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.


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