Rotation #1 Review and Tips

Hi All!

My first rotation has been very interesting! I started in the ER (3 weeks), spent 2 days in Nephrology, and have since been in Internal Medicine (outpatient)! So I’ve got 2 reviews for everyone!

Emergency Medicine:

Working in the ER is tough; you have no idea what’s going to come through the door and the moment someone does come through, it’s GO, GO, GO! I saw MVAs, strokes, seizures, MIs, AKI, fishing hooks in fingers, lacerations, fevers, fractures, muscle strains, pain, wounds, bleeds, infections, and lots more.

  1. SCHEDULE: 12pm-12am shifts with certain preceptors; this allowed me to have several days off depending on when my preceptors where working (I think I worked 10-11 shifts total in 3 weeks, sometimes weekends). Make sure to eat before, have a snack on hand, and arrange for dinner.
  2. CLOTHES: change into hospital scrubs on site.
  3. SHOES: with 12 hour shifts, you need comfortable shoes; I have flat feet and own some heavy, super supportive Dansko shoes–however, my feet would be aching halfway through my shift. I bought a pair of Crocs (without holes) and they have been light and great–they just don’t have as much support. Some of the doctors also recommended Birkies (Birkenstock).
  4. Why it’s AWESOME:
    1. You get to see some really interesting pathology. I saw a patient with Erythema Multiforme (from Terbinafine use) and a patient with Temporal Arteritis.
    2. You get to do a lot! I removed stitches, help with reducing a shoulder dislocation, nail removal (super bloody), catheterizations, blood draws, IV line insertions, give shots! I even did a pelvic exam on a pregnant patient.
    3. In the ER, everything just happens. Literally. Blood work and imaging come back so quickly! It’s amazing. I got to go in for some of the ultrasounds and see the techs at work too.
    4. You get to do some OMM. I did some cervical spine treatments for a few patients after an MVA. However, in some cases the issue is too acute to treat with OMM.
  5. Why it’s TOUGH:
    1. You have to be prepared for ANYTHING. We had a patient come in from the Washington State Penitentiary (with armed guards!) with massive epistaxis–he lost 20% of his total blood volume! At first, I was apprehensive of both the patient (he was in an orange jumpsuit) and of all the blood loss (2 tubs were filled), but as I interacted with him, I was able to let go of my judgement and fear and simply treat him like any other patient.
    2. You have to be ready to do whatever you need to do in order help the patient–including getting out of the way.
    3. It’s difficult with kids–especially because they’re not feeling food, are injured, need to be cath’d, need to get a shot, or need to have their eyes dilated.
    4. You don’t know what’s going to happen to the patient. A lot of the time, the ER physician is simply trying to keep the patient alive. Long term issues or even concrete diagnoses are not always addressed. Everything is very acute and that was very frustrating for me. I wanted to get to the root of certain issues, but in the ER you just need to keep the patient alive and then release, admit, or transfer them.
    5. You don’t have time. You don’t get to really talk to patients and their families or get to know them. I realize that spending time with patients is limited in every setting, but I think getting to know patients is something that’s important to me.
    6. Your heartstrings get tugged on. We had a patient who was transferred to the ER from a nursing home, without any friends or family, because the nursing home knew he was dying. Since he was alone and my preceptor was catching up on some paperwork, I was able to sit with him as he passed. The experience still resonates with me.
  6. RECOMMENDATIONS:
    1. Studying:
      1. Know your ACLS algorithms, treatment for acute issues (like MI, stroke, CHF exacerbation).
      2. Review how to read a chest x-ray and EKG.
        1. CXR mnemonic: ABCDEFG-L (Airways-trachea, bronchi, Bones-ribs, clavicle, pedicles/SPs on vertebral bodies, spaces between vertebral bodies / Breast shadows, Cardiac – silhouette, size, aorta, AP window, pulm art, Diaphragm-costophrenic angles, air underneath, especially on the right as the left can often be stomach bubbles, Esophagus-not usually seen, Free air anywhere, Gunk anywhere, Lungs)
        2. There is no COMAT exam for this rotation.
    2. Brush up on your suture skills before this rotation
      1. Duke’s Suture Skills Course
    3. Get light, comfy, protective shoes
    4. Be mentally prepared for anything!!
    5. Take care of yourself; reflect on what you see and let it go.

Internal Medicine (Outpatient):

Outpatient IM is a totally different world than the ER! You’re in an office setting with scheduled patients and you usually work set hours.

  1. SCHEDULE: 8am-5pm M-F
  2. CLOTHES/SHOES: Professional dress with white coat and comfortable shoes
  3. Why it’s AWESOME:
    1. You get to spend time with patients! You get to know them and you can counsel them on diet, exercise, and smoking cessation. We had a patient with Non-Alcoholic Fatty Liver Disease (NAFLD) and I was able to spend a few minutes with him talking about dietary changes and what to expect if the disease progresses. I couldn’t imagine spending that much time with a patient in the emergency department.
    2. You get to work on your H+P skills. My preceptor is really nice and the patients love him. He enters every patient’s room with me, introduces me and asks if the patient can spare a few minutes to talk to me while he finishes up some paperwork. I then get some time with each patient to complete an H+P, which has really helped me figure out what’s important to ask (any nausea or vomiting with your headache?) and to differentiate lung and heart sounds!
    3. You get to see some really interesting pathology. I saw a patient with argyria (blue man syndrome after years of taking colloidal silver suspension), Marfans, SLE, the aftermath of narcotizing fasciitis, candidates for bariatric surgery, psoriasis, shingles, and more.
    4. You get to do some OMM. You’ll see pregnant patients, patients with back, neck, leg pain, and so much more. My preceptor (who is an MD) asks if I can do some “magic” for these patients and it usually helps!
  4. Why it’s TOUGH:
    1. It’s a juggling act. These patients have many things going on–not just diabetes, hypertension, and hyperlipidemia, but anxiety, OCD, and stress.
    2. There’s always a time crunch. Each appointment is only 15 min long, and you’re seeing anywhere from 18 – 25 patients in a day and there’s still charting to finish!
    3. You’ve got to be up to date! Medications, research, procedures, insurance codes, other requirements are all constantly changing and growing. You’ve got to be on top all this information!
  5. RECOMMENDATIONS:
    1. Check your patient list before
      1. We are able to access our physician’s patient list on EMR, so we can check to see why patients are coming in (this is not always accurate though). If you can do this as well, I’d recommend brushing up on those things for that day.
    2. Know your meds
      1. Psych: There were a lot more patients that I expected who are on various combinations of antidepressants and anti-anxiety drugs, so it’s important to know the side effects and indications for these.
      2. Schedule II and III: Lots of patients come in for pain. They must come in to get their Rx filled every month or so.
    3. Lots of geriatric patients – make sure to speak up when they can’t hear you!
    4. Studying
      1. At our site, we have outpatient and inpatient IM (6 weeks each) and our COMAT exam is at the end of the 12 weeks. My next IM rotation isn’t until 2016. I would recommend going over some common chronic diseases (DM, HTN, thyroid, CAD), medications, and psych diseases.

I hope your Emergency Medicine and Internal Medicine rotations go well and that this long list is helpful!! I had a great time during both! 🙂

-Priya

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