Baffled in Brooklyn

The Art of Sign-Out (Spoiler Alert: You’re probably doing it wrong)

Sign-out is the art of relaying large amounts of medical information in the fewest words possible.  All meat, no filler.  Truly great sign-out is not only about what you say, but about what you choose not to say, and even how fast you say it to your colleague.  Really great sign-out  technique is an acquired skill that is increasingly essential in today’s increasingly shift work based medical system yet very few, if any, programs out much emphasis on teaching it to their residents.  Every transition of medical care is an opportunity for mistakes that lead directly to patient-care errors.  Have no fear kids, Dr. B is here to help you give better sign-out.

If you don’t care about medical sign-out you probably shouldn’t click read more.

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Pediatrics Residency and USLME vs COMLEX (Rebloggable by request)

 Anonymous

Tips For a Successful Pediatric IV Insertion

I guess most of these tips are really applicable to any IV placement, but since I’m a pediatrician I’m including some extra tips that a re pediatric specific. Also, it’s my blog and I can do whatever the heck I want. I’m talking about a routine IV placement here. Obviously in an emergency situation things work differently.

1. Go to the procedure room
Most pediatric units have a special room to take kids to when they need blood draws, IVs and other bedside procedures. There are a few reasons for this, but the main reason is so the child knows that his bed and his room are safe. Also, procedure rooms are typically well stocked with all appropriate supplies.

2. Wake the child up
NEVER try to insert an IV (or do any other procedure) in a patient that is not awake. Obviously if the patient is not arousable for a medical reason it’s a different. Being awoken by the pain of a needle can be extremely frightening.

3. Make the parents wait outside
It’s will help eliminate unwanted stress. Parents are very anxious about procedures. They will hover over you. They will be disruptive. Sometimes they faint at the sight of blood which is VERY distracting.

4. Adjust the bed/chair to your level
Be sure you are in a comfortable position. If the bed is too low, raise it up. If its too high, lower it. Make your job as easy as possible.

5. “Do or do not. There is no try.”
Don’t walk in and announce to everybody you are going to try and get an IV. Walk in and announce that you place an IV. Mindset is important. Not only for the parents, but for you as we’ll.

6. Have all equipment ready to go
Make sure you have all appropriate items set up and easy to go. Tubing, flushes, tape, IV board, dressings, etc. Also, don’t bring a lifetime supply of crap. You are placing ONE IV, not 20. If you walk in with 15 angiocaths and 20 alcohol swabs it LOOKS like you have no clue what you’re about to do.

7. Check everywhere and find the best option
Never walk into a room with a predetermined notion of where you’re going to place an IV. Don’t just place an IV in the right antecub because that’s the side the pump is on. Look everywhere and find the best vein you can.

8. The needle is longer than the catheter
This is an important piece of information to remember. When you see blood flash back it means the blood has entered the vein. The catheter is a few millimeters behind the tip of the needle. If you stop advancing the needle to suddenly, the catheter might not be in the vein.

9. Security is everything
Secure your IV well, but in a way that allows nursing to periodically evaluate the side for infiltration.

10. 3 Strikes an you’re out
If you miss 3 times, get help. Obviously, if you are the attending physician at the top of the totem pole, you get more tries.

11. Going blind
“Going blind” is when you attempt the IV placement despite not seeing/feeling a vein. As a resident, this is generally not advised. If you must go blind, don’t announce it to familial observers (which we’ve already discussed should be waiting in the hallway).

How to fail a rotation with Dr. Baffled

Walk into the OR for a c-section a full 6 minutes after you were paged WITHOUT putting on a cap and mask.

Everybody Lies: My Two Cents

This is a key tenet of medicine that everybody must learn. The sooner you learn it, the better your life as a physician in training will be. The first time you will see this in action is when you do your first H&P on a patient as a med student. You will do what you truly believe is a thorough H&P with lots of great information. You will write it all down in agonizing detail and present it to the intern/resident/attending. Then they will go in to the room and perform another H&P and you will listen in wonder as a completely different story is told. You will then ask yourself, “Who is this person and what have they done with the patient I interviewed?”

Then you start to wonder, “Did I not ask the right questions? Was my bedside manner so terrible that the patient felt like he had no choice but to lie to my face?” Then your panic shifts from the patient to yourself. “Am I that incompetent? Does the intern/resident/attending think I lied to him/her? Should I just drop out now and fill out an application at Taco Bell? Taco Bell isn’t that bad. They’ve got health insurance and a 401k for full time employees. I’d get free tacos. I like free tacos.”

Relax.

Don’t panic.

This is what always happens. Most patients will tell a new story to everybody who enters a room. If 3 people interview a patient you will end up with AT LEAST 3 different stories. Your seniors know this is going to happen and will not hold it against you.

Everybody lies.

Prepping for Interviews, Part 6

Don’t underestimate the value of showing yourself at top choice residency programs before & during interview season.  Actions speak louder than words.  Demonstrating that you are a competent student physician who would be an asset to their program goes a long way.  We match residents to our program each year based mainly on their performance on elective rotations within our department.  Residents who’s applications would not have otherwise made the cut.  

If your schedule doesn’t allow you to visit your first choice program in a timely matter, talk to the people at your school.  Many times they will work with you.  Keep in mind that it is in your medical school’s best interest to help you match in the best places possible.  It makes them look better.

Prepping for Interviews, Part 5

Submit your application as soon as possible.  The process of reviewing candidates and offering interviews starts as soon as the application submission process begins.  People who submit earlier are more likely to be offered interviews.

This isn’t technically about interviews, but it will help get you to interviews.