Category Archives: Little White Coats

04.30.13
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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
03.15.13
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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
01.30.13
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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
10.03.12
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The Cost of Victory

A few weeks ago, I moved into the SICU, a medical gauntlet for which I was unprepared. Ten minutes into my first day, I started CPR on an ailing patient, a procedure, at least, that years on the ambulance and months in the ED have made familiar.

 

Twenty minutes later, I was introduced to a new world of ventilator settings, vasopressors in sepsis, and open abdomens that, in short, scared me. The fact is, for more than two years now in medical school, I’ve never quite been exposed to anything that was so alien that it was intimidating. The sickest of patients never showed up on my shadowing census or were so far gone they required only continued rounds of ACLS.

 

I’m enjoying critical care. In fact, I wake up each morning with an excitement to enter the hospital that I haven’t had since leaving my emergency medicine elective a few months ago. Certainly, I look forward to each day nearly as much as I dreaded another hour in the OR watching the intern dissect around the Triangle of Calot.

 

Here the patients are sick and frequently unstable. Here I study each evening with an extra fervor, alight with the chance that the ailing patient just around the corner from the ICU workroom might benefit from my late night research.

 

But as much as I take pleasure in each day, as much as I learn from every patient and team member, I find myself faced with no small amount of conflict. So many of our charges have little hope of ever escaping from the prison of mechanical ventilation. Too many require heavy doses of Levophed just to achieve some semblance of a blood pressure. We sustain life with CRRT, ECMO, and ARDSNet, all with end goals that seem paltry at best. I entered medical school with dreams of staving off disease and defeating death, but over the past few weeks I’ve questioned the cost at which we achieve our victories.

Tags: emergency medicine, critical care, SICU, cost of care
Published: 10/3/2012 1:19:00 PM