Brett Biebelberg, MD

8) Growth. Flipping your body's schedule, triaging an overwhelming amount of cross-coverage requests, admitting patients w/o much supervision, doing procedures, and running rapids all were scary before this rotation. But I feel amazing growth & confidence after just 2 weeks.
/🧵

In one case, it was 3 AM, but a patient was acutely decompensating and I knew we had to call the attending on a consulting service. When he picked up the phone, I began with, “I’m sorry to wake you up, but I’m worried about this patient and I need your help.”

Speaking of shit hitting the fan: this will happen. Patients got dangerously sick fast. If you're in a time-sensitive situation and don’t know what to do — and if you’re an intern, you often won’t — your job is to call for help from people who do. Your senior, the ICU, a consultant, etc.

We felt safe asking each other questions. And when shit hit the fan, we stopped what we were doing and had each other’s backs.

7) The people you work with matter. On night float blocks, there really isn’t much time outside the hospital for anything besides eating and sleeping. You invariably lose contact with friends and family. My night co-residents became my friends and support system.

Likewise, when the night team signs out a new admission to you, spare them your curiosity. Unless you have a question that would change your pre-rounds management, you have more time during the day to dig into things than the night team did.

And for day teams — don’t Monday-morning quarterback your night team’s management. They don’t have the luxury of time and focus that you do in the afternoons. As a friend says: “Nights are for survival. Plans are for the day team.”

And our attention is constantly being pulled away overnight by cross-coverage for the 40 patients already admitted. So I have new-found respect for any overnight resident who is able to produce an even half-coherent H&P.

6) It’s really hard to admit new patients overnight. Not just from fatigue, but because doing so requires intense thought and focus to wrap your head around their history, presenting complaints, all of their objective data in order to make diagnoses and plans.

And I’m really grateful anytime someone in the ED has already called relevant consults and received/acted on recs before handing them off to us to admit them.

Because of boarding, you’re often getting sign-out from someone who was not involved in their triage or initial treatment. If there’s something urgent you need done before admitting their patient, like a repeat lab, they’ll be happy to order it for you.

The job of an EM doctor is not the same as an IM doctor. EM’s role is to resuscitate acutely sick patients, decide whether to admit or discharge, and keep flow moving through the ED. Their attention is also being pulled in all different directions.

5) Admitting new patients from the ED. The ED is a hard place to work. I know first-hand because I did two EM sub-Is when I was still undecided before settling on IM. So be kind to your EM colleagues who are handing patients over to you.

If a nurse asked me to see a patient, I always tried to. Part of this requires triage, and if I determined it wasn't urgent, I’d let the nurse know that I’d be by to lay eyes on the pt the next time I was on their floor. If nothing else, it helped to build trust.

4) Going to bedside. Because of the aforementioned duties, I can only come to bedside for patients requiring time-sensitive clinical reassessment, and my determination of who requires that may not always be the same as a nurse’s. That said, take nursing concerns seriously.

Nurses don’t always know the ins and outs of our complicated and ever-changing schedules, so I found that offering a polite reminder that I was covering 40 patients and admitting new ones helped to address a perceived delay in addition.

3) Appreciating grace from nurses. If we take a while to respond to a non-urgent message or seem short in our replies, don’t take it personally. We're getting bombarded with msgs about our other pts while also trying to get tasks done, resuscitate sick pts, and admit new pts.

If a patient had a vital sign abnormality eg tachycardia: did you repeat it? How are the other vital signs? Are they having any symptoms? If they have a new rash or blood in their emesis/stool, send a photo. Good nurses give this context up front which makes triaging and decision-making faster.

2) Gratitude for nurses who manage up. Given time constraints and lack of familiarity, context is helpful. So if you’re reaching out because patient is in pain, it’s helpful to also know: is this pain new or similar to prior? Have they received their PRNs? Did any of them help?

1) Good anticipatory guidance is gold. I didn’t know these patients nearly as well as their day teams do. I’m grateful Penn uses a dedicated platform for this because clear guidance from primary teams for pain, agitation, or decompensation made for a smoother and safer night for all.

Like most night float rotations, I covered those 40 patients in addition to admitting new patients and responding to rapids in the hospital.

Some observations and reflections:

I covered the 40 patients on our inpatient pulmonary and hepatology services. Our pulm service is a de-facto MICU step-down unit and our hepatology service is comprised mostly of patients with decompensated cirrhosis or acute liver failure. So these were all very sick patients.

Me hyping myself up to try, again, to place an ultrasound–guided IV

This is intern year except every 2 weeks you go back to rolling a wooden box filled with patients you know nothing about, subspecialty services you have no experience in, new attending and senior resident preferences, and
bathrooms you don’t know the codes for 😀

Wow! Glad you’re doing well. Thanks for reading.

Tetrahydrocannabinol Intoxication from Food ... This report describes THC intoxication among patrons ...

5/ Read the CDC MMWR here: cdc.gov/mmwr/volumes...

#medsky #publichealthsky #publichealth #toxicology @ryanmarino.bsky.social @deborahb.bsky.social @sejordt.bsky.social @clairem402.bsky.social

4/ THC wasn't immediately known to be the cause.

Emergency services initially tested the restaurant and the homes of several customers for carbon monoxide but found no leaks

Instead, one of the pizzeria patrons who went to the ED had a UDS collected which was positive for THC

3/ The owner of the pizzeria told officials they'd run out of cooking oil and grabbed what they thought was canola oil from the shared commercial kitchen

In fact, they had grabbed hemp-derived THC-infused cooking oil

They didn't know 'D9' was short for Δ9-tetrahydrocannabinol

2/ the restaurant's food had been contaminated with THC.

Oops.

The pizzeria operates in a building that shares a commercial kitchen with a state-licensed maker of edible THC products.

What happened, exactly?

1/ Last October, 85 people ages 1-91 developed dizziness, drowsiness, anxiety, and/or memory distortion. Some went to the ED. They'd all recently eaten at a Wisconsin pizzeria.

Local public health officials investigated. As reported in last week's CDC MMWR, they found