EM Audition Rotation

[IH8ColdWeath3r]

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So, I know there have been a lot of threads started about this. Was hoping for advice specific to my case, and some guidance if possible. All advice is appreciated by those who have been through this nerve racking process..

I am a DO. I am only interest in doing ACGME EM. I didn't do great in my pre-clinical years and well, we all know about the first time administered EM COMAT this year (what a joke). I took USMLE Step I, did pretty average 220's, and luckily, was granted audition rotation at some ACGME EM programs.

I was wondering, what would you guys recommend that I do in order to impress people on my rotations. My EM rotation 3rd year was great, but I mostly sutured and did I&D's. No lumbar punctures, chest tubes, intubation or anything like that. Unfortunately, I won't have an anesthesia rotation prior to going on auditions.

Worth it to look over these procedures, the steps, indications, contraindications?
Also, my surgical rotation was pretty terrible/malignant and I did not get much practice hand tieing, worth it to revisit some of this?

I've started read up on some of the more prevalent topics, like work-up/treatment of
migraine HA, syncope, weakness.. etc. etc.

But is there anything else you guys would recommend reading on? like the new sepsis guidelines? fluid resuscitation? side effects of anesthesia drugs used during intubation?


Thanks everyone for the advice.

 

[Petypet]

So, I know there have been a lot of threads started about this. Was hoping for advice specific to my case, and some guidance if possible. All advice is appreciated by those who have been through this nerve racking process..

I am a DO. I am only interest in doing ACGME EM. I didn't do great in my pre-clinical years and well, we all know about the first time administered EM COMAT this year (what a joke). I took USMLE Step I, did pretty average 220's, and luckily, was granted audition rotation at some ACGME EM programs.

I was wondering, what would you guys recommend that I do in order to impress people on my rotations. My EM rotation 3rd year was great, but I mostly sutured and did I&D's. No lumbar punctures, chest tubes, intubation or anything like that. Unfortunately, I won't have an anesthesia rotation prior to going on auditions.

Worth it to look over these procedures, the steps, indications, contraindications?
Also, my surgical rotation was pretty terrible/malignant and I did not get much practice hand tieing, worth it to revisit some of this?

I've started read up on some of the more prevalent topics, like work-up/treatment of
migraine HA, syncope, weakness.. etc. etc.

But is there anything else you guys would recommend reading on? like the new sepsis guidelines? fluid resuscitation? side effects of anesthesia drugs used during intubation?


Thanks everyone for the advice.

Lots of info on the EM forums about this so take a look there. Honestly, having done 3 EM rotations and 1 SICU rotation, I found that people don't care how smart you are, or how technical your procedures are, or if you can recite the sepsis guidelines. People in the ED they want someone that is hard working, can make decisions, and be responsible. Quality over quantity. Pick up a patient, do H&P, present patient, come up with a plan, a differential, and follow through with stuff. If there are labs or imaging watch for those and update your resident/faculty, if a consultant needs called offer to do it, if drugs need reconciled call the pharmacy, if a pelvic needs done get the supplies and grab a female nurse and get the resident when you are ready, if you want to mess around w/ ultrasound wheel it in and try to use it. You get the point. Do all of this before getting another patient. Once your patient is tidied up and dispo'd pick up a new patient and rinse and repeat. Some shifts I would carry 3 patients for a 9 hour shift due to the amount of work that needs to be done for that 1 patient. For example ICU patient may have lots of imaging and labs, may need intubated, ICU needs called and report given, transfer orders need to be placed, family needs called, meds need reconciled, etc. If you can help with a chunk of that you have helped out the team considerably.

 

[Frazier]

If it provides you any comfort, pretty much everything you need to suture as a med student can be tied with instrument tie. In other words, if you aren't an ace at throwing single hands, don't fret.

 

[Rendar5]

I don't expect a single procedure short of suturing. I want as said above a plan to work up the patient, a follow through on labs and imaging, and a plan to disposition the patient. No more than 3 active patients at any one time. Knowing your patients and knowing what the next steps are for their care is what will impress me. Not procedural acumen. Residency is for mastering procedures and subtleties, not med school.

Btw the only times you hand tie in the ED is for, central lines and chest tube securing. Just review it prior to residency orientation, don't worry about it now. K

 

[racerwad]

So, I know there have been a lot of threads started about this. Was hoping for advice specific to my case, and some guidance if possible. All advice is appreciated by those who have been through this nerve racking process..

I am a DO. I am only interest in doing ACGME EM. I didn't do great in my pre-clinical years and well, we all know about the first time administered EM COMAT this year (what a joke). I took USMLE Step I, did pretty average 220's, and luckily, was granted audition rotation at some ACGME EM programs.

I was wondering, what would you guys recommend that I do in order to impress people on my rotations. My EM rotation 3rd year was great, but I mostly sutured and did I&D's. No lumbar punctures, chest tubes, intubation or anything like that. Unfortunately, I won't have an anesthesia rotation prior to going on auditions.

Worth it to look over these procedures, the steps, indications, contraindications?
Also, my surgical rotation was pretty terrible/malignant and I did not get much practice hand tieing, worth it to revisit some of this?

I've started read up on some of the more prevalent topics, like work-up/treatment of
migraine HA, syncope, weakness.. etc. etc.

But is there anything else you guys would recommend reading on? like the new sepsis guidelines? fluid resuscitation? side effects of anesthesia drugs used during intubation?


Thanks everyone for the advice.

As others have mentioned, as a medical student, the floor is quite low. If you were proficient at all of the tasks you've mentioned, why would you need a residency at all?

@Petypet said it perfectly, so I would follow their advice.

 

[DrYoda]

I was wondering, what would you guys recommend that I do in order to impress people on my rotations. My EM rotation 3rd year was great, but I mostly sutured and did I&D's. No lumbar punctures, chest tubes, intubation or anything like that. Unfortunately, I won't have an anesthesia rotation prior to going on auditions

I wouldn't necessarily expect to do big procedures like that as a medical student. But this will depend on the culture of the department you're rotating in as well as the resident and attending you're working with. One particular program I rotated at as a student let student's put in all kinds of central lines, but I think they are probably the exception. At least for me I'm willing to let student's do most procedures but it needs to be the right situation(i.e. you're not going to intubate the cspine precaution trauma patient). Not sure I've ever had a student put in a chest tube but I've let them intubate, LP and put in lines, but it has to be a patient who looks like they won't be a difficult case and they have to be stable-ish. Early in the year when most auditions take place is kind of rough as far as those type of procedures because if the senior residents are going to punt a line/chest tube/lp to someone it's likely going to be to the interns who don't have their procedure numbers yet. As far as impressing, follow up your patient's imaging/labs (surprisingly a lot of student's don't seem to bother with this), be pro-active in seeing patient's and have a good knowledge base of EM related things. If you're working with a good resident they should talk to you about your patient's problem and sort of coach you as far as what pimp questions might come at you prior to talking to the attending to make you look good . Procedure wise anesthesia is a better rotation (as a student) for getting intubations, I have a few of my co-resident's who did CT surgery at places where they didn't have resident's that got chest tubes (in the OR) as students. As boring as radiology is IMO, I did get to do a bunch of lumbar punctures as a student when the IR guys were who I was working with (granted this was fluro guided and not the blind ones like we typically we do in the ED).

Worth it to look over these procedures, the steps, indications, contraindications?

Yes, popular test questions, popular pimping questions are procedural landmarks, indications and contraindications.

Also, my surgical rotation was pretty terrible/malignant and I did not get much practice hand tieing, worth it to revisit some of this?

No. You should be able to hand tie, however EM people generally aren't as snobby as the surgery people are about it. I largely instrument tie unless it's a crash line or chest tube.

But is there anything else you guys would recommend reading on? like the new sepsis guidelines? fluid resuscitation? side effects of anesthesia drugs used during intubation?

EM is so broad it's hard to make specific recommendations. Sepsis is a big thing in EM and is worth reading about, however the new metric guidelines (or any metric guidelines) are not typically things I ask students about but that might just be me. As far as medications go I do advise most student that if you're going to learn med doses and what not before residency it should be ACLS and RSI meds so if your going to read up on medications read up on those because when you're an intern everything else you can go back to your desk and look up and your patients and the nurses will never know that you didn't know the weight based azithromycin dose. To be broad big topics in EM tend to be chest pain, trauma, and airway management. Realistically though, we take care of any and everyone that walks in the door so there isn't anything that isn't worth knowing about in our case.

 

[IH8ColdWeath3r]

WOW, just would like to say thank you to everyone who commented and provided very insightful advice. It definitely gives me some new perspective on expectations and what I need to do moving forward.

One other specific question that I had regarding auditions was the length of time to interview the patient, and then subsequently present to the attending. So, obviously there is some resident/attending preference to this, but, what would be the appropriate amount of time spent in a patients room and how in depth do you need to go? The reason I ask is, for example, at my hospital, when I was on internal medicine, my attending literally wanted every single piece of pmhx, past surgical history, allergies, family history (and he would write it all down by hand on a piece of paper for each patient as we did bedside rounds). Sometimes, it took upwards of 30 min to present a patient. I would usually save myself a lot of time in the patients room by first reading the electronic record on the patient's pmhx, meds, etc. because we all know how long it takes a 65 year old to try to replicate their prescriptions from memory.

Anyway, as a visiting student at most places, do you have access to your own computer/login so that you can look at the patient's history/meds/pmhx so that you can walk in and take a focused history that doesn't take 10+ min. The reason I ask is because as a 3rd year student, one of the biggest pet peeves of the EM doctors that precepted to us was when a student would take too long in a patients room (one of my classmates would take upwards of 20+ min). But it was really because she tried to get every piece of history and didn't have access to the computer records and so had to, one by one, as for a list of the meds/pmhx/sochx/fmhx. This was painful for all parties, and really slowed down the flow. Worse, neither of us had access to the imaging/labs that would come back (I had access the pertinent HPI information on my computer), and so we could not update the doc when a UA was collected, what meds were administered, and if they patient had their pertinent imaging?

So, point being, do all places grant you computer access, even if your rotation is not specifically listed as a Sub-I? If you have access to a computer and the patients pertinent pmhx/pshx/sochx/fmhx, what is the ideal amount of time that you would like a student to be in the room gathering a concise but focused history and physical exam?

Thanks again to everyone who provided great feedback from my prior question!

 

[IH8ColdWeath3r]

Anyone care to chime in on my last post?

 

[Rendar5]

15 minutes max for H&P unless it's an uber-complex patient. Computer access is site-dependent. I'd rather see you look for 1 minute max and get in there then spend lots of time on the comp reviewing stuff before seeing the patient. You can always do a chart review after you see them