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June 22nd, 2011
01:00 PM ET
Why you should never go to the hospital in July
Anthony Youn, M.D., is a plastic surgeon in Metro Detroit. He is the author of “In Stitches,” a humorous memoir about growing up Asian American and becoming a doctor. Do not get sick in July. Why? You might die. A 2011 study published by the Journal of General Internal Medicine reported a 10% spike in teaching hospital deaths during the month of July due to medical errors. We call this spike “The July Effect” and we attribute it to the influx of new interns and residents. Typically, medical students graduate in June and begin their first year of residency training — internship — in July. This group of eager new interns invades the hospital to learn, care for patients, and make medical decisions. One problem. They don’t know what they’re doing. Like most interns, I arrived with four years of medical school under my belt, an M.D. after my name, and virtually no practical knowledge of medicine. Although I wore the long white coat of a doctor, I kept my pockets packed with condensed medical manuals that we called our “peripheral brains” to make up for the lack of knowledge held in my actual brain. Thank God for these manuals. Otherwise I would have been part of “The July Effect.” My first night on call. I walk down a dimly lit hallway toward my call room, the only sound the intermittent beeping of a heart monitor. Suddenly, a loud siren rings overhead. A nurse rushes out of a room right in front of me. “Call a code!” she yells to a secretary. The nurse looks in my direction and asks, “You’re a resident, right? I need you to run this code!” I look left, right, and behind me. Gulp. She’s talking to me. “OK,” I say, hoping that she hasn’t noticed that my voice has leaped an octave. The truth is, I’ve just finished orientation, which included a course in Advanced Cardiac Life Support, but I have not spent a minute reviewing the manual. Confession: I’m not feeling all that confident. I rushed with the nurse into the patient’s room. I see on the cardiac monitor that the patient is in ventricular fibrillation, the heart rhythm that immediately precedes death. Squeezing an oxygen mask, a nurse stands above the patient’s head. A second nurse runs medications into an IV. “What should we do, doctor?” My mind goes blank. I have absolutely no idea. I pull out my “peripheral brain,” flip to the section on “ventricular fibrillation.” Aha! Got the treatment. Cardioversion - commonly called electric shocks. [By cardioversion, I'm using a general term for restoring a heart to its correct rhythm. ] “Get me the paddles!” I say, my voice rising. The nurse shoves the paddles into my hands and sets the power to the appropriate level. “Clear!” I yell, and place the paddles on the patient’s chest. “STOP!” the nurse screams. She grabs my hands and moves the paddles to a different spot on the patient’s chest. One more second and I would have shocked his liver. “Clear!” I yell again, and press the defibrillation button. The patient jerks slightly and for an instant the heart monitor goes wild. Then it completely stops. We stand still, staring at the monitor for what seems like minutes, awaiting his new cardiac rhythm. Beep… beep… beep. Normal. He’s saved. I let out a breath of relief. Within seconds, several residents enter the room and take over for me. I gladly step aside. I go back to my call room, both exhilarated that I’ve saved a patient’s life and freaking out that I nearly made a mistake would have cost it. I’ve learned my lesson. I pull out my heart book and study it cover-to-cover until dawn. Everyone - even doctors, especially doctors - have to learn and train in order to become proficient. Interns start out as rookies, not seasoned veterans. Experience takes time. So if you have to go to a hospital in July, treat the new interns with patience and respect. Then check with your nurse to make sure they know what they’re doing. soundoff (2,421 Responses)1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 Next »Leave a Reply to judge advocate tactical staff officer course
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Get a behind-the-scenes look at the latest stories from CNN Chief Medical Correspondent, Dr. Sanjay Gupta, Senior Medical Correspondent Elizabeth Cohen and the CNN Medical Unit producers. They'll share news and views on health and medical trends - info that will help you take better care of yourself and the people you love.
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Nice article, but it concerns me that you hadn't even looked at the materials. Concerns me because I know you're not the only one.
I think tenured nurses should have more "say" than a brand-new resident in an emergency situation. My sister was a nurse for many years and has all kinds of stories of new doctors with chips on their collective shoulders, causing more problems than good. Eventually, thankfully, most of them get it.
Agreed! My mother is a nurse and has had many similar experiences. (However, she reports that in recent years the new residents have gotten a lot nicer about taking advice from the nurses.)
Once while suffering a nasty reaction to a bee sting, I had a "tenured" nurse try and give me a shot of epinephrine, in my iv line instead of im or sub cue. They all scare the hell of me!!!
Only one problem with your solution: the nurses aren't accountable. My wife is a medical resident (one of the good ones) and several times in her intern year went against the advise of long-tenured nurses... who were making decisions that would have killed patients. Had her confidence waned, and she followed the advise of the nurse, the nurse doesn't get slapped with the malpractice suit, she does.
It's all fine and dandy to say the nurses have been there longer, let them make the decisions, but at the end of the day, they don't have the training the doctors do, and all the responsibility for the patient rests on the shoulders of the person with "MD" after their name.
There's definitely a balance to be had and lessons to be learned here, but there's a reason nurses are not docs and vice versa. The real trick is knowing what you don't know or where your competence ends regardless of your station.
Having worked as an EMT, I can say the same is true for even "seasoned" nurses who have tried to tell me to do something that would literally kill a patient. I don't think you can make a rule like you're saying, people make mistakes, other people recognize those mistakes and correct them. Like I had to do with several trauma nurses more than once.
Just as many 'seasoned' nurses think they know what they're doing and really have no clue. And that's every month of the year.
This bit about having the long-time nurses having more say in emergency situations- Throughout med school all of my faculty told me the same thing- listen to the nurses- they've been doing this longer than you have. But as I got into residency I realized that the better advise would have been "trust your own instincts" I can't tell you how many times I've walked into an emergency situation and had the nurses give me exactly the wrong advise. But I stuck to what I knew and what I had studied and in the end made the right decisions and saved peoples lives because I trusted my own instincts.
There are nurses I trust completely. I know them. I work with them on a daily basis. But I've learned by experience that just because someone has more time doing something doesn't mean they have any idea what needs to be done.
And yes. There IS hands-on experience in medical school. Dr. Youn overstated the issue to make a point.
'The July effect' is old news, but makes for good headlines. It's still safer to go to hospital in July than it is to stay at home with a significant medical problem.
You really think nurses want this responsibility and the liability that goes along with it? If that is really what they want then they should go to medical school. Plus you don't want 2-3 people standing over a dying patient trying to agree on what should be done. One person runs the code – the physician. For better or worse, that is the way it should stay. Until physicians are replaced by computers...
To AK- Actually, RNs are held accountable. We can get sued for malpractice, and do carry malpractice insurance. We also can lose our licenses, just as an MD can. There is such a misconception about what RNs actually do. We are held responsible for everything with out patients. For example, among many things, if a doctor writes an inappropriate order, we are responsible for recognizing that and addressing it. If a doctor writes an order for a particular drug to be given that is detrimental to the patient, and I give it, when that case goes to court, its not only the doctor's butt on the line, its mine too because it is with in my scope of practice to know what the actions, side effects and any drug interactions of that medication are. I can not only lose my license, but I can be held liable for any compensation awarded to the patient by the judge. Don't discount what a good nurse can offer. Often, the nurse who has been working in his/her specialty for years has more experience and knowledge regarding that specialty than a first year resident who rotates through each specialty for a couple of months at a time. We all have a role in patient care. We are all professionals and are there to support each other and ensure our patients are getting the best care possible. The truth is that neither can work with out the other. Lets give both RNs and MDs the respect they deserve
edit: We are responsible for everything that happens with our patients, not "with out"
Let's not put down nurses, OK? It takes ALL of us to see the patients get well. It behooves you to listen to the nurse who's been there awhile. I had to explain compartment syndrome to a psychiatrist (not a resident) in order for my patient to get the pain medication she needed. I had to explain how gabapentin works to an oncology surgeon.
I - the nurse who spends time with the patient - am the doc's eyes and ears. I can't tell you what to prescribe or plan your care, but I can tell you what's worked for other patients I've seen in the past and what's going on with YOUR patient. I can tell you what symptoms I'm seeing, as well as what the patient has confided to me, but you have to interpret what that means, and how to treat it .To listen to me, though, you have to read my notes or make time for me on your rounds, and far too many of you don't.
I know not every nurse is as good as I am, and I know there are nurses far better than I am, but you have to listen to what we say; the patient will not tell you everything; either they forget or they think they are wasting your time.
Luckily, I'm in a position to choose the doctors I'll work with, and I have good ones who listen. If you're a doc, be one of those that listen. We are all better for it.
@AK and Ian The problem that you are describing is there are a lot of treatments that you learn in theory that will not kill the patient but MD residents are told will. I agree there are some nurses that don't have a clue but I'd trust a seasoned nurse over a new resident any day. They may not have the book background but you learn very quickly what works and what doesn't by seeing it done. As an EMT and new resident, you may know a little about a lot of things but you certainly are not an expert. Many nurses work for years in a department and become very good at knowing what (and what not) to do even if the "book" says not to. Most mistakes I've seen other residents make is to not due enough for fear of hurting the almost dead patient. Residents don't take very long to become very good. They just need the hands on learning curve just like everyone else.
"Then check with your nurse to make sure they know what they’re doing."
That's the most important part of the entire article.
I very much agree. My mother has been an RN for 30+ years and runs the show more often than not.
Sounds like the problem is really with Dr. Youn's medical education, as you correctly point out. Whose responsibilty is it that Dr. Youn "did not look at the materials"? He should be embarrassed that he put himself and patients in that position. Probably a good thing that he is in the "respected" medical profession of plastic surgery. But it also exemplifies another troubling point – the lack of practical experience that medical students and interns now receive. Because of the limited work hours, medical students and interns get precious little practical experience. We are more concerned about them being tired or stressed out than we are concerned about them getting an adequate educational experience. Dont just worry about July -worry about who is going to take care of all of us 20 years from now – with the lack of practical experience there will be no one that is really experienced enough. We are becoming over run with supposed "experts like Dr. Gupta and Dr. Youn that are more concerned with how their hair looks for the TV cameras in the morning, then what they actually learned from the sick patient they could have been following last night (except for the fact that they were not there due to the work hour restrictions).
You know, its a team effort. A nurse is not a doc and a doc is not a nurse. They have different roles but are on the same team. An experienced nurse raising a concern should be taken seriously and give pause. The same should be that if a beginning nurse is working with an experienced secretary raising a concern. they all work as a team and if someone with more experience raises a concern everyone should give pause.
This does not mean that the secretary should take the place of the nurse or that the nurse should be the doc. It just means everyone should work as a team.
As to the part about a hospital not having experienced docs...everyone has to be on their own sometime....and it will be difficult no matter when that time occurs. There is no way around it.
Someday physicians will be replaced by computers; but nurses won't.
How comforting. That hospital should be ashamed of itself for not having an experienced doctor around. This really bothers me.
July 4th Weekend....all the experienced doctors are gone
The same can be said for any holiday! I had an emergency c-section on New Years Eve. My scare is the worst I've ever seen! To this day, hubby swears something did not go as planned!
How will you produce these "experienced doctors" you speak of without letting them intern?
And who are the first ones to complain about how expensive Dr's are. It's hard to expect people to be around and the numbers of doctors going up when you are cutting salaries. Doesn't seem you can have cheap doctors and doctors who are around all the time.
Scary... but very funny! Will def buy your book, like the way you write. Good luck to all new interns... remember..LISTEN to your nurses.. many of them have been there longer and know a LOT more than you give them credit for... let down your guard and be HUMAN to each other. Good luck to all of you!
Maybe you just mis-stated what you meant–but you don't cardiovert V-Fib, you DEFIBRILLATE it. If you try to cardiovert, it won't work because when you press the "sync" button (which is what puts the monitor in cardiovert mode) it starts looking for "R" waves on the EKG to time the shock properly. In ventricular fibrillation, there aren't any "R" waves, just quivering, dying heart ("squiggles" on the monitor screen), so the monitor would not shock if you tried this.
Paging Dr Gupta
I'm glad he wasn't on my code
...maybe that's why the author went into plastic surgery! 🙂
I am a surgeon. Residency training is a harrowing experience (maybe for both doctor and patient).
At the same time this story is clearly exaggerated for effect. A 'code' would generally not be run by a resident on his or her first day. Resuscitation of a patient in cardiopulmonary arrest requires a lot more knowledge than where to put paddles; someone would be directing that nurse regarding which medications and what doses to place through the IV. An anesthesiologist would be called to put in a breathing tube, etc. This has more the feel of something out of the TV show 'ER' than a real event. Plus the shocks given for ventricular fibrillation are generally referred to as defibrillation and not cardioversion.
not in a short staffed hospital...especially in Detroit
I think you are forgetting who the audience is. He cant exactly quote from Harrison' s and expect them to keep scrolling down the page.
According to ACLS protocols, nurses can run a code until a doctor arrives as long as they are ACLS ceritifed. And we do run codes. That is why the protocols and algorithms are in place. Once the doctor arrives control is often handed over–though not always. In a perfect world the anesthesiologists are just a few steps away to place a breathing tube. In the real world you're bagging a patient for 15 minutes until the one on-call can get out of the emergent case in the O.R. In the real world, the nurses are the ones running the code until the hospitalists deem fit to arrive.
My family has always been told over the generations to avoid surgery in the summer. The heat makes infection more likely and more serious.
Twenty years ago when I was a paramedic, one of our local teaching hospital had us, the paramedics, teach the new interns how to start IVs, intubate and run a code. I finally asked why and the head ER nurse told me it was to subtly teach new interns that experienced nurses and paramedics knew more than did about actual medical care. It worked beautifully. The interns and residents treated us and the nurses with respect and they became MUCH better doctors than at the other teaching hospital across town.
Hey...at least he's honest about it! conversely you have older doctors "a.k.a. seasoned" who are more concerned about investments or golf outings or other junkets... they all PRACTICE medicine... key take-away is STAY OUT OF THE HOSPITALS!
Next time you have a life threatening emergency you can go to your local shaman, or chiropractics office instead of the hospital if you so choose.
The "July Effect", as it is referred to above, has been bandied about for decades. Nurses calling in sick more commonly to avoid the new interns. The study referred to above does do a comprehensive job looking at mortaily rates back to 1979.
However, every study has limitations, and none of the popular media outlets discuss these. First of all, this study looks at a 28 year composite of data from 1979-2006. There is no analysis of the individual years, or decade based trends. It may be that in 1979, prior to many of the currently existing safeguards that are in place, new interns may have contributed to a massive spike in deaths, and that data point could have skewed following years on average. The raw data for this is not available from the paper. Also, having sat on a hospital's Pharmacy committee, there are many more safeguards in place than there were even 3 years ago to prevent these exact errors.
Since 1979, hospitals have put multiple safeguards in at the nursing and pharmacy levels to prevent avoidable medication errors. Teaching physicians are much more vigilant over their students than in the 70's, 80's, and 90's. To extrapolate this data to draw conclusions about current teaching hospitals would be of dubious value.
Ultimately, a sensationalist media environment loves to publish articles about why you should be afraid...frankly, fear sells media time. I am a full time teaching Internal Medicine physician working at an academic community hospital...last July, I had no fear taking my wife into the hospital for a medical issue. I'd be much more afraid of media hype than a hospital in July. Is any hospital 100% safe? Absolutely not. A complicated system never is. Is it better than it was in 1979? Yes.
Well said
This is why my family always requests NO INTERNS on the intake forms and on notes to the nurses station.
Of course I see where such an idea comes from, but imagine a teaching hospital where the interns have to stand outside the patient's door while the residents and attendings evaluate and treat the patient. Yes, it might suck to be treated by less-than-stellar docs, but everyone needs to learn. If you don't want interns treating you, don't go to teaching hospitals. Keep in mind that some poetic license has clearly been taken here - nurses know exactly what to do for V fib, and like he said, the code team was in the room within seconds. Interns make mistakes, but supervision is fairly keen at most hospitals. I made a few mistakes as an intern; due to close supervision and maybe a bit of luck, nobody was hurt.
So go easy on the interns. They'll spend more time with you figuring out what's wrong than anyone else in the hospital, and they write the most legible notes.
Yeah... and then I am sure people like you go on to complain about the nurses and everyone else there as well... First of all, there are people who are not fully competent in every line of work... Nurses, techs, even doctors such as the author here who writes an article for CNN without checking when to you Cardiovert vs defibrillate (or maybe that was his state of mind at the time)... WHAT THIS ARTICLE NEGLECTS TO MENTION IS THE FACT THAT INTERNS IN JULY ARE THE MOST ENTHUSIASTIC ABOUT PRACTICING MEDICINE. THEY MAYBE LEARNING, THEY MAY NOT UNDERSTAND EVERYTHING THAT IS GOING ON BUT THEY MAKE UP FOR IT BY GOING OUT OF THEIR WAY FOR PATIENTS.... Everyone in a hospital knows there are plenty of "I have been doing this for 20 years" nurses who are far, far more dangerous and incompetent than interns... Everyone has to start at some level in there jobs.... I would rather have someone who makes up for the fact that they are new by showing more interest and care for me then some nurse or tech that think they are better than anyone else because they have been doing this for 20 years!!!!!
i wish docs could respond with "NO CRONES" for patients like you who show up
Now that's not fair. The interns are excited to be there and will work hard to take good care of you. As long as their decisions are passed by a supervising physician first, you should have no problem with them. Besides, the attending MD should still be periodically examining you as well.
As for the comment about "experienced nurses" – it is true that some older nurses do not bother to keep up with new trends in medicine (which is ALWAYS changing) and can therefore have outdated thinking and practices. I have worked with some of these, and they are "stuck in their ways." This is unfortunate, because in medicine, yesterday's gospel truth is tomorrow's mistake. For instance, MDs used to think stomach ulcers were caused by "Type A personalities" – until research proved 90% of them are caused by a bacterium. Continuing education and flexible thinking are critical for doctors and nurses alike. – an NP
The last I knew you defibrillated ventricular fibrillation, not cardioversion.
Dr. Youn, Why can't anything be done about this situation? Is this the case in other countries? It doesn't seem like it would take reinventing the wheel to do better.
This is why holier-then-thou doctors (specifically new residents) need to respect nurses more. Nurses that might have been there much longer than you who knows what they are doing. Doctors tend to hold little respect for nurses because...ahem...they're a Doctor
Funny story.. having been an EMT, I have been involved in several codes myself. These sort of happenings are typical for new doctors and they have to learn somehow. I could not agree more with being nice to nurses.... they do run the hospitals and are better educated and better prepared for emergencies then we know. They have an extremely tough job – so give them some love!
Mrs. Late Bloomer, obviously I respect your desire to obtain the best possible medical care for yourself and your loved ones. However, if every patient requested NO INTERNS, how would doctors in training ever gain the skills and confidence to become successful attending physicians?
why do you think the attending physicians like to take the first two weeks of July for vacation!
To avoid their responsibility to education and their patients? Hopefully, any responsible attending physician will keep close track of their patients and their students to make sure that mistakes are avoided...if it means more 3am "how much Tylenol do I give" calls from the interns, well, that is our mandate and privilege.
Also, July is a popular time off because A) kids are home from school and B) hospital patient volumes decrease (in general) over the summer.
Now that's just irresponsible.
I avoid hospitals at all costs except for maybe a broken arm or leg. My mom worked for doctors for years and told me stories about doctors leaving swabs inside patients, cutting of the wrong limb, operating on the wrong organ, etc. Iatrogenic diseases caused by being in the very toxic hospital environment is also a very real and frequent occurrance. More than 90,000 people die every year from errors committed in hospitals. Go to a hospital? NO WAY!
This is one of the great urban myths of medicine. While interns are "new" on July 1, they have had training during their 4th year in medical school as "sub-interns" where they assume the responsibilities of the intern with more oversight. Also don't forget that they have 4 years of medical school training to prepare for a careeer to which they dedicate our lives to. While it may make other hospital staff (the majority of which are experienced and knowledgeable) feel better about themselves to belittle the new MD's, the interns are enthusiastic, well taught, and intelligent womena and men. As an attending physician, I look back on my intern year as a privilege and with a great deal of pride.
I would also add that Dr Youn's statements about interns "not knowing that they are doing" and forgetting to read the ACLS manual makes for a good humorous article, but any doctor who feels this is acceptable on the job should think twice about their career choice.
Ridiculous. Quite a funny story but people don't need to know this. You did just what you should have done and that was exactly all you should say if someone where to ever ask.. People's opinions of doctors are allready at an all time low. This kind of story doesn't help.
Not only that but you defibrillated the patient. You didn't cardiovert him.
No hands-on, application, or synthesis in med school? So for 7-12 years med students read textbooks? Unreal.
And how many people's doctors have asked them, "Do you mind if a med student examines you?" And the first thing the patient says is, "NO WAY!!!"
And, of course, the doctor has to respect that. So the med student misses out.
Whenever my doctors have asked if a med student can take a look, I always say yes. How else will we have good doctors in the future?
Where did you get this impression of medical school from? First of all, medical is 4 years prior to the start of residency. The first year of residency is referred to as the "intern" year. During medical school, medical knowledge is gained from reading, anatomical dissection, and direct patient contact. Most medical schools have embraced simulation either with real people or simluators to teach the physical examination and clinical history taking. The "intern" you encounter on July 1 is a far cry from the caricature portrayed in the article above.
I would say there are tons of variables that come into play. Getting to a hospital at the same time as a shift change can also affect an outcome. Wires get crossed, communication fails, someone doesn't follow through on something. Then, maybe they're shorthanded and a lot is going on at once. It becomes a triage situation and maybe you're at the bottom of the heap. And we all put a lot of trust and faith in health care professionals and expect a lot from them, but in the end...they're human beings, capable of making mistakes...just like anyone else.
Sometimes, a resident is the best possible doctor you can get. Why? Because older doctors are so stuck in their ways, and might not be willing to consider things outside the box.
Take my case. I was 29 years old, running low-grade fevers daily for weeks, joint aches, exhaustion, memory gaps and mental fog. Generally healthy otherwise, with a good body weight, in good cardiovascular condition. The regular doctor said, "It's mono," despite the fact that I tested negative for mono... and my thyroid and other basic tests came back perfectly normal. I kept getting worse.
Then, a RESIDENT looked a my overall symptoms one day when I went back in and the regular doc wasn't available. He ordered an ANA (anti-nuclear antibody) test. It was the first thing that came back positive. He ran all the follow-up tests and sent me promptly to a rheumatologist. The diagnosis? Rheumatoid arthritis.
The regular doctor would have left me waiting and suffering for ages (because they can't possibly be wrong – it must be mono), possibly until I started developing long-term damage from the condition. The resident was willing to think outside the box. I'm doing much better now, and my GP is a resident (about to finish her residency now) who listens to me, puts the clues together, and takes me seriously. What more could I ask for?
Don't discount residents. Some of them are brilliant. Sure, they need experience, but how else will they GET experience?
I'm an NP and I knew your diagnosis before the test was mentioned. That first doctor was an idiot.
All residents must be supervised by a senior physician. This guy was not as alone as he wants his audience to think.
Nurses... Making sure doctors dont kill you.
I've had the pleasure of running a code over shift change, and watching all the nurses running the code with me switch out to go home. Dedication, but to what exactly?
Q: Anyone know how to say "Up Yours" in (Tagalog) Filipino? A: "Right away Doctor"
Great.....a friend is in surgery today and I have to have surgery in Aug. So reassuring!
thx dr. youn for throwing all your rookie colleagues under the bus! yes, interns are unseasoned and are learning as they go along, but an intern will not kill you, in fact i've never heard of or seen an intern running a code on their first day, that never happens. part of the leverage interns have to practice procedures and medicine in general is not revealing to every one of their patients that they are a brand new doctor, that just makes everyone nervous which in turn makes the intern uneasy making it more likely that he/she will mess up. writing this article and telling everyone to avoid the hospital, in july, be it in jest or not, might in effect cause more people to refuse treatment by interns giving them even less experience to one day become "seasoned" or "well qualified" docs as some have put it. many "veteran" docs in emergency situations such as pathologists, radiologists who are caught walking around in a hospital unsuspecting like the intern in your story would have fared far worse. also all the people commenting that they would not let interns take care of them at the hospital should be ashamed of themselves, go instead to a private hospital, if you're want to go to a teaching hospital expect to be cared for by residents. and for all the holier than thou nurses, get real, interns are taken advantage of by the supports staff and more worked is dumped on them because they don't know any better their first few months in the hospital, why do you think by their second and third years in residency they become bitter?
I think a more even-handed and accurate representation of most situations is that interns, residents, nurses, attending physicians and support staff all have a lot of work to do and a lot of responsibility and would be better served helping each other to help patients instead of engaging in skirmishes about who knows more or works harder.
i already dont like doctors. this scares the living @#$% out of me! im a US Marine. when there are brand new guys we call them boots. boot is short for "Barely Out Of Training" and they dont know anything. same goes for the brand new LTs. we joke and say "whats the difference between a PFC and a 2ndLt? the PFC has been promoted!" its not a joke. the new LTs dont know anything and yet theyre in charge. thats what this reminds me of. a bunch of new guys who have the world in their hands yet have no experience. thankfully, like the nurses to the new doctors, the new LTs have a bunch of seasoned (especially these days) NCOs who make it work. time and experience is what it takes. the doctors will get better only if they listen and work. maybe it goes for everything out there.
well no one was born running. gotta learn to sit, then stand and then walk
FYI for anyone who read the article.......You don't cardiovert someone who is in VFib. You DEFIBRILLATE them.
I'm calling BS on your story. You are full of it. I hope your 'life saving' story makes up for your personal feelings of inadequacy. Which is probably why you went in to plastics in the first place. If you wanted to write a story about intern medical errors, maybe you should have told the story about when you did mess up (more likely to be the truth) and the outcome of that mistake. I am certain that Dr. Youn made much more serious mistakes during his intern year and even after, we all do. Everyone should know that in July, and throughout the rest of the year, interns are under the instruction and watchful eye of more senior residents and attendings. The worst thing that an intern can do is not ask for the help from a more senior physician, or nurse or whomever. The fact of the matter is you did wrong in this instance and you have yet to acknowledge it this many years later. You never asked for help- you didn't have the knowledge or experience to do what was needed and instead of proceeding in the manner that you should have- you BS'd your way through it. You have perpetuated the myth that asking for help is a sign of weakness, and this will continue the rate of medical errors. You, again, are full of it.
Agree. I don't even think this is a true story.
Next CNN headline...'Why you should never go to the hospital on the weekend."
This is true. My wife right eye suddently closed. I took her to ER, the she was hopstialized for many days. The resident doctor had no clue. She was taken the MRI, found nothing. Then she was asked to take the liquid from the spinal cord. The resident took this test. Now her eye is still closed and has so much pain on head and on right leg. She can not walk due to pain. Her medical condition got worst since the doctor in ER has no idea what they are doing. I have to take my wife to other country for cure.
First, a code involves a person who is dead or has just lost vital signs. I tell my new residents to relax and fall on your training and be aggressive because you cannot make a mistake on a dead person. You can only "win" in a code situation. A "failed" code results in a dead person remaining dead. Don't shock someone with a pulse is a pretty universal rule with few exceptions. Other than that, go for it and don't put the weight of the patient's survival or death upon yourself - no one is that important or powerful to completely alter the outcome of a code. They were dead before you came into the room or else the "code" would not have been called. Oftentimes, the patient has been dead for an indeterminate amount of time before the nurse or family notices that they aren't breathing or responding. Best thing to do when signs of rigor are present is to pronounce the patient and console the family.
Furthermore, most patients in the hospital should be "no-code" anyway. This is a huge failing of our primary care doctors and internists who are supposed to have this "close, personal" relationship with the patient and family. If so, that should include a frank discussion of end-of-life measures BEFORE the patient ends up in the hospital so that the patient's wishes are CLEAR TO ALL before the last few conscious (maybe) seconds or minutes of the patient's life is spent with a team of people crushing their ribs and sending 360 joules of electricity though their chest over and over again.
CPR and defibrillation are techniques designed to rescue patients from traumatic injuries, acute anesthetic reactions, and acute cardiac decompensation and arrhythmias. These are true "saves" and oftentimes, these patients leave the hospitals and lead quality lives.
CPR is NOT designed nor does it work effectively for: terminal cancer patients, renal failure patients, patients in with pneumonia and end-stage COPD who are at the end of their ropes - so sick that their hearts stop or fibrillate. These people may not die immediately after a code, but they often don't make it out of the hospital and frequently die within days to weeks after suffering from broken ribs and endless venous and arterial sticks for lab that is ultimately worthless for them because it has NO EFFECT on their outcomes. They are just as dead 2 weeks after ICU care as they would have been if the doctors and families had had just a little more common sense and foresight. Only difference is that you can GUARANTEE that they suffered and added more cost to the already bankrupt system. Congratulations, doctors and families. Good save.
I fully agree that new doctors (and older ones too) should treat all health professionals with equal respect and be willing to shut up and learn from other people's experience and knowledge.
You're still safer in most any hospital in July if you are seriously ill or injured than trying to take care of yourself at home. I think to tell people to not seek medical attention simply because it is July is a disservice.
I shocked someone with a pulse last night. It's called cardioversion and is the treatment of choice for unstable V-tach and other tachy-dysrythmias that don't respond to medical therapy.
Furthermore, most patients in the hospital should be "no-code" anyway.
This is an idiotic statement.
Yes, young lady, I mentioned that there are few exceptions. Attention to detail, please, before smarting off.
30year nurse: I agree. Dumb. Should have said, "Most seriously ill patients with chronic, irreversible disease..."
Certainly don't mean that the routine post-op or Peds or OB patients should be no-code. I agree with you. Idiotic. My bad.
Not trying to smart off, just totally disagree with you.
You make it sound as though everyone in the hospital is near their end-of-life. That's absurd.
And you most certainly can make a mistake on a "dead" person. The wrong drug can guarantee the failure of a resuscitative effort. It concerns me to think that residents are being taught not to worry about the code victim because they're already dead anyway. smh.
Okay, we were cross-posting. That is a much better wording. Thank you.
Yes, 30year. Of course the patient who codes can be mismanaged. Most new residents are terrified in their initial code situations and often fail because of that fear of messing up. What I attempt to convey to them is that the patient who is being coded is about as messed up as possible. Relax and utilize the training that you have been given and relieve yourself of the delusion that the patient's life or death is solely in your hands. I've had countless residents comment back to me that in the heat of battle of a code blue, they have harkened back to my simple advice and it has helped them.
Sometimes, in these back & forths comments it is difficult to convey the true meaning of what is written down. Of course I am not some ogre who dispenses medical care without compassion for the patient. Quite the opposite. I think that I have had so many episodes of being involved in a code where the team exhausts every option and themselves physically and emotionally, ultimately failing and then the family responds, "Well thanks, but he didn't really want any heroics at the end of his life."
To which you want to say, "Well why the hell didn't you say so BEFORE he quit breathing???!!!" This is the failure of the system and doctors in general to have the balls to have a "heart to heart" discussion about the end-of-life issues with the patients and make darn sure that these poor elderly people are not tortured during their last moments or days on earth. In my haste, I over-generalized to make the previous "idiotic" statement that you rightly corrected me.
My Internal Medicine preceptor determined CODE or NO CODE status for every admission. The NO CODE patients had a little happy face sticker placed on the outside of their chart. Why happy face? She said it was to remind us that the patients had considered their options, and were comfortable (happy?) with their decisions.
And if the sticker fell off it was better to code a NO CODE patient, than to NOT code someone who wanted it all done for them!
Well said.
The problem with discussing codes with families is that many of them are paralyzed by that decision. They would rather "let fate decide" than take on the responsibility of making a choice for their loved one. Also, docs seem to fear that if they bring up the whole "death" issue upon admission, it will scare the patient into thinking that coming into the hospital was a bad idea.
I hope he thanked her/him.
i remember when i was a kid i broke my arm during the summer and needed emergency surgery in another country, Canada. The hospital insisted on having an intern do the operation. He would've hacked my arm off. Good thing my parents graduated from medical school in Canada and had quite a few connections with the hospital. They got the Chief of Surgery to do the operation on me and prevented me from becoming a victim of the July Effect
@ ranier–nurses are accountable, sweetie. I work in healthcare. They are licensed in whichever state they work in. And if they don't adhere to the standards of practice/scope of practice, they can very well loose their license.
The data for the conclusions are based on thirty years of data. The culture in medical training has changed significantly. Residents and interns have much more supervision than even 5-10 years ago. Residents have work hour restrictions and now even supervision requirements. An attending surgeon will clearly not allow a fresh intern to perform any part of a major operation. In major teaching hospitals there are always higher level physicians "in house" at all times.
A hospital is no place for a sick person.
This is another example of why there is so much distrust in the medical community. To the plastic surgeon who posted this article, as many have pointed out, you have shown your persistent ignorance with this "code." As a "seasoned physician" please use currect terminology when publicly speaking since all the answers are on the internet. Furthermore, you have been though at least 7 years of post-graduate training and apparently still confused. I concur the hospitals are safe and maybe safer in July because of all the safeguards. At this time of the year, most reputable humans/interns realize their own limitations and seek help often and early. Not to mentioned as a seasoned physician, I will be covering until after the 4th of July in order to avoid exposing interns to that rush. A lot has changed since that article was published, and the biggest threat in medicine as I see, is the resistance of staff and patients to take the advice of the physician. Nurse are huge part of the everyday management of our patients. However, the education is different and the accountability is much different. By next July that intern will have worked more hours than a nurse that has been practicing two years. Not to mention there are few if any caps on the patient load during those hours. All that to say, everyone starts somewhere. The interns are a very valuable part of my team, and often accomplish task and relay information that I do not have the time or resources to complete. Furthermore, nurses have studied to be nurses and should advise their trainees as the doctor should advise his trainees. And one last thing, if the attendings or chief residents were half as rude to the nurse externs and students......they would be written up and the nurse extern probably would never have regain the confidence to come back to work. So please lay off the new physicians nurses............because your trainees are pretty green too!
Does Gupta ever come down from the Twittersphere long enough to read this crap? Today's pearl of wisdom..."my wife told me I looked better now than the day we were married. nice. inspired to kill it during my workout." Gag. She was actually referencing your bank account, sport.
That's comforting.
OMG, as a Nurse I have known this for years. Great to finally see it out there so all know to be careful in the emergency room in July!
Dr. Youn,
That was a brilliant article. I hope everybody makes a mental note "never to go to the hospital in July". If they are having crushing chest pain radiating to their left arm, new neurologic deficits, or simple hemorrhagic shock, its best to wait until August.
Thanks
What an irresponsible 'article'. I am currently an upper level resident in a hospital and I can't believe a fellow doctor, especially one in an esteemed profession of plastic surgery, would throw young doctors under the bus in such a public fashion. It's already hard enough to deal with patient's mistrust of resident doctors during their training, and now we have fellow doctors adding fuel to the fire. I guess since "Dr. Youn" is done with his training he has forgotten what it feel like to be in the trenches. And apparently he has also forgotten that you DEFIBRILLATE v-fib, not cardiovert. Just another indication that maybe you deserve to repeat another internship, sir. You are clearly out of touch.
Bravo!
So if there's an emergency in July, I just wait until August Doc?
very nice article!!
As a nurse for 30 years, most of which has been in an academic setting, I can tell you that this story is grossly over-exaggerated. Yeah, we make jokes about the horrors of July, but in reality, a brand new intern is never left in charge of the hospital (not here anyway, and I'm in *gasp* Alabama). Yeah, he might have to run a code in the middle of the night on a weekend because the senior resident is in the ER, but the nurses run the code. The intern is just there for moral support.
Patients don't need to worry about going to the hospital in July any more than any other time of year. Frankly, I'd be more afraid to go to a rural hospital that's staffed with a private practice doctor with 20 years experience that hasn't learned anything new in the past 15.
This is really irresponsible, and CNN should not publish this material. Really – you want people with serious illnesses to wait a month or two before seeking treatment? How stupid can you be? I can just hear the lawyers gearing up to go after CNN over this one, should even one person take this "medical" advice to wait to seek treatment. Take this article down, it does not help anyone and makes the author and CNN look really stupid, and maybe even negligent and liable.Do your attorneys know this article has been posted? And what medical school graduated an idiot who did not know where the heart is???
Well this is proof that you don't have to be a superstar or true genius to be a plastic surgeon.
What you seem to be lacking is a good Respiratory Therapist.
Truly the unsung hero of the hospital, the RT. I applaud anyone who can deal with sputum all day. I can wipe poo, vomit, blood, and NG drainage and not bat an eyelash. Sputum skeeves me out. 😀
ditto the unsung hero
Um, ever heard of being humble enough to say "I don't know how yet, we need to get someone else" rather than risking someone's life for the sake of your ego? I'd say dealing with ego is the biggest thing med students need to work on; it's amazing the quality of medical care we'd get if that happened.