Communication Breakdown: Get 'em booked

One of the most intimidating tasks for a student in the ED is getting patients admitted.  You want the responsibility.  You want the sense of ownership.  You want to prove that you can be persuasive and get things done.  Successfully booking an admission accomplishes all of these things. I am more impressed with a student who can complete a tough admission than if they can close a complex laceration.  

Conversely, should the admitting conversation not go well, you may feel embarrassed or inadequate.  If your supervisor has to take over, their evaluation of your performance may go down.  

There is no surefire, guaranteed, approach that will sell even the obstructionist medicine resident.  But there are some things you can do to keep your admission call from going down in flames.

Walk a mile in their clogs

Understand the perspective of the person on the other end of the phone.  This may be easier as a student, having recently been on these other services,  than a couple years from now when you are firmly entrenched in the ways of the ED.  

Dig up those detailed IM presentation skills and give them a deluge of data.  Often times they do not want you to tell them what you think is wrong with the patient, they want you to give them the information so that they arrive at the same conclusion you did.  This is, of course, the exact opposite of what we are looking for in the ED - for you to make an assessment and come up with a plan.  

But if you are talking to a surgeon, you need to give them a very specific reason for why the patient should be admitted to them.  Not, “because they have belly pain”, instead, “we believe they have appendicitis”.  

Use the hammer

The hammer is the point that cannot be argued, that no physician behaving in a remotely professional manner can ignore:  “the best interest of the patient”.  This is a powerful tool.  You will encounter many objections from people you have contacted asking them to do work.  You have added to their task list.  They may be thinking in terms of what your request means for their day/night/weekend.  By judiciously using “the best interest of the patient” you can wear down almost anyone.  

In the same vein, you will often encounter pushback on “social admits”.  These are patients who cannot go home, but not for a strictly medical reason.  These patients are very frustrating for in-patient doctors and so they will often work hard to convince you that they do not need to take them in the first place.  But if a patient is unsafe, or can’t walk, or can’t control their pain at home, going back to “the best interest of the patient” is a hard thing to argue effectively.  

Practice makes perfect

If possible, run your admitting presentation by one of your supervisors.  If that is not time practical, at least make sure that the reasons for the admission are clear.  Make sure that you understand why the patient will benefit from being in the hospital.  If you do not know or if you are struggling to put the rationale into words, this is probably not a good admit for you to attempt because you are likely to fail.  

It is important to remember that even if you do everything right, sometimes you will have to call in your supervisor because the person on the other end of the phone is not being reasonable.  This has happened to everyone.  Making your calls within earshot of your supervisor helps them realize when it is not you that is the problem.  

If you want additional tools for getting others in medicine to do what you want, have a listen to an EMRAP Educators Edition podcast with Dr. Chad Kessler on communicating with consultants.  

Good luck!

Scoring Procedures

One of the goals most students have for an EM rotation is to get some procedural exposure and experience.  There are some procedures that that the residents will happily give to you, like ABG's, NG tubes, suturing, and anything involving pus.

However, the procedures you are really hoping for are the ones with greater complexity, like intubation, central venous access, and lumbar puncture.  These are usually much harder to get.  You may even be in competition with an intern for these, especially in July and August.

Here are some tips that can result in more complex procedural opportunities:

1. Be involved - Your supervisors will be much more interested in finding cool stuff for you to do if you are engaged and participating in what the team does.  
2. Be ready - You need to have background knowledge on indications, contraindications, landmarks, and technique for any procedures you would hope to get the chance to do.  Your supervisors may use screening for this knowledge to decide if you get the chance to do the procedure.  Also, take any chance you get to practice on a simulator before trying this on a real person.  
3. Be proactive - It does not hurt to ask for the opportunity.  The worst thing that happens is they say, "no".
4. Be honest - Actually, the worst thing that can happen is that you claim to have experience you do not have, get found out, and then get demolished in your evaluation and letter.  Lack of experience won't keep you from some opportunities but lack of honesty will  

What in the world is FOAM... and where can I get some???

The new education trend sweeping Emergency Medicine is FOAM (Free Open Access Medical-education), also known as #FOAMed.

Offering medical knowledge free to the world is a break from the pay-to-learn model that has existed in medicine (buy a textbook, subscribe to a newsletter, pay for CD's, etc. etc.).  But information wants to be free and educators are finally embracing that it is more satisfying to expose a larger audience to what you have to teach.

Everything a student of Emergency Medicine could want to know is now out there for free. The challenge has become:  how do you find what you want to know.

As a student just getting started in this specialty you are faced with a daunting mountain of resources.  And many of these sites, blogs, and twitter feeds are not targeted to the early EM learner.  So where should you begin?

Well, two of the best sites for students recently posted some great content on getting the most out of this  wonderful new world:
Academic Life in Emergency Medicine 
iTeachEM

Enjoy!

Should I do combined EM/IM residency?

If you ask most people who trained in just Emergency Medicine they will tell you that EM/IM training is not necessary.  They may even look at you funny for voluntarily doing more ward medicine months.

As an advisor, my best "pro" for dual training was that it left open the option for Board Certification in Medical Critical Care.  With that pathway now open to those who train solely in EM prior to Critical Care Fellowship, I have had to reevaluate who I recommend EM/IM too.

But instead of listening to me, take a look at what Dr. Matt Astin had to say about his own experience over at Academic Life in Emergency Medicine.  

Stuff for Students: EM Basic

EM Basic is a podcast and blog by Dr. Steve Caroll.  The sub-heading on his home page reads: "Your Boot Camp Guide to Emergency Medicine".  That about sums it up.

Listening to this podcast will give you a solid foundation in clinical Emergency Medicine.  He started with approaches to common clinical complaints like chest pain, abdominal pain, etc., and progressed to reviewing essential evidence and discussing elements of EM practice like trauma resuscitation, procedural sedation, and much more.

You can find EM Basic on iTunes or download the files from his website.

Enjoy!

Stuff for Students: ALiEM and Patwari Academy videos

Academic Life in Emergency Medicine (ALiEM) is a wonderful blog started by Dr. Michelle Lin for Emergency Medicine enthusiasts.  There is now a stable of authors providing useful content for anyone interested in EM.

Particularly helpful for students and early residents are the Patwari Academy videos they post every Sunday.  These are short videos, Kahn Academy style, of an expert breaking down an EM topic on a "whiteboard".  Here is a link to the most recent on Salter Harris Fracture classification.  Other recent topics include Early Goal Directed Therapy, Approach to Altered Mental Status, and a series on Chest Trauma.

To get caught up you can go to the ALiEM blog and go back through the posts, OR search the blog for all "patwari" posts.

Enjoy!

Stuff for Students: SAEM Website

SAEM is the Society for Academic Emergency Medicine.  A natural part of their mission is to provide resources for medical students, especially those with an interest in a career in academics.  They recently revised their website to make it more functional.  There are still a few bugs and misplaced links, but there is also a ton of resources for students.

Follow the "Membership" tab to the "Medical Students" page and have a look around.  What follows are a few of the most useful resources.  You do not need to be a member to use any of these, but membership does confer additional benefits, though at a not insubstantial price.

Full disclosure:  I am a member of an SAEM committee whose mission is to find ways to better serve  medical student's and resident's.  I do not think this creates any conflicts of interest.

The most invaluable resource SAEM provides are their Directories, including their Clerkship Directory and their Residency Directory.  These are interactive maps of the U.S. with links to information on most of the EM rotations and all of the Allopathic EM residencies.  This is a great place to start researching the programs you may want to apply to.  The information here is very helpful.  A word of warning: not all of the details are right (I found several errors on my home institutions page).  A residencies actual website, usually linked to in the profile, should be considered a more definitive source of information.

Another incredibly useful service provided is the E-Advisor program.  This is a great way to get advising on a different region of the country from where you go to school.  This is also a great way to connect with an adviser if you do not have a local EM program.

One more to highlight is their collection of Student Resources.  Included are a variety of documents answering common questions and providing advice on numerous issues facing students applying to EM.

There is a lot more as well including award and grant opportunities, and information on the Annual SAEM meeting (next week in Atlanta).  Enjoy!