bottle of tonic

the journey and ramblings of a fourth year medical student, heading into internal medicine. noun ton·ic \ˈtä-nik\   1. an agent, such as a medication, that is supposed to restore or improve health or well-being   2. one that invigorates, restores, refreshes, or stimulates physically, mentally, or morally.   Disclaimer: Any and all patient identifiers will be altered to protect patient confidentiality and ensure HIPAA compliance.

[bottleoftonic-blog]

Most bang-for-buck things every intern should know before starting inpatient wards

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

University of Virginia's guide to the Head CT

[thedisagreeabledoctor]

The Truth Behind Stereotypes

While preparing for my next patient I read in her previous note that she “..is a Vietnamese immigrant who works at a nail salon.”  I stifled a laugh as I recalled Dat Phan’s comedy bit on the Vietnamese taking over the U.S. one foot at a time.  I mentally scolded myself as I tried to dismiss my racist stereotype.  Yet, you cannot deny that this is one stereotype that frequently plays true. 

She smiled as I entered the room, remaining patient as I fumbled with the pronunciation of her name.  After exchanging pleasantries we discussed her reasons for coming in: a lingering cold and a skin lesion.  I noted that she had missed multiple appointments prior to this, failing to get follow up labs from over a year ago.  She blamed this on her busy schedule, caring for two children and working full-time.  For providers the chronically busy patient can seem as frustrating as the chronically sick patient.

Next we proceeded into her exam.  The stigmata for bacterial infection were conspicuously absent.  I described my findings to her, watching her mood deflate slightly when I explained that antibiotics would not help.  I continued to work my way down her body in a systematic exam, explaining as I went.  As I came to her hands I winced.  The skin was thickened, dried, and cracked.  My hands began to hurt in sympathy.

“Tell me about your hands,” I said.

She responded in deeply accented English that her hands became like this after working with the nail chemicals all day. 

“And do you like this job?” I asked.

“I hate it,” she responded.  I continued to inquire why, if she hated her job and it hurt her skin in such a terrible way, she did not seek other employment. 

“In my country I was a nurse.  But here I would have to start schooling over.  It would take twice as long because I would first have to take English classes.” She continued to explain that when coming over, many Vietnamese people worked in nail salons because that is where other Vietnamese people worked.  In other words, it was one of the few places they could get a foot in the door as untrained workers who barely spoke discernible English.  Suddenly the Dat Phan comedy bit seemed a lot less funny.

“Why come to the U.S.?”  I asked.  “If you were a nurse in Vietnam, why immigrate to a place with few job opportunities.”

Her answer?  She makes more here as a nail technician than a nurse in Vietnam, meaning she can send money to her family at home.  And being here gives her two teenage children a better opportunity for employment as they grow up.  In short, this woman gave up a job she enjoyed, to work in conditions she hates, in order for her family to have opportunities she never could.

Long after I wrote her note and sent her on her way, my Vietnamese patient lingered in my mind.  Interestingly, the more I thought the more I realized she did fit into a stereotype, although I had placed her in the wrong one.  Perhaps it is partially true to think that many Vietnamese immigrants are nail technicians.  But I think the better way to look at immigrants, in all flavors, is with the lens of selfless hope they often bring with them, rather than the employment circumstances they often find themselves in.  She, like the most tremendous among us, gave up her life goals in order to propel her family into a new socioeconomic class.  That to me doesn’t fit the image the media promotes for immigrants, but rather the image I think of when I see working class mothers struggling for their family’s sake.  And I think that stereotype, an example of the best that people have to offer, is a stereotype I can live with.