October 25, 2020 monicarose

Emergency Medicine (EM) Sub-Internship (Sub-I)

Medical School

I spent the second month of fourth year on my sub-internship in the Emergency Department (ED)!  Since I am applying for emergency medicine residency this fall, this was definitely the most important rotation of medical school for multiple reasons.  Emergency Medicine requires a special letter of recommendation called a “SLOE – standardized letter of evaluation” (previously called SLOR – standardized letter of recommendation) that is based on data and shift evaluations collected throughout the month-long rotation.  Many program directors state that the data from the SLOE is one of the most important things they look at when reviewing applications.  Also, this year due to COVID, EM applicants were advised to only get one SLOE. 

It was also important on a personal level, since it was finally the most time I would be spending in the ED as a medical student, I was excited to see how much I love it.  Going into the rotation I was very nervous, wanting to perform my best, and hopeful that I would “fit in” with the other residents and enjoy my shifts.  I reviewed some common chief complaints beforehand, I liked this M4 curriculum in addition to several EM podcasts that also broke information down based on chief complaints.  Overall though, I knew that there would only be so much preparation I could do, and it would come down to learning quickly on my feet and improving throughout the month. 

On my first time being a “sub-intern”

In fourth year there are special rotations that qualify as a “sub-internship”.  They are all month-long rotations (rather than 2-weeks), and the term sub-intern infers that we will have as much responsibility as we can as a medical student in preparation for being an intern next year.  (The first year of residency is called intern year.) This was my first sub-internship, and I was definitely curious to see how different it felt or what additional responsibilities I was trusted with now that I’m at this level of medical school. 

Overall I think the differences medical students experience in terms of responsibilities will depend heavily on where you rotate, what your residents are like, and on how much initiative you were taking as a third year student.  I found that as third year went on, I was able to pick up on more and more little ways I could help my resident team, and continuing to do this as a sub-intern was definitely helpful and I received positive feedback on this.  I found that the residents trusted my physical exam findings more readily than when I was a third year student, even if they still had to recheck themselves.  One thing I love about the ED is seeing the patient’s progression as they are in the department in real-time, and it did take me a few shifts but eventually I was much better at remembering to recheck on my patients and I know that that’s helpful to the residents as well.  My residents had realistic but high expectations of me in terms of having thorough differentials, and an assessment and plan in mind for my patients.  For me this was the most intimidating but exciting area to work on, and I still have a ton of room for growth and I know I’ll continue improving throughout residency. 

The residents at my EM rotation were extremely supportive of medical students in many ways, including trying to help us get to do some procedures! I was so excited to get to do my first three ultrasound guided central line placements with the help of residents who made the entire experience positive.  I was also excited that I was trusted with laceration repair supplies and a lot more autonomy than I would have gotten as a third year student.  Getting to do hands-on things like bedside ultrasounds, incision and drainages, even pelvic exams, were all moments when I definitely felt closer to being a real-life intern than ever before.  I love that the culture at my school’s EM residency program encourages medical students and interns to get as much hands-on exposure as possible, because those moments definitely bring such a unique feeling I can only describe as thinking “wow I’m making it”! 

Some advice and reflection on the balancing-act of being a medical student 

I always appreciate when residents and other mentors verbalize and validate the unique ways being a medical student can be so difficult, so I’d like to reflect on that for a moment.  

A lot of the advice and feedback you’re given as a medical student comes in statements that reflect the fact that you are constantly trying to balance between two ends of a spectrum.  Some examples: 

• Try to get faster, but still be thorough and don’t miss important history.
• Be eager and ready to help, but don’t be annoying or get in the way.
• Be personable and be yourself so they can get to know you, but don’t chat so much that you seem lazy or uninterested in the medicine.
• Demonstrate that you’ve studied or read up around your patient, but don’t be overconfident or a “know it all”.
• Try to ensure that everyone knows your role, but only introduce yourself when the time is right. 

I was definitely internally being harder on myself than on any other rotation during my emergency medicine month because there was so much at stake, and that was uniquely exhausting.  I have always struggled with anxiety about introducing myself to attendings in all specialties; I’ve never interacted with doctors before, so I always find myself intimidated regardless of how personable or supportive the attending may be.  However, I know that identifying myself and my role as a student is extremely important, especially in the ED, for patient safety and for the sake of being a useful team member.  So advice on this for any medical students reading: just keep practicing.  The best time is definitely at the beginning of the shifts, and just try to make eye contact naturally but don’t be afraid to speak up and introduce yourself even if the attending isn’t immediately acknowledging you.  My goal as a resident in the future will definitely be to help my medical students with their introductions, and I was so grateful for all the residents who helped me as well. 

My other piece of advice in terms of being a medical student finding your way through your first sub-internship: always be actively pushing yourself to improve on new things every day, and don’t be afraid to verbalize those goals to your residents.  I appreciated when my residents would ask “what do you want to work on today?”  It helped me focus the shift, it showed that they cared that I gained the skills I am hoping for, and it made feedback I got at the end of the shift even more useful.  Some things I worked on throughout my month were things like: remembering to recheck on all my patients, getting more efficient at seeing new patients and developing my assessment and plan, verbalizing a clear list of differential diagnoses with a focus on the life-threatening, organizing my assessment and plan and looking up details such as medication dosages, focusing my presentations to include only pertinent information.  I, of course, have tons of growth and learning still to do on these goals, but it was also really encouraging to receive feedback that I improved throughout the month. 

A few patient encounters that stuck with me 

One of the many things I love about emergency medicine is that we get to see so many new patients throughout our days! 

Some interesting cases:
I saw my first patient with a scorpion sting, and saw the nystagmus that that tends to cause, and thankfully the patient just required observation and they improved and went home.  
I saw a patient with a large percentage of their body area covered in a sloughing rash, and also a burn patient, and I learned a lot seeing how we acutely manage these patients. 
We had a patient with osteogenesis imperfecta. Although this was medically interesting, speaking with the patient and their family member I realized that you often don’t consider the long-term or psychological impacts of diseases during the first two years of medical school, until you have a face of a patient reflecting the disease process.
I got to assist with my first shoulder reduction which was really awesome to help with, and it was of course great to see the patient’s pain improve right away.

Prior to this rotation I had not performed chest compressions on a patient.  We unfortunately had two patients in cardiac arrest come in during my shifts, so I did chest compressions for the first time.  The process is definitely much more traumatic to the patient’s body than TV shows ever let on, and of course was extremely different on a real patient than on a mannequin where we learned for BLS.  I really appreciated that my residents offered to debrief after the codes, because it definitely is a unique experience to see a code for the first time. Overall, I found myself of course feeling sad for the patient and their families, but I also know as I’m applying for emergency medicine that losing patients is part of the job, so I learned as much as I could by listening to the team’s plans and debriefs afterwards.  

The patients who came in in shock (hypotensive for any number of reasons) were definitely some that stuck with me the most.  Emergency physicians are the ones who lead the acute stabilization of patients, and this part of the job is one that definitely exhilarates me. However, I also find it extremely humbling as it makes me realize I have so much to learn.  It was incredible to listen to the resident and attending teams talk out loud about their assessment, differentials, and planned interventions all within minutes of the patient arriving.  The team environment specifically of the ER is another thing that draws me to it, and I learned so much being near or part of these encounters.  These patients were some of the sickest I’ve ever seen as a medical student, and I definitely found myself being surprised at how low some of their blood pressures could be while they were still temporarily compensating.  

The last patient encounter that stuck with me was a transfer from another facility who was having a thoracic aortic dissection.  They were having some mild chest pain that felt like indigestion and had resolved already, and the previous facility had seen mediastinal widening on chest x ray, and then found the aortic dissection on a CTA.  When the patient came to us, they were sitting up, completely oriented and very pleasantly talking with us.  On physical exam the only immediately notable thing was that we couldn’t palpate a radial pulse in one arm. Otherwise the patient appeared totally fine and had no acute complaints.  Unfortunately, we read the vascular surgeon’s notes later in the shift, which showed that the patient did not make it through the surgery, which is common with that type of process.  What stuck with me about this patient encounter was how unsettling it was that within minutes they went from looking fine to acutely decompensating and dying. It definitely reinforced the importance of a good physical exam.  I and the other members of his EM team were some of the last people to talk to the patient before they died.  It’s hard to put into words how that feels, especially experiencing something like that for the first time, so I’ll just leave it at being very unsettling. 

Overall feeling reflecting on my sub-internship:
I LOVE EMERGENCY MEDICINE! 

Though I’m shifting from writing about some really emotionally difficult or sad cases to this last section, I think that’s an appropriate reflection of what emergency medicine can be like.  I am drawn to the fact that it forces you to go into each patient encounter as a completely new experience from the last.  You never know what each shift, each hour, will bring, so you have to be ready to face whatever comes to you, and be ready to earn the trust of your next patient.

This was the first rotation where I was always excited to be there, where the 12 hour shifts truly flew by, and where I was confirming once again that this is what I want to do for the rest of my career.  I also really loved the residents I worked with, and their genuine mentorship and support was one of the highlights of my month, and of my entire medical school experience.  This rotation and the following ones have helped me understand why people say that the fourth year of medical school is the best.  It’s the best because you know a lot more than when you started (even if it doesn’t feel like you do) so you’re more useful, and because you’re finally on the rotations you want.