Reflection

My Emergency Medicine rotation at NYPQ was nothing short of amazing. When I started the rotation, I was unsure if I would like the pace or “chaos” of emergency medicine. Though, from day one, I kept an open mind and immersed myself in growing as a future clinician, with an immediate focus on growing as an emergency medicine clinician. The teams with which I worked, including the attending physicians, the resident doctors, PAs, NPs, RNs, ED technicians, etc. helped facilitate academic and technical learning.

During my rotation, I gained exposure to new techniques for performing several procedures. For example, during one of my “Urgent Care” shifts, my patient required a Posterior Leg Splint. My preceptor showed me an alternative, faster, way to apply the webril first to the splint itself, and then to the patient. I was surprised to find that this technique was just as effective as first wrapping the webril around the leg itself. Additionally, I learned how to instill local anesthesia in a wound as well as perform a digital nerve block for patients that would require suturing. An orthopedic resident that was consulted for a patient’s dislocated shoulder allowed me to assist him in a traction-countertraction reduction. During this procedure, he taught me about several modalities to reduce dislocations and the benefits/risks associated with each.

One skill that I am continuing to improve upon, though I constantly feel challenged by, is presenting an HPI to my preceptors. Though there is slight variation as to what each preceptor “likes” during an HPI presentation, it roughly remains the same. I sometimes have trouble presenting the “timeline” of the patient’s illness, especially if there are other elements of the story that occurred weeks/months ago. Throughout the course of my rotation, though, I could feel that my presentation skills were including – that, for example, my HPI contained pertinent positives and negatives that accounted for broader differential diagnoses. I can improve upon my HPI presentations by asking my preceptors for feedback at the end of my shifts and getting opinions from resident doctors. I can also practice by reading the HPIs that my preceptors and colleagues write up themselves.

Queens is very diverse, and as such, the use of interpretation services is common in the NYPQ emergency department. Though using the interpreter services is usually not too complicated, an experience I had during my final week was very challenging. The patient and his wife spoke a Chinese dialect that was not available through interpreter services. In order to communicate with the patient, I had to use a Mandarin interpreter, who then called the patient’s daughter (who spoke Mandarin), who then was able to communicate with her parents. The line of communication was as follows: I asked a question in English à the interpreter poised the question to the daughter in Mandarin à the daughter poised the question to her father (the patient) in their dialect à and then the chain of response occurred in the reverse fashion. This was challenging, not only because of the extra time that was required to see the patient, but also because of the fact that there were so many people trying to speak at one time. This experience was useful in that it showed me that as clinicians, we may be faced with tedious situations, though the quality of care we deliver must never be compromised.

One memorable patient that I will carry with me and reflect on was a middle-aged gentleman I saw during my second-to-last week at NYPQ. The chief complaint on AllScripts read that he was coming in for a complaint of abdominal pain and chills. I’ll never forget that when I found the patient, he was shivering more-so than I had seen any other patient, ever. This was what rigors looked like. After accessing an interpreter, I approached the patient and his discomfort was very evident. While taking a brief history, I began palpating his abdomen. His abdomen was rigid to the touch. Again, this is something I have experienced when examining a patient. At that point, just a few moments after my initial contact with the patient, I decided to alert my preceptor to the patient’s condition. The patient was taken for CT scan of the abdomen and was diagnosed with ascending cholangitis. This experience will stay with me for two reasons: it was one of the few patients I saw during my time in the ER where you could look at them and immediately draw the conclusion that they were sick (versus not sick). This experience was also something I will reflect on because at the end of my shift, my preceptor said she was very happy to have had me as a part of the team that day. She informed me that I was essential in getting the patient to CT early and to the team making an early diagnosis of the patient’s condition.

Another memorable experience that I had was during one of my “Red,” or Critical Care, shifts. We had an elderly, septic patient that would require bilateral percutaneous nephrostomy. At that time, I assisted the resident doctor in bringing the patient up to the Interventional Radiology suite. When we arrived, I was pleased to find that Professor Sadat was working. The resident doctor I was working with encouraged me to stick around to observe the procedure that would be performed. It never crossed my mind that an opportunity to observe such a procedure would occur, and I was grateful to have had the opportunity. During the procedure, Professor Sadat asked me to start a Normal Saline drip and additionally asked me about what technique the Physician was using when inserting the wire, followed by the catheter… (Seldinger!) This experience was fascinating from a medical standpoint and Professor Sadat helped facilitate learning throughout.

The knowledge I’ve gained at this rotation site is broadly applicable. The good thing about emergency medicine is that you get to see patients that are complaining of a variety of different symptoms that encompass multiple different specialties. Beyond just gaining further medical knowledge, the emergency room is a great place to learn about how members of a healthcare team work together in the care of their patients. Each “cog” is playing his or her part in order to maximize the patient’s outcome. Additionally, apart from the team that is immediately present at the care facility, the emergency room providers constantly communicate with the patients’ primary care doctor and other specialists to notify them of their condition and to arrange for proper follow up care.

In my future rotations, I hope to further improve upon creating an assessment and plan for my patients. During my emergency medicine rotation at NYPQ, while I felt that I had included certain key components of the assessment and plan for my patients, there were other things that I had not considered. My action plan to improve upon this area is to continue presenting what my assessment and plan would be for the patient to my preceptors, and then ask for feedback as to what was good or what could be done differently. Additionally, in the event that my preceptor is busy and doesn’t have adequate time to do this for every one of my patients (which is certainly possible giving how busy healthcare is!) I can review their notes.

During this 5-week rotation, I learned a lot about how to think like an emergency medicine clinician. My differential diagnoses began to take shape into what diagnoses were the most life-threatening at the time and ensuring that our patients were not suffering from them. I learned how to take a history and perform a physical exam in an expeditious fashion that still allowed for comprehensiveness. I learned that I can survive working overnights! (This was the first time I have ever worked from 7PM to 7AM!)

I am excited for my next rotation, Surgery at NYPQ, where I expect to challenge myself and continue growing academically, professionally, and personally.