10 Things Med Students Shouldn’t Do

This is my first year of being a senior resident and it is only January; and yet I have seen all these things happen.

Sadly, this has all led me to the grim realization of why I got such good evals as a medical student: it wasn’t because I was some sort of social genius. (And yes, I really thought I might have been a social genius.) No, it was because I did not do the following things, ALL OF WHICH I HAVE SEEN WITH MY OWN EYES.

Seriously, if you don’t do these things, don’t worry. You will be fine. Your residents will love you.

  • Do not claim to be late to rounds because you had a “Cat medical emergency last night.” Unless your cat is dead. But even then…. maybe don’t use the phrase “cat medical emergency”.
  • Certainly do not voluntarily (and eagerly!) disclose that your “Cat medical emergency” consisted of “I thought my cat was constipated but he wasn’t.”


  • DEFINITELY do not follow that up with “So the vet prescribed him kitty prozac. And I couldn’t sleep because I was so worried about the side-effects of the kitty prozac, so I was late.” Believe you me, I would rather you had just overslept.
phone 2

No judgement for ‘kitty death’. Lots of judgement for ‘r/o kitty constipation.’

  • Do not respond to the attending’s hopeful query “So, are you interested in [our specialty]?” with “Eeeeehhhhhh…
  • If a 4 month old is mildly tachycardic, do not suggest obtaining orthostatic vitals.
  • When a patient is admitted with, say, an asthma exacerbation – and you have happened to read in a past note that they are undergoing long-term therapy for PTSD- it is probably unnecessary and ill-thought out to open with “Hi! I’m a med student! So… it sounds like you were raped? Like, last year I think the chart says? How is that going?”

uh no


  • If I go through your patient presentation with you twice before rounds, in the most open, non-judgemental of ways, asking you repeatedly ‘Any other questions?’ – it is in the foolishly earnest hope that in front of the attending the words “So.. they were born at 38 weeks… is that preterm? Sorry, haha, I don’t know what preterm is” will NOT come out of your mouth.

what is this jeez no text

  • I will point out to you that the healthy teenager with the urine output of “0.3 cc/kg/hr” is likely not saving their urine. This is a gift. I do this to HELP you. I do NOT do this so that you can present the patient to the attending as “Initially, we were worried about kidney failure. After a lot of thinking about it, we  discovered that the patient was not saving their urine. Doing this led us to rule-out kidney failure, which we were initially very worried about, as I said.” (WHO IS WE. I DON’T EVEN KNOW YOU.)
  • Do not demonstrate “Suprapubic tenderness” by helpfully palpating my uterus.
  • Seriously, just… hands off your senior resident’s uterus.


Thoughts From The NICU, PICU, and Nephrology:

  • The parking garage elevator at 6:05am is a comforting Who’s Who of other residents who don’t have their shit together.
  • Strive to write the kind of H&P that, years from now, will still be worth blatantly copying.
  • The NICU is the perfect place for people who want to spend their day doing only 1 thing really well. The PICU is the perfect place for people who want to spend their day bitching about the ineptitude of the floor teams.
  • The secret to a successful intubation: More anterior than that. Keep going. Keep going. Goddamnit, AS ANTERIOR AS HUMANLY POSSIBLE. There.
  • “So, wie es ist, bleibt es nicht” – Brecht
  • A good way to teach 4th year medical students without boring powerpoints is to teach them how to write orders.
  • Nobody is allowed to die without steroids.
  • Do not mess with: the pancreas. a cardiac baby. a grown woman’s precedex drip.
  • Just because you can rap the phrase “We think she’s hypertensive ’cause she’s volume-overloaded” does not mean anyone else will appreciate it.
  • Bad things happen when sodium runs amok.
  • Q4h labs will ruin your night shift.

“and oftentimes I am awoken at three in the morning by screams in the attic I’ll run upstairs, wrench the door open call out a warning (and try not to sound panicked) but my hammering heart hears the voices of spirits that tempt us, the scorn that they’ve spoken I’ll remember the sad frightened noises of an old friend who dreamt once of storms on the ocean

and black eyes looking up from below”

File Under “Med School Never Taught Me This”

So I’m getting an admit with a complicated history, right? One of those “__ year old male with h/o X, Y, and Z now s/p M complicated by A, B, and C with resulting D requiring M which is now s/p revision of X with resulting D who is now presenting with chief complaint of C ” patients.

Anyway, so that was fine. I have clinical skills. First things first – I carefully considered the most likely causes of C based on my extensive education in pathophysiology and instinctively deduced AHAHAHAHAHA aaaaah, haha nope.

sorry, can’t take myself seriously there.

Yeah, no, first things first – I looked up the most recent H&P in the EMR for reasons of borderline intellectual plagiarism.

As one does.

And do you know what I found, dear readers?

I found the following H&P, written by one of our illustrious fellows:

An H&P for this patient has been completed within the last 30 days. It has been reviewed and the patient has been examined with the following changes to the patient’s condition and exam: There are no changes in the patient’s condition or exam.

– Fellow McFellowton, MD

Followed by.. nothing. That was it.

That was the H&P.

infuriated silently

Absolute shoddiness. That fellow should be ashamed of himself.

(… small side-note: also, why can’t we do that? I DEMAND THE RIGHT TO BE SHODDY.


i feel like i can't say anything and you can say everything

No. This will not stand. So I’m just gonna write

“An H&P has been completed for this patient within the last 30 days. It has been reviewed and the patient has been examined. There are no changes with the exception that this time the chief complaint is diarrhea, but otherwise, you know, samesies.

– Action Potential, MD”

I predict it will go… well.

The NICU: My Own Personal Hell Is Repetitively Stabbing Babies.

It’s sort of the exact opposite reason of why I went into pediatrics in the first place. Because I like babies, damnit.

I especially like babies who keep their blood inside their bodies.

… unless I need said blood, in which case I like just clicking on a “lab draw” order, pretending the Magical Blood Fairy shows up and waves a magic wand, and – poof! – the results magically pop up in the EMR.

But my faith has been shaken: it’s hard to believe in the Magical Blood Fairy when you’re staring at your hand holding a needle the size of an invisible artery.

It’s almost as hard as then actually managing to draw blood out of said invisible artery.

this isn't working is it

no but i liked that you tried and that you know when to give up

My attendings are undeservedly optimistic.

Last week, my attending pulled me aside after rounds.

“Listen, I just want to tell you that you’re doing an AMAZING job. Maybe the best intern we’ve had all year. Really super job.”

“Oh, thanks.”

So that was clear: she was about to compliment-sandwich me.

I hate compliment-sandwiches.

“But… “

There it is.

“It seems you haven’t gotten an arterial stick yet.”

“Yeah, no…  I haven’t.”

“You have to have 3 arterial sticks as an intern, you know.”

“Sure, I mean – I’ve tried – a lot! – but I just.. I haven’t had any luck. Or maybe I’m not a procedural kind of person?”

I was hoping she’d nod and agree.

In the subspecialty I’m going into, I will not have to do art sticks.

It is inhumane to babies for me to continue to try.

These are all good reasons for her to agree I should just stop.

“Wrong answer. You’re going to get an art-stick this week.”


“You look like you don’t believe me. I really want you to believe me.”

“Ok. I’m… going to get an art-stick this week.”

“Good! Don’t worry, everybody goes through this. Once you get one, they’re ridiculously easy. This will be your week!”

It was not.

Every single new admit, the attending would give me an exaggerated head nod which was my cue to grab everything I needed, confirm collateral circulation, sterilize the wrist, expertly poke the baby… and…


… usually create a hematoma.

when you make a mistake

After so many failed attempts, I just don’t know what to tell my attending.

I can’t really say “I think the babies are going to unionize and file a formal complaint against me.”

I also can’t say “I know you really want me to get this. But I think I’m causing more harm than good. If you could just stop thinking of me as a competent person, I think every baby in the NICU would be happier.”

I mean, she’s trying really hard. She’s the kind of attending most residents can only dream of! She really wants me to have this magical experience where I get the ABG and then turn into an awesome medical resident who can do procedures.

She would be so goddamned happy if I could just STICK THE NEEDLE WHERE IT BELONGS.

self pep-talk gif

But no matter how hard I try, the evidence is against me: I seem to be the kind of less-awesome medical resident whose days largely consist of me antagonizing innocent newborn babies with sharp instruments that I am in no way competent at wielding.

… So, right: +10 points for efficiency, minus several billion for the growing daunting weight of the knowledge that I will be going to hell.

… perhaps we’ll call it a wash.

My Old Nemesis, The NICU: Part III

“Hi. I’m the new very, very late intern. Where should I be?”

I just didn’t want to get yelled at. I knew I could make it through the day if the attendings and NPs were just politely irritated with me, but if I got outright YELLED at I’d definitely start crying -, and if there’s one thing I’ve learned neonatologists have in common with surgeons, it’s absolutely zero tolerance for clinician breakdowns.

So that was going to be my order of priorities:

  • #1, Absolutely no crying, and
  • #2 demonstrate that, on the plus side, I’ve already had the month of hell that is NICU as an MS-4 and I at least know the relevant math and fancy acronyms and therefore am not too much of a burden and perhaps might even (hope to god) be useful.

It was go-time.

I had thrown on my scrubs while calling the chief resident (who, upon learning that I was not in fact actually dead, seemed just as disappointed as I was about it. Can’t blame him for that one: there’s probably a set protocol for dead interns. It must be less clear how to manage the dumb oversleeping ones.)

After almost locking the door behind me, I suddenly realized what I needed, and took 20 seconds to run back into the house just to grab a pair of thick, horn-rimmed glasses.

No, I don’t need glasses. I never wear them.

But if there’s one thing I learned from TV it’s this: Nobody yells at the girl with thick glasses. They just vastly over-estimate her IQ and general reliability.

Yes, it’s dumb, but that kind of over-estimation was just what I needed to pin my hopes on in order to not just succumb to my innate desire to write off the entire month and possibly also drive off a cliff.

The difference between

The difference between “Aw, poor girl – that’s a rough start to the rotation” vs “Irresponsible and needs YELLING.”

It might sound dishonest, but I was honest where it counted: when the unit secretary pointed me toward the neonatologists, I walked up and told them straight-up “Hi, I’m Action Potential, I have no excuse. I slept through my alarm. I know it’s inexcusable. What should I get started with?”

Apparently the answer was an ABG, a central line, and pre-rounding on 4 patients in the 30 minutes I had before rounds.

BUT! No yelling!

… Yay?

So, had I been allowed to do ABGs and central lines in medical school, we would be back in the territory of things I could conceivably do.

But I wasn’t.

So we weren’t.


On the bright side: I prerounded on everyone and managed to come up with plans that made some clinical sense and just generally didn’t suck.

On the shadier side: ABGs and central lines on infants weighing less than a kilo… whose parents trust you because you are wearing a long white coat and introduce yourself as a doctor before torturing their tiny, innocent baby in the name of “practice”…

The NICU and I just don’t get along.

I am beginning to think we never will.

My old nemesis, the NICU: Part II

So we’ve established that my NICU Sub-internship as an M4 left me with nothing but the strong, permanently ingrained sense that “this hell had damned well better be worth it”.

And it sort of was, in that I came to the NICU rotation as an intern already knowing all the lingo and TPN calculations. Which is half the battle! On top of that, I spent the weekend reviewing all the popular pimp questions, making flashcards, and preparing myself for battle.

I was ready. I was going to show those goddamned former residents that this former-M4 was, in fact, perfectly capable of being a NICU superstar and permanently erasing the bad memories of my NICU experience. That horrible M4 month of pain was going to be worth it even if I had to kill myself in the process.

All I had to do to shine, essentially, was show up.

So I carefully went through my 2 page set of alarms and selected the ones for 4:45, 4:50, 5:00 and 5:30…..

… PM.

fucks up consistently

Yes, I set my alarms 12 hours late.

So I awoke Monday morning, bleary and well-rested, to a strange sound.

It was like my alarm but my phone wasn’t making noise? I tried to hit my phone a few times but it didn’t stop. The noise was coming from OUTSIDE MY PHONE.

So I sleep-walked towards the horrible noise and found myself standing in front of my hung-up white-coat, picking up my pager out of the pocket.

Pro tip: If you find yourself waking up in the process of  staring at your pager, it never says anything good.


holy shit

what is this jeez no text

To be fair, that’s a bit of dramatic license. The page actually said “Just heard from the NICU that you are not there. Please call [chief cell phone] immediately.”

… but it doesn’t change the fact that my immediate reaction was “Shit, I’m not dead.”

if i could breathe i would vomit

yelling into pillow aaaaaaagh

My old nemesis, the NICU: A flashback (Part I)

Some of you might remember the many subdued, nuanced posts I made in 2013 about how my NICU sub-internship made me want to quit medicine, quit life, become a hobo who hops trains for a living and never have to calculate a TFL or realize I forgot to write down a UOP or adjust 42 meds for the brand-new weight of +5 grams ever again so help me god.

fucks up consistently

But more likely none of you remember these NICU sub-I posts because, in looking back to link to them, I realize I must have deleted them all in a fit of self-awareness.

Regardless, it was in 2013 – and lucky for you I lack that same sense of self-aware professionalism 2 years later- so LET ME GIVE YOU A RECAP:

  1. My first day, I was given a “feeder and grower” baby who was supposed to be my simple exercise in NICU mathematics (calculating intake per kilo, counting apneas / bradys / destats, etc.)
  2. My first day, said baby had an eye exam and promptly decided to stop breathing, stop pumping blood, and just generally feign death. Which is apparently a thing that NICU babies like to do.
  3. My first day I was essentially somewhat convinced, for at least the duration of the code blue, that I had murdered the baby.
  4. Probably by failing to properly calculate the fluids/kg/hr.
  5. My second day, I had to present the above to a new attending (who apparently didn’t hear about the code on sign-out? What?) while the mother was in the room (What?)
  6. It was my first NICU patient presentation.
  7. It went poorly.
  8. The senior resident noticed and took me quietly by the hand afterwards to ask me what the hell I was thinking in trying to give a narrative account of what happened as opposed to just going by systems.
  9. You could tell he was disappointed because he literally walked with me for about 20 minutes just trying to find a place quiet enough to loudly voice his disapproval. That made it so much worse.
  10. It’s a little like when a delivery note describes a baby as “stunned”. I was ‘stunned’. I was out of my element. There was no placenta. There was only an angry senior resident speaking words I did not understand.
  11. I cried.
  12. a lot.

The rotation had a few ups on its way to a largely permanently downhill slide, but largely the only redeeming factor it had for me was that goddamnit, I did it. I left that rotation with a well-earned sense of THIS MAY HAVE SUCKED, BUT WHEN I AM ON NICU AS AN INTERN I WILL BE THE BEST NICU INTERN EVER.

i will take what is mine with fire and blood

The worst thing about my NICU sub-I, as a 4th year med student, was that you couldn’t overcome inadequate knowledge with superhuman effort: I tried showing up to pre-round 2 hours earlier, and I learned the hard way that it just meant that all of my calculations would be 2 hours behind everyone else’s. 

When you think about it, that’s just supremely unfair.

(“Uh, sorry, med student? you said the urine output was 3.2? It was actually 2.9. Try doing your math again” “Oh, but I calculated from 5am-5am…” “Well, don’t do that. It’s 7-7am. Because reasons.”)

infuriated silently

But again with the optimism: Most peds interns have no NICU experience when they start- but I had a full month! A bloody, torturous, terrible month as a sub-intern! I know what TPN is and what the abbreviations mean! I know that “trialing CPAP” means trialing off CPAP. I know that grunting is auto-PEEP, and I know how to ask insightful questions when the RT explains HFOV, which will never make any damned sense to anyone, sorry.

(it works by magic.)

the more you know


I started NICU again on Monday: but this time, instead of being the scared sub-I who cries when the intern berates me for reporting 4 bradycardias in 24 hours instead of 5 (“I’m sorry, this makes a difference in your management HOW?”) (<– is a thing I should have said) I will instead BE THAT INTERN.

i'm free 1

Also I don’t have a senior resident.

should i have

Also this may be the worst month of my life.

what have i become eh what are you gonna do

Last month of general peds as an intern

This is beautiful.

I can answer almost all RN questions in satisfying ways that include a confident explanation of the relevant physiology and discharge criteria.

On D/C day my scripts are signed, my follow-up appointments are made – and when attendings ask questions I get to answer “Yes, I thought so too, so I already called X and scheduled Y as an outpatient” and see said attending nod happily in approval as they make a little tick mark on their sign-out sheet.

Sign-out is quick and painless.

I finally understand that when we talk about ‘correction’ insulin it refers to sliding scale orders and not, in fact, carb correction. This is because the medical world is a goddamn madhouse.

This misnomer is still as dumb as ever, but no longer bothers me to the point where it keeps me up at night.

I emailed my new intern ‘buddy’, who is still currently an M4 and has matched here. She will take my place in July and I will get to finally work legit 80 hour weeks (and not the fake 80 hour weeks I’m currently working where seniors and chiefs keep asking me “WHY ARE YOU STILL HERE” and I have to duck behind a chair and respond “I’M A FIGMENT OF YOUR IMAGINATION finishing up my work. I’m not DOCUMENTING it. Shoo. I’m imaginary“)

My new intern buddy doesn’t know what she’s in for.

She’ll have fun though, I think.

I mean – I have, so far.

It’s been a good year.

Newborn Nursery

… is the closest medicine will ever get to an assembly line.

Sure, I have a certain appreciation for how evidence-based newborn medicine is: The NRP algorithm (the process we go through with neonatal resuscitation) is rock-solid. The science is satisfyingly pure physiology. There is no Past Medical History. If the baby so much as blinks at you funny, you simply send it to the NICU for a rule-out sepsis work-up.

And the answer to 99% of new parent questions is “Ah, that’s perfectly normal newborn behavior. Your baby’s body is just trying to figure out how to adapt from being in a dark swimming pool to being in the outside world.”

… literally, that’s pretty much the stock answer I use for almost any parent question.

Sure, I like to change it up a bit sometimes – for newborn congestion I’ll say that it’s the baby’s mucous membranes that are getting used to air instead of water… for erythema toxicarum I’ll say it’s the skin cells… occasionally I’ll have to talk about in utero positioning or birth trauma, sure, but… largely, everyone’s simple.

In fact, I’m getting this weird phenomenon where I really enjoy nurses stopping me in the hall to ask me questions. There’s no dread! No sinking stomach feeling! No problem I cannot solve with stock answers!

No matter what the RN asks, the answers are always so clear! It’s so different from general peds! It’s either

  • “Oh, really? Let me take a look and then we’ll notify NICU.”
  • or “That much weight loss? I’ll go talk to Lactation.”
  • or “OK, I’ll put in the order for bili lights.”

And newborn exams are beautiful. Sure, sometimes, when the census is full, I wish I could just line up all the babies in the hallway and do a slow-mo run down the hallway high-fiving all their anterior fontanelles (“Soft and flat! Soft and flat! EVERYBODY’S SOFT AND FLAT! And I’m done with pre-rounds.”)  to improve my efficiency, but usually I’m okay with going to their rooms individually.

I guess the biggest problem is that newborns are essentially just fat irritable potatoes.

I really miss being able to make faces at babies old enough to laugh or mimic my dumb expressions.

I think I even miss the babies who are old enough to shoot me skeptical looks.

Mostly I just miss babies who are real, live, people.


(One more week…)

Peds Urgent Care

“My baby has a cough. Does he have ebola?”


“My son got this lump on his neck right with his cold, do you think it’s cancer?”


“Lovely presentation. Do you want to do any work-up?”


“What about a CBC, CRP, LDH, LFTs, Monospot, and CXR?”


“Okay, we’re going to get them.”


“Do you think this kid needs to be admitted?”


“We’re going to admit him.”


“It’s a soft call, but it’s a Friday, and I have 32 years of experience. This is where experience tells you if a child will get worse before he gets better.”


“Uh, thanks for calling me – most interns don’t remember to call the floor senior before a new admit – but I’m confused… Why are you admitting a totally stable kid?”

Because it’s a Friday. And my preceptor is citing his experience. So, you know.

“Okay. Does your preceptor have any idea of what we’re admitting him for?”

Well, either the lump in his neck will turn out to be a deep neck infection that will cause him acute respiratory distress and send him to the PICU, or it will not. So watch out for that.

“Thank you.”


“My baby is here for his well-child check.”

Your baby is blue.

“He is here for his well-child check. How many shots will he be receiving today?”

He will be receiving resuscitation. Incidentally, why is your baby blue?

“I will need a note for work. Saying that I was here for his well-child check.”

We are calling a code.

“May I have a note now?”

You may not.