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What additional skills do you think are important to master before entering a 4th year ER rotation (intubation, suturing, composure, etc.)?
WoW Factor!!
- Thread starter RobbingReality
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Far more important than any procedural skills are the ability to identify the salient features of a presentation and do develop a good differential diagnosis. If you can figure out the real reason why a patient came to the ED and give a succinct presentation that excludes non-relevant material while hitting the high points (I want to know if that person with chest pain is a smoker, but I don't care if the guy with an ankle sprain has a family history of breast cancer) and be able to list 5 diagnoses that are likely or at least need to be considered then you'll be in the top 5% of med students.
In terms of what you can do in the ED to impress:
1- Arrive early.
2- Be eager to do any and everything.
3- Try watching what menial tasks need to be done to move patients along (filling out radiology order sheets, admission forms, etc.) and once you've seen how it's done, do it without being asked on a few patients & bring the completed forms to your resident or attending for review / signature. This will make you stand out in a very positive way.
No one expects you to (nor will they let you) do a central line or intubation unsupervised / instructed. However, having reviewed landmarks / positioning / contraindications / complications ahead of time will make you very well prepared.
Just do your best to have a good attitude & be respectful. If you can do both of those things you'll likely do just fine.
In terms of what you can do in the ED to impress:
1- Arrive early.
2- Be eager to do any and everything.
3- Try watching what menial tasks need to be done to move patients along (filling out radiology order sheets, admission forms, etc.) and once you've seen how it's done, do it without being asked on a few patients & bring the completed forms to your resident or attending for review / signature. This will make you stand out in a very positive way.
No one expects you to (nor will they let you) do a central line or intubation unsupervised / instructed. However, having reviewed landmarks / positioning / contraindications / complications ahead of time will make you very well prepared.
Just do your best to have a good attitude & be respectful. If you can do both of those things you'll likely do just fine.
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Learn the difference between sick and not sick. This is by far the most important thing for young interns to know. Not sick patients can get leisurely H&Ps, long IM type presentations and be worked up ad nauseum with extensive differentials, tests and zebra hunting. Sick patients need to be recognized and have a senior or attending alerted immediatley on detection.
Sick patients have things like abnormal vital signs, pallor, diaphoresis, altered mental status and should make the hair on the back of your neck stand up. Early on anyone making your hair stand up, even if everything else seems ok, must be presumed to be a sick patient.
Sick patients have things like abnormal vital signs, pallor, diaphoresis, altered mental status and should make the hair on the back of your neck stand up. Early on anyone making your hair stand up, even if everything else seems ok, must be presumed to be a sick patient.
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Brush up on your crash airway skills.
Just kidding. There's some great advise from the masters above. I'll throw in my 2 cents.
What Wilco said is right on. The trick is knowing which questions to ask which patients. It's quite algorithmic. There are 3-4 questions that are essential for each chief complaint beyond the usual H and P stuff. For instance, in a r/o ectopic you should ask about vaginal bleeding, fertility med use, Ob/gyn history. It sounds simple, but believe me you can forget. And you look pretty dumb when the attending asks "so did the patient have any vaginal bleeding?," and you hadn't asked. Same for minor trauma and asking about the tetanus shot. Hand injury - there's a few physical exam things they'll always ask you about. Headache - oops I forgot to do a neuro exam. Back pain - How's their gait? Oh, I didn't actually walk them. So I think running through the agorithms for each common complaint would help - or would have helped me anyway.
Another thing is being able to exude confidence while you give a 3 minute presentation without eh, um, uh, pausing alot and diving right into your differential then you plan. It should all flow fast and nicely without forgetting major portions. It should feel more like "hey I just saw this patient in room X, this is what I thought was important/remarkable, I think it might be A or B, this is what I'm doing, how does that sound to you?" This is easier said than done. It's hard enough to just get a decent H and P from some of our patients but you've got to go beyond, make it sound smooth, and have the loose ends tied up. Do the chart biopsy before you present. Have the old EKG in your hand. Know your renal patients last Creatinine. Otherwise you'll be sitting there while the attending looks it up on his own. All this little stuff adds up.
If you want to do procedures like central lines, intubations, reductions etc - you should read up on them in Roberts before the opportunity arise. When you ask "hey can I do that central line," people love to say "sure, have you read about how to do it?"
The more reading you can do in an EM review book (like First Aid or whatever you like), the better off you'll be because once the Sub-I you are being evaluated from day 1. Fist Aid is decent. If you don't like reading, ACEP-EMedHome.com has some good lectures for cheap.
Don't see too many patients. This was really hard for me. In my experience, interns and junior residents were impressed when I saw a lot of patients; senior residents and attendings were not. Every patient you see is more work for your preceptor. They generally don't mind, but if you miss something or aren't around to fill out the discharge paperwork because you're trying to juggling to much then you're making even more work for them.
Oh yeah, and hop in on the non medical conversation. Act like a real person not just a go-getter.
The nurses should know you and like you. EP's trust and respect their nurses.
Always have trauma shears.
Well, I hope that helps. Maybe you can learn from some of my mistakes!
Just kidding. There's some great advise from the masters above. I'll throw in my 2 cents.
What Wilco said is right on. The trick is knowing which questions to ask which patients. It's quite algorithmic. There are 3-4 questions that are essential for each chief complaint beyond the usual H and P stuff. For instance, in a r/o ectopic you should ask about vaginal bleeding, fertility med use, Ob/gyn history. It sounds simple, but believe me you can forget. And you look pretty dumb when the attending asks "so did the patient have any vaginal bleeding?," and you hadn't asked. Same for minor trauma and asking about the tetanus shot. Hand injury - there's a few physical exam things they'll always ask you about. Headache - oops I forgot to do a neuro exam. Back pain - How's their gait? Oh, I didn't actually walk them. So I think running through the agorithms for each common complaint would help - or would have helped me anyway.
Another thing is being able to exude confidence while you give a 3 minute presentation without eh, um, uh, pausing alot and diving right into your differential then you plan. It should all flow fast and nicely without forgetting major portions. It should feel more like "hey I just saw this patient in room X, this is what I thought was important/remarkable, I think it might be A or B, this is what I'm doing, how does that sound to you?" This is easier said than done. It's hard enough to just get a decent H and P from some of our patients but you've got to go beyond, make it sound smooth, and have the loose ends tied up. Do the chart biopsy before you present. Have the old EKG in your hand. Know your renal patients last Creatinine. Otherwise you'll be sitting there while the attending looks it up on his own. All this little stuff adds up.
If you want to do procedures like central lines, intubations, reductions etc - you should read up on them in Roberts before the opportunity arise. When you ask "hey can I do that central line," people love to say "sure, have you read about how to do it?"
The more reading you can do in an EM review book (like First Aid or whatever you like), the better off you'll be because once the Sub-I you are being evaluated from day 1. Fist Aid is decent. If you don't like reading, ACEP-EMedHome.com has some good lectures for cheap.
Don't see too many patients. This was really hard for me. In my experience, interns and junior residents were impressed when I saw a lot of patients; senior residents and attendings were not. Every patient you see is more work for your preceptor. They generally don't mind, but if you miss something or aren't around to fill out the discharge paperwork because you're trying to juggling to much then you're making even more work for them.
Oh yeah, and hop in on the non medical conversation. Act like a real person not just a go-getter.
The nurses should know you and like you. EP's trust and respect their nurses.
Always have trauma shears.
Well, I hope that helps. Maybe you can learn from some of my mistakes!
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I agree with all of the advice about being apply to develop a good list of differentials and know what to do to rule in/rule out eat of them. The rest will come with experience. Still, you have to make sure that you interact with the other residents and attendings while at work. Remember that your sub-I is like a very long job interview and these people are mainly want to know two things (1)that you will be a competent EP and (2)that they will be able to work with you and enjoy your company. Many 4th year students try so hard to impress all of the residents and attendings with their work ethic, knowledge and commitment that they forget to just relax sometimes and enjoy the moment with the residents while in between pts or on lunch pause.
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None. Don't worry about procedures. I couldn't care less if med students show up without knowing how to do a single procedure.
You need to be able to do a reliable, accurate, and efficient history and physical. You need to know everything that is going on with the patients you see.
Many residents brag about all of the procedures they have mastered, and how many billion thoracotomies they have done. Often these residents are lacking in the basic skills they need.
Life's not about procedures, or doing cool things.
Try and take something from every patient you come across. Everyone, even down to the most meaningless URI has something interesting to add to your education, and you probably won't realize it. The more you get comfortable with seeing what's normal, the better you'll be able to pick up what's abnormal.
And remember, everyone deserves a heart and lung exam. It'll make em feel like you're doing something, even if they're there for something unrelated.
Try and take something from every patient you come across. Everyone, even down to the most meaningless URI has something interesting to add to your education, and you probably won't realize it. The more you get comfortable with seeing what's normal, the better you'll be able to pick up what's abnormal.
And remember, everyone deserves a heart and lung exam. It'll make em feel like you're doing something, even if they're there for something unrelated.
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I did several away EM and Peds EM rotations. My #1 pice of advice would be to make a table for every patient presentation with three columns. One program specifically asked for this, 2-3 others wanted this information and appreciated an organized presentation of it.
1) List of diff diagnosis
2) List of dx that are life threatening
3) List of most likely dx that you want to test for now
Being able to do this, mentally or in writing, will put you way ahead for internship.
Finally, be positive. Residents want to see 4th years that are easy to get along with and enjoy seeing patients.
1) List of diff diagnosis
2) List of dx that are life threatening
3) List of most likely dx that you want to test for now
Being able to do this, mentally or in writing, will put you way ahead for internship.
Finally, be positive. Residents want to see 4th years that are easy to get along with and enjoy seeing patients.
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Just jump in and help.
Often in the ER things are so busy that no one has time to "babysit" the students and tell you where to go or what to do. Some easy things you can do to help out are:
* starting IVs or drawing labs for the nurses when things are crazy...if the nurses love you they will tell the attendings and residents good things about you, if they hate you they will make your life miserable and it will be nigh impossible to impress the program.
* As mentioned above, always have trauma shears...one thing a med student can always do in a trauma is make people naked
*Be eager to do anything (yes, I'd love to disimpact that patient or sure I can do those sutures, it doesn't matter that my shift ended 20 minutes ago...)
*Do your paperwork on time, I frequently amazed people that I had my paperwork filled out and ready to go before I gave my intial presentation...efficiency impresses and residencies do not want a resident that they are going to have to chase down for their charts and paperwork.
*No matter how busy it is ALWAYS ask for help if you feel in over your head, you will get in more trouble for just blindly stumbling along and screwing up then you will if you just ask for help anyday.
Of course I am just an as yet unmatched MSIV...maybe I don't know what I'm talking about
Often in the ER things are so busy that no one has time to "babysit" the students and tell you where to go or what to do. Some easy things you can do to help out are:
* starting IVs or drawing labs for the nurses when things are crazy...if the nurses love you they will tell the attendings and residents good things about you, if they hate you they will make your life miserable and it will be nigh impossible to impress the program.
* As mentioned above, always have trauma shears...one thing a med student can always do in a trauma is make people naked
*Be eager to do anything (yes, I'd love to disimpact that patient or sure I can do those sutures, it doesn't matter that my shift ended 20 minutes ago...)
*Do your paperwork on time, I frequently amazed people that I had my paperwork filled out and ready to go before I gave my intial presentation...efficiency impresses and residencies do not want a resident that they are going to have to chase down for their charts and paperwork.
*No matter how busy it is ALWAYS ask for help if you feel in over your head, you will get in more trouble for just blindly stumbling along and screwing up then you will if you just ask for help anyday.
Of course I am just an as yet unmatched MSIV...maybe I don't know what I'm talking about
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Last year I asked how to do well on my rotation, got some great advice and it worked like a charm. Here is the link.
http://forums.studentdoctor.net/showthread.php?t=382745
http://forums.studentdoctor.net/showthread.php?t=382745
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I think this comes with experience. I just wrapped up an EM rotation and by the end I started to really get a feeling for the sick and those looking for a warm bed, percocet, or work note. One thing that I learned was to approach every patient like a blank sheet. Nurses (even worse the triage note) would be terribly off and would get me thinking along one line, when I should have been thinking along another. I found out later that the nurses triage "notes" were completely point and click from a computer program. So they would click on symptoms that were "most like" what the patient was trying to describe to them. After the first week I just looked at the vitals, meds, pmhx, and went about my business. Triage notes declaring abdominal pain turned out to be AMS etc...It was a real learning lesson. I did get suckered by this really cute little 19 year old girl who played me big time. She was drug seeking and I told my attending we should get her some pain meds quickly. He smiled and pulled up about 20 very recent ED visits, as well as 20 more from the sister hospital across town....I was humbled
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being the EM forum, i was expecting a post on how to network in World of Warcraft or emergency medicine/spellcastinghealing on MMORPG's or something.
turns out it was just a normal advice post.
--your friendly neighborhood ex-starcraft addict caveman
turns out it was just a normal advice post.
--your friendly neighborhood ex-starcraft addict caveman
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I was also expecting WoW....
As to the advice to know the ddx and which ones were immediately life threatening: read through the beginning of Rosen's textbook for a ton of 'cardinal presentations' with lots of helpful info. At least, I think it was Rosen's, but maybe it was Tintinallis.
As to the advice to know the ddx and which ones were immediately life threatening: read through the beginning of Rosen's textbook for a ton of 'cardinal presentations' with lots of helpful info. At least, I think it was Rosen's, but maybe it was Tintinallis.
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