Tips on Surviving Internship By Clare Di Bona JHC ED Registrar

Being an Intern is Challenging!

But also Rewarding!

It’s ok to feel unsure-there’s lots of people to help you.

Clare’s Recommended Intern Textbook: On Call Principles & Protocols

Objectives for this week  Find out what the expectations of your team are  Find out how to login to: Medway (blood test results), PRC (radiology), MIMMS, Therapeutic Guidelines  Feel competent in writing medical notes  Feel competent in summarising the patient  Feel competent to identify the sick patient  Feel competent to ask for help

How do I Find out what is Expected of me?  ASK MEMBERS OF THE TEAM THAT YOU ARE ASSIGNED TO  Ask the Intern-what time do you get in? where is the patient list? Daily tasks?  Ask the Registrar-how do I contact you if I need help? Do I perform tasks during ward round or after? How do I prioritise my jobs?  Ask the Consultant/s-Introduce yourself and be enthusiastic to help!  Remember to become friends with the nurses, pharmacist, allied health team, ward clerk….friends help friends.

How to Write in the Medical Notes  Date, time, your name in left column  Title: for example Ward Round (W/R) Drs A,B,C present  Presenting Complaint  History of Presenting Complaint  Past Medical/Surgical history  Medication list  Allergies  Examination  Summary  Form a DDx  Form a provisional plan that you will check with your senior  Sign the bottom  Provide updates including test results

The Following Slides are Based on Three YouTube videos on Clinical Reasoning 

Prior to a patient assessment/note writing ask yourself is this patient sick? Do I need help now?  The bedside observations give us important clues  High respiratory rate is bad  Acute low 02 saturations is very bad  Tacchycardia is bad  Low BP is bad  High temperature is bad  Acute confusion/altered mental state is bad  Not passing urine is bad  Severe chest pain or SOB is bad

Presenting Complaint  Semantic Qualifiers help to reframe the patients language into medical language  Onset: abrupt or progressive, acute or chronic  Course: continuous or episodic  Site: unilateral or bilateral, proximal or distal, diffuse or localised  Trigger: postprandial, exertional, pleuritic, positional  Painful or Painless  Pain Questions (SOCRATES; site, onset, character, radiation, associations, time course, exac/relieving, severity). *Think about your DDx early but beware of anchoring bias. * Identifying key features (positive and negative predictors) to distinguish between diagnosis takes experience and a thirst for evidence based medicine!

History of Presenting Complaint Sometimes the initial notes give important clues: ED nursing triage, SJA Note the initial observations and current observations Chase any recent discharge summaries or investigations Compare current blood tests with old blood tests Ask family members for additional information

Past Medical History/Medications/Allergies  Include past surgical history  Don’t be afraid to TAKE YOUR TIME if the patient is stable  Be curious about things….  Get an accurate medication list  Ask about medications that thin the blood  Clearly document allergies and details about the reaction  GP medication lists are commonly outdated and include all medications the patients have ever been on. So go through and check each item.  Local pharmacies can help  Recent discharge letters can help

Examination  Gain consent, stand right side of bed, position bed to match your height, expose when necessary in a respectful manner (double check consent after explaining).  Note the observations at the time of your review  Start with the relevant body system  If the patient is stable TAKE YOUR TIME and be thorough

Summary  1-2 sentences  1) Age and Gender  2) Highly relevant PMH  3) Primary symptoms using semantic qualifiers  4) Highly relevant exam findings and available test results  5) Most likely clinical syndrome

When talking to your colleagues they want to know why you are calling them  “Hi its Clare the gen med intern can I please ask your advice on a patient” Ie if your comfortable, just need some phone advice Versus “Hi its Clare gen med intern I have an unstable patient that I need your help with now please” ie sick patient who does not meet MET criteria but you are concerned Versus “Hi …..I’m requesting a non-urgent ward review” ie from another specialty team

Example of a Summary  Joan Smith is a 70yo lady on ward C1  She has a history of prior MI, HTN,T2DM  She has cardiac sounding chest pain for the last hour radiating down the left arm  ECG shows ST depression inferolaterally (new compared to her old ECGs)  I have given GTN, put in an IVC and sent bloods including a troponin  She has ongoing chest pain and doesn’t look well, can you please come now to review her

How to Develop a DDx  A clinical syndrome ie sepsis is not the same as a DDx  Saying a patient has chest pain is not a diagnosis  We need to develop frameworks for our patients symptoms/signs/tests to further develop our differential diagnosis For Example in regards to chest pain Pleuritic: pneumothorax, pericarditis, pleurisy, pulmonary embolus Acute coronary syndrome: heavy/crushing/aching central pain down the arm/s or neck Dissection: Violent pain that is widespread, widened mediastinum, unequal pulses/BP GIT: esophageal (spasm, tear, rupture), stomach (gastritis, GORD, ulcer, perf), pancreatitis, cholecystitis or biliary colic Musculoskeletal: rib fracture, costochondritis, muscle sprain/tear *Need to use your assessment to identify the key features and which of the above diagnoses warrants further investigation

Formulating a Plan  You will look very smart if you come up with a provisional plan!  Therapeutic guidelines can help you  It’s important not to order unnecessary tests so please check with your registrar initially prior to ordering tests  Soon you will figure out which tests your registrar is happy for you to order by yourself  Please don’t prescribe any medication your unsure of…..always think safety first!!  Always check your patient’s drug allergies prior to prescribing-prescribing a medication the patient is allergic to is the most common medication error in this hospital!

How to Ask for Help  Your registrar will most likely be the person that helps you the most  Always ask up ie it is not wise to ask another intern who is at the same level as you  You have the right to ask lots of questions!! Please do!!  If the patient is stable you do have time to think and assess the patient thoroughly prior to asking for help  Summarising the patient is a very important skill, try to keep it brief.  If the patient is unstable or sick say this first  Its ok to ask your senior colleagues for a bedside review they get paid lots of money to help you!!

What if you are Struggling to Cope?  Please let your team know if you are struggling to cope  Often your registrar will be in the best position to guide you  The hospital has a network of support services available  Don’t feel pressured to know everything, we all remember what it was like to be an intern  Ask lots of questions!!!