3rd year doing an EM elective - questions

[fiznat]

I'm in the 6th month of my 3rd year, and due to an unanticipated schedule change am currently on an elective in Emergency Medicine. I am working at a facility that does not have a trauma designation or EM residency (though FM residents are frequently rotating through), but the ED is fairly busy with about 60k patients yer pear. It seems only about half the docs here are residency trained in EM, while the others are FM with fellowships.

I have a paramedic background, and have always been interested in EM (though I am considering other specalities as well). I was hoping you guys could help me with a few questions:

1. What should I be trying to get out of this rotation? Is the goal to learn how to do things (fast/focused H&P, presenting, some procedures, etc) or more to evaluate the specialty for my own consideration?

2. How can I excel as a 3rd year? The docs here let me pick up charts at will, assess and report, but they don't really seem to care too much about what I say. Not that they should- I'm a 3rd year - but I'm curious as to how I can make myself more useful. I read every day, and I am self-motivated enough to keep moving and picking up charts throughout the shift. I can competently read 12 lead ECGs, start IVs, intubate, get ABGs/other labs, run ACLS (I'm an instructor), help nurses etc but everyone is so busy it doesn't really seem to get noticed.

3. How can I tighten up reports to attendings? I'm struggling with deciding what information to include when I present a patient as this is so different from Internal Medicine. Too much info and they stop listening, too little and it feels like I haven't done my job.

4. Does anyone ever eat? Seriously, I'm working 12 hour shifts and my attendings don't eat a single thing the whole time. They hardly even drink water.

Thanks everyone!

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[BoardingDoc]

As an MS4 going into EM here are my 2 cents.

1. What should I be trying to get out of this rotation? Is the goal to learn how to do things (fast/focused H&P, presenting, some procedures, etc) or more to evaluate the specialty for my own consideration?

1: Make sure you like being in the ER. Make sure that the bread and butter boring cases are fun for you to do. You aren't going to be intubating people every day. You aren't going to see crazy trauma every day. You're going to see a lot of pneumonia, drug seeking, low back pain, kidney stones etc etc etc.... If seeing that over and over again is still fun, good. If not, you should figure that out now before you say "yep, EM wins."

2. How can I excel as a 3rd year? The docs here let me pick up charts at will, assess and report, but they don't really seem to care too much about what I say. Not that they should- I'm a 3rd year - but I'm curious as to how I can make myself more useful. I read every day, and I am self-motivated enough to keep moving and picking up charts throughout the shift. I can competently read 12 lead ECGs, start IVs, intubate, get ABGs/other labs, run ACLS (I'm an instructor), help nurses etc but everyone is so busy it doesn't really seem to get noticed.

2: Smile. Be willing to do whatever they ask you to do. Be punctual. Yes, you were a paramedic. Yes, you have an impressive skill set compared to many MS3s. That said, you are still a MS3, so you're probably not going to be intubating people or running codes until you're a resident. I'm not saying that you shouldn't look for opportunities to use your skill set, but don't be surprised if they don't really have a use for you. It sounds like you're already looking for ways to help out using those skills which is good, but the vibe I'm getting from your post seems like you might be the sort of person to keep asking and asking despite how busy the staff is. This won't ingratiate yourself with them, it will just make you seem like a pompous ass.

3. How can I tighten up reports to attendings? I'm struggling with deciding what information to include when I present a patient as this is so different from Internal Medicine. Too much info and they stop listening, too little and it feels like I haven't done my job.

3: Age, sex, chief complaint, relevant positives and negatives, what you want to do with them. Is their FH or SH relevant? No? Don't mention it. Just know it in case they ask. Same with everything else in their Hx. The best feedback I got during my 3rd year rotation was when I finished my presentation with what I would do with the patient and see what their response was. Huge learning experience whether you're right or wrong with your plan. It's also great prep for your SubI as a MS4 when you'll actually be putting in orders yourself (depending on the institution).

4. Does anyone ever eat? Seriously, I'm working 12 hour shifts and my attendings don't eat a single thing the whole time. They hardly even drink water.

4: Nope.

 

[fiznat]

Thank you for your detailed reply!

I'm definitely trying to be mindful about the procedures. I do frequently ask if I can do things, because naturally I want to show off my strengths whenever possible. It has been a long time since I've been able to say "yes I can do that, I've done it lots of times" to just about anything. I understand that there are other dynamics at play though and I need to remember that. Thanks for reminding me.

Just as a followup to the presentation question.. How long should a typical patient presentation be? In IM they said 5 minutes, but I'm wondering if it isn't closer to 30 seconds in the ED.

No food for 12 hours? I'm not looking to sit down with a knife and fork but damn....

 

[BoardingDoc]

5 min is definitely way too long. It will vary depending on the complexity of the patient but I would say that less than a minute has served me well. Just try to present as often as you can. There's a knack for it that is hard to explain and which almost everyone sucks at first, myself included, but you get better pretty quickly.

Also, I always bring snacks. My go to is bite sized snickers bars. You can always find somewhere to pop off for 10 sec and toss one in your mouth.

 

[fiznat]

You can always find somewhere to pop off for 10 sec and toss one in your mouth.

hehe

 

[HolyWowBatman]

Never hurts to just ask your attending how they like presentations. Most will tell you straight up: soap, sbar, whatever.

Don't try to present in under 1 minute unless specifically asked to...it's hard to do and will indeed seem like you're skimping weather or not you actually are. Aim for 2-3 mins (including your plan) and you'll be golden. Again, always have an assessment and plan...it doesn't matter if you're right or way off. You need to show that you're at least trying to move patients toward their dispo.

 

[Charles_Carmichael]

This was handy during the week I spent in the peds ER, so look over it (especially since you seem to be having trouble with presentations):

http://www.saem.org/docs/2012-annua...tion-a-variation-on-a-theme-pdf-.pdf?sfvrsn=2

 

[Droperidol]

Caveat-I'm a PGY-3 currently, we work with students nearly every shift. As a third year in the ED, I expect a longer presentation than a 4th year. 3-5 minutes is a good starting point. You may see a few eyes glaze over but we know you're a 3rd year and h&p mastery is the expectation. Bonus points for a good a/p. one big note, always have a reason for why you want certain labs. You will be asked at some point why you want a CBC. Don't reflex to what med school teaches you about wbc and say that you want to check for infection. You will incite a long response on how leukocytosis and neutrophilia don't always mean infection. However, know that it is one of the sirs criteria and mention that it may help evaluate with sirs.

Also, know that you have less patients/more time. Update families, round mentally on them and check labs vs and studies. Informing me of a bottle neck or a lab before/shortly after we know about it will give you a heads up.

Always be polite to your ed nurses and techs. If you aren't, we will hear about it and make sure it is reflected in grade-ms3 or slor-ms4.

Never spend longer than 30 minutes in the room. Just don't do it.

Ask the resident or attending how they would present this patient. As you get to know people more you can cut down your presentation accordingly.

Identify yourself to nursing and state that you would like to help with iv placement. We will all notice and be more likely I give you procedures after seeing your technical prowess.

You will also be a sewing machine. As an early med student you want to sew but don't have the technical skill. As an attending you will be an expert but never want to sew. But it is these vital 2 years where people both want to sew and have the knowledge. We will capitalize on this.

Be prepared to know your simple repairs, stellate/corner repairs, when/how to perform horizontal or vertical mattress sutures, what type and size of sutures to use and how long they should be in. Know and love pus. You will be doing i&d. Know paracentesis, lp, and know your intubating drugs. I will let you have my tube if you know your drugs, hemodynamics of said drugs, contraindications, and dosing. You may already know this as a former paramedic.

Most of all, have fun. Shoot the $hit with residents and figure out if this is what you want in life.

 

[TooMuchResearch]

OP, as this thread indicates, there is variability in what is expected in presentations. Best bet is to ask at the beginning of the shift. As an MS3, I worked with residents who were bored and cutting me off 30 seconds into a presentation. As an MS4, I worked with residents annoyed when I didn't present for 3+ minutes.

 

[alpinism]

OP, as this thread indicates, there is variability in what is expected in presentations. Best bet is to ask at the beginning of the shift. As an MS3, I worked with residents who were bored and cutting me off 30 seconds into a presentation. As an MS4, I worked with residents annoyed when I didn't present for 3+ minutes.

This.

Every attending has their own preference for presentation length.

Some like em short and to the point, basically CC, HPI, +ROS, relevant PMH/SH/FH, +vitals, condensed DDx, and most likely Dx.

Others like em more in depth similar to IM, basically CC, HPI, full ROS, complete PMH/SH/FH, full vitals, full DDx, not to miss Dx
(most likely to kill), most likely Dx, plan.

Agree w BoardingDoc about adding your plan at the end, its a great way to practice and get feedback.

Most people I've worked with also seem to love adding the not to miss Dx even if they don't ask for it.

 

[herewego]

I'm a 4rth year so expectations were a little different but this is what I did on my 3.5 EM rotations to get the honors. I'm gonna give back to this forum cause its helped me so much.

-What to get out of the rotation? I'd say get your stock questions and stock plans developed and ready for when you're a 4rth year and it really counts. For example, a female of child bearing age with abdominal pain, I already have an exact set of questions to ask to cover all my bases and I know exactly what labs I'm going to order, +/- what imaging to order depending on presentation. Make sure your questions cover the EMERGENT concerns, like for example above, is she pregnant? last LMP? vaginal discharge or vaginal bleeding?

-Always have a plan for what you want to do with the patient. It depends on the resident/attending but as they got more comfortable with me sometimes I didn't even give a differential because they could tell from my plan that I was covering my bases. Obviously feel it out with who you are presenting too, some people always want a differential, but regardless if they want the differential or not they'll always want a plan in my experience.

- Take ownership of your patients. Know their labs inside and out, always go to your attending/resident periodically and ask them if you can update them on your patients/run the list. This includes constantly REASSESSING your patients. I can't tell you how many times I've gone in, and pain is improved, or SOB is improved, nausea is better etc and that was the last piece for disposition. I'd go in and tell my attending/resident, and they would say "Great I'm gonna start the discharge paperwork." What you're doing is helping their patient flow/moving patient care forward.

-if a patient is SICK (hypotensive, severe asthma excerbation, obvious distress), STOP, and go get your attending/resident. I've ran up to my attending and interrupted during their conversations to say my patient BP is 70/50 all of a sudden, or this person needs O2, duoneb, and CPAP RIGHT NOW. They've always appreciated it, and I've seen attendings bitch out support staff for not realizing that the patient was "sick." So much of EM is just making that distinction, are they really sick or not. Show your attending/resident that you "get it."

-Always look at imaging for your patients and give your initial impression to attending/resident. I've told them I think theirs an opacity here, heart looks big, no obvious deformities etc. I've caught an epidural before rads read it, made me look like a superstar to everyone, and it showed up on my eval.

Hope this helps.