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Attending: Can you explain the mechanism of post-extubation diuresis?

Me: Well I know those intubated have increased intrathoracic pressure decreasing preload to the heart. So someone extubated will have decreased intrathoracic pressure, the preload will increase leading to increased cardiac output. Then the heart will perfuse the kidneys more which causes more urine to be produced.

Attending: That’s right.

Me: Shit, that was the most educated guess of my life.

Nurse: The patient has mild delirium.

Me: Hello sir, are you having any pain?

Patient: I know you’re a pain in my ass.

Me: Patient is answering appropriately to questions.

GUYS its NOM week! NOM Week brings the osteopathic medical profession together to focus on one common goal - increasing awareness of osteopathic medicine and DOs in communities across the country.

A quick elevator pitch:

       *There are two types of fully licensed physicians in the U.S. – MDs and DOs.

       *Our training and education are very similar and equally rigorous, but DOs come at the practice of medicine from a different philosophy.       *We tend to partner with our patients to help them get healthy and stay well.

“Your short white coat is a symbol for everyone to know that you are a novice and that you are working hard to stay vertical some days, never mind become the brightest clinician you can be. Be like a duck, but don’t frazzle your feathers”

Today my attending and I called a patient’s bother and power of attorney. We explained to him that his brother (who had multiple serious medical comorbidities) had been found in cardiac arrest after an unknown period of time, and while the paramedics had gotten his heart to start beating again, he was in very grave condition and given his multiple other health problems, we didn’t know what his chances for recovery looked like or what his quality of life would be if he did.

The brother stopped us. “I’m a doctor in (Town a few hours away)”, he said, “And he’s been miserable these past few years, being as sick as he is and going through the treatment he did. He wouldn’t want this. I’m leaving to drive there as soon as I hang up, but I want you to take the tube out, put him on comfort care, and if he starts to die before I get there, let him go. Don’t put the tube back in, don’t start pressors, don’t do CPR, just let him go, I don’t want him to suffer any more for my sake.”

I can only imagine how hard that must’ve been for him.

We would’ve completely understood if he’d wanted us to keep his brother intubated until he got here and could be with him as he died, but he wanted us to make and keep him comfortable, instead.

As requested by arabgirl88 :)

Everyone- literally everyone- dreads this question. One of my friends has a particular hatred of this question because in one of his interviews, one of the interviewers asked him this question, and when he mentioned research the interviewer asked him why not a Scientist and when he mentioned teaching asked why not a Teacher and so on and so forth in a spiralling nightmare of “Why a Doctor and not This-Other-Job-Which-Also-Does-This?” until one of the other interviewers effectively told Interviewer Number 1 to shut up. 

So. Assuming you won’t end up in the same terrible situation as my friend, why a Doctor and not a Nurse/ another allied healthcare profession? 

Okay, so I’m going to work on the assumption you’ve never Googled this before and start from the basics.

Do NOT at any point in your response criticise nurses. Their jobs are difficult. As a doctor, you simply won’t have much time to give individual patients while for nurses- this is their job. Healing isn’t just physical and often nurses can give the emotional support patients need to get better or at least, feel more comfortable. They are also heavily involved in the day-to-day running of wards and doing jobs that need to be done which doctors just don’t even consider or, if they do, at least don’t consider part of their job. Just try and work effectively in a ward after pissing off the nurses, I challenge you. 

So yeah, in response to this question, NUMBER ONE: Always acknowledge that nurses are incredibly important in the functioning of a ward and also in the healing process of patients. Medicine is a profession where teamwork is fundamental, and patient health relies on strong communication between doctors and nurses who spend much more time with patients and so can report on what has occurred between ward rounds. For bonus points, you can also mention that nurses have a lot more responsibility in roles more traditionally considered the doctor’s. Some can prescribe medicine, participate in research and nurse specialists can even gain clinical expertise in certain fields.

HOWEVER: You want to be a doctor because it allows you to go a step further. While only some nurses can prescribe, all doctors can. While nurses who specialise tend to have clinical expertise in that one area, as a doctor you have been trained to have a strong grounding in all areas and so recognise co-morbidities, with the ability to continue even further in specialties and join the Royal Colleges which nurses do not have the clinical training to do. Nurses may get involved in and play an important role in research, but doctors are the ones who run and lead the projects. If you have an interest in surgery, you can mention that while some nurses are allowed to scrub in, they will never be running or leading the surgery. Doctors also have a responsibility to teaching their juniors, so if this is something which interests you, you can also mention that. Basically- you can’t say EVERYTHING, so pick whatever reasons truly DO make you want to be a doctor instead of a nurse. 

I hope I’m not too late in answering this, sorry but I didn’t get ANY notifications of inboxes and checked by chance to find a heap of messages.

I’d say the most common skills that you’ll need are your vital sign survey, primary and secondary survey and CPR. 

Advice

Be prepared: make sure you have all your necessary equipment, pens, a notepad, stethoscope, shears, PPE, penlight, ID, food and water, some study work and any other paperwork. In my notebook, I always print little copies of assessments, drug calcs and normal vital signs and glue them in the first few pages as a reference. 

Communicate well: Be clear with your mentors on what level you’re at skill and knowledge wise. Introduce yourself well and ask questions when you need guidance. If appropriate, ask questions while on calls to increase your knowledge.

Take initiative: Offer to help your mentors with things such as stocking the truck, checking gear etc. Ask to take vitals and do other skills for the practice. Obviously make sure you do this in the right situation, a cardiac arrest call probably isn’t the best time. Arrive early (20mins is my rule of thumb) and stay until everything is finished for the shift (most mentors will let you go on time where possible but it’s still good to offer). 

Talk to the patients: Again, where appropriate,  talk to the patient. Get comfortable asking questions, doing assessments (if your mentors are cool with it). This will be the biggest thing you want to be comfortable doing, as your communication and people skills are super important. 

THINK: On every call, go through the process. So when you get a call come in, think about what possible issues the patient might have and what assessments you would do. As you’re watching your mentors assess the patient, really try and follow the conversation. Assess the patient in your mind. Decide what treatment YOU would do. On the way to the hospital, mentally prepare a handover for the nurses. This helps develop your critical thinking. 

Use your time well: When at station, take some time to reflect on calls, take notes on anything you’re not familiar with. Spend some time practicing skills and studying. Make sure to relax a bit too, a 12 hr shift is long as it’s okay to sit back for 30mins and watch tv or whatever.