this (future) med life

A compilation of chrome extensions and iOS + Android apps (some are paid and some are free)  °☆.。.:*・°☆

| For your computer |

fliqlo

momentum

lanes

clarity

embark

minimal clock

infinity

currently

polar clock

caffeine

f.lux

be limitless

leoh

dream afar

| For your note taking |

evernote

onenote

simplenote

somnote

iNotes

notability

notes plus

google keep

quip

inkflow visual notebook

jot

good notes

noteshelf

| For your to-do lists | 

wunderlist 

moo.do

todoist

habitica

trello

any.do 

priority matrix

do

glass planner

swipes

timetune

| For your planners + calendars |

myStudyLife

myHomework

sunrise calendar

google calendar

plan

sol calendar

| For your timing + focus | 

tide

forest

pomotodo

flat tomato

pomello

pomodrone

clearfocus 

tomato timer 

30/30

focusnow

tasks and measures

self control

stayfocusd

timewarp

cold turkey

atimelogger

writer’s block

| For your presentations |

prezi

powerpoint

emaze

raw shorts

powtoon

| For your storage | 

google drive

dropbox

| For your mindmaps + diagrams | 

mindmeister

lucidchart

goconqr

gliffy

google drawings

| For your tests + flashcards | 

goconqr

quizlet

flashcards+

anki

| For your writings | 

zotero

grammarly

hemingway

| For your health |

fabulous

plant nanny

safetrek

sleep bot

sleep better

to bed

nike + running

waterlogged

period tracker

weight loss coach

health mapper

medisafe

| For your inner peace  | 

stop, breathe & think

headspace

pacifica

noisli

sleepio

infinite storm

relax melodies

calm

sam

thunderspace

mindshift

taomix

i am

pillow

Dear rising MS3s,

Welcome to the big show - sorta.  Third year is this magical time where you are expected to know how to take care of real patients.  Rather than worrying about that, I am sure you are busy taking selfies with your white coat on and stethoscope around your neck while tweeting about how early you have to start getting up, #medschoolproblems.

This may come as a shock, but you are a clinical moron.  The sooner you accept that, the sooner we can move on to improving it.  I don’t care if you are coming off your 260 step 1 score, real patients don’t present with multiple choices.  All that score means is you are good at diagnosing and treating paragraphs of words, not people.  I am only saying this from experience.

When you start your first day on the wards you are going to realize you got pushed into the deep end of the pool, sans floaties.  Like someone truly drowning, you will be tempted to flail about, reaching out for anyone to save you.  Don’t.  No one has time to hold your hand, and you will quickly make people hate you if you constantly beg for advice/help/guidance, etc. 

Have no fear, I am going to give some tips to make the transition easier and help you look semi-competent.  Behold my list of life-saving resources for third year. 

1. Scut Sheets (http://www.medfools.com/downloads.php) - you will likely follow 1-5 patients while on the wards.  This sounds easy, but things move fast and you don’t want to be presenting old data on rounds.  Scut sheets allow you to organize your patient information in a way that is easily accessible and portable (iPads are great, but in my experience you can’t beat good old paper).  Further, the H&P sheets help to remind you of all of the things you need to examine/inquire about.  You don’t want to be the student who comes back to report on a patient with epigastric pain in whom you never examined the cardiopulmonary system.  Print a couple of each style to find one you like.

2. Stanford 25 (http://stanfordmedicine25.stanford.edu/index.html) - remember that time before step 1 studying, when you had to practice actually touching people?  That was called the physical exam, and you are expected to actually do that… on every patient… everyday.  Better refresh on it so you don’t look like a fool palpating the thyroid over the thyroid cartilage.  Go to the website, click “The 25″ button and see the 25 physical exam skills every student should know, along with detailed explanations.

3. MedCalc (http://medcalc.medserver.be)

Enough said.  Qx Calc is also worth downloading (http://www.qxmd.com/apps/calculate-by-qxmd).  

3. Journal Club (http://www.wikijournalclub.org/wiki/Main_Page) - I guarantee that during the year some jerk-off attending is going to ask you, “what is the best NOAC for atrial fibrillation?”  Obviously, like most, you will stutter because all you know to use in Afib is warfarin.  Then he or she will smile, knowing they have established their superiority, and tell you to look it up and do some sort of presentation.  Welcome to the best tool ever for such scenarios.  This wiki is run by a team of physicians who synthesize large trials into digestible snippets.  The app is well worth the money too. (The answer to the above question is apixaban, by the way, as determined by the ARISTOTLE trial; not that this scenario is based on a real event that occurred to me or anything). 

4. Smart Medicine (http://smartmedicine.acponline.org) - this app is amazing.  Seriously.  It is free to American College of Physician (ACP) members; and membership is free to students.  You should join just for this app.  This is much less cumbersome than UpToDate and will will make you shine when you present your assessment and plan (also, rumor is that DynaMed and ACP have teamed up to create an even more amazing tool that is coming out in August, also free to members).

5. Medscape (http://www.medscape.com) - this is an awesome resource that is free. Medscape is one of my go to apps for understanding disease pathophysiology.  Another feature, which most students don’t realize, is the articles on surgical procedures.  This is HUGE for your surgery clerkship.  You can read over the procedure, see relevant anatomy and know just enough to be one step ahead of this guy:

Plus you get updates on medical news, have access to practice questions, etc.  Get it, use it, love it.

6. Online Med Ed (https://onlinemeded.org) - aside from learning real medicine, third year is about preparation for the step 2 of the USMLE.  I advise finding a question bank and organized program to keep your studying on track throughout the year.  Enter God’s gift to med students.  This is one man and a mystical dry erase board that will make learning clinical medicine easier than cooking a Totino’s pizza.  And it is one of the few things cheaper than a Totino’s!   

So there you have it.  You now are better equipped for the coming onslaught of pimp questions.  My suffering is your gain.  Below I will list a few other apps I have used this year that were less important to my success.  Happy studying.

ASCVD Risk Estimator (http://tools.cardiosource.org/ASCVD-Risk-Estimator/) - I believe there is an app in the app store as well.

Anticoag Evaluator (http://www.acc.org/tools-and-practice-support/mobile-resources) - see the risk factors for coagulation

CDC vaccine schedules app (http://www.cdc.gov/vaccines/schedules/hcp/schedule-app.html)

Read by QxMD (https://www.readbyqxmd.com) - allows you to get medical articles directly to your phone using your institutional access.

Sensitivity and Specificity (http://lifeinthefastlane.com/techtool-thursday-055-sensitivity-and-specificity/) - link to the app and review 

I’m on cardiology right now, and yesterday the fellow taught us some basics for interpreting EKGs. The trick is the have a thorough algorithm and do it every time so you don’t miss anything.

Disclaimer: Obviously this is just a cursory intro so folks won’t look like complete fools like me- who, when asked to interpret an EKG, went into a cold sweat and said, “Well, it looks like the heart is beating.” Attendings do NOT like that.

INTRO

This is what a normal lead II EKG one beat reading should look like. TAKE NOTE LITERALLY EVERYONE STOP CALLING YOUR SQUIGGLY LINES HEARTBEATS IT IS WRONG GAAAHHHH.

Normal EKG.

What the various leads are monitoring.

1. Rhythm: Sinus or not- aka, is the SA node talking to the AV node correctly? Check in leads V1 and II- if there is a P wave before every QRS you have sinus rhythm. If this is not the case, you do not have sinus rhythm! A whole discussion on things messing up sinus rhythm will come when I have a better grip on it myself.

2. Rate: How fast is the heart beating- aka, how fast are the ventricles depolarizing? So EKGs are little tiny boxes in bigger boxes, right? There are several methods for calculating rate using the boxes, but the one that works for my brain is to count the big boxes between R’s and divide that by 300. So, 1 big box between R = 300/1 = 300 bpm. 2 big boxes between R= 300/2= 150 bpm. And so on.

In general, any heart rate above 100 is tachycardia, and any heart rate below 60 is bradycardia. These values may vary (ex: SIRS criteria counts heart rate above 90 as tachy). Normal heart rate is around 75 (exceptions include athletes- look up athletic heart syndrome)

3. QRS Complex: Wide or narrow- aka, is the Bundle of His bossing the ventricles around? Basically, a nice narrow QRS complex generally indicates the bundle of His is intact and operating how it is supposed to. A wide QRS complex indicates something is awry with the Bundle of His- could be an organic pathology, could be a medication side effect (ex: antiarrythmics, TCAs, quinidine, to name a few), could be an electrolyte imbalance (ex: hyperkalemia), could be other things.

4. Axis: Is the heart depolarizing the way it should- aka right shoulder to left nipple. I, personally, am still sorting out the axis system, and it’s hard to do in this format. The first, most basic place to start is checking if lead I and aVF are POSITIVE, meaning their QRS complexes go ABOVE the isoelectric line. If that is the case, you are probably ok axis-wise.

Essentially, lead I’s vector goes from left to right, and aVF’s vector goes from head to toe. So the average of those vectors is the general path of depolarization of the heart. You want the axis to be between -30 and +90.  So, if aVF is positive, but lead I is negative (the QRS is below the isoelectric line) that means it is going from left to right instead and would be classified as a right shift. Likewise, if lead I is positive, but aVF is negative, that means it is going down to up and would be classified as a left shift. There is soooo much more to axis interpretation, this is just a starting point.

5. Intervals: Again with the conduction system, it’s, like, totally important that it obeys all the rules every time. PR= <.2 seconds, or one big box QRS= <.12 seconds, or 3 small boxes QT= < ½ the RR interval

6. ST segment changes: checking for CAD- aka, is the myocardium getting enough blood/oxygen?  Since the folks in the South seem to consider butter a food group and know that if it can’t be fried it’s not worth eating, CAD is a huuuuuuuuge issue here. When blood supply to the myocardium is compromised, there will usually be characteristic EKG changes. Note- not every episode of angina/MI will have EKG changes though! - Inferior leads –> right coronary artery. - lateral leads –> circumflex artery - anteroseptal leads –> left anterior descending. Disclaimer: does not apply to everyone all the time, some folks have variant coronary anatomy.

So the EKG changes to look for must be seen in two contiguous leads, aka, two inferior leads or two lateral leads. - Ischemia (low oxygen) = ST depression or T wave inversion (EXCEPT T wave inversions are ok in leads V1 and aVR)

- Injury = ST elevation

- Old infarct/dead myocardium = pathologic Q waves. Basically that first negative vector (aka, the Q of the QRS complex) should never be bigger than one tiny box.

And, that, friends, is a basic algorithm for reading EKGs! There is a lot more, but if you follow these steps every time, you will look like a rock star on wards. Good luck!

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AS PROMISED, IT HAS ARRIVED.

What this is: ideas and tips from a soon-to-be R2 who has survived intern year to help you function as an effective intern so you can focus on the important things: caring for your patients, learning and growing as a physician

What this is not: an encyclopedia, a bible you follow to the letter. The Immutable Truth of Intern Year Reality. This is not going to teach you medicine. This is not geared toward a specific specialty; it is designed to be helpful to an intern starting in any specialty training program.

Where did the self-care part go? For every time I attempted to write it or sought folks to help me write it, I came to realize that everyone’s idea of self-care is different. The basic tenet of self-care in intern year is: remember that if you don’t care for yourself, who will care for your patients? So remember that you deserve and need time and attention for your sanity. And everyone gets by better when they help each other. 

“Everything will be okay.”

“You’re so strong!”

“Pain is what forces you to grow.”

“God has an amazing plan for your life!”

“God is using this for your good.”

“God just wanted another angel in heaven.”

“It could’ve been worse.”

“At least you’re still alive. At least—”

“Cheer up and stay positive!”

“Everything happens for a reason.”

“I understand what you’re going through.”

“Time to pray really hard and read more Bible.”

“God is using this as a wake-up call.”

“Be the change you want to see in the world.”

— and other motivational poster clichés.

Things I’ve learned to say in the hospital at the very moment of pain and tragedy (and even then, not every time):

“I’m sorry.” “How are you right now?” “I don’t think it’s wrong to be mad.” (Or scared, or hurt, or sad, or weeping, or uncertain.) “How can I pray for you?” “I’m always here.” Or the best thing: listen.

“your reaction is your own, and there is no wrong or right way to deal with this” “we aren’t here to judge” is particularly important if you’re dealing with a stigmatised condition. “we are going to do our best, and we are here for you and your family through everything” “it’s OK to cry.” “You don’t have to apologise for how you feel, your feelings are valid”. “I know it’s a lot to take in, and as soon as I leave you might have more questions.” followed either by instructions to write them down and bring them up next time, or to approach myself or the nurses If any new concerns come up.

Alright, Here are: 

Dr. Dre’s Top 10 Tips for Excelling as a Third Year Medical Student

1. Be on time!

For Christ sake, be on time! Every time. It is the most simple thing you can do but that simple thing becomes excessively complicated when you sleep a MAXIMUM of 4 hours a night on your transplant surgery rotation. Set 10 alarms if you have to. Don’t let being late be something that shows up in your evaluation. 

2. Always say YES! (to the dress)

I don’t care if it is a rectal exam, abscess drainage, fecal disimpaction, SAY YES! Your goal should be to try at least everything once. You don’t know you don’t enjoy prostate exams until you have done 10 of them. “No” is not in your vocabulary during third year.

3. Read up on your patients.

I prefer UpToDate, which I unfortunately have no stock in. Each patient presents an opportunity for learning. Try to read in real time after you have seen the patient, if there isn’t time, read that night. Not only will it help with your shelf exams but also impress those you work with.

4. Act like the specialty you are on is the one you are going to go into.

You are on urology, pretend to be the ext greatest urologist. You are on OB/GYN, you live and breathe OB/GYN. Getting into this mindset will: make you want to study more for that specialty, make residents and attendings want to show you more cool stuff and give you greater tasks, it will give you a true window into the specialty and if it is the right one for you.

5. Be upfront with your superiors “I want to do well on this rotation”

One of my best rotations, I started by telling the residents “Hey, I want to get honors on this rotation, let me know what I can do to get there.” Why be shy? What is wrong with wanting to do well. Let the residents know I wasn’t messing around. They challenged me and gave me constant feedback on my performance. Crushed it.

6. Let others know where you are going and when you will be back.

I hate hearing “Where is the medical student?” It is simple, tell the resident where you are going, how long you will be there and when you will be back. They can then tell you how to find the team when you return to prevent you aimlessly wandering the hospital halls. Or sending an annoying “Yo, where you all at?” page. I have heard from many colleagues who had evaluations read “Medical student was missing and unreliable.” Don’t let this be you.

7. If you don’t have enough to do help out with other residents patients.

On one of my easier rotations, I was so bored because my patients were not active. I wanted more to do. During rounds, I would listen to the “To Do’s” for the rest of our team’s patients and write them down. I would pick easy ones I could do quickly, Hey I can call speech language pathology for you, Oh I already looked at her urine bag, no blood.

8. Nurses can be your GREATEST asset.

Love them and respect them. They will really save your booty with your patients. They know more than you so listen to them!

9. NEVER EVER EVER ask if you can go home! 

This right is reserved for second semester 4th year medical students. instead, always ask “Is there anything else I can do for you?” I know I know, you want to get home, eat, study, sleep but this is the way it goes. Some residents are cognizant of your needs and let you go. they remember what it felt like to be in your shoes. Yet, some are just plain mean. Making me check a patient for hypocalcemia symptoms at 8pm at night!

10. HAVE SOME FUN!!!!

I’ll add my corollary to #9: Never question an offer/command to go home. If someone in authority (ha, let’s face it, you’re an MS3, EVERYONE around you is “in authority”) tells you to “go home, if you want, there’s not much going on, go on get outta here, I bet you have plenty to study tonight at home”… DO NOT ACT RELUCTANT, DO NOT BARGAIN (”well ok, if there’s no more consults this hour”), DO NOT ASK “ARE YOU SURE?”.

Just go. Be gone, already. These moments are rare in MS3, and you should grab them with both hands as you fly out the door.

In honour of impending changeover day, here are some tips I thought our new generation of juniors might find useful. Feel free to share your own… Before you start:

Get your paperwork, living accommodation and IT/security privileges sorted early. You don’t need that kind of stress.

Find out where the ward lists live.

Learn how your team’s list can be found and updated.

Invest in your wardrobe.  No need to be a supermodel, but after 4 days on call you are so bloody tired that the last thing you want is to be forced to wash the 3 outfits you have practically daily just to have something to wear. Smart dressing doesn’t have to mean expensive.

Wear comfortable shoes. Brogues or loafers are generally more comfortable than pumps, which are more comfortable than most heels.

The most comfortable things are either theatre clogs/crocs or plimsolls but the scope for wearing either is usually limited.

Sort your finances. Microsoft Excel is your friend.

Set up any of the necessary bills, taxes etc when you move.

Looking after yourself:

Don’t skip breakfast, even if you’re running late. The only thing worse than running late is still running late and being hungry on an endless ward round. 

Every time you sit down to write a discharge summary or re-board a drug chart, or some other paperwork, pour yourself a glass of water. Like a hydation drinking game.

There is always time for tea.

Learn where the hospital mess is. Often it contains food and drink paid for by juniors. 

You will be tempted to put off lunch so you can do ‘one more job’. Don’t. Routine jobs can wait. The only thing that should delay lunch is sick patients; everything else can wait.

Don’t be afraid to ask for help from your peers. Give help freely; if you see a colleague looking frazzled always offer to lend a hand.

If you have a needlestick, follow needlestick protocol and get yourself seen ASAP. This is very common but must NOT be ignored.

If you are sick, follow your hospital’s protocol for calling in sick They won’t ask you why (you can self-certify as sick for up to 7 days). Do NOT be a martyr! If you feel that terrible, you are not safe to look after other people’s lives.

If you are stuggling with things, you have mentors, tutors and peers. There are also nation-wide doctor-doctor support networks out there. Do not suffer in silence. Your mental health matters as much as your physical health.

Do not suffer alone.

Do not let anyone else suffer alone. We have one rule: nobody gets left behind.

For taking bleeps:

Keep a spare sheet of paper handy.Write down the number of all bleeps you recieve as soon as it rings. You may get more bleeps in a minute than your pager can hold.Answer them all in turn.

If someone bleeps twice, it is usually serious. Prioritise this call.

If they are still on the line so you can’t get through, call again in 2 minutes.If the person paging has walked off and their colleagues can’t find out who it is, don’t panic. They will page again.

Encourage the person on the other end to use the SBAR framework. They may be panicked; do not be mean!

Always ask for the name, hospital number, DOB, ward, observations and background before you hang up. At the bare minimum.

Triage your bleeps in order of piority; seeing a patient who may be septic is much more important than siting a cannula for tomorrow’s procedure.

You will sometimes be bleeped about silly things. People make mistakes; do not hold it against them.

It is acceptable to tell the nurses that you can’t do something non-urgent now (because you are with a sick patient). It is not acceptable to be horrible about it.

For ward cover on calls:

Many hospitals have a ‘ward doctor list’ sheet, or list document so that the day team and nurses can leave a list of jobs for you. Know how to find it.

Take a good loook at the list before you do any of the jobs.

Do any patient reviews first. You really should be paged about reviewing patients rather than it being buried on the list but this can happen.

Once you’ve reviewed any sick patients and dealt with them appropriately, you can move onto the less urgent jobs.

Check bloods around the time you usually expect labs to be back (in most NHS hospitals this will be in the early afternoon, assumingthey were taken in the morning. FBC takes around an hour if non-urgent, biochemistry takes a bit longer. Don’t waste time checking bloods too early.

Make sure all the wards known which bleep you are contactable on.

some hospitals employ night technicians to do things like taking bloods, cultures etc. Find out if yours does.

For sick patients:

ABCDE. Always.

Examine them properly; never treat someone you have not examined.

There is usually time to look through the notes. This is important, too.

There is an on-call safety reg. You will have senior cover; do not panic. All you need to do is ask for help. They have all seen sick patients before.

Most hospitals have an outreach team of critical care nurses who are excellent. Know how to contact them. Do not forget to ask at morning handover who your seniors will be and how to get a hold of them.

You can contact any member of staff through switchboard if you ask for them by name. They will put you through to their mobile. Do not be afraid of using this if necessary.

Your reg will want you to do as much as you can first. Assuming they are relatively stable, this means things like an appropriate level of oxygen, taking bloods/cultures, running an ABG and actioning anything it shows, starting antibiotics and fluids if necessary, and requesting blood if necessary.

It is usually a good idea to have done all the above before asking for senior advice, or they will just ask you to do it and call them back.

But if the patient is really sick, and you are worried they are in serious trouble, you can absolutely call them earlier.

Earlier is always better than late.if you think they are about to arrest, there is nothing wrong with calling an arrest or peri-arrest call. This is usally by dialling 2222 in most hospitals.

You will also usually have dedicated on-call microbiologists and haematologists which are contactable by phone. They are saviours.

Many nurses and HCAs can do bloods, run ECGs and generally save your life. They want to help; ask them nicely.

Make sure the nurse stays close whilst reviewing a sick patient; you may need all hands on deck. If you feel cofident you can do it alone, let them know, but don’t be afraid to ask them for help if necessary.

If you think it is urgent, let the nurse know; they are not mind readers and they have other jobs too. 

if there is more than one sick patient, make sure to get enough information from the referring nurses so that you can triage the order you need to see them in.

Let your med reg know if you have more than one sick patient to deal with at once; they or outreach may be able to see one of them sooner.

Essential kit:

clipboard folder containing all the paperwork forms you need to request things at your hospital. Whether it be bloods, investigations, reviews by other teams, etc.

A spare ABG or butterfly does not go amiss either.

plenty of black biro pens. By the bucketful.

spare continuation paper for notes.

cough sweets. Any kind of sweet.

Simple analgesics for yourself, and any of your usual medication. Set an alarm on your phone to remind you to take it regularly.

Sanitary products at all times.Stress can do funny things to the cycle.

pentorch

spare tourniquet

sachets of lubricant for examination purposes

a crib sheet with all the most important extension numbers and bleep numbers written on it. 

You may need to note down your GMC number

Door codes for all the clean utility/treatment/equipment rooms

the ‘induction’ app by Podmedics. Users upload all the extensions and bleeps from their hospital; very useful!