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Thread: Bronx-Lebanon Peds

  1. #1
    otanis is offline Member 510 points
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    Bronx-Lebanon Peds

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    I've been searching the forums about this rotation and can only find info on it from 2008. Has anyone recently finished this rotation and would you mind sharing your experiences? Any bit of information would help. Thanks!

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    vett9d1 is offline Junior Member 510 points
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    I think the lack of response here is due to the fact that myself and the five other students in it currently are the first ones to do a Peds core at BL. It has a decent mix of outpatient and inpatient and is structured as follows:
    2 weeks outpatient clinic (1 week general 1 week specialty) Hours 8-4ish
    2 weeks of ER (1 of which is night float) Daytime hours 8-5
    Nightfloat hours 10P-9A
    2 weeks of wards (1 of which is night float) Day hours 630-5ish
    Nightfloat 10P-9A

    The good thing is no 24hr calls due to nightfloat weeks. Bad news is the neighborhood; I haven't gone in at night yet but I hear there is a fair amount of gang members that come out to do their thing. The train is multiple blocks away and if you drive, even in a $20/day lot you will walk a ways as well.

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    Itempest is offline Senior Member 515 points
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    So I thought I'd bump this and see if there's any new insight on the B-L pediatrics rotation in the year that has gone by.
    I start there in a few weeks and I was trying to figure out a place to stay and am curious what the hours are like, as in, what time will I be expected to be there every morning... I think knowing that will help me decide how long of a commute I am comfortable doing haha...

    Any other insight into the hospital or the peds rotation there?

    Thanks!

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    AUCMD2013 is offline Senior Member 527 points
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    Quote Originally Posted by Itempest View Post

    Any other insight into the hospital or the peds rotation there?

    Thanks!
    Bulletproof vest.
    American University of the Caribbean School of Medicine Graduate

    Basic Sciences [X] Step 1 [X] Step 2 CS [X] Step 2 CK [X] Cores [X] Electives [X] Match [X] M.D. Diploma [X] Step 3 [X] IM Residency [X] Medical license [X] Internal medicine boards ABIM [X] Board certified practicing Hospitalist [Hidden Content ]

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    Itempest is offline Senior Member 515 points
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    Quote Originally Posted by AUCMD2013 View Post
    Bulletproof vest.
    Excellent... this is something I was born with.

    What time does the day start? Like when do I need to show up?

  6. #6
    SchoonerJay is offline Member 526 points
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    Otanis and Itempest, glad you asked! Time for me to do my usual post-rotation summary and I hope you'll find all your questions answered below.

    Locations: Most of your rotation is conducted at Bronx-Lebanon Hospital Center on Grand Concourse and Mount Eden (pediatric ward and emergency department), and two weeks are conducted at satellite sites (such as the clinic on 3rd Avenue and 145th Street, and the POE clinic at Grand Concourse and 187th Street). This is the first time in doing rotations at this hospital that I've had to walk around the area at night, and it's not a comfortable thing to do... wouldn't recommend it after dark. The Pediatric Pavilion at BLHC (Selman Ave entrance) was recently built and is quite nice; ward is on the 4th floor. The peds ED is separate from the main ED, which is nice too, and is nowhere near as chaotic as the adult ED is. The 3rd Ave clinic was recently renovated and is extremely nice! However, the POE clinic is in bad need of updating: we had a heat wave come through recently and I understand the clinic was without AC for part of that heat wave before purchasing and installing a bunch of portable AC units.

    Transportation: The D (and rush hour B) train stops at 174th street, one block uptown from the hospital, and also stops at Fordham (188th Street), half a block uptown from the POE clinic. The 4 train stops at Mt. Eden, a few minutes' walk from the hospital (although I wouldn't make that walk in the dark; instead, connect with the D train at 161st St.-Yankee Stadium and ride up to 174th Street instead). The 2 and 5 trains stop at 3rd Avenue and 149th street, a few blocks uptown from the 3rd Avenue clinic. The Bx1 and Bx2 buses both stop directly in front of BLHC and the POE clinic, and the Bx2 stops at 144th Street (across the street from the 3rd Avenue clinic). Taxis are ubiquitous, although I've never used one, so I can't comment on their rates. Some students do drive, but parking around the area is quite expensive (again, I can't comment on how expensive).
    Note on commuting from 3rd Ave clinic to BLHC, which you'll have to do for afternoon lectures: you can take the Bx2 bus to BLHC, but give yourself a round 45 minutes to do so. It's a bit faster to take the trains but also much more tedious. Take the 2 or 5 train downtown from 3rd Ave-149th St one station to 3rd Ave-Grand Concourse, and get on the uptown 4 train to Mt. Eden. Walk west two or three blocks and there's the hospital. This can also take about 40 minutes if connections aren't happening fast enough.

    Rotation Setup: This is a six-week rotation scheduled through MEAS. There were six of us from AUC, and we rotated with four students from Albert Einstein COM. (The Einstein students had a weird schedule, seven weeks, and also had different requirements from us, but they were a good group of students and pretty sharp in their knowledge!) You'll have two weeks of inpatient, two weeks of emergency department, and two weeks of clinic (one week of general clinic, and one week of specialty clinic). Hours are as described below, but basically it's Monday through Friday, no weekends, and no call. However, you do have two weeks of night float, one each on inpatient and ED.

    Teaching: Teaching here was both phenomenal and fractured for several reasons. Basically, there are lectures every morning at 8 am (Tuesdays are grand rounds) for an hour, and lectures almost every afternoon usually at 4 pm. Additionally, every Monday evening at 6 pm, a senior resident gives a pediatric shelf review. All lectures are mandatory attendance with the following exceptions: since it takes so long to get to the 3rd Ave clinic, students rotating there do not attend morning rounds (except the once a month grand rounds plus M&M); also, students on night float don't attend afternoon rounds or shelf reviews. In that sense, you get a fractured mix of didactics that, when attended, were generally useful, but you felt you were missing out on important stuff too (especially compared with the Einstein students, who don't have night float and therefore attend all the lectures). Also, my specific rotation overlapped the new resident work year, meaning our lecture schedule was jumbled up frequently for the new residents to have special trainings and workshops. Understandable in the circumstances, but I'd think carefully about scheduling future rotations around July 1st. However, there was quite a lot of bedside teaching going on in the ED, wards, and clinics, so you'll be able to supplement what you miss in lectures with impromptu teachings by residents and attending physicians.

    Workday: Hours vary by where you are rotating, as follows:
    Inpatient (days): Arrive between 6:30 and 7:00 am to pre-round on your continuity patients or pick up a new patient if yours have been discharged. Everyone attends lecture at 8:00 am, and attending rounds start when everyone gets back. (Mind, some of these rounds were LONG. Like, longer than internal medicine.) Once rounds are over, it's a good time to get lunch and write notes on your patients. (Also, on Monday, Wednesday, and Friday, there are radiology rounds at some point in the afternoon; make sure to ask the residents when this will happen and be there! It's a good learning opportunity.) Afternoon lecture is at 4:00, typically at the same time as the residents are signing out, so you won't usually be able to sign out your patients (no worries, since a resident is also seeing your patient). After lecture, you're free to go home, around 5:00.
    Inpatient (nights): Arrive at 10:00 pm, take sign-out from the residents on call with you. (The Einstein students do a few nights of short call to 10:00 pm, so you may get to sign-out with one of them.) The night's duties really only depend on the patients you have (scheduled blood draws, sick patients requiring close monitoring, and new admissions). The only scheduled events are morning lectures at 8:00 am and attending rounds afterward. Yes, you do have to stay for at least the first part of attending rounds, when you present the overnight patients... it sucks, but I didn't typically leave until 11:00 am or later. By the way, when on nights, you start with Monday night and finish with Friday night, so technically you do stay over to Saturday morning. (No lectures on Saturday mornings, obviously, so you leave at 8:00 am when the day team arrives.)
    ED (days): Arrive at 8:00 am for lecture, then report to the ED. See patients all day, taking a lunch break whenever appropriate, and excuse yourself for afternoon lecture. You're done with the day after lecture.
    ED (nights): Similar to nights on inpatient, you show up at 10:00 pm and start seeing patients. Attend lecture at 8:00 am, and then go home after lecture. Again, nights are Monday night through Friday night.
    Clinic: Go to 8:00 am lecture (unless you're at 3rd Ave, in which case you show up in the clinic at 9:00 am) and then report to clinic. See patients until the residents/attending physicians take lunch, then see more patients in the afternoon. Excuse yourself for afternoon lecture and then home after lecture.

    Student responsibilities: More specific info about what to do in each location:
    Inpatient: You should present at least one patient every day, and write at least one note every day. I hate to say it so negatively, but I felt like these were some of the hardest presentations I've done in several rotations. Residents frequently jumped in and took over our presentations, which really took away from the whole experience. (Note to everyone... please remember what it felt like to be a medical student and have your presentation "stolen" away from you after so much work to get it right! When you're a resident, shut your mouth, resist the urge to jump in, and give your students a chance to sink or swim. ) If you're on days, you should present a SOAP note on a continuity patient; if on nights, you should present a new admission from overnight. The hospital policy on notes is that you can write a progress note, countersigned by a resident, but that note cannot replace a note written by a resident, so he or she will have to write their own note too. However, your admission note cannot be a part of the chart, so when on nights you'll just want to take good notes for yourself on the admission for presentation in the morning. It takes a team effort to draw blood and urine samples from kids (who knew a two year-old could be so strong??? those little guys can kick your butt!), so be available to help hold down kids and ask to be shown how to do blood draws! Experience with blood draws on adults certainly helps, but I'm telling you.. these kids have impossibly tiny veins, and if you can stick a four month-old, you can stick anyone!
    ED: One of the best parts of this rotation, you get to be a junior resident! Literally, as patients are registered, grab the first chart off the stack, find an empty exam room, call the patient to the room, and take a focused history and physical. Then you report to the attending physician on duty, the two of you see the patient again, and afterward you write an ED note on the patient. Definitely a great experience in terms of autonomy and developing your own "style" of history taking, physical exam, presentation, and documentation without someone breathing over your shoulder. If you are uncertain how "focused" your H&P should be, follow a resident for a couple of patients, and then go off on your own. These two weeks are probably the best practice you'll get for Step 2 CS so take it seriously! Advice: remember not to give the patient and parents a diagnosis before you meet with the attending! You may think it's herpangina, for instance, but it's not (yet) your role to say so. For the first few patients, you'll probably forget a few routine questions to ask (such as diaper changes, feedings, etc.) but you'll get the swing of things really quickly and should have a lot of fun with it. The attending physicians do take presentations seriously, so you might want to take a moment to compose your thoughts before presenting. "This is a (age) m/f with CC for [timeframe] with associated symptoms of... no history of associated... and PMH of... born at FT/NSVD no complications etc. On PE the vitals are... and remarkable findings are... negative findings are... My assessment is a (age) m/f presenting with CC consistent with likely [diagnosis, or differential if you're stuck]. I would recommend the following plan." Even if you're wrong in your diagnosis, they will love the format and the consistency! Also, be minded that you'll do your observed clinical encounter (see below) in the ED, so brush up on those H&P and presentation skills!
    Clinic: Depending on who the attending is in your clinic, you may be a fly on the wall, or you may be an active participant, seeing your own patients and presenting them just as you would in the ED. As an example, my general clinic attending gave me sick visit patients to see (which are just like ED patients), but did all the well child visits herself while I observed. One of the specialty clinic attending physicians saw all her patients and I observed; one let me see patients on my own; and two others sent me with the residents to observe. (Your experience may vary.) Even if you're just relegated to observing, be sure to ask plenty of questions (after patient interviews of course, never interrupt the attending). When seeing your own patients (especially in the specialty clinic) be sure to take a very thorough history, probably more than you would in the ED. Specialties you can see at POE include endocrinology, allergy and immunology, GI, and developmental/neurology. I highly recommend seeing at least developmental/neurology (as you get first-hand experience with autism spectrum disorders and ADHD as well as other learning disabilities), and allergy and immunology.
    Note: it is not required that you do a rotation in the nursery or NICU, but if you wish to do so, you may do a day or two there. It's recommended you do so during your specialty clinic week. I did neither, but we did have one practical lecture in the nursery so at least I did get to see how to examine a newborn child. Although I didn't do it myself, I think I'd recommend a day in the nursery as a good experience.

    Student evaluation: Unfortunately, this ends up being a lot of work on your part and is probably one of the less pleasant aspects of this rotation. The preceptor will ask you to obtain at least six, preferably eight evaluations from attending physicians, residents, or support staff with whom you've worked closely. She'll give you copies of the evaluation forms (they're AUC's own forms), on which you'll put your name, and then hand over to whomever you'd like to evaluate you. I agree with the philosophy: if your final evaluation is averaged over many individuals, you lessen the chance of being tanked by one or two tough graders, but in practice it becomes a real pain to try to track these down. Most people are more than happy to accept an evaluation for you, but you'll have to chase them down in order to make sure they actually do it. Residents typically fill it out on the spot and hand it right back to you, whereas attending physicians tend to say they'll get it back to you at a later date (or will give it directly to the preceptor for you). Don't trust that! If they say they'll get it back to you, go back often and ask if they have it ready. If they say they'll give it to the preceptor, ask her often if she's received it. If you wait until the last week to track these down you may come up well short, especially as some of the ED physicians seem to take long vacations and may not return until after your rotation is over. Keep a few blank evaluation forms in your pocket or at ready access, as several times I was directly asked by a resident or attending to have one filled out for me.
    There is also a write-up due on Friday of the third week of your rotation. Ideally this should be for a patient on the inpatient ward, but you might not have rotated there yet (in which case you can use an ED patient). This is a full history and physical write-up, and you're expected to include a two or so page appendix discussion on that topic. I was lucky enough to see a malaria patient (malaria! in the US! okay, he had just arrived from Ghana, but still... man I love NY sometimes), so my appendix included a differential to consider when you have a patient with fever, myalgias, vomiting, and headache, with a discussion on each differential and why it doesn't fit this particular patient (based on historical or physical exam findings). This is a bit of work so don't leave this for Thursday afternoon before it's due! (Unfortunately, when I asked for feedback on my write-up from the preceptor, I was told that she didn't have it yet... disappointing, I find. So I can't yet speak to how thoroughly it's graded.)
    Also, you'll do an observed clinical encounter (OCE) in the ED at some point in time. This is done with an attending observing your entire H&P. Honestly, when on night float is probably the best time to do this, but unfortunately that didn't work out for me (we were flat-out slammed for two nights all the way to the morning lecture, and the other nights we were hopping until about 3:00 am or so and then no new patients... missed the opportunity), so I ended up having to go back in the morning one day and doing it then. Early morning is best (right after lecture) since few patients are coming in, and the attending can afford to spend thirty minutes with you on the evaluation without worrying about patients piling up. See pro tips below! They'll be very useful here! If you read over the OCE form, you'll see that it's very heavily focused on the history, so make sure you use a good opening, use open-ended questions as much as possible, show compassion/empathy/comfort for the child and parent, and wash your hands before beginning a physical exam. Just like Step 2 CS, yeah?

    Impression: Overall, I felt I got a good experience out of this rotation. The ED portion in particular is well done, and I had a fantastic time being a "resident" for two weeks. I also got a chance to practice blood draws more in the ED than in the inpatient ward; the nurses here were very efficient and friendly. The clinic experience was exceedingly disappointing for me, coming as it did on the heels of my ED experience, and my being relegated to more or less a fly on the wall. However, the allergist was more than happy to let me see my own patients, and I did learn a lot by observing the residents working with the ASD/ADHD patients. The inpatient experience was a shadow of my internal medicine experience, with the long rounds without the benefit of an opportunity to be an integral part of the patients' care. Nevertheless, the teaching was well-received and I did learn a tremendous amount.

    Pro tips! If you get yourself on a daytime sleep schedule when on night float on the floor, you might have a lot of free time all night long to study! I had only one busy night where we were pretty much unable to sit still for more than half an hour; the other nights, we pretty much admitted a few patients right away, and the residents went to sleep until another admission hours later came in. Fantastic study time, I did some of my best step/shelf preparation those nights. In the ED you'll typically be very busy for the first half of the night and it may slow down enough to study later in the morning. I'll be honest and admit that I didn't do a terrible lot of pediatrics-specific studying since I'm preparing for step 2 CK right now (my shelf isn't for another six weeks), but other students were using Case Files and Blueprints. I'm becoming very disappointed with First Aid for Step 2 CK and I don't really recommend that book at all. It shouldn't be much surprise, but this was the first rotation where Mass General's Pocket Medicine guide wasn't much use (even though I thought it would at least help with conditions that are common to both kids and adults, such as diabetes and asthma... as it turns out, that's not at all true! Remember: kids are not mini-adults. ) Maxwell's is still useful, although the normal ranges for CBC and electrolytes values depends on age. Common diseases you may wish to read up on beforehand: asthma vs. RSV, diarrhea in different age groups, cellulitis and abscesses in different age groups, immunization schedule, developmental milestones, and rashes (classic exanthems as well as eczema, urticaria, and angioedema). When you take a pediatric history, be sure to always ask detailed questions about the mother's pregnancy (GDM, pre-eclampsia, PIH, etc.) as well as the mode of delivery (including why a C-section was indicated), and any post-natal complications (such as phototherapy). Ask how the child is being fed (formula vs. breastfeeding, how many ounces and how often, and how well tolerated) and if there is decreased appetite; if so, is the child still drinking fluids? How frequently does the child have wet diapers, and has that number changed since the child became ill? Etc. You still ask about sick contacts, travel, and associated symptoms, but keep in mind that young children don't verbalize chest pain, abdominal pain, ear pain, etc... they pull at their ears, pull their knees up to the chest, or seem fussy and inconsolable. On PE, always check both AF and PF in a child under two years of age. I recommend starting with the least noxious parts of the PE first; once the child is screaming and crying, you won't be able to hear clear lung sounds! If need be, examine the child first in mom or dad's lap, and always stick the otoscope the ears last. Be sure to check for red reflex on infants too.

    All the best! Kids are fun, even if sticking them with needles is NOT FUN AT ALL, and parents are absolutely crazy, but you should have a good time with this rotation.

  7. #7
    LinkMoto is offline Member 517 points
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    Night Float that starts at 10pm...better walk around with protection in that case :O
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