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Behind The Knife: The Surgery Podcast

Intern Bootcamp - Scary Pages

Behind The Knife: The Surgery Podcast

Behind The Knife: The Surgery Podcast

Science, Health & Fitness, Medicine, Education

4.81.4K Ratings

🗓️ 6 July 2023

⏱️ 23 minutes

🧾️ Download transcript

Summary

Buckle up, PGY-1’s! Intern year is starting whether you’re ready or not. Don’t fret, BTK has your back to make sure you dominate the first year of residency.

Today, we’re hitting the wards and tackling some of the scary clinical scenarios you will see as an intern.

Hosts: Shanaz Hossain, Nina Clark

Tips for new interns:
THINGS TO REMEMBER
· BREATHE. In most cases, you have a little bit of time – at least enough to take a breath and calm down outside the room before heading into an emergency. Panic doesn’t help anybody.
· See the patient. Getting a bunch of pages? Worried about someone? Confused as to what’s going on? Go see the patient and chat with the bedside team.
· Know your toolbox. There are a ton of people around who can help you in the hospital, and knowing the basic labs/imaging studies and when to use them can help you to triage even the sickest patients.
· Load the boat. You’ve heard this one from us all week! Loop senior level residents in early.

HYPOTENSION
· Differential: measurement error, patient’s baseline, and don’t miss – SHOCK.
- Etiologies of shock: hemorrhagic, hypovolemic,
· On the phone: full set of vitals, accurate I/Os,
· On the way: recent notes, PMH/PSH including from this hospital stay, and vitals/I&Os/studies from earlier in the day
· In the room: ABCDs – rapidly gives you a sense of how high acuity the patient is
· Get more info: labs, consider imaging, work up specific types of shock based on clinical concern.
· Initial management: depends on etiology of hypotension; don’t forget to consider peripheral or central access, foley catheterization for close monitoring of urine output, and level of care

HYPOXEMIA
· Differential: atelectasis, baseline pulmonary disease, pneumonia, PE, hemo/pneumothorax, volume overload
· On the phone: full set of vitals, amount of supplemental oxygen required and delivery device, rate of escalation in oxygen requirement
· On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection
· In the room: ABCDs, pulmonary and cardiac exam, volume status exam
· Get more info: basic labs, ABG if worried about oxygenation, CXR, consider bedside US of the lungs/heart, if high suspicion for PE consider CTA chest
· Initial Management: supplemental O2, higher level of care, consider intubation or other supplemental oxygenation adjuncts, additional management dependent on suspected etiology
· ABG Vs VBG (IBCC): https://emcrit.org/ibcc/vbg/

ALTERED MENTAL STATUS
· Differential: stroke, medication effect, hypoxemia or hypercarbia, toxic or medication effect, endocrine/metabolic, stroke or MI, psychiatric illness, or infections, delirium
· On the way: review PMH/PSH, recent notes for evidence of altered mentation or agitation, or signs hinting at above etiologies
· In the room: ABCDs, focal neuro deficits?, alert/oriented? Be sure the patient’s mental status is adequate for airway protection!
· Get more info: basic labs, blood gas/lactate, CT head noncontrast if concerned for stroke.
· Initial management: rule out above; if concerned about delirium, optimize sleep/wake cycles, pain control, and lines/drains/tubes.

OLIGURIA
· Differential: prerenal due to hypovolemia or low effective circulating volume, intrinsic renal disease, post-renal obstruction
· On the phone: clarify functional foley or bladder scan results, full set of vitals
· On the way: review PMH/PSH, known injuries (known hemothorax/pneumothorax? Rib fractures? Chest tubes in already?), risk factors for DVT/PE, review I/Os for evidence of volume status, vitals and labs for evidence of infection
· In the room: ABCDs, confirm functioning foley catheter
· Get more info: basic labs, urine electrolytes, consider fluid challenge to evaluate responsiveness, consider adjuncts including renal US
· Initial management: typically consider IVF bolus initially, but if patient not volume responsive, don't overload them -- look for other etiologies!

TACHYCARDIA
· Differential: sinus tachycardia (pain, hypovolemia, agitation, infection), cardiac arrhythmia, MI, PE
· On the phone: full set of vitals, acuity of change in heart rate, updated I/Os
· On the way: Review PMH/PSH, known cardiac history, cardiac and PE risk factors, volume resuscitation, signs concerning for infection, updated I/Os
· In the room: ABCDs, cardiac/pulmonary exam, evaluate for any localizing signs for infection
· Get more info: basic labs, EKG, consider CXR, troponins
· Initial management: depends heavily on etiology

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.

If you liked this episode, check out our new how-to video series on suture and knot-tying skills – https://behindtheknife.org/video-playlists/btk-suture-practice-kit-knot-tying-simulator-how-to-videos/

Transcript

Click on a timestamp to play from that location

0:00.0

Behind the Night, the surgery podcast, relevant and engaging content designed to help you dominate the day.

0:13.0

Hey BTK listeners, the weather is getting warmer, the days are getting longer, and that can only need one thing.

0:27.0

It's time for new interns to hit the hospital. Don't worry though, we've got your back. I'm Eden Clark, and I'm Shnatsu Sen, and this series will give you some practical tips and tricks for dominating your intern year.

0:37.0

In this episode, we're going to have some fun with a rapid fire review of the common scary pages you're very likely to get this year.

0:44.0

First, Nina, what's your general approach to addressing pages from the floor?

0:50.0

I think whenever I get an urgent or an emergent page that makes me a little scared, the first step is just to breathe.

0:56.0

I've noticed talking to interns and junior residents that often in these situations the initial move is to panic. It really doesn't help anyone to panic yourself included.

1:05.0

99.9% of the time you have a little time to figure things out, get a lay of the land and make a plan.

1:11.0

So before you answer that stat page or walk into the coding patient's room, just take a deep breath, clear your mind, and then go.

1:17.0

You know a lot more about these patients than you think you do, even these early days of residency.

1:22.0

The next tip I have is to always err on the side of seeing the patient. It gets really easy in residency to become attached to your computer screen and your page.

1:30.0

If you're getting paged over and over again, if you're concerned at all, or if you just aren't even really sure what's going on, just go see your patients.

1:37.0

I promise you'll get more information from looking at them, talking to them, and chatting with the nurse than you ever will from back and forth chart checking and phone calls.

1:45.0

Third is knowing your toolbox. There are a lot of people who can help and studies that can give you a lot of information about an unstable patient very quickly.

1:53.0

From a person's standpoint, you have your senior residents and attendings, but you also have people on other teams, the bedside and charge nurses, the rapid response or stat team, and a handful of ICUs with people who can help you if you need them.

2:05.0

More on this when we get to the next part, but you also have a handful of labs and imaging studies that can give you a lot of information if you know how and when to apply them.

2:13.0

In general, a CDC, BMP, VBG or ABG with lactate, a chest x-ray, and an ultrasound machine can give very rapid and pretty comprehensive information. Finally, load the boat.

2:24.0

All of these people I listed before are here and have almost certainly got years of experience with hospitalized patients that you just don't have when you're at the stage.

2:32.0

Don't let a patient decompensate alone. As a senior resident, I'm never mad when somebody tells me that they're worried about a patient and they're actually okay, but times when patients are decompensating and I don't know about it, keep me up at night.

2:44.0

We all know that this is part of the learning curve for the job we do, and a great way to get better managing sick patients is to loot people in who know more about it than you do and watch how they do it.

2:53.0

That was a really great overview and how to approach needed while keeping your pool and not panicking. Now that we got the framework, let's get into some of the most common pages that will make your stomach turn over as an intra.

3:05.0

The pages we talk about today should generally all be reasons to call your seniors as soon as possible, especially during your first few months, and as you're developing your own judgment for sick versus not sick.

...

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