jenzmed

Child care is a mental health issue. I can’t help a client who works 80 hours per week to afford daycare, and doesn’t have the time or energy left to come see me. 

Drug policing is a mental health issue. I can’t help a client who ended up in prison because they got caught self-medicating with illegal substances. 

Police brutality is a mental health issue. I can’t help a client whose ‘anxiety’ is a very real and justified fear of ending up as a hashtag. 

Nurse: Doc, why don’t you wear make up to work?

Nurse: Doc, why don’t you wear make up to work?

I’ve had countless sessions and lectures on ECGs. I don’t know how many websites I have bookmarked, or how many times my eyes glazed over reading Dubin. I’m also terrible at cardiology. I was on my way to accepting my fate of being horrible at ECGs forever, until I had a life changing session on ECGs taught by a great ER doc. I want to post it here because it was probably the most useful thing I learned in med school, and it will stick with me for the rest of my career. 

WHEN LOOKING AT ECGs FOR THE FIRST TIME:

1. One ECG is never enough. Always get old ones for comparison. If none available, do another one. Because. One ECG is never enough. 

2. RATE. Look at the number on top of the printed ECG. It’s stupid not to use that number. Yes, you should know the rule, 300-150-100-75-60-50. People say you shouldn’t trust the machine because… well, it’s a machine, and it can make mistakes. This is true. I don’t like to look at their “diagnosis” until I have gone through it myself. But the rate is just a number. Plus you should be able to eyeball it and be able to tell if it’s tachy, brady, etc. If the machine is telling you it’s 200 and if it looks tachy, then it’s probably the right number. 

3. RHYTHM. Is there a p-wave for every QRS and a QRS for every p-wave? Is the p-wave upright in lead II and down in aVR? Good. Done. BOOM. It’s sinus rhythm. ***if you cannot clearly see the p-waves then you cannot call sinus. move on.

4. AXIS. Again, look at the number at the top of the page. If it’s between 0 and +90, then it’s normal axis. If the number isn’t provided, or if your preceptor doesn’t believe in the convenience of machines/technology, look at the QRS complex of lead I and lead II. 

up in lead I, up in lead II: normal axis

up in lead I, down in lead II: left axis deviation (most common causes are left anterior hemi block and left ventricular hypertrophy)

down in lead I, up in lead II: right axis deviation (most common causes are right ventricular hypertrophy…PE)

5. did someone say HYPERTROPHY?

look at V1

is the R wave tall? (greater than 7mm?) right ventricular hypertrophy.

is the S wave tall? (greater than 11mm?) left ventricular hypertrophy.

  6. P-waves

look at lead II

is it wide? left atrial enlargement.

is it tall? right atrial enlargement.

7. PR interval

should be between 0.12 sec and 0.2 sec (3-5 small boxes). I used to always get this interval and QRS complex (less than 0.12 sec) mixed up. Think: atria depolarizing + shit getting to ventricles is gonna take longer than ventricles depolarizing. [2 things happening] versus [1 thing happening]. [0.12 sec-0.2 sec] versus [<0.12 sec].

long PR interval means there’s some sort of block at the AV node. 

1st deg block. PR interval is long. everything else is normal. cool. 

2nd deg block

type I: PR interval progressively gets long. eventually a dropped QRS.

type II: PR interval is constant, but randomly dropped QRS. 

3rd deg block “complete block”

there is no association between P waves and QRS. they run separately. **QRS does NOT have to be wide. Just look for P wave/QRS complex disassociation. I sometimes get this and 2nd deg type II mixed up. The only difference I try to remember is that PR interval is constant in 2nd deg type II, but is variable in 3rd deg. 

8. QRS complex

narrow or wide? 

narrow: good. signal coming from somewhere above ventricles. 

wide: think BBB (bundle branch block)

LOOK AT V1 ONLY.

if the last deflection of QRS is DOWN, then it’s a left BBB

if the last deflection of QRS is UP, then it’s a right BBB. super easy. no more of this bunny ears crap. 

9. ST segment

always look from J point, and compare with the isoelectric line of T-P segment (NOT PR interval). 

elevated/depressed… STEMI… duh. indicates ACUTE ischemic changes. 

look for reciprocal changes of the heart. if ST elevation in lateral leads, could see ST depression in the septal leads. PAILS:

posterior up, anterior down

anterior up, inferior down

inferior up, lateral down

lateral up, septal down.  

LBBB can look like STEMI. How to tell?

disconcordant changes is normal. (QRS and STEMI on opposite sides of the isoelectric line.)

concordant changes is abnormal. 

massive discordance is abnormal. (STEMI is greater than 5mm)

this isn’t that important. Moving on. 

Inferior STEMI. Could right ventricle be involved? 

DO NOT GIVE NITRO DO NOT GIVE NITRO DO NOT GIVE NITRO.

order a 15 lead

is STE in lead III > lead II? likely RV involvement

INFERIOR MI? 15 LEAD NO NITRO

INFERIOR MI? 15 LEAD NO NITRO

INFERIOR MI? 15 LEAD NO NITRO

10. T waves

is it inverted? indicates recent ischemic changes. 

11. Q waves

is it significant? indicates old ischemic changes. will likely be present if followed rule number 1 of reading ECGs. (1 ECG is never enough= look at old ECGs). 

I literally go through this list of 11 points in my head when I’m reading an ECG, regardless of whether or not I have an atrial flutter jumping at my face or if I see a massive anterolateral STEMI. Obviously I needed background knowledge on ECGs and the physiology of the heart before constructing this list, but this basic checklist has been very, very useful to me so far. It might look lengthy, but it doesn’t take a lot of time at all- a patient is not likely going to have all these issues with their heart. 

  Anyway. I still don’t love ECGs, but it feels pretty wonderful to be able to be able to evaluate it in a systematic manner, and get the theory behind interpreting the scribbles of an ECG reading. I don’t get these moments as much as I would like to, but it’s that crosspoint where my classroom learning actually meets real-life applications that gives me happy brain-gasms for days. I love knowing things and more importantly, knowing why.

Sometimes I look at my study blog and the studyblr tag and worry that we’re painting a too ‘perfect’ image. I really don’t want people to look at it and think ‘I could never be like that’. It must be easy to think that all studyblr’s are perfect straight A students - after all, what other kind of people would have a blog mostly devoted to it and post their pretty notes? 

But I really don’t want people to think that’s the idea. Ok, I’m a fairly well-known studyblr and have been around for a few years now. I’m not a perfect student, in fact far from it. I find my course really hard. I failed first year, just scraped through 2nd and 3rd. My overall decile is in the bottom half for my year. I sometimes have really bad study habits and procrastinate for ages. 

I also started my studyblr to motivate myself and hold myself accountable. And I’m just not motivated by unattainable perfection. 

I’m not a perfect student either - both in terms of grades and work habits. After 5 years of medical school, I still fall into the same trap of only studying the month before exams. Don’t get me wrong, I think cramming is a perfectly legitimate study method for some people. However, for me, knowing I can cram a pass in June devalues what I do/should be doing throughout the year. And it’s unfair to myself, as well as my future colleagues and patients. 

Source. A collection of Meddit resources and advice on what bread-and-butter topics interns would most benefit from brushing up on/memorizing prior to the beginning of their internship. 1) Fluids. How and when to use them, dosage, timing and other pearls.

Review of fluids (not how to use them per se) by Dr. Strong /u/ericstrong

Maintenance Intravenous Fluids in Acutely Ill Patients - NEJM.

Pretty thorough review of fluid management on openanesthesia.org

2) Nausea. When to treat, how to treat and at what dose.

3) Standard pn orders: pain killers, sleep aids and antiemetics aka how to reduce nighttime calls from nurses by 25%

4) “Reflex” antibiotic choice for routine inpatient infections.

http://www.bpac.org.nz/Supplement/2013/July/antibiotics-guide.aspx /u/ChristianM and /u/ive_been_up_allnight

5) Initial work-up and treatment of dyspnea. (more realistic to approach by symptoms as, unfortunately, you first have to diagnose whats wrong. E.g. heart failure, pulmonary edema, embolism, COPD, pneumonia).

6) Initial work-up and treatment of oliguria/anuria.

7) A sensible initial approach to suspected ileus.

8) Blood. When, how, why to replace.

9) Pain. Optimal management without inducing narcosis.

Managing cancer pain: Frequently asked questions: CCJM

10) Potassium. When, why and how to shift or replace.

A review on both potassium and sodium disorders by Dr. Strong /u/ericstrong (Not reposted in 12) hyponatremia but applies there as well) https://www.youtube.com/playlist?list=PLYojB5NEEakXVIAapcSEleP4doUdHVtld

11) Hyponatremia. Most common electrolyte disturbance, commonly mismanaged.

12) Resuscitation aka commit the ACLS algorithms to memory.

Current ACLS guidelines. https://www.acls.net/aclsalg.htm

Would love a video series, interactive cases etc.

13) Basic EKG interpretation.

Whole EKG video courses

A whole free youtube EKG video review course by meddit’s own u/ericstrong

An alternative EKG course that takes you through all the basics. This however has no free version and costs 96$ a year. The quality is amazing. Here are 6 basic sample videos on youtube. The paid course is available on http://www.ecgteacher.com/

I have to admit I haven’t used this course personally but his free youtube videos are on-point and he seems like a good teacher. Also behind paywall. Free youtube samples are here. The full course can be found here https://www.ecgacademy.com.

EKG video cases

Amazing case-of-the-week emergency medicine EKG videos on youtube by Dr. Amal Mattu

– If you like Dr. Mattu’s cases (and you most certainly will) he is still posting every single week on his new site https://ecgweekly.com. It costs 4 starbucks coffees a year and is going to save someones life.

Practice EKGs with answers

Watching videos isn’t enough, you still have to grind out EKGs to keep your game strong. Visit http://ecgmadesimple.com and http://ecg.bidmc.harvard.edu/maven/mavenmain.asp for this.

EKG blogs

I recommend signing up for some kind of RSS feed (e.g. https://feedly.com/) and subscribing to the following EKG blogs:

http://hqmeded-ecg.blogspot.is (Dr. Smiths ECG blog)

http://www.ems12lead.com

http://ecg-interpretation.blogspot.is

http://jhcedecg.blogspot.is

EKG resource libraries

Life in the fastlane has a nice resource to look up a specific EKG finding, criteria or concept.

http://www.practicalclinicalskills.com/ekg.aspx /u/collidge

14) Know when to order ABGs and how to interpret them.

Almost too detailed video lecture series on ABGs and how to interpret them by Dr. Eric Strong (/u/ericstrong)

Practice makes perfect. ABG interpretation generator. https://abg.ninja/abg

Bonus 15) Basic CXR interpretation

CXR video lecture course

Again, Dr. Eric Strong has an excellent video course for free on youtube

Step-by-step guides to basic CXR interpretation

The Radiology Assistant: Chest X-ray - Basic interpretation

Radiology Masterclass step-by-step basic CXR

University of Virginia’s step-by-step basic CXR

All inclusive resources

The art and science of thoracic imaging All inclusive resource for all things thoracic! Jokes aside amazing resource.

UPenns CXR learning website

Loyola Universities excellent CXR Atlas Most outdated look but amazing content.

Checklist approach to CXR

Bonus 16) Overnight o-shit-what’s-that Head CT interpretation

Midnight radiology: Emergency CT of the head

Anatomy:

1–> KLM for Gross Anatomy

2–> Snell’s Anatomy

3–> BD Churassia

4–> RJ Last

5–> Grey’s Anatomy

6–> Langman Embryology

7–> KLM for Embryology

8–> BD For General Anatomy

9–> Dissector

10–> Di Fore Histology

11–> Junqueira’s Histology

12–> Netter Atlas of human Aantomy

Folder link–> https://drive.google.com/open?id=0B3WdpdsqpX0LYV9KQ3lxY29FY28

Physiology:

1–> Guyton

2–> Ganong

3–> Sheerwood

4–> Sembulingam

Folder link–> https://drive.google.com/open?id=0B3WdpdsqpX0LdXlCSjdZM214dEE

  Biochemistry:

1–> Harper

2–> Lippincott

3–> Chatterjea

4–> Satyanarayan

5–> Stryer

6–> MRS Biochemistry

Folder link–> https://drive.google.com/open?id=0B3WdpdsqpX0Ld0o3WnhCR2VEczg

Pathology:

1–> Big Robins

2–> Medium Robins

3–> Pathoma

4–> Goljan

5–> Harsh Mohan Pathology

6–> Atlas of Histopathology

7–> Levinson

8–> MRS microbiology

9–> Microbiology by Jacquelyn G. Black

10–> Color Atlas of Microbiology

11–> Kaplan Pathology

Folder link–> https://drive.google.com/open?id=0B3WdpdsqpX0LYkRYdjFrTm5MR0U

  Pharmacology:

1–> Big Katzung

2–> Mini Katzung

3–> Kaplan Review

4–> Lippincott

5–> Pocket Katzung

6–> Rang and Dale’s Pharmacology

7–> Atlas of Pharmacology

Folder link–> https://drive.google.com/open?id=0B3WdpdsqpX0LMkE1UUVRZGwtTlU

Forensic Medicine:

1–> Simpson’s Forensics

2–> Krishan’s Forensics

3–> Atlas of Autopsy

4–> Atlas of Forensic Medicine

Folder link–> https://drive.google.com/open?id=0B3WdpdsqpX0LQXVwOGoyWnFSV2s

Ophthalmology:

1–> Jogi

2–> Jatoi

3–> Parson’s Textbook of Eye

4–> Kanski

5–> AK Khurana

6–> Atlas of ophthalmology

Folder link–> https://drive.google.com/open?id=0B3WdpdsqpX0LOHc5WVZMdkJjX2M

Otorhinolaryngology:

1–> Dhingra

2–> Logans Turner

3–> Color Atlas of Otorhinolaryngology

4–> Maqbool’s Text Book of ENT

5–> Clinical Methods in ENT by PT Wakode

6–> ENT at a Glance

Folder link–> https://drive.google.com/open?id=0B3WdpdsqpX0LaDY2a0lFNDlfTGc

Community Medicine:

1–> Monica’s Text Book Community Medicine

2–> Mahajan And Gupta Text Book of Community Medicine

3–> Bancroft’s Text Book of Community Medicine

Folder link–> https://drive.google.com/open?id=0B3WdpdsqpX0Lc1RCMml2NjhFNjA

Internal Medicine:

1–> Churchill’s Pocketbook of DD

2–> MTB Step 2 Ck

3–> Davidson Essentials

4–> Davidson Principals and practice

5–> Harrison’s Internal Medicine

6–> Internal Medicine USMLE Nuggets

7–> Internal Medicine on call bt LANGE 8–> Oxfords Specialties

Folder link–>https://drive.google.com/open?id=0B3WdpdsqpX0LeEFJNG5TMlc4eWc

Surgery:

1–> Bailey_love short practice of Surgery

2–> Churchill’s pocketbook of Surgery

3–> Deja Review of surgery

4–> Farquharson’s Textbook of Operative General Surgery

5–> Hamilton Bailey’s Physical Signs

6–> Oxford Handbook of Clinical Surgery

7–> Schwartz’s Principles of Surgery

8–> Macleod’s Clinical Examination

9–> Macleod’s Clinical Diagnosis

Folder link–>https://drive.google.com/open?id=0B3WdpdsqpX0LRFpFSG5hZ1pVWkE

Obstetrics & Gynecology:

1–> Case Discussions in Obstetrics and Gynecology

2–> Deja Review of Obstetrics Gynecology

3–> Obstetrics by Ten Teachers

4–> Gynaecology illustrated

5–> Gynaecology by Ten Teachers

Folder link–>https://drive.google.com/open?id=0B3WdpdsqpX0LMU1LRjFDa1FrbjA

Pediatrics:

1–> Nelson Essentials of Pediatrics

2–> Nelson Complete

3–> Pediatrics Review

Folder link–>https://drive.google.com/open?id=0B3WdpdsqpX0LUkdTQkVuNV92Yzg

Hey y’all! This post is aimed at people who are making the transition from textbook-based science classes to article-based science classes. Scientific journal articles are dense compared to textbooks and aren’t written with the intent to teach basic concepts but rather with the intent to expand scientific knowledge. It can often be very confusing to figure out what is going on. Here’s how I was taught to read them 10+ years ago and how I still approach them today. 

(I) After reading the title, start for real with the Results section. 

Why would you do this when you know the abstract will give you a basic overview of the study and the introduction will set the context? Because you want to be an active reader. You want to figure out what happened in this study in a way that makes sense to you rather than be able to parrot what the author’s say happened. This is the major difference between reading a textbook (where you need to regurgitate the information later) and reading an article (where you need to be able to intelligently discuss the content either in class or in writing). 

Look at the tables and figures first. Can you tell what the independent variables were? What the dependent variables are? What might the relationship between them be? What trends or patterns do you see? Depending on your style, it may be a good idea to mark up your document with this information or jot some notes down somewhere else. 

Now read the text part of the results. What parts of the figures are the authors choosing to highlight in the text? Are there any results buried in the text that you can’t connect to part of a figure?   

Now pause and think. What is the most important result of the study? Highlight where this appears in the text and figures. Remember that important doesn’t necessarily mean statistically significant! A good p-value doesn’t signify real-world meaning; you need to make that connection yourself. Take a moment in this step to notice what results still don’t make sense to you– no need to panic or write questions down yet because you haven’t read the rest of the paper. 

(II) Get the gist of the Methods. 

Chances are your professor did not assign you this reading with the intent to make you replicate the study. You don’t have to understand every sentence (or even most sentences!) of the methods unless you’re an advanced graduate student. You do have to be able to explain in layman’s terms what the researchers did. 

Particularly important questions to answer that can be found in the text include: What were the independent variables? What were the dependent variables? What variables were controlled for, either statistically or through researcher manipulation? What statistical methods were used to look for an association?  In health research, we use the acronym PECOT to deconstruct method’s sections.  

P = population– who was being studied? 

E = exposure– what variable were the researchers trying to determine the impact of? This might be an intervention (ie., a smoking cessation video) or something outside researchers’ control (ie., at least 5 years of daily smoking). 

C = comparison– who is the population of interest going to be compared to? This may be a formal control group (ie., smokers who were shown a video on handwashing) or something outside researchers’ control (ie., former smokers of a similar demographic background who haven’t had a cigarette in 5 years). 

O = outcome– what were the researchers looking for? This is also known as the independent variable. 

T = time– how long were participants/subjects tracked and when were measurements taken? 

(III) Read the Introduction. 

Now that you have a very good idea about the design and results of the study, you’ll be better able to understand the introduction of the study. The basic goal of an introduction in any scientific paper is to explain why the study happened. The background may give you some helpful context, or it may be redundant at this point. I typically don’t spend much time on the introduction except for the end where the study purpose/research question and hypotheses are usually written. Mark these in the text! You should already have a good idea of the study’s purpose from the methods and results. Here’s some questions you should answer internally or in your notes at this point: 

Did the methods align with the purpose? 

Did the results support the hypothesis? 

What are the scientific implications of these results? 

(IV) Read whatever is at the end of the article: Discussion, Conclusion, Reflection, Limitations, Research Implications etc. 

It is very important that you save these sections for last because these sections are where researchers tell you what to think of the results. You need to be prepared to critically engage with their interpretation of the results by already having your own. That’s what the three questions above are about! Of course, the discussion was probably written by multiple advanced scientists and you are but a lowly student. That doesn’t mean you should accept their conclusions without seeing their logic. As you read the discussion, think about these questions: 

Do the researchers think the results support the hypothesis? 

How are the researchers interpreting the primary results? [Bonus: what other interpretations are there, and are they mentioned?]

What do the researchers think the scientific implications of these results are?

What limitations do the researchers acknowledge, and how could those limitations be impacting the results?

(V) Synthesize it. 

Try to boil down everything in the paper to just a few sentences that an 8th grader could understand. Whether you think through it internally or write it down is up to you. I usually print out my readings and write my synthesis on the blank back page using the following sentences starters: 

The researchers wanted to know whether… 

They found that… 

This means that… 

Taking the time to write the synthesis and any lingering questions you have can be really helpful if, like me, you do reading far in advance of class and need a quick refresher to glance at before class starts. It can also be helpful for paper writing or exam studying later. Consider revising your synthesis after you participate in the class discussion or hear your professor’s take on the article in lecture. Don’t rely on the abstract– that’s someone else’s synthesis, not yours.

— 

I hope this was helpful!! Don’t feel bad if this process is ridiculously time consuming. I have spent probably 3-4 hours on a 5-page study before. The goal of science writing is to be as concise as possible, which makes reading short articles more difficult than longer ones. I am a graduate student at a top American university, and I typically read 9-12 articles per week this deeply. If a professor assigns more than 4 research study articles per week for a regular course, make sure they explain what students are supposed to be getting out of each article so you can target your reading better. Chances are, you can skip some sections and focus on coming to class with clarifying questions rather than a firm understanding.

Happy reading!!