AN INTERNS

SURVIVAL
GUIDE
From the personal notes of
VJ and Giselle Velez, MD
St. Vincent Charit Medical Center
De!art"ent #$ Internal Medicine
Table of Contents
I. Gearin% &! $#r the $l##r'&nit r#tati#ns
(Inside the a)era%e la* c#at+
II. Ti!s $#r the ,l##r
a. Earl -ird
*. De)el#! a r#&tine
c. ,l##r R#&tine
d. Techn#l#%
e. Dress C#de
$. Ad"it .rders
%. /a%in%
h. 0#s!ital /h#ne Sste"
i. /rescri!ti#ns
1. Dischar%es
2. C#""#n ni%ht !r#*le"s
l. R#&nds 3ith Resident
". R#&nds 3ith Case Mana%er
n. Re$erences'-##2s t# read
#. Si%n4#&ts
III. G#lden R&les
IV. C#ncl&si#n
XIV. GEARING UP FOR THE FLOORS/UNIT
5hats inside a residents la* c#at6 A la* c#at isnt 1&st a !iece #$
cl#thin% $#r sh#3, *&t it is as $&ncti#nal and as li$esa)in% as a s!aces&it
(and !r#*a*l as hea) 3ith all !#c2ets $illed7+.
/#c2et 8
ID *ad%e
Meal tic2ets
/ens 9 #& 3ill need at least :
/enli%ht
/#c2et :
/atient lists
R#&nds re!#rt
Si%n #&ts
/al" /il#t'/#c2et /C
/#c2et ;
Ne&r# ha""er
/a%er
/ac2ets #$ l&*ricant and st##l he"#cc&lt cards
/#c2et <
Ee chart
ACLS cards
/#c2et "edical re$erence
San$#rd G&ide
Call Sched&les
/#c2et =
Mini4CE> $#r"s
Chart Stic2ers
/r#ced&re -##2let
/rescri!ti#n /ads
Ar#&nd #&r nec2
Steth#sc#!e
There #& ha)e it7 N#3 #& ha)e all it ta2es t# *e ?*attle4read@.
D#nt $#r%et t# *rin% #&r *rain #$ c#&rse.
M#st SVC0 residents *& all their h#s!ital needs at Mathe3s
-##2st#re 3ith tele!h#ne and address as $#ll#3sA (:8B+ ::C4BCDD; C<=8
E&clid A)e Cle)eland, .0. The st#re is an eEcellent s#&rce #$ *##2s,
steth#sc#!es, %ad%etsF all re$&nda*le 3ith #&r G;DD ed&cati#nal
all#3ance #$ c#&rse.
/#c2et /Cs and'#r /al" !il#ts are *est !&rchased thr#&%h the
internet. M#st %ad%et st#res (i.e. Circ&it Cit, Radi# Shac2, -est -&+ d#
n#t ha)e a 3ide selecti#n. /#c2et /Cs are a *etter ch#ice *eca&se
/al" /il#ts and their !r#%ra"s are n#t rei"*&rsa*le thr#&%h #&r
ed&cati#nal all#3ance. /#c2et /C &se is enc#&ra%ed d&e t# $&t&re !lans
t# inte%rate these handhelds 3ith the h#s!ital c#"!&ter sste".
XV. TIPS FOR THE FLOOR
a. Early bird
Start earl t# $inish earl. Us&all, a ;D4"in&te "#rnin% dela
&ncannil translates t# an additi#nal 84h#&r #$ 3#r2 later in the da (Ver
tr&e $#r s#"e reas#n+.
b. Develop a routine/system
At the end #$ the ear, each #$ #& 3ill ha)e de)el#!ed their #3n
r#&tine. Dail 3#r2 3ill see" sec#nd nat&re. De)el#! #r%anizati#n s2ills
earl. Als#, d# tas2s in the #rder #$ &r%enc and i"!#rtance.
c. An interns typical floor routine (around midyear onwards)
BADD4HADD 9 see and eEa"ine all !atients, #*tain si%n #&ts, tal2 t#
n&rses re%ardin% #)erni%ht e)ents
HADD4IA:D 9 3rite all n#tes and !lans
IA:D4IA;D 9 -REAJ,AST77 I$ !#ssi*le
IA;D48DADD 9 r#&nds 3ith resident
8DADD48:ADD 9 Attendin% r#&nds (M454,+
8:ADD48ADD 9 N##n C#n$erence
All da &! t# =/MA d# ad"issi#ns (:A;D c&t4#$$+, #)er$l#3s, trans$ers
(;/M c&t4#$$+, and dischar%es.
d. Take advantage of technology
/DAs !r#)ide &se$&l re$erences, dr&% data*ases, sched&le
#r%anizers, tas2 lists, and !h#ne *##2s. These %ad%ets c#&ld *e &sed t#
st#re !ers#nal n#tes, re"inders and "ne"#nics. ,eel $ree t# a!!r#ach
c#llea%&es $#r *ea"4a*le !r#%ra"s and'#r $iles.
e. Attire
Men sh#&ld strictl adhere t# the dress c#deA nec2ties, #n dress
shirts at all ti"es, "#st es!eciall at the c#ntin&it clinics. Jeans, sh#rts,
and sli!!ers are de$initel n#t all#3ed. The dress c#de $#r 3#"en is
"#re $leEi*le, s2irt (3ith h#sier #r 2nee4his+, *l#&se #r !ants that $it the
descri!ti#n #$ @!r#$essi#nal4l##2in% *&siness attire@. Scr&*s c#&ld *e
3#rn d&rin% #n4call and !#st4call das #nl.
f. ormat of Admitting !rders
As interns, #& 3ill *e 3ritin% "#st #$ the #rders in the chart
incl&din% the ad"issi#n #rders. 0eres an eEa"!leA
Ad"it t# 4 Indicate the l#cati#n and the na"e #$ the attendin%
!hsician (e%. Ad"it t# :a 3ith tele"etr &nder Dr. Christie+
Dia%n#sis 4 this is #&r ad"ittin% dia%n#sis
C#nditi#n 4 3hether the !atient is sta*le, critical, $air, %&arded
Vitals 4 h#3 #$ten #& 3ant the )itals t# *e chec2ed. M#st #$ the
ti"e 3e 3rite ?!er $l##r #r &nit !r#t#c#l@
Aller%ies 4!ertains t# dr&% aller%ies. I$ n#ne, #& can 3rite NJDA
3hich stands $#r ?N# Jn#3n Dr&% Aller%@
Acti)it 4 i.e. ?*ed rest@, ?as t#lerated@, ?$all !reca&ti#ns@
N&rsin%4 i$ needed, strict Is and .s, Dail 3ei%hts, Acc&4chec2s
$#r *l##d %l&c#se "#nit#rin% KAC and K0S
Diet 9 i.e. "a *e N/., re%&lar, : %ra" s#di&" $#r
0!ertensi)es, 8IDD4:DDD Jcal ADA $#r dia*etics, <D4ID %ra"
!r#tein diet (renal $ail&re+, !&reed diet $#r edent&l#&s !atients.
IV, 9 Intra)en#&s $l&ids (e%. N#r"al saline at 8DD cc'h#&r > 8
liter+
.E%en 9 i.e. :L/M nasal cann&la'' n#n4re*reather'C/A/
La*s 4 (C-C, -M/, Chest >as, EJGs+
Meds 9 i.e. Anti*i#tics, anti4h!ertensi)es, Ins&lin slidin% scale,
aer#s#ls, h#"e "edicati#ns. In 3ritin% the "edicati#ns, *e
s!eci$ic. EEa"!leA Lisin#!ril 8D "% /. dail. 0#ld $#r S-/ L 8DD
/r#!hlaEis 4 DVT !r#!hlaEis 3ith TED 0#se st#c2in%s'he!arin
=DDD &nits SM -ID'!ne&"atic c#"!ressi#n. GI /r#!hlaEis 3ith
/r#t#n /&"! Inhi*it#rs li2e /r#t#niE <D "% /. dail #r /re)acid
;D "% /. dail, i$ indicated
C#ns&lts 9 i.e. GI c#ns&lt. Indicate na"e #$ the c#ns&ltant,
reas#n $#r c#ns&lt s&ch as rectal *leedin%, and 3hether #r n#t
#& ha)e n#ti$ied the attendin% #r his'her ans3erin% ser)ice
alread
S!ecial (Case Mana%er C#ns&lt, 5#&nd Care C#ns&lt, /T'.T
e)al&ati#n, Res!irat#r+
NThen si%n #&r s&rna"e le%i*l t#%ether 3ith #&r !a%er n&"*er
g. "riting scripts
The h#s!ital has its #3n #$$icial !rescri!ti#n !ad (3hite $#r re%&lar
!rescri!ti#ns and ell#3 $#r re%&lated "eds li2e narc#tics+. It 3#&ld c#"e
hand i$ #& ha)e a $e3 #$ the 3hite scri!ts in #&r la* c#at at all ti"es.
In 3ritin% !rescri!ti#ns, al3as *e s!eci$ic.
/r#)ide the na"e #$ the "edicati#n, the d#se, the r#&te, $reK&enc
#$ ad"inistrati#n, d&rati#n (i$ #&re !rescri*in% a c#&rse #$ anti*i#tics+,
a"#&nt #$ ta*lets'&nit t# *e dis!ensed and h#3 "an re$ills. D#nt $#r%et
t# 3rite #r !&t the !atients na"e #n the scri!t t#%ether 3ith the !atients
a%e and date. Then si%n #&r !rescri!ti#n and 3rite #&r $&ll na"e.
- la3, a "aEi"&" #$ ; "edicati#ns are all#3ed #n #ne scri!t *&t
its al3as %##d !ractice t# 3rite #ne "edicati#n !er scri!t. O#&r DEA
n&"*er (&sed $#r narc#tics and re%&lati#n dr&%s+ 3ill *e !r#)ided d&rin%
the #rientati#n.
EEa"!leA
Patients name: VJ Velez Age: 30/M Date: July 1,
2006
Rx:
Lisinopil 10 mg P! "aily ######$30 ta%s

D& Maia 'iselle Velez
1 e(ll )*'+,D
D,A num%e -i. nee"e"/
#. "riting discharge orders
O#& 3ill *e res!#nsi*le $#r 3ritin% the dischar%e #rders #nce a
!atient is read $#r dischar%e (as !er attendin% a!!r#)al+. 0eres a
sa"!le dischar%e #rderA
Dischar%e !atient t# h#"e ()s. n&rsin% h#"e+ 3ith 0#"e 0ealth
Care (i$ indicated+. S!eci$ the reas#n $#r #rderin% h#"e health care
(i.e. "edical c#"!liance, $#r h#"e sa$et e)al&ati#n, $#r /T'.T
needs+.
This is usually based on the evaluation of the physical therapist
or the case managers. This is one reason why you should refer your
patient to PT/OT for evaluation or discuss it with the case managers
as early as possible (earliest would be as soon as the patient gets
admitted). Bear in mind that discharge planning begins upon
admission.
,#ll#34&! 3ith Dr.Christie in : 32s 4 As2 the attendin% h#3 s##n
he'she 3ants t# see the !atient in the clinic
,#ll#34&! 3ith (c#ns&ltants, i$ indicated+ 4 Als# as2 the c#ns&ltant i$
the !atient needs t# $#ll#3 &! hi"'her
Discharge $edications: O#& are reK&ired t# c#"!lete the list #$
h#"e%#in% "edicati#ns &sin% the Medicati#n Rec#nciliati#n $#r"s.
/r#)ide scri!ts $#r ne3 "edicati#ns #r chan%ed "edicati#ns. EEce!t
in cases 3here "edicati#ns 3here chan%ed d&e t# $#r"&lar
&na)aila*ilit (i.e. ir*esartan chan%ed t# )alsartan+. -e "ind$&l #$
these chan%es t# a)#id sendin% a !atient h#"e #n t3# "edicati#ns
#$ the sa"e class. The !&r!#se #$ the h#s!itals Medicati#n
Rec#nciliati#n $#r"s is t# a)#id these "isha!s.
Ir*esartan H="% /. dail
Met#!r#l#l =D "% /. -ID
As!irin I8 "% /. dail
S!ecial instr&cti#ns 4 Indicate i$ #& ha)e s!ecial instr&cti#ns s&ch
asA ?D# n#t ta2e a"l#di!ine at h#"e@. ?,#r #&t!atient chest E4ra,
C-C, INR, etc. #n (date+@.
k. The most common reasons for pages while on%call
,ail&re t# in$#r" n&rses 3hen #& 3ill *e *e *ac2 t# ta2e care #$
r#&tine iss&es
Electr#lte deran%e"ents (Na, J, M%+
Gl&c#se deran%e"ents (Ins&lin ad"inistrati#n and slidin% scale+
Chest !ain
Ins#"nia
Na&sea'V#"itin%
0eadache
,e)er
-/ deran%e"ents
Rash'Aller%ies
J#int /ain
A*d#"inal /ain
/#st4#! !ain
.E%en desat&rati#n
Sh#rtness #$ *reath
A%itati#n'/sch#sis'AnEiet
,a"il 3ishes t# s!ea2 t# d#ct#r #n 3hats %#in% #n6
/atient 3ishes t# %# h#"e a%ainst "edical ad)ice
l. &reparing for 'ounds with the supervising resident

5ill *e disc&ssed in detail d&rin% the #rientati#n
m. &reparing for 'ounds with the (ase $anagers
eport on pro!ected patient disposition
"tate reason why patient still needs to be in the hospital
Possible roadbloc#s to discharge planning
n. )seful references/websites
-##2s 9 C&rrent (CMDT+, 0arris#ns, G#rr#lls ,a"il /ractice
G&ide, -ates /hsical EEa", D&*ins EJG
/#c2et Re$erences 4 ,erris, 5ashin%t#n Man&al, .E$#rd, /#c2et
0arris#ns
5e*sitesA SVC0 *l#%s!#t, AC/ /ier, Nati#nal G&ideline Clearin%
0#&se, NEJM, /&*"ed, G##%le Sch#lar, U! t# date
o. Things to include in the Electronic *ign%outs
$hief complaint
Problem %ist (not symptom list please)
&nticipated Problems
'eds
&llergies
$ode "tatus
$onsults on board
elevant Plans
Detailed instr&cti#ns #n h#3 t# create si%n4#&ts $r#" the Meditech
c#"!&ter sste" 3ill *e disc&ssed at the #rientati#n.
XVI. GOLEN RULES
All work and no play is no good+
Cle)eland is an a"azin% !lace. 5e &r%e #& t# eE!l#re and en1#.
Lea)e #&r 3#rries in the h#s!ital 3hen #&re #$$. Re$er t# the list
a*#)e in the RECREATI.N SECTI.N $#r $&n thin%s t# d#. .ther3ise,
heres a c#&!le #$ s&%%esti#nsA
Dine #&t. G##d resta&rants are in %reat a*&ndance here, s# *e
ad)ent&r#&s. (i.e Le%ac Villa%e in -each3##d, Little Ital, 5est B
th
, the
,lats+.
Redisc#)er "&sic and arts. 5e had se)eral !r#$essi#nal acts
!er$#r" here in Cle)eland. 5e als# ha)e the Cle)eland .rchestra,
se)eral "&se&"s, the theatre district and the $a"#&s R#c2 and R#ll 0all
#$ ,a"e "&se&".
Visit n&"er#&s !&*lic !ar2s and the Cle)eland z##.
5atch an N-A %a"e7 5e ta2e !ride in ha)in% the neEt Michael
J#rdan (in the !ers#n #$ Le -r#n Ja"es+ ri%ht in #&r *ac2ard. The cit
als# #$$ers *ase*all (Indians+, $##t*all (-r#3ns+, ann&al %rand !riE racin%
and air sh#3s.
"ork hard and party hard+
Residents at St. Vincent are t!ical hard 3#r2ers *&t 3e d# 2n#3
h#3 t# ha)e $&n. 5hen #& $inall %et here, #& 3ill *ec#"e $a"iliar 3ith
the 0#&se Sta$$ C#""ittee. The are a %r#&! #$ residents elected $r#"
#&r Internal Medicine and /#diatr !r#%ra"s. The c#""ittee %enerall
"a!s #&t s#cials s&ch as #&tin%s, !arties and %atherin%s. .ne #$ the
"#re $a"#&s e)ents #$ the ear is the Di3ali !art ($esti)al #$ li%hts+. D#
n#t $#r%et t# *rin% an ethnic c#st&"e ($r#" #&r c#&ntr #$ #ri%in+ $#r this
#ccasi#n.
O#&r c#llea%&es 3ill als# *e #&r $riends. N&"er#&s residents
&s&all als# arran%e 3ee2end !lans a"#n%st the"sel)es *e it dinin% #&t,
!icnics, !lain% tennis, *ad"int#n, s#ccer #r )#lle*all.
Dont forget to eat
N# "atter h#3 hectic #&r call is, re"e"*er t# %ra* s#"ethin% $r#"
the ca$eteria *e$#re it cl#ses. O#&ll al3as ha)e ti"e t# eat later #n #nce
thin%s start t# settle d#3n. It als# hel!s t# ha)e #ne4d#llar *ills in #&r
!#c2et $#r the )endin% "achines $#r STAT drin2s #r $##d.
,eep supervising resident informed
Re"e"*er that #& are al3as a !art #$ a tea". O#& 3ill initiall *&%
#&r residents $#r e)er little K&er. -&t as #& learn h#3 the sste"
3#r2s, #&ll *e "#re c#n$ident t# "ana%e si"!le thin%s #n #&r #3n,
3ith ti"e. Ne)er hesitate t# in$#r" #&r resident i$ #& ha)e d#&*ts and i$
#& need an hel!. Let #&r s&!er)isin% residents 2n#3 #$ e)er
i"!#rtant &!date #n #&r !atients.
'ecogni-e and sei-e learning opportunities from attending
physicians and consultants on the floor
O#& #nl rea! 3hat #& s#3. /&rs&e learnin% #!!#rt&nities
3hene)er the arise since learnin% is rarel a !assi)e !r#cess. Disc&ss
#&r cases 3ith #&r attendin%, *e !er!et&all c&ri#&s a*#&t that 3hich
#& d# n#t 2n#3.
XVII. CONCLUSIONS
The internshi! ear 3ill *e the "#st di$$ic&lt ear in an residenc.
E)er eE!erience (3hether !ain$&l #r !leasant+ 3ill #nl "a2e #& a
str#n%er and "#re c#n$ident !hsician.
Alth#&%h the SVC0 #rientati#n is #$$iciall c#&nted as t3# 3ee2s, the
realit is that the #rientati#n is inde$inite *eca&se there are n# li"its t#
thin%s #ne "a disc#)er a*#&t residenc, the cit and this c#&ntr.
GOO LUC!"