EM Intern Road Map – the first 30 days

Congratulations…you made it!   You’re a “real doctor” now. Everything for which you have worked so hard has finally paid off and your career in Emergency Medicine is officially launching.  Internship is an exciting (and challenging) starting point in that launch sequence.  A smooth and successful internship can set a positive tone for your residency experience and help establish the foundation for a successful and satisfying career.

Now that you are settled into to your new home, figured out where to park at the hospital and know how to get to the restroom (ah, the mundane but crucial details!), here are a few things to keep in mind during your first 30 days of intern year.

OUTSIDE THE ED

Managing Residency

Get to know your residency leadership and administrative staff.  This starts with your residency coordinator. He or she will be your best friend and closest ally for the next few years.  The crucible of residency is compounded by administrative duties, paperwork, regulatory requirements and institutional tasks.  Compared to patient care and medical education, this stuff is tedious and boring. It will quickly slide to the backburner of your brain because it’s not particularly interesting and its relevance to you may not be immediately obvious. Don’t let it. It will come back to bite you.  Think of it as a caged lion.  If you feed it regularly with timely email replies and task completion, the lion is happy.  Ignore it for too long, and you will have to go into that cage to face a ‘hangry’ lion whose bite can be painful (loss of hospital privileges, disciplinary action by your program, loss of credentials, etc).  Keep the lion happy!

Connect with your residency coordinator to determine where you stand with requirements. And for your own sake, read and answer your emails promptly.  Establish a habit of solid communication and compliance with paperwork.  Your residency coordinator will help you with this – notice that I write “help you with this” and not “do it for you”.  They cannot help you if you are constantly MIA or a chronic late-responder. Don’t be the procrastinator in your class. Get to know your coordinator, and treat her/him well…they have rescued many residents from the administrative abyss and they can help you feed the lion.

It goes without saying, but communicate regularly with your program director and other members of the residency leadership (assistant and associate program directors).  They will keep you on track and they can help when you fumble, stumble or struggle.   They should be checking in with you on a regular basis – but they like it when you initiate dialogue, too.

Medical Knowledge

You have probably realized by now that all that “stuff” you learned in medical school is important, but not always practical for what you will be doing on a day-to-day basis.  You have a mountain of emergency medicine knowledge to tackle and this can be overwhelming.  So, start with the basics. Stick with basic EM texts to read about “bread and butter” emergency medicine. You will hear your senior colleagues talking about cutting-edge topics they discovered on social media outlets, podcasts, and journal articles. Don’t get swept up in that just yet.  You’ll get there.  For now, read the basics.  Build a solid foundation of EM knowledge now.  Supplement with the advanced stuff later. And, of course,  attend EM conference, even while on off-service rotations (if possible).

INSIDE THE ED

Your role in the ED

Try to understand your role in the ED as a brand new intern.  Pay attention to the team structure and investigate what is expected of you.  What type of patients should you be picking up?  Should you participate in resuscitations from day #1 or should you focus your attention on lower acuity patients?  How many patients should you carry? Are you responsible for checking any equipment?  Should you work on charts during or after your shift?  The answers to these questions will vary from shop to shop, and they may even vary from attending to attending.  Keep your ears and eyes open, and ask your seniors for guidance.

Procedures

You’re an EM doc now so you want to perform surgical airways and lateral canthotomies.  Of course you do.  And you will….but probably not yet. As with medical knowledge, slow and steady wins the race. If you are fortunate enough to participate in an advanced procedure – terrific! But if you get elbowed out of the way, don’t take it personally.  Remember, there may be a 3rd year resident who is lot closer to graduation and practicing on their own than you.  They may be a little desperate to get that procedure.  Or, the attending may want someone with more experience to perform that difficult procedure. And that’s okay.  If that happens, ask to observe or assist – there are many ways to learn.  Your turn will come.  In the meantime, practice your basic procedures.  Become very efficient and skilled at wound repairs, I&D’s, peripheral IV’s, ultrasound, central lines…it will come in handy later!

Professional Attitude

Lastly, a few words about professional attitude.  We see interns struggle in 2 ways:

The first is the intern who is ‘professionally restless’. Eager to excel and do it all, this intern neglects their limitations and neglects to master the basics. They see seniors and attendings doing advanced stuff and it looks really fun. So, they focus all their time and effort on those “fun” parts of EM. But that intern forgets that those advanced skills are built upon a solid foundation of medical knowledge, hours of practice, and a mountain of experience.  You just can’t accelerate experience.  It takes time, patience and perseverance.

The second is the intern who has ‘summer camp syndrome’. Most interns arrive at internship directly from college, summer workshops and medical school. Sometimes the mentality that we develop while in these environments lingers into residency.  Up to this point, we have paid handsomely for a product – higher education, career preparation, an advanced degree.  Included in the price are often benefits like a meal plan, housing, and campus amenities.  Coming from that environment it is easy to develop certain expectations.  In college, we show up and we think “ok, now teach me something” or “where’s lunch?”  At $40K tuition, these are reasonable expectations to have.  But if you carry these expectations into residency, you might be disappointed.

Things are different now.  This is not just a summertime gig. And while it’s called residency training, we are salaried employees with a benefits package. In some cases, we may get free parking, free scrubs, free lab coats, email account, free call rooms, and access to all the resources a medical facility has to offer.  We get everything we need to do the job and learn our specialty.  Some places even provide conference lunches, recruiting dinners, and paid trips to educational conferences.  On top of all this, an amazing education is provided for you.  Dedicated faculty members spend time and effort providing world class medical education – lectures, labs, simulations, journal clubs. Not to mention, countless hours of bedside teaching.

In short, this a job…a special, important and amazing job.  We get paid to do this job. Treating patients is an incredible privilege and each patient encounter is a learning opportunity.  The intern who recognizes this, and approaches residency as the golden opportunity that it is, will quickly achieve a healthy understanding of the service-education balance in residency.  They recognize that the ‘work’ in residency is highly educational. This intern will have a great attitude about their job and will excel.  Residency training is hard work –but it can be fun and highly rewarding if you make it so.

Stay tuned for the next installment of the Intern Road Map

Lead image adapted, courtesy of Flickr and clement127 and Creative Commons.

The Angry Toddler Whisperer

Few tasks are more challenging than getting a reliable abdominal exam on an upset child. Over the years I have developed a strategy that has increased my success rate exponentially and it can be distilled down to a few key factors.

Know what you’re up against

As the great sage G.I. Joe once said “knowing is half the battle.” Many children are upset and resistant to being examined for the simple reason that they are uncomfortable or in pain as a result of their illness. They have also learned in their few years of life that the doctors office often leads to pain in the form of uncomfortable exams or shots. On top of that you are a new strange person to them and your simple presence stimulates significant stranger anxiety. Clearly the deck is stacked against you.

Set things up to your advantage

If you can, be sure that these children are evaluated in a space that caters to them. I have the luxury of a dedicated pediatric ED but many community EDs have pediatric rooms or at least private rooms where you can work in a quieter and less anxiety producing space.

Whenever possible I allow the child to stay in the caregiver’s lap or embrace. I find that this reduces much of the stranger anxiety these patients have when I start the exam and it helps keep the parents involved and in control of what is happening.

Get on their level

There are two parts to this one. The first is obvious – try not to tower over these little people! Sit next to them on the bed or sit in a chair. When you don’t seem so big you also don’t seem so scary.

The second part has to do with how we speak to small patients. Whenever possible I try to engage them in conversation related to something they like. Parents love this and will almost always try to help you out. Kids start to see you as a person and not The Scary Doctor (service mark pending).

Cartoons

copyright Casey Glass, all rights reserved
Even my 10 month old can do it!

Really I mean “distraction” but that isn’t a catchy heading. Our rooms each have a television in them and usually I walk in to the middle of Sponge Bob or Bob the Builder or some other Bob-related cartoon in progress. When possible I will move quickly through the above steps and then proceed directly to the abdominal exam. If the kiddo spooks a bit I’ll start talking to them about what they’re watching and keep examining. I can’t remember the last time I wasn’t able to get a good exam when Nurse Sponge Bob was in the room.

Sometimes the TV isn’t on or the child hasn’t really zoned out into the screen yet. In these cases I will usually combine the exam with the conversation step above. Another option is an iPad or phone type game. We keep an iPad in the department for just these types of encounters with various kid-appropriate apps ready to go.

Take your time

When I perform an abdominal exam on a small child I usually spend at least 2-3 minutes palpating the abdomen. I start out with a light touch and the distraction techniques described above and proceed to deeper palpating and more focus on the relevant abdominal zones as the exam goes along. Although I’ve never kept count I would estimate I cover the entire abdomen about 10 times in an exam. By the end of it the child is so accustomed to your touch that they tend to give reliable feedback on the location of pain and relative discomfort of the exam.

Altogether I suspect that my process adds 2-3 minutes to the visit but the payoffs in diagnostic accuracy and patient satisfaction are totally worth it. What tips do you have for the pediatric abdominal exam? Let us know in the comments below!

Featured Image adapted from from Rich Johnson on Flickr and via Creative Commons.

Aortic Dissection – What’s the Party Line?

In this month’s issue of Emergency Physician Monthly Dr. Cedric Lefebvre reviews ACEP Clinical Policy: Aortic Dissection for the evaluation of potential aortic dissection. It has always been difficult to make the diagnosis of aortic dissection as the condition is rare and the presenting symptoms can be quite variable. Dr. Lefebvre does an admirable job of pointing out potential pitfalls in the guidelines and limitations of the current diagnostic options. Check it out!

Pulmonary Contusion and the Hyperimmune Response

Faculty member Dr. Lane Smith’s comments on his paper that was published in the Journal of Trauma and Acute Care Surgery, titled, “SIRT1 mediates a primed response to immune challenge after traumatic lung injury:”

My research interest focuses on methods to modulate/modify the immune system in sepsis to create a less destructive response. We have identified certain injury patterns as priming events for downstream infection. Pulmonary contusion is one of those events that lead to a hyperimmune response to infectious insults that occur a few days after injury. Not only does priming result in a more destructive acute phase in early sepsis, it also hampers the later adaption and recovery phases.

A class of molecules know as Sirtuins play a role in the inflammatory and metabolic responses to sepsis by inactivating pro-inflammatory genes. Sirtuins are also metabolically active and drive mitochondrial oxidative phosphorylation and fatty acid beta-oxidation during the later adaptive phases of sepsis. Sirtuin activity and number are decreased by antecedent injury and play a major role in priming the immune system for badness after and injury. Basically, the body can’t tamper the hyper-immune response and switch to efficient metabolism in the adaptive phase of sepsis when the sirtuins take a big hit.

Our lab hopes to better understand this pathway and someday find a treatment that can be given at the time of injury (i.e. in the ED) to prevent priming. So far, certain compounds such as resveratrol and even n-acetylcystein are candidates since they activate sirtuins.

See the citation on Pubmed…

Featured image courtesy of University of Liverpool Faculty of Health & Life Sciences via flickr and creative commons.