Monthly Archives: August 2015

Immersion Phase Update: Emergency Medicine (8/3 – 8/28)

The month of August was a whirlwind.

I completed my required Emergency Medicine rotation this month, which was an experience unlike anything I’d had before.  At Vanderbilt, this rotation consists of daily morning lectures, case conferences with residents, several shifts in affiliated emergency departments, and a couple of exams.  In essence, it’s a miniature version of a third year clerkship with a dash of first year didactic learning–lots to know, lots to do, lots to be evaluated on.  There were less than 20 of us on the rotation, including several visiting students hoping to match into emergency medicine.

To be honest, I was interested to see what sitting in class for roughly 4 hours each morning would be like after so long.  I wondered if I’d take better notes, if I would feel more confident about speaking up in class…whether my attention span had gotten better or worse since December 2013.  I took slightly better notes (having an iPad with a dedicated note-taking app helps), but neither my shyness nor my attention span had improved much.  Our lecturers expected class participation, and the class was small, so often I was called on directly to read an example EKG or to answer a question; otherwise, I kept pretty quiet.

For the most part, the lectures themselves were excellent.  Most were 50-minute overviews of various topics that we would encounter on emergency medicine–everything from pediatric emergencies to toxicology to environmental exposures (frostbite, snake bites, and everything in between).  The majority of the lecturers had their own quirks or teaching styles that made them quite engaging.  One of our main lecturers frequently quizzed us on buzz words for particular conditions–ventricular fibrillation = “shock,” hyperkalemia = “EKG,” hyponatremia = “be careful [when correcting the abnormality],” and so on.  He also made countless Seinfeld and “classic” movie references and expressed his disappointment when we didn’t know where they came from (coincidentally, I had just started binge-watching Seinfeld at the beginning of the rotation, so I was pretty happy about some of the quotes he pulled out).

In addition to traditional lectures, we also had a few simulation and procedure labs.  The first lab was an overview of how to suture, how to do a spinal tap, and how to intubate (I was pretty terrible at all of these).  We also had a lab on how to apply splints to fractured limbs, during which we covered each others’ arms and legs in plaster and ACE bandages.  The most rewarding labs were done in the simulation center, where we interacted with simulation robots that can be made to blink, talk, and even sweat.  We were divided into groups, given a patient’s age and chief complaint, and asked to manage each case, asking for vitals, ordering labs, starting medications, and calling for consults based on what we were told and what we saw on the monitors.  Afterward, we had debriefing sessions during which we learned what the key teaching points and optimal management strategies were.  I wish we were able to use the simulation center more throughout medical school; it’s a great way to learn how to diagnose and treat in real time.

Of course, in addition to lectures and labs, there was also “on the job” training in the form of our shifts.  Each of us had a total of ten shifts scattered throughout the month and at different times of day: five at the Vanderbilt Hospital adult ED (one in the triage area, two in the high acuity “A Pod,” and two in the lower acuity “B Pod”), two at the Children’s Hospital ED, two at the VA’s ED, and one at the Sumner Regional Medical Center in Gallatin, Tennessee.  Each type of shift required a different level of responsibility from medical students.

  • The triage shift was a time for us to work with EMTs, going to Rapid Response calls in the hospital and learning to start IVs on patients who came in from the waiting room.  Unfortunately, my shift was pretty quiet, so I didn’t get much practice, although one of the EMTs offered to let me stick a needle in his arm (I declined, although I’m not sure whether he was joking).
  • On the A Pod, where trauma cases as well as seriously ill patients are seen, our role was mainly to see patients with the residents, go to the trauma bay when patients were brought in, and assist where we could with procedures, updates, and other tasks.
  • On the B Pod, we served as the main “resident” seeing some of the patients, presenting to the attending physicians, writing notes, and signing out to other providers at the end of our shifts, provided that it wasn’t too busy in that part of the ED; otherwise, we functioned much like we did on A Pod.  One of my shifts–my first–was a typical B Pod shift, which was so fast-paced that I could barely get used to it.  On my second B Pod shift, both the waiting room and the ED were full, so residents and attendings saw all of the patients themselves while I acted as a “sponge” and learned as much from them as I could.
  • Peds was similar to B Pod–seeing patients solo, presenting to attendings, writing notes, keeping family and staff informed–with the added opportunity to see pediatric trauma cases.  One of my Peds shifts happened to be my one “overnight” shift (10pm – 4am).  Surprisingly, I was pretty functional during those 6 hours.
  • At the VA, medical students did not have computer access.  Instead, when a patient came in, the attending or resident might tell us about them, hand us a short information sheet about why they’d come in, and have us see the patient first.  For other patients, I simply shadowed the resident.
  • The Sumner Regional Medical Center shift gave us a chance to see what care is like outside of the Vanderbilt system.  It’s a smaller ED that is a bit slower-paced than Vanderbilt even though it is still fairly busy.  Patients are sometimes “transferred out” to different facilities for a higher level of care, a process that we do not encounter at Vanderbilt since it is typically on the receiving end of such transfers.  On my Sumner shift, I did not see any patients who needed to be transferred, so it was reminiscent of a VA shift.

It was often difficult for me to figure out how I best could function on my shifts, but once I got the hang of things, I enjoyed the clinical experience and was able to learn more about the medical knowledge and thought process required of an ED physician.  In the ED, a huge part of the work is determining the patient’s disposition, deciding whether the patient should be admitted to the hospital or whether s/he can go home.  This decision often requires the provider to rely on an understanding of the patient’s past history, lab and imaging results, and sometimes his/her instincts about “how sick” the patient was upon arriving to the ED.

Surprisingly (to me at least), my experience also dispelled a quiet myth that there isn’t any continuity in emergency medicine.  While it is true that ED physicians usually don’t see the same patients over and over again, I worked with several attendings who followed up on patients after their shifts were over, seeking to learn about their working diagnoses or their hospital course.  One attending I worked with on my second Peds shift made sure to tell me about the results of one patient’s lab work the next day after class.

As I mentioned, this rotation had a few exams.  One was for Advanced Cardiac Life Support certification.  We spent a considerable number of our lectures learning how to manage various situations, such as encountering a patient in cardiac arrest or someone who has an abnormal heart rhythm on a monitor.  They stressed how much we would need to study to pass the certification test, telling us to make flashcards and quiz each other.  I came into the ACLS certification extremely nervous, but it ended up not being too bad.  So I’m officially ACLS certified to do CPR and run codes…although I hope I never actually have to use that knowledge.

Yesterday, I took the exam for emergency medicine.  This was my first computerized NBME shelf exam; I’m on the fence about whether I prefer that method to Scantrons.  In any case, the exam was pretty difficult, and I wasn’t the only person who thought so.  It felt like a combination of all of my other shelf exams, with the addition of weird things that an ED physician would be the first person to see, like animal bites, acute wound care, and fractures.  I came into it thinking that I hadn’t studied nearly enough, and I left feeling like studying more wouldn’t have helped.   Speaking of studying, for anyone who’s wondering, I only used PreTest.  I don’t even think I got halfway through the book, but I’m still proud of the amount that I was able to do in about a week and a half at the end of the rotation.  I’d planned to also read through First Aid for Emergency Medicine, but that didn’t happen either.  In any case, the test is over, and hopefully I passed.

Somehow I still managed to do “other stuff” this month.  I was able to arrange my schedule such that I only missed church on one Sunday morning and one Wednesday night.  I attended a gathering for members involved in the worship ministry and am still hoping to get more involved myself.  The Psychiatry Interest Group had their first event, a barbecue hosted by one of the current psychiatry residents, and SNMA had their introductory meeting as well.

All told, this month was exhausting.  I’m not going to say everything went well or that I didn’t feel overwhelmed some (read: most) of the time.  If I could do this month all over again, I’d definitely do things differently.  But now that the rotation is behind me, I can’t deny the fact that this was one of the most educational months that I’ve had since starting the Immersion Phase back in January.

Immersion Phase Update: Physical Medicine & Rehabilitation Elective (7/5/15 – 7/31/15)

As I alluded to in my last post, this past month I took an elective that offered an introduction to physical medicine and rehabilitation (PM&R).  This specialty looks at restoring or maintaining activities of daily living, mobility, functional capabilities, etc, in patients with permanent or temporary disabilities.   It’s a broad field, dealing with everything from chronic musculoskeletal pain to cerebral palsy to traumatic brain injuries.  Physicians in the field–known as physiatrists–work closely with physical, occupational, and speech therapists in both inpatient and outpatient settings.  The department and the residency program are quite new to Vanderbilt, but they welcomed me with open arms for the month and taught me so much about the specialty.  I initially chose this elective because I’d had absolutely no exposure to PM&R, and I was pleasantly surprised by how much I enjoyed it–in fact, I’ve been recommending it to just about every medical student I’ve talked to.

Throughout the month, I rotated through a number of outpatient settings that gave me a better idea of the breadth of PM&R.  I saw more typical clinics that served pediatric and adult patients presenting with mainly orthopedic or neurologic chief complaints.  I got to observe several procedures, such as botox injections (for limb spasticity, not for cosmetic reasons), spinal injections, and joint injections.  I even helped out with a few of these; for the most part, I simply helped the physician draw up medications into syringes or held the ultrasound probe, but one morning the attending let me inject steroid into a patient’s hip.  I was so excited to do this, even though the attending was holding my hands the whole time.

I was also placed at fairly unique clinical sites that medical students usually do not get the chance to experience.  In “wheelchair clinic” at the pediatric rehabilitation suite at 100 Oaks, I observed a physical therapist and equipment vendors as they fit children for colorful wheelchairs and car seats.  When I shadowed the physical and occupational therapists at the VA, I learned about everything from paraffin baths for arthritis to dry needling techniques for painful trigger points; I even got to go inside a balance assessment machine, which uses various tests to determine the level of function of certain neurologic components of balance.  I also observed a physical therapist in what is called lymphedema clinic; this site typically serves patients who have swelling due to lymphatic issues or muscle tightness after surgery, and the therapists there recommend equipment and perform maneuvers to help decrease patient discomfort.  On two mornings of the elective, I went to the Dayani Wellness Center, a fitness center geared toward patients with heart diseases, lung diseases, and other similar diagnoses; nurses, exercise physiologists, and other personnel create workouts, hold fitness classes, and use health coaching strategies in order to help patients meet their exercise and nutrition goals.

Additionally, I spent a week with an inpatient attending at Stallworth Rehabilitation Hospital.  Before that particular week, Stallworth was simply the place where patients often got sent when someone felt they needed “inpatient rehab” after a stroke or some other debilitating injury.  I didn’t really know anything else about it, but I learned quickly.  Typically, patients spend about 2 weeks at Stallworth, receiving some combination of physical/occupational/speech therapy daily depending on their needs and goals.  If the patient was admitted for a spinal cord injury, they usually stay a few weeks longer and receive the same services during that time.  Physicians make rounds every weekday, talking to and examining their patients, assessing for new medical concerns, writing prescriptions, and other typical tasks.  Meanwhile, case managers work on discharge planning, figuring out where the patients will go–home or to a skilled nursing facility, to name a few options–and what type of follow up they will need with therapists or physicians after they leave Stallworth.  In addition, the patient’s team of nurses, therapists, physicians, and case managers meet together during the week to discuss medical, social, and other barriers that might lengthen his or her stay.  I found that Stallworth is an environment built upon interprofessional care, with the idea that many medical professionals can and should work as a team to effectively meet their patient’s needs.  This came in handy, because I was taking a concurrent class on interprofessional education that required me to shadow two care providers who were not physicians (I chose to observe a case manager and a speech and language pathologist).  In addition to learning about the system and general routine of Stallworth, I talked at length with the PM&R attending on various topics; it turns out that he is quite interested in the intersection between his field and neuropsychiatry, so we ended up having lots to discuss!

When I wasn’t doing work for the rotation, I spent quite a bit of time working on my residency application.  This past month, I met with the Dean for Student Affairs to discuss the medical student performance evaluation (MSPE) that will accompany the application.  At this point, I am up to my neck in editing my personal statement and curriculum vitae.  At the time of my last writing, I hadn’t started writing either of them; however, I was able to put together working first drafts of both while I was away in Detroit a couple of weeks before starting the PM&R rotation.  I’ve since sent them to several friends and faculty members and have received great feedback on both.  I am also working on finalizing the list of programs I’ll apply to, as well as collecting letters of recommendation.  In the midst of all this, I found out that I passed Step 2 CK, so I’m almost done with the exams whose scores I’ll need to include with my application.

Despite having my hands full with all of the above, I still had time for some extracurriculars.  A week after I got back from Memphis, two of my dear friends from church got married; it was wonderful to be able to celebrate with them.  A week or so later, I entered a vocalist search that EDM genius Zedd opened up to his fans; I wrote and recorded lyrics for a new instrumental track that he’d made, and although I haven’t heard back from the artist himself, I’ve gotten great feedback from friends since posting my vocal demo on SoundCloud and YouTube.  In addition to all this, I joined some of my classmates in welcoming the Class of 2019 during their orientation week; aside from making me feel really old, they seem like a pretty cool bunch of people overall.  Several of them signed up to join the a cappella group, and they eagerly showed up for our first rehearsal; despite some of them saying that they had never sung before, we were able to sight-read and sing through a song that the group had performed previously.  I was also able to go back home for a children’s and youth conference at my church there, during which I met Travis Greene, a gospel artist who sings one of my current favorites (it’s such a favorite that I did a cover of it on my YouTube channel).  And this past week, I went with a friend to Bridgestone Arena for the Nashville leg of Outcry 2015, a brand-new tour featuring Christian music greats such as Passion, Trip Lee, and Hillsong.  I was exhausted the next day, but it was totally worth it.

Thanks for reading!  Stay tuned for my next update.  On Monday, I start my month of Emergency Medicine, which will include lectures and ED shifts occurring at various times of day (and night).  Wish me well!