Things I Wish I Knew - Third Year

And now for one of my favorite posts of the year; taking a look back at everything I have experienced and attempting to come up with a few things that helped me succeed. I would like to invite you to share your input as I may have overlooked a number of useful ideas. As in years past, I am including my weekly intensity chart.

The Year Reviewed

I will be the first to admit that this year's intensity chart has little benefit to anyone but myself. Everyone experiences rotations in different orders and each has a varied feel depending on site, preceptor and specialty. For the most part it was on a steady continuum. The occasional peaks and troughs were likely tests or vacations respectively. The large dip representing my vacation month when I was recovering from surgery and the recent peaks reflecting weeks that I left nothing to chance on elective rotations in emergency medicine. These later markings also show stress that has been mounting in anticipation for board examinations. Without further delay, below are those things which I wish I knew coming into third year.

1. Maintain an open mind - Every specialty has something to offer, even if you are not enthusiastically interested in the field. You never know when a lesson learned from a particular patient will come in handy on another rotation or even later in your career. There is always something to be learned, even if you are not fascinated by the work before you.
2. Participate actively - It is easy to observe and nod your head when preceptors carry about their normal activities. Encourage them to teach by asking thoughtful questions or volunteering to participate in procedures. One night during my studies I watched how to place a central line only to be asked the following day if I knew the steps. Because I was familiar with the procedure I was given the opportunity to place the line and have been entrusted numerous times since then. Always be ready to step in to answer questions or use your hands and actively learn.
3. Avoid easy rotations - Every now and then it is nice to have a rotation that demands less, but too many of these can be detrimental. This is the best time to interact with patients, perform procedures and learn from attendings. We pay good money to be in clinics and hospitals, why read about the diseases when they are in the room next door ready to be seen first hand. Even if you are on an "easy" rotation, push yourself to take advantage of the little time you are there, you can read later when you get home.
4. Pace yourself - There is more information than you can possibly consume in a few short weeks about any one subject. Start studying the specialty early on in the rotation and regularly review the "bread and butter" topics. By the end of your time there you may become exhausted when shelf exams are just around the corner. Cramming for the end of rotation exams is not going to help you in your career as much as regular study.
5. Enjoy your time off - It is really easy to get swamped by the books, board exams and stress of preparing for residency. There is a little more time in third year to break away from school and it can be a perfect therapy for all the stress that will inevitably mount. Be sure to have regular time set aside for exercise and breaks. Work hard, play hard.

Question of the Week

A 67 year old male patient presents with mild confusion, diarrhea, and a new skin rash. These symptoms have been present for 1 week according to the patient's wife. What is the most likely nutritional deficiency that this patient is experiencing?

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B5
E. Vitamin B6


Answer & Explanation

Good News Test Results

Despite the normal challenges of being on rotation, this week had at least one positive outcome. Like the good ol' days when report cards made their way to the refrigerator door, so did the test results of my most recent exam. It was partly for nostalgic effect and partly because this was by far the most expensive exam I had ever taken. Tabulated expenses were a total of $1,500!

COMLEX Level 2 PE

Being that this test was among the medical school series of board exams, it comes as no surprise that the results were a relief. The examination itself was not horrific, but the cost was ghastly. I was more worried about having to fork out another payment than studying all over again should I have to retake it. I now feel one step closer to graduation and have only one more exam remaining to make it out of medical school as a doctor. That is a really good feeling that is going to be much better when the next board examination is behind me.

Preparing for the exam was not as difficult as I expected. Classmates and I would get together a couple times each week for a month and perform timed practice scenarios from the book First Aid for the USMLE Step 2 CS. Taking turns as patient and doctor, we slowly got into a rhythm that would set the pace for exam day. The video orientation on the NBOME website provided test site details that helped to plan resources and expectations on test day. The rest was a matter of showing up for the exam on time and keeping calm. Faster than I expected, the day was over and weeks later I have my passing grade. Two board exams down, one more to go.

Question of the Week

A 19 year old male comes to your clinic complaining of a sore throat with no cough for the last three days. Vital signs are normal except an elevated temperature. On exam you note the patient has "kissing tonsils" with exudate and cervical lymphadenopathy. If this patient did not receive treatment at this time, he would be at risk for which of the following conditions?

A. Subacute Sclerosing Panencephalitis
B. Wegner's Granulomatosis
C. Membranoproliferative Glomerulonephritis
D. Rheumatic Heart Disease
E. Chédiak–Higashi Syndrome

Answer & Explanation

Providing Fresh Air

I have yet another first to add to my list of many as I trudge along the med student life. Like many, this one is procedural. In emergency medicine the procedures continue to accumulate the longer you are there. I think it falls into the "see one, do one, teach one" mantra.

Rapid Sequence Intubation

With little success at my previous attempts, intubations were starting to concern me when I could only see the epiglottis and no vocal cords. That was the closest I came before patients would start to lose oxygen and the attending moved in to finish the job. After wondering why I was going to an extra shift last week, I was glad it fit into my schedule. We had a patient with respiratory distress needing rapid intubation. Despite their predetermined status as a "difficult" airway, my attending gave me the opportunity to perform the skill. Focused and determined to finally have a successful intubation, I meticulously placed the endotracheal tube on my first attempt...in the right place! In a specialty where airway management is critical and a career of it ahead of me, it is nice to see where my first success actually occurred.

The physician with whom I was working mentioned the day before, "you have to respect the difficult airway." Although I may not completely understand that statement at this point in my career, I know that the skill is important enough to appreciate pitfalls and workarounds. My extra shift turned out to be rewarding on this particular occasion. A simple procedure to some happened to be another milestone in my book.

Question of the Week

A dialysis patient has missed their routine treatment and is now currently in respiratory distress as a result. You choose to intubate the patient. In preparation for this procedure, the use of which of the following paralytic medications would be discouraged?

A. Succinylcholine
B. Rocuronium
C. Vecuronium
D. Pancuronium
E. Rapacuronium

Answer & Explanation

Prepared for Chaos

As a young Boy Scout, I always loved reading through the handbook and learning how to MacGyver objects on hand into something useful. It was continuous testing of the Boy Scout motto "be prepared." In emergency medicine the challenge is similar; always being prepared for the worst case scenario. [Pictured: Make-shift hospital outside St. John's Regional Medical Center in Joplin, MO. Image provided by Mercy Health]

Ready at a Moment's Notice

In recent headlines, tornadoes have shown their gruesome force by leveling towns and causing mass chaos. The incident in Joplin, Missouri was no different and Dr. Kevin Kikta shared his experience of the night the tornado destroyed his hospital in 45 Seconds. This is a prime example of being ready for the moment when everything is wrong. He managed the care of patients with the limited tools on hand as he moved from one to the next. He didn't need functional rooms, a full set of staff, or the best equipment. He knew what needed to be done and found a way to make it happen. He was prepared.

I suppose this is the "what if" game so many emergency medical professionals play when they have time to think. "What would I do if...?" we think to ourselves and play out a scenario that one would never expect to happen. After playing the game enough times, you start to realize how your response to a particular situation changes to maximize your performance. Should the situation play out, you might just be one step ahead rather than caught up in the element of surprise. Whether the Boy Scout manual was premature training or the "what if" game preparatory, I hope that in those unsuspecting situations I will be prepared to act accordingly.

Question of the Week

Shortly after having a subclavian venous catheter inserted, a patient is noted to be acutely short of breath with rapid and heavy breathing. He is not yet in respiratory distress. A chest x-ray reveals a pneumothorax. Management should consist of

A. removal of the central line.
B. insertion of a new central line on the other side.
C. insertion of an angiocath in the third intercostal space on the side of the central line.
D. insertion of a chest tube on the side of the central line.
E. insertion of a chest tube on the side opposite the central line.


Answer & Explanation