Do an ER elective

[drnick07]

I just got done with a 9 hour shift in the ER and i had a really good time. Yes, i'm gonna boast a little (again) but i want to suggust to everyone to schedule an ER elective if possible. The main reason is that it draws together all the main areas of medicine. Although i'm in the ER of a pediatric hospital, i have already had to: deal with psych patients, take OBGYN histories, do a MMSE, do 2 DREs, and do a full neurological exam. Tonight the other med student did a pelvic exam (the last pt i had who needed one refused to have a male do it). Dx's have included asthma, ulcerative colitis, sickle cell, asthma, conversion disorder, constipation, UTIs, asthma, ankle fracture, knee fracture, dehydration, asthma, intractible vomiting, arm fracture, dental abscess, FSGS, suicidal ideation (in an 8yo), asthma, schizophrenia, infected stitches, tracheomalacia, pneumonia, oh and asthma. And it has only been a week!

Tonight i got to sew up a 3 cm laceration all by myself. (Yeah, i know i sound like a little kid who just went potty for the first time without help.) With that, i also want to urge everyone to learn how to suture during your surgery rotations. That is a skill that is applicable in almost any specialty (my lac tonight was on a psych pt). I also got to put in a couple staples in a kid's head. Once again, i got really good (i.e. confident) at doing that in my surgery rotation (ok, i know its not brain surgery, but confidence is 50% of the battle). I also watched a conscious sedation and got to talk with the orthopedic surgeon at length about fx's in children.

And in the ER as a 4th year, you will probably be expected to write Rx's. Learning pharm is one thing, seeing someone's mile long med list is another, but writing for drugs is totally different (thank God for my pharmacopeia). Better to learn that skill under the watchful eye of a physician than be expected to know how to do it the first day you start residency and not have a clue. (plus when you have to re-write the Rx 5 times, you're not paying for the extra script pads).

I did 2 weeks of ER (they call it A&E) in england in an popular retirement area. Now I can do the H&P on a hip fx in my sleep. There i got to do ABGs, IVs, and draw blood (i wasn't scutted enough in my IM and surgery cores). I'll never forget the 10yo boy with a GCS of 13 and major AMS. Ask me sometime how to calm someone down who is on another planet (no drugs involved).

I can't think of a better place to learn physical exam skills. (Learning about them from "Bozo the clown" is one thing, but really practicing them on people with positive signs and then comparing results with an attending is totally different.) Can you hear the difference between dull, tympanic, and normal percussion? How do you rule out an acute abdomen in someone with ulcerative colitis? What does the fundus of the retina really look like and can you find it immediately? What does a papule, macule, or pustule look like and how are they different?

SGU doesn't require an ER elective, or even a neuro rotation, so those are areas where you might find yourself lacking behind your US-taught counterparts (although when it comes to parasites no one is better). A neurologist was making rounds the other day on one of my patients and actually asked (pimped) them on what nerve controls the anterior belly of the digastric. They didnt have an answer and my neuro anatomy is a little shaky. (its CN V3) On the other hand, when did knowing that tidbit of info actually come into play in diagnosing or treating someone?

So, if you're looking for electives that will help you be a better well-rounded MD, i suggest ER even if you don't plan on going into EM. Especially look for one that doesn't have residents (if your licensing will allow that) and tons of patients = a med student gets to see and do alot. Where i'm at they have scheduled me just like a resident, so i have great access to the attending (usually it is just the attending and me for 10 beds).

For a related thread, please see http://www.valuemd.com/st-georges-university-school-medicine/57109-what-clinicals-have-been-like.html

For those of you still looking up the acronyms:
MMSE=mini mental status exam
DRE=digital rectal exam
pt=patient
Dx=diagnosis
fx=fracture
UTI=urinary tract infection
FSGS=focal segmental glomerulosclerosis
lac=laceration
Rx=prescription (also called 'script)
A&E=accident and emergency
H&P=history and physical
ABG=arterial blood gas
GCS=Glascow coma scale
AMS=altered mental status
IV=intravenous line
CN=cranial nerve
EM=emergency medicine
did i miss any?
pharmacopeia=(look it up on amazon)
pimp=(see definition in Surgical Recall)

[drwanna]

Hey Dr Nick, I totally understand where you are coming from. I'm an emergency department assistant in a busy a and e in the UK and you get so much variety (will really miss my patient contact when I start at sgu). I already get to do ecgs, take bloods, do cpr, and assist in suturing. We have a lot of maxfax patients and the surgeon always needs someone to cut the sutures and dab the wound, last night I spent 2 hours assisting him to re-attach an ear and the cartilage of a guy hit by a cricket ball. That jackass movie has a lot to answer for too, and the number of people that put things in places that they shouldn't.....not to mention all the deliberate self harm, alcoholism, drug taking, and attempted suicides. I can't imagine working anywhere else, there is nothing like the buzz of working as a team in resuss or the 12 hours night shifts. Our doctors are great too and are keen to teach wannabe med students. Will be interesting to see how I change/develop over the four years of med school as I plan to continue my post in a and e during the vacations.

Nuff of my ramblings, but I think evryone should work in a and e if they get the chance. Even if its just to get an understanding of the time targets and pressure that doctors face off the wards and in a and e!!

[cavalletti]

drnick... thanks for the advise. Inspirational as always.

[emt036]

So how many EM electives can we schedule? :-)

And secondly, stop trying to increase my competition come residency time!

[jaywalk81]

can we possibly do 2 EM electives? one in the adult ER and one in peds ER?

[tralfaz]

It's fun even in st vincent. God, I wish I had more time to spend there. Get to see a lot of stuff (and sometimes even do it). Really cool (and they have a/c!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!).

[jaywalk81]

i thought the hospital in SVG is w/o ac...? or is it just the ER has AC and rest of hospital doesnt

[rokshana]

i thought the hospital in SVG is w/o ac...? or is it just the ER has AC and rest of hospital doesnt
some places in the hospital do - the ED being one of them, the path lab is another (unfortunately the morgue is NOT!!!).

[tralfaz]

some places in the hospital do - the ED being one of them, the path lab is another (unfortunately the morgue is NOT!!!).

The psych office (tiny though it is) in the mental hospital also has it. Just don't get lost getting there.

[EMT2RN2MD]

From what I've read, the general idea is no more than 2 EM rotations. Otherwise, you'll be missing out on too many other opportunities such as radiology, neurology, cardiology, orthopedics, ICU/CC, Toxicology, ENT, Opth., etc..... All of which would be very helpful for an EM residency.

Although, I did read a forum post from a US med student who was doing 4 EM rotations. To me, that's a waste of valuable time.

[drnick07]

From what I've read, the general idea is no more than 2 EM rotations. Otherwise, you'll be missing out on too many other opportunities such as radiology, neurology, cardiology, orthopedics, ICU/CC, Toxicology, ENT, Opth., etc..... All of which would be very helpful for an EM residency.

Although, I did read a forum post from a US med student who was doing 4 EM rotations. To me, that's a waste of valuable time. I totally agree. Do rotations in the area you applying for residency in (and at programs you're applying for) and then spread the rest among the other areas, not spending too much time in one. 4th year is the last chance you have to broaden your horizons. After that you're generally in one field.

[summerwind]

Thanks drnick for sharing your experiences!

[emt036]

From what I've read, the general idea is no more than 2 EM rotations. Otherwise, you'll be missing out on too many other opportunities such as radiology, neurology, cardiology, orthopedics, ICU/CC, Toxicology, ENT, Opth., etc..... All of which would be very helpful for an EM residency.

Although, I did read a forum post from a US med student who was doing 4 EM rotations. To me, that's a waste of valuable time.
j/k I wasn't really thinking of doing that... :-)

[drnick07]

Something else i forgot to add: Everytime i go into one of the exam rooms to do an H&P, i swear it feels like i'm back doing my CS exam. I actually have to remind myself that these are real patients, not actors. Its really strange. Translation: getting an ER rotation in before you take the CS is a good idea if you can work it in.

[mortigitempo]

....Coney Island Hospital. Trust me... unless you want a 4-6 week vacation, don't come here. We go in at 8am for rounds, which no one cares if we are there.... then have lecture from 9-10am which is the only good part of the day. Then we go 1. play pingpong on the 10th floor 2. go to starbucks 3. go home 4. sleep.

If you don't believe me, ask one of your SGU peers about the rotation here. If still not convinced, you are more than welcome to schedule your "vacation" at Coney Island