There is no shortage of interesting stories in the emergency department. If you want to have an adventurous life in medicine, it is the place to be. One minute you are discharging a grown man with a stubbed toe; the next you are running a code on a lady in cardiac arrest. At times the work is slow and tedious; at others the department is swept up in a hurricane and it seems like there will be no end to the chaos.

Having worked in the emergency department as a tech for two years, I can say with certainty that I thrive in this environment. But it is not for everyone. As you work in emergency medicine, you will meet providers who have been working for 30 years and absolutely love their job. You will also meet providers who are “burnt out” and frankly miserable. While it is advantageous to be tough or thick-skinned, there must be balance. Even the best of providers lose their tempers at times. The important thing, though, is that you don’t lose your sense of compassion. No matter how many patients seek drugs or ‘abuse the system’, your focus should always be on the patients who genuinely need your help. Emergency medicine is a difficult career, but a rewarding one.

 

My Experience

This rotation was a homecoming for me. I rotated at the emergency department in Charleston where I worked for two years, and it was great to see my former co-workers again. When you work in the ED, you come to call these people your family. Let’s face it, you see them more than you see your own family, and you have some wild, even harrowing, experiences together. (There is something about being knee-deep in C-Diff with a coworker that binds you to that person for life).

One major advantage to doing a rotation at my former place of employment is that the providers and nursing staff trusted me the second I walked in the door. My main preceptor, Chris Stephanoff (PA-C), has been a great friend and mentor to me since I started working in the ED four years ago. He encouraged me when I was a tech and is part of the reason I decided to become a PA. In addition to being a fantastic provider, he has a sense of compassion and humor that make him a joy to work with.

Perhaps the best part of this rotation was the amount of procedural work that I got to do. I sutured some gnarly lacerations, including a guy who sliced his leg open with a buzz-saw down to the muscle. I also drained abscesses, reset fractured/dislocated bones, applied splints, placed catheters, performed pelvic exams, tapped joints, started IVs, and even got to intubate. There were also several chances to help work on codes. This kind of work is right up my alley and makes a 12 hour shift seem like a breeze.

My favorite patients to work up in the ED are the abdominal complaints, since there are so many potential diagnoses. While an experienced provider may find these patients tedious, as a student it was exciting to put my physical exam skills to use and choose the appropriate tests/studies to narrow down a complex differential.

In addition to loving the rotation, I also appreciated being home in Charleston again with my friends and fiancee. Year one is so work-intensive that it is almost difficult to remember how to relax and have fun again. I spent some time at the beach this rotation (with my textbook, of course), tried some new restaurants, and took our dog on long walks. If there is one good thing about being bogged down by work in PA school, it is that it makes you appreciate your time-off that much more.

 

Advice/Lessons-Learned

  1. Practice suturing before this rotation. I was fortunate that I had already done my ambulatory care rotation prior to this one, because I was already practiced in simple sutures and instrument ties. You will impress your preceptors if you come in comfortable with suture techniques. While there is nothing you can buy that is going to give you the experience of suturing human skin, some commonly used materials for practice are: bananas, oranges, pigs feet, turkey breasts, siblings (kidding, please don’t).
  2. Study the toxidromes early. They are probably one of the tougher topics to memorize, so I suggest getting a head start and then repeating the information to yourself throughout the rotation. As a general guide, remember that withdrawal symptoms tend to be the opposite of the effect of the drug. Also, remember that, in overdose, things that excite may cause seizures or coronary vasospasm while things that depress may lead to respiratory depression. There are many nuances though that you must commit to memory.
  3. On morbid humor. As someone who previously worked in the ED, I can tell you that you will witness a lot of morbid humor. There is a  reason why it is rampant in emergency medicine. In the ED, you witness tragedy nearly every single day. You will not survive emotionally if you do not have ways to distance yourself from your surroundings. Morbid humor is a defense mechanism (though not a great one). While it has its utility, you will also notice nurses/providers who take it to far. My advice is that, as a student, you should avoid this type of humor (even if everyone around you is doing it). It may reflect negatively on you in the eyes of your preceptor, and it is a bad habit to develop. If at any point morbid humor replaces your sense of empathy, then emergency medicine is not for you.
  4. Practice your ‘elevator pitch’ when presenting patients. One of the most frustrating things about being a student is that every preceptor expects something different when you present a patient. Some providers want a formal presentation that covers every detail of a patient’s history and present illness. Others are more casual and just want to have a conversation about a patient. For the most part, there is no time for lengthy reports in the ED. Most providers want only the details that are relevant to the diagnosis and treatment. This may include elements of the patients past medical or surgical history, but only if they are relevant. Imagine if you typed out your presentation on a computer. What might you type in bold font so that it pops out of the page? Think of this and then try saying ONLY that content to your preceptor. If they want more details, they can ask for them.
  5. Ask for opportunities. There are a ton of experiences to be had in the ED, but you will not get to do very much if you are a fly on the wall. Your preceptors will be incredibly busy and most of them will not actively seek out experiences for you. You need to be a go-getter. For instance, we had a patient come into our department who was in status epilepticus. A doctor who was not my preceptor was treating this patient. When I overheard the doctor say that he was going to intubate, I politely asked if he would be comfortable with me doing the intubation. Not only did he agree, but he was enthusiastic about teaching me how to intubate. After a successful intubation, he spent time reviewing the medications used in rapid-sequence intubation and taught me how to program the ventilator. It was an incredible educational experience that I would have missed had I not simply asked.