An Eye-Opening Opportunity in a Rural ED

I met Jeffrey when he came to the rural emergency department where I’ve been assigned this month. Restless in one of the small unit’s three acute beds, I quickly noticed the large abscess over his left elbow that had brought him to our door. The pain was apparent, the fear only slightly less so. With no CT or ultrasound, much less the MRI he’d ultimately require, the decision was quickly made to transfer Jeffrey to the larger hospital an hour up the road, where half an hour in a whirring machine would eventually show the bacteria that had invaded his joint and bone.

We chatted for a few brief minutes — about the drug use that had led him to this point, the depression he found himself sinking more deeply into by the day — the same topics, really, that we’ve come accustomed to with the victims of addiction we see all too often. Before the night drew on much longer, Jeffrey had been whisked off by the critical access hospital’s dedicated transfer unit.

After four exciting and challenging weeks at one of the nation’s leading emergency medicine centers, my school has shipped me off to a small community in rural Pennsylvania. The experience, in the two short weeks I’ve been here, has been unlike any other rotation of medical school. I awake each morning to a low-lying mist that conceals the mountaintops on either side of this tiny town. The hospital — no more than a mile down the road — requires me to pass through the town’s only stoplight, which is unfailingly red when I pull up to the white line. I find myself in little time, however, in the parking lot of the small complex nestled into the side of the southern mountain.

I spend most of my days seeing patients in a two-room clinic across the gravel road from the ED. When an ambulance rumbles by or my pager sounds, I hurry next door to start the workup while my attending makes his way in or begins charting. Our catchment area has no more than a few thousand potential patients and a yearly ED census somewhere in the high triple digits, and I’ve quickly come to know many of the residents of this small and tight-knit town. Patients I see in morning clinic wave from their porches as I pass on my evening runs. The nurse who helped me fix a bleeding PICC on Tuesday is the one who slides me a sweating drink from behind the bar on Wednesday. Jeffrey, freshly returned from a weeklong inpatient stay two towns over, flags me down at the gas station to show me how well he’s doing.

Where I’d been initially hesitant about this mandatory month far from home, my experience so far in rural emergency medicine has been an eye-opening opportunity. I’ve taught basic skills to the borough’s fledgling rescue squad, and roared off into the night with the volunteers in their incongruously well-appointed ambulance. I bumped down abandoned dirt roads in the forgotten hours of the morning, and I’ve stabilized patients in the back of the rig and been able to then continue their care in the emergency department. With no imaging, consults, or backup, I’ve learned volumes from the emergency physicians who staff this medical outpost.

Two more weeks to go until I pack up the car and head back to Philadelphia for another month in a mecca of emergency medicine. Until then, each day here in rural America provides another chance to be a part of a hospital so thoroughly interwoven into the surrounding community. Each patient offers another opportunity to witness the special medicine practiced by an emergency physician known and trusted by his patient-neighbors.

Tags: Medical Student, Emergency Medicine Training, Residency, Mentors, Match, FOAMed, ED
Published: 8/27/2013 8:32:00 AM

Matters of Weight, Figuratively and Literally

I walked out of Step 2 on Wednesday and felt like a major weight had been removed. No matter how it turns out, it’s done. My last exam of medical school is in the bag, giving me a few short days to get my life in order before hunkering down for my next rotation. A haircut that I’ve been postponing for far too long. The laundry I should have folded last week. The phone calls, dinners, and emails that tend to accumulate at the wire.
 
It’s no secret that medicine has a tendency to envelop your life, and I can only imagine the extra hours that residency will claim. Things get pushed to the side, priorities are readjusted, and the elements that used to complete your day slowly disappear. It’s a simple reality that sacrifices will have to be made to dedicate the time and effort that the profession demands. The future reality has only become more apparent as my fiancée kicks off her second week of OB/GYN residency. All that being said, though, it seems that emergency physicians in particular have a knack for holding on to an outlet — some distraction, dedication, or hobby that pulls you back and helps to keep the big picture in mind.
 
Once upon a time I was a somewhat decent runner. I'd wake up every day to blaze through a few miles with the team, relishing the view of the morning sun rising over the Chesapeake as we sprinted through the last straightaway. We'd do it again in the afternoon before collapsing on the grass in front of Luce Hall, lungs burning with each gasp. Each mile helped to define my experience, and nothing was better than getting lost in the steady shuffle of sneakers around me. But that all ended after I tossed my cap in the air. A few years passed, and I started running less and less. Miles on the trail were replaced by hours on watch. When medical school began, it was an escape to the gym for an hour and a half between studying. Then an hour. Then three quarters.
 
It was in Cambodia that I started to run again. There was so much I wanted to see — the temples, the palace, the dusty dirt roads that led to somewhere unknown — and running was the perfect way to do it. I was surprised at first by how much speed and endurance I'd lost, and I struggled in the oppressive humidity. Slowly, though, my legs came back to me. I stole a few coveted miles on my way home inside of the Seoul-Inchon Airport. I overcame jetlag over the next few days by trading rest for road. And the morning miles steeled me for each day when school began again. The pains in my knee and the dripping sweat offered brief but welcome solitude and helped me to organize my thoughts and plans.
 
But I couldn't seem to regain the passion and pace that I maintained so easily a few years ago. I embraced the peace of the run, but my mind would still drift to the to-do list that beckoned from my desk. I cut the miles shorter with unread journal articles and unpublished research as my excuses. If I missed Thursday's easy run or Sunday's sprints, I would rationalize with responsibility. When the gun went off at the Thanksgiving 5K, rubbery legs and burning lungs underlined my procrastination. A terrible finishing time highlighted it.
 
Reluctantly, I’ve come to the conclusion that I’ll never again break the turns like I once did. It’s a terrible irony that medical school ended up being such a detriment to my health, but I know I’m certainly not the first. With rising responsibilities and an increasingly shaded calendar, it becomes important to inject these hobbies where we can.
 
My next rotation is just 10 miles down the road, but that amounts to at least 45 minutes in the daily snarl of Philly traffic. It’s the perfect opportunity to pull my bike out of the garage, brush away the cobwebs, and start each day with a nod to the cardiovascular past. Making sure to remember the things that define us, the daily diversions that make us who we are, help us face each day with the same passion and ardor that brought us here.
Tags: medical school, time, health, running, residency, long hours
Published: 7/15/2013 11:31:00 AM

Entering Fourth Year a Little Wiser

My third year of medical school ended last week, marking a transition to senior year that seems much less momentous than this same month a year ago. Last time the move from books to bedside felt like a pinnacle of achievement, but this time I’ll pick up almost exactly where I left off. There are no board scores crawling through the mail, no ceremonies, no pomp, no circumstance. The graduation to MS4 is not an achievement as much as an expected progression. It seems obvious and, well, boring, but the ease of the transition is, perhaps, what makes it important.

I began clinical clerkships with an outsider’s knowledge — a peripheral understanding of the world of medicine. Through the dedicated instruction and committed mentorship of so many, my classmates and I have broadened our horizons and found a long-awaited place among the health care team.

Maybe what’s more momentous about the move to my final year is the realization of how growth in medicine is accompanied by growth independent of it. Where once I may have seized every chance to be in the ED or on the ward, no longer is that the default. Not because of exhaustion or satiety — far from it — but rather because of the recognition that there is more to becoming a good physician than the lessons within the hospital walls. The early morning basketball game that helps up forget the frustration of editing an abstract for the fifth time. The long-overdue dinner and a movie that reminds us that we’re still loved, no matter what the surgery attending has to say in his fit of rage. It’s the stolen moments with family and friends that show us how success comes not in spite of others but only because of their support and company.

So, I’m a fourth year now, a little older, a little wider, and maybe even a little wiser. Monday morning the alarm will sound just like every day of third year, and I’ll drive to the hospital along the same old roads. There is one important difference, though. After too long apart, I’m finally back in the emergency department, starting a long stretch of auditions for a coveted residency spot.

Published: 6/5/2013 7:53:00 AM

Yearning for the ED

With less than a month left in third year, I’ve moved into the psychiatric crisis center of a local hospital system. The 10 beds of Crisis house patients with acute psychotic breaks, suicidal ideations, or even just a BAC not conducive to the emergency department. My fellow student and I move from room to room, doing our best to examine these patients while striving all along to learn the best approach to the manic 40-year-old or how to assess the suicidal teenager.
 
I … am … tired. As much as I savor every moment of the medicine I’m learning, I can’t help growing frustrated. I become exasperated when the patient in Room 3 bemoans her lot of poverty and signs the charity care paperwork, all while she pulls her iPhone 5 from a Coach pocketbook, cigarettes falling to the floor. I sigh when an entire day on the wards is spent holding on the phone with an outside hospital assigned to obtain a patient’s discharge records but mired in the HIPAA concertina wire.
 
As much as I should just accept it as part of the process, I am disappointed when patients refuse to see anyone but the attending, their expectations of residents and students formed not by experience but by “Grey’s Anatomy” and daytime medical dramas.
 
I can’t wait to be back in the emergency department, not because these stressors will stop — they’ll probably, in fact, only increase — but because within the ED rests the cure for a medical student’s disenfranchisement. It’s within the emergency department that a student can always find a nurse, physician, or staff member ready to share knowledge and experience. The willing teacher will always stand as the trusted map on a student’s wavering journey.
 
So in June I’ll find myself back in the ED, this time as an auditioning candidate for a coveted residency spot. Until then, it’s back to Crisis and the depressed patient in Room 7.
Tags: medical student, resident, emergency medicine, ED
Published: 4/30/2013 10:38:00 AM

The Problem With FOAMed

FOAMed is everywhere. Free Open Access Meducation, a term coined last year by Dr. Mike Cadogan, has inundated every blogroll, every news site, and every Twitter feed. Sites such as Free Emergency Talks, EM Basic, and Academic Life in EM add more to my reading list every evening. The amount of evidence-based and clinically reviewed medicine available to the medical trainee has never been greater, and it is clear that we are witnessing a monumental shift in medical education and its delivery.
 
But FOAMed’s ubiquity and breadth — perhaps its greatest assets — may also be its biggest challenges. For a junior trainee such as myself, it can be all too easy to doggedly follow a heated debate between Minh Le Cong and Nicholas Chrimes on cricoid pressure, but that too frequently comes at the expense of that evening’s planned preparation for pediatrics clerkship or OB/Gyn rotation.
 
Unfortunately for my USMLE score, I have little interest in memorizing vaccination schedules or surgical techniques. Rather than study board review books that list beta blockers as primary interventions in ACS, I’d prefer to understand the science behind David Newman’s rejection of the same on The NNT. It’s the irony of medical education that these extracurricular explorations, which might make me a better physician in the future, make me a worse student in the present.
 
So it’s obvious, then, that a balance must be sought. For the student or trainee whose foundation is still being formed, perhaps it’s best not to build with FOAM. Maybe we must learn from the same resources that our role models in health care social media did, and sample sparingly from the constant stream of clinical wisdom being shared. It seems prudent for me to learn the basics from the time-tested and guided curricula available, and save Dave Neubert’s daily cases or Scott Weingart’s podcasts as deeper dives into a few core topics.
 
I love #FOAMed. The global reach and accessibility of expert medicine embodies the best of what our profession seeks to be. It has become clear that open access medicine is the key to molding ourselves into the best physicians we can be, but it is still the task of traditional resources to shape us into the doctors we first must become.
Tags: FOAMed, medical education, emergency medicine residency,
Published: 3/15/2013 8:00:00 AM

Bright Red Buoys

A lot can happen in a few months. As the days and weeks of MS3 year have passed, I’ve learned clinical pearls and academic curiosities. I’ve spent a few more nights teaching, a few more weekends working, and any number of hours reading up on unfamiliar disease processes from the day before. I got engaged. The ever-changing environment — moving from hospital to hospital, never knowing which clinic badge I’ll be wearing Monday morning — can be confusing and frustrating. I worry about being close enough to home to make it back before the rest of the house is asleep.  I get anxious about the hours my dog spends home alone. Above all, though, I fret about the future.
 
It’s a rare night when talk about residency locations, wedding plans, or board exams doesn’t cross our lips at least once. Indeed, I write this missive as my fiancée and I drive North for yet another of her OB/GYN interviews. (I get dragged along, but comfort myself with the knowledge that I’ll always have a gynecologist to consult at 3 am). Every decision we make, from wedding invitations to the color of bananas we stock, seems to require a careful accounting for the uncertain future.
 
But this, you see, is where I have benefited the most from my early interest in emergency medicine. Since the very beginning of medical school, when a hesitant email to my rescue squad’s medical director introduced me to a world of academic physicians, I have had the hazy path outlined by those who have gone before. Dr. H’s monthly emails act as the bright red buoys from my past, always providing a sure course. Drs. N and C, their plates already full, never fail to offer advice when needed. I came to know Dr. B through SAEM’s Mentor Match program and Dr. A through ACOEP’s poolside conventions. The list goes on, an alphabet of assistance from those who seem to define the camaraderie and excellence I’ve aimed all along to be a part of. Where friends of mine might struggle to learn the road to otorhinolaryngology or general surgery, I’ve found a flagman at every detour.
 
The journey to residency is nearing the beginning of its end. When the snow melts and spring hits, I’ll begin my final year in medical school. I’ll audition, apply, interview, and match — and it will all be possible because of the guidance I’ve gotten along the way.
Tags: emergency medicine, residency, mentors, match
Published: 1/30/2013 9:42:00 AM