whys: with a corresponding TEDx talk. I’ve been indirectly affected by resident suicide and obviously this leaves a mark. This is a touching article on the suicide of a family medicine resident (French; use Google Translate). This is another, more recent one. If you’re thinking about suicide, please get some help. A mentor, program director, suicide helpline… There is help.

Good JAMA article on the topic.

There’s been some debate about the root cause of this tendency of suicide. Some believe it’s due to the unrealistic expectations (patient care, calls…) combined with a physician’s tendency to be a perfectionist and not accepting the fact that we just can’t do it all. They say the solution is to re-think the residency training to allow more time to study and to do extracurricular activities. I disagree; this is not only most likely to remain unchanged (in my mind), but it would only delay the problem until a later date. Everything does not magically get better when you’re an attending — it often gets worse. We’re always going to be evaluated (yearly “productivity” reviews) and we’re probably always going to be taking exams (maintenance of certification).

Obviously the problem is very complex and there’s never going to be “one” solution. One part of the answer probably lies in stress-coping techniques, ideally starting at an early age so that we’re not trying to learn stress management skills in med school. This will never solve all the mental health problems that plague us, but it would be a good start.

First Night On Call: How To Prepare

Wed, 09 Sep 2015 21:15:03 +0000

Hopefully, unlike my situation, you’ll have time to prepare for your first night on call. It can be so stressful that many forget to bring some essentials with them. Here’s a list on what to bring with you.

Toothbrush, toothpaste. Self explanatory.
Glasses, contact lens case / cleaner. Your eyes will get dry, I guarantee it. Consider artificial tears.
Deodorant ± shower supply. You don’t want to be the smelly one on the wards.
Food, especially if your hospital doesn’t have a 24h cafeteria. At least have some healthy snacks.
Comfortable shoes.
Phone charger. Don’t. Forget. Your. Charger.

Food strategy

Before the big day, make sure you know the operating hours of the cafeteria and places to find snacks in the hospital. Set an alert on your phone so you don’t miss snack time. I also recommend you look at what’s available in the vending machines. Ask around to know where to get the best coffee.

Check with your fellow residents. In my hospital, we would get together and order out (usually Cambodian food; my favourite). It was always the highlight of the evening. Well worth it.

Know your way around the hospital

Make sure your ID badge works with the door locking system. Mine didn’t and it led to an interesting evening. It’s so much easier to get that fixed during the day. You also want to know where the Call Rooms are, how to access that section and which room is yours. You don’t want to walk in someone else’s room in the middle of the night.

If you’re lucky, your seniors will have printed a list of important numbers and contact information. If not, I recommend you take time and gather that information, just in case. The operator usually has the numbers close by, but it’s more efficient to have them handy.

Know where to find the information you need

Often, there’s a “secret” on call document being handed from seniors to juniors. They often contain protocols as well as general advice on how to survive the night. Unfortunately, they usually contain copyrighted material and therefore cannot be mass printed or sold at the bookstore. Try to get your hands on it.

I’ve noticed that the best “first days information” is only discussed during the first few days of internship - residency. Unfortunately, many off-service residents will go through the “tougher” rotations later in the year and after the seniors have finished the “welcome to hell” introduction at the start of the rotation. You’re then supposed to figure out things for yourself. Instead, take a few minutes to ask them if they have any advice for you and if there’s a “secret book”.

Also, ask your seniors where the hospital protocols are located. For example, my hospital had an insulin sliding scale protocol, but the hospital where I attended medical school did not. If you’ve never written orders for an insulin sliding scale, you’d rather not give it a first try at 11PM. Ultimately, the goal is not only to know how to access them, but what is available in your center so you can be better prepared.

I strongly recommend having at least one “On Call” book or app on your phone. Make sure you know what it contains and the structure of it before you start. This shouldn’t take very long. At 3AM, you’ll want to find what you’re looking for fast. The main advantage of a book is that it can’t run out of batteries (see “charger” in the list above), which is unfortunately still a problem with today’s phones. If you carry a tablet, you’re probably going to be ok. On the other hand, books tend to be heavy. On top of that, I was never able to find one with the type of information I wanted. — That’s partly why I wrote MD on Call. Regardless of the tool you choose, make sure you know how to use it.

Medical Apps For Starting Residency (iOS)

Sat, 08 Aug 2015 21:15:03 +0000

Our apps are good, but they don’t cover every aspect of a resident’s required app collection. Here are my recommended apps for iOS.

MedCalX

There are many medical calculators on the App Store. My personal favourite is MedCalX and it’s the one we’ve integrated with our apps. Re-written from the ground up in 2014 (with a name change in 2015 – it used to be called MedCalc), it was clearly designed by physicians for physicians. Attention to details and good support with regular updates is the hallmark of the app. On top of that, formulas are clearly referenced with links to Read by QxMD so you can… hum hum… freshen up on the different clinical scores (so you look like a champ during rounds!)

I recommend taking a few minutes creating a “favourite” list with the formulas you plan on using frequently. Don’t forget to “turn on” the integration with MedCalX in MD on Call (in Settings) for a quick access to the formulas discussed in the app!

Lanthier

Lanthier - Practical Guide to Internal Medicine is a personal favourite of mine and I’m sure you can spot the similarities with MD on Call. That’s because I’m responsible for the “app” version of that book *disclaimer*. For those who are not familiar with Lanthier, it’s an internal medicine pocketbook, very popular in Canada. The English edition has been held back due to distribution issues, but the app format has allowed it to really take off.

I really like the bullet point format of the text. It’s not meant to replace UpToDate — It’s different. More succinct, better adapted for the fast pace of the clinic or the ward.

As with MD on Call, I recommend setting up the note synchronization feature of the app. We made it free so you don’t lose your precious notes if you ever lose or break your device. Also, make sure you enable the integration with MedCalX for easy access to the recommended formulas from Lanthier.

UpToDate

The classic. I started using UpToDate when I was in my fourth year of medical school. I wasn’t a huge fan of the app when it first came out, but it’s been improved. I still prefer using it on my iPad because the long texts are better suited for the bigger screen. Now that the iPhone 6s Plus is out, my preference may change.

Evernote

I’m writing this on Evernote. I studied for my board exams using Evernote. Why? Well, it’s the best one to easily create an app from personal notes.

Evernote syncs your notes in real time across all your devices (including your laptop). You can attach almost any type of file to your note, search them, and reorganize them.

The service is free for a “basic” account. The Plus and Premium account benefits changes from time to time. For me, the ability to work offline is the best feature of the Plus upgrade. — Especially good for use in hospital basements.

Michael Hyatt wrote some good blog posts on how to work with Evernote. iMedicalApps did something similar but less extensive (but more medically focused — although it’s getting old…).

I strongly recommend NOT taking patient notes using Evernote. It’s not HIPAA compliant and could get you in trouble if there’s ever a security breach.

Other apps offers similar features, such as Microsoft OneNote. I haven’t tried them so I can’t comment on their functionalities.

Procedure apps

Let’s face it. We have all “YouTube’d” procedures that we were not familiar with. It makes medical educators cringe, but it’s real life.

RealWorld Procedure is a good place to start instead of the ’Tube for general procedures. It’s based on the PocketSnip Prodedural Skill Project (PocketSnips.org) so at least you know the information is backed and produced by multiple Faculties of Medicine. Great content, all for free.

Medication app

There are two well-known players in that field. Epocrates and Micromedex. There are many others, but I’ve never seen anyone use them. I’m personally not a huge fan of either as the user interfaces are lacking. I tend to prefer Epocrates. Epocrates is technically free and Micromedex just recently started charging $2.99 for the app. Both apps sell some of your information such as specialty or browsing history to pharmas, which is something you need to be aware of.

Overall, it’s not my favourite business model, but people have to understand that putting all that information together costs a lot of money and they run a business. This tweet from @isaiah sums it up and is worth saying again: “either you pay for a service, or it’s selling you. There really isn’t a third option.”

I recommend downloading both and deciding which one you prefer. $2.99 for Micromedex is not a lot compared to that hardcover copy of Harrison’s you’re using as a doorstop.

Read

Read by QxMD will allow you to stay updated on the latest literature. It essentially act like a FlipBoard for medical literature. I especially like the fact that it allows you to connect to your hospital or university’s library VPN so you can easily download the papers to your device. I enjoy getting their emails, which highlight the “most read papers in your field”. It’s one of my favorite app and I think everyone should get it.

Siri, reminder, task lists…

I like using Siri to set reminders for things like checking blood work and converting units.

There are tons of apps for managing lists. My personal favourite is Clear. It’s simple, elegant and syncs via iCloud with the Mac, iPhone and iPad client.

The Story

Tue, 07 Jul 2015 21:15:03 +0000

I started working on MD on Call at the end of my first year of residency while I was still fresh from the steep learning curve of that demanding year. During that year, I had struggled with many little things that I never thought would become an issue. How do you replace calcium? At what point do you ask for an ECG in a patient with hypokalemia? “Can you come and pronounce patient in room 1004?” — How am I supposed to do that?? I bought an “On Call” book, but it wasn’t “to the point”. I don’t want to read a book at 2AM. I just want to get things done.

I also noticed that the more senior residents often create a similar guide, which they photocopy and distribute to their friends. Those guides are often difficult to get a hold of and they tend to include copyrighted material, meaning that they can’t be widely distributed. I wanted to create a better tool, and have it available to as many junior docs as possible.

Benoit, a childhood friend who already had a few apps on the App Store, offered to partner with me to build an iPhone App with the material. This was the beginning of a great working relationship.

Many people helped me get Version 1 on the way and I’m grateful to this day that they contributed to my project. Shortly after the launch, the App was featured by Apple on the main page of the App Store and by iMedicalApps.com, the respected medical app review site.

More than 25 000 people around the world now trust MD on Call and I routinely get great feedback from doctors around the world.

My first night on call — the story

MD on Call was created to help junior residents / interns on their first nights on call. It’s designed to provide you with just the right amount of medical information while allowing you to stay efficient so you can assess the next patient on your list. Here’s the story of why I created MD on Call.

Second block: general internal medicine. I had received the call schedule for that block. I was on the first Saturday, covering for three teams. The first day on, I realized I hadn’t done “real medicine” in more than 6 months! My last electives of medical school were Psych, some Rad Onc. and studying, then vacation.

Hypokalemia

I had only four patients on my list (the seniors were very nice to me; they would take their own patient!). My third patient was admitted for hematuria and multiple comorbidities. I got a call from his nurse: his potassium was 2.8. I thought to myself “this is quite low… I know I can’t replace K+ “too quickly”… But how quick is too quick? Is 2.8 reasonable for PO replacement?? Should I get an EKG??? Is MY patient ok? Is he going to DIE??

He seemed fine, lying in his bed, his two-way Foley doing its job. It had been some time since I last wrote an order for K-dur, but I thought to myself “but I’d like something faster. I sure don’t want MY patient to have an arrhythmia because I didn’t replace his K+ fast enough.” and then the inevitable “Damn, I can’t even replace potassium without freaking out! How will I survive my first night on call! Oh well, we’ll see on Saturday!”

I decided to do an EKG “just to check”. I ordered it (paper chart) and flagged the order as I was instructed to do. Two minutes later I get a call from the unit clerk: “The EKG tech is gone; it’s after four. You have to do it yourself” MYSELF?? I have to do an EKG? How do I set up the leads? I remember seeing a quick schematic when I was learning about EKGs, but it’s been a few years. It was the first time I worked in a hospital without 24h access to an EKG tech. Oh well; Dr Google to the rescue!

After I finally got that EKG, I realized I didn’t remember the features of hypokalemia on an EKG. I mean, I remembered a few, like prolonged QT, but not the fine details. I remembered it for the exam, but it was then quickly out of my mind. At that time, the hospital didn’t have access to UpToDate, so I had to ask another resident to show me the hypokalemia page. Half an hour of reading and I had my answer. I felt stupid that it took me so long to find that piece of information. I would have been able to find it within 2 minutes using my book, but it was on my desk, at home.

The EKG was fine — no ST depression, prolonged QT… The patient’s K+ renormalized. Everyone was happy except me - my pride was injured!

The next morning, I went to sign in rounds at 7:45 as usual. Interesting cases and free coffee. A few minutes later, I walked by one of the nursing station to see “Tonight for team A, B, C: Dr Plourde” on the whiteboard. I thought to myself “Interesting! Another Plourde in the hospital, also on internal medicine!” Then I had a look at the pager number below the name. It was mine.

Surprise! It’s Wednesday. I thought my first night on call was going to be Saturday. Panic!!

My senior was kind enough to cover me while I walked home to get my glasses and a toothbrush. This was going to be a long night.

Patient shaking (??)

5:05 PM: first call:

Nurse: “Hi it’s Linda, Mrs. Smith’s nurse from Davies 4 ICU”.
Me in my head: “No one ever told me I was covering the ICU!”
Me: “Hi! How can I help you?”
Nurse: “Mrs. Smith is shaking like I’ve never seen anyone shake. She says she’s ok though, and her vitals are stable”.
Me: “So it’s not a seizure?”
Nurse: “No, it really doesn’t look like a seizure, but it’s weird”.
Me: “Ok, I’ll go have a look”.

Poor Mrs. Smith. She was an older lady. I don’t remember her age, but I remember her face like it was yesterday. She was wearing the super comfortable bi-pap mask, her cheeks puffing with the flow of the machine, and she was shaking like you wouldn’t believe. I asked her if she was ok. She says, “Yes, I’m fine” with a big smile, her voice muffled by the large mask. Her O2 sat was fine; she was fine. I sat down to have a look at her chart when my pager went off. I have a quick look at the pager and it goes off again. This was going to be a long night.

It turns out Mrs. Smith had had a lot of Ventolin that day. It took me a while to figure that one out.

My first night on call was relatively smooth. Didn’t sleep much, but it’s part of the game I guess.

Reversing opioids

Fourth night on call: I get a call that a patient is bradypneic at around 6 breaths per minute, O2 sat in the low 80s. Patient is receiving high dose opioids for chronic pain and the day team recently increased her hydromorphone. Patient was unarousable. I knew I had to be extra careful with naloxone, so I thought to myself “I’ll give the smallest dose and wait a few minutes. Naloxone is supposed to work fast. We’ll see”. Well it turns out that the smallest dose recommended by the manufacturer is about 10x as much as experienced physicians use in similar cases. Sure enough, Mrs. Doyle woke up a few seconds later. I said to her:

“Hi Sir! How are you doing?”
“Did you just call me sir?” She said, amused.

In my defense, Mrs. Doyle had bilat BK amputations, was obese, diabetic and on chronic prednisone so that her beard (ahem cushinoid features) hid her womanly features. I knew naloxone wouldn’t reverse her condition for too long and that she would have to be monitored to some extent, but at least now, she was awake with O2 sats in the 90s.

After a quick assessment, I went back to the Nursing Station to write a quick note. A few seconds later, I heard Mrs. Doyle screaming. She was in atrocious pain. I knew naloxone is a non-competitive opioid receptor antagonist, meaning that you can’t displace it from the receptor by giving more opioids. You just have to wait. It was horrible. I called my senior and we tried everything we could. After 30 minutes of screaming, she settled. We spent a quite a lot of time that evening titrating the diluted naloxone for Mrs. Doyle. I thought about what happened that night over and over again. We learn by making mistakes and I learned a lot that evening.

Pain crisis

Towards the end of my first year, I was again doing general internal medicine. I was post call and it was 12:45 PM the next day. I remember because I was hungry and tired and I needed a shower. That was before the newer work hour restrictions. One of our team’s fourth year medical students was treating a younger woman with metastatic breast cancer who had been admitted with pain. The patient was in a pain crisis at that point with her teenage daughter and husband watching as the scene unfolded. That poor medical student was frightened, understandably. She knew she wanted to give some IV opioids, but which one? How much?

I had already dealt with a few pain management issues and I knew how to approach the problem. A few minutes after 10 mg IV morphine, the patient was feeling much better. That gave us enough time to re-evaluate her pain medication and order the investigations to try to find the reason for the sudden pain crisis (pathological spine fracture - no spinal cord compromise).

I thought to myself: “That medical student is almost finished her training and she’s a “good one” (we all know what that means) and she wasn’t able to handle that crisis. Granted, it wasn’t an easy situation with the family standing around on top of everything else, but something needs to be written to help us during those first few months of practice”.

The result

After that year, I started writing what would become MD on Call. A lot of friends and colleagues helped me get the content just right. Now that MD on Call has reached Version 4, its ongoing success keeps reminding me of the importance of helping junior docs go through this difficult period of training.

I hope you’ll enjoy using the app; especially at 3:15 AM ;-)

6 Tips for Being a Good Teacher

Sat, 06 Jun 2015 21:15:03 +0000

Teaching is part of a resident’s role. It’s also part of a practicing physician’s role — even those not working in academic centers. Unfortunately, it’s a topic very often overlooked in medical school. All of a sudden, you’re expected to teach (as well as take care of a long list of patients, read and write papers, and live a healthy, balanced life…). Here’s a few tips to get you going.

Create a friendly environment

This goes without saying, but medicine, in general, is a field well known for an archaic hierarchal system. Be nice and others will be nice to you. Grilling is so 1992.

Identify goals and audience

You have to adjust your teaching to your audience. Try your best to picture yourself at the level of the learner. Remember when a CT scan was as mysterious as an abstract painting? Remember; always remember.

Have topics to teach on the fly

Pro tip: when you are finished giving a formal presentation, scribble a few teaching points and approaches. This can come in handy when you’re asked to teach junior residents or medical students at the last minute.

Powerpoint

This is just my opinion. I dislike Powerpoint presentations. As a resident, the best teaching sessions were the ones where we saw a patient and ran through the issues and teaching points on the whiteboard. Canned presentations are usually very boring. The drawback here is that you have to be really comfortable with the topic. Slides are a good way to hide a lack of true understanding…

Short and sweet

I was sitting in the staff room the other day and the urology staff walked in and started an hour-long teaching session. That was on a Friday. At 6PM. Come on guys! Aim for 15 minutes (unless a schedule has been assigned) and keep track of time. Stop when your time limit is over, even if your topic is “super interesting”.

Summarize

When you’re finished your presentation, try to summarize the topic in one sentence. Not easy, but being able to summarize a topic on the spot is a super useful skill to develop as a physician. Plus, it will help you create better Tweets, which will help with your social media skills.

Giving Feedback

Tue, 05 May 2015 21:15:03 +0000

As with teaching, giving constructive feedback is an important skill to gain. Here are a few tips to make it easier. As a bonus, it’s an acronym. We all like acronyms!

Frequent.

We’ve all heard stories of someone going through a rotation “smoothly” and on the last day, they get a terrifically poor evaluation. Frequent feedback will allow the student to adjust to your style and improve.

Expected.

Start a rotation clearly stating that you will give feedback to your students.

Explicit.

Try your best to give feedback on specific behaviours. No general statement such as, “your performance is not adequate”.

Directly observed.

Give feedback about things you’ve witnessed. Let others provide their own feedback, especially if it’s “constructive”.

Balanced.

Get the learner’s perspective on the situation. Their point of view is important as well!

Action.

Provide a plan for improvement.

Clear.

Communicate the goals and objectives for which you’ll evaluate the learner.

Kind.

Respect brings respect. You may be in a position of authority, but that’s not a license to be an @$?hole.

Starting Residency: Some Free Online Resources

Sat, 04 Apr 2015 21:15:03 +0000

MD on Call and Lanthier are good tools to use to get started, but residency is not just medical; it’s also everything else around medicine. Learning, teaching, preparing for your own practice. Here’s a list of resources I came across that may be of interest to fans of our apps.

Studentdoctor.net
No need for introduction. This site was around before I started medical school and was already popular back then. Lots of helpful advice and an active forum.

Reddit
Everyone should know Reddit, the best site ever to waste precious time looking at pictures of cute kittens and great memes. However, Reddit also has an active medical community, with a sub-reddit dedicated to residents (/r/residency). It’s a good forum for asking people about things you don’t otherwise want to ask people you know.

Life In The Fastlane
ECG library, procedure videos, podcast… A site I wish I had put together. The quality of the content is outstanding, all for free.

Dr. Smith’s ECG Blog
Next level in ECG interpretation. A cardiology keener’s dream come true.

NEJM procedure video database
What more is there to say?

CXR atlas
We added X-ray examples to the newest version of MD on Call to allow the user to have access to clinically meaningful X-rays quickly, but sometimes, we want to study using a complete library, and this is the best I have found. It hasn’t been updated since 2006, but let’s face it… X-rays haven’t changed much, so I assume it’s still current.

REJ
For our French-speaking residents, here’s a great summary from our Sherbrooke residents. It’s loosely based on MD on Call, but in French!

Have a good website to add to this list? Send me an email marc-emile@messil.com.