History & Physical:

EM H&P 3

 

Site Evaluation Presentation Summary:

For my first site evaluation, I submitted 2 H&P’s. One was on a patient that presented with SOB and my second was on a patient that presented with RLQ pain. For the evaluation, I presented the patient that presented with SOB because the ED could not find an etiology for her fluid overload and she ended up being admitted. My site evaluator found the case interesting and we discussed differentials. For my second site evaluation, I presented a patient that complained of RLQ pain as well but I found this case more interesting because it was not what I thought it was. I thought the patient was 100% going to have appendicitis but he ended up having a kidney stone as well as a horseshoe kidney. I then presented an article on the accuracy of patient reported stone passage for patients with acute renal colic treated in the emergency department. We discussed my article because my site evaluator found it odd that repeat CT imaging to confirm stone passage was done in practice. Then we discussed the rotation and asked any questions we had.

 

Journal Article & Summary:

Accuracy of Patient Reported Stone Passage for Patients With Acute Renal Colic Treated in the Emergency Department

The point of this article was to study patients who initially presented to the Emergency Department with acute renal colic to determine if patient-reported stone passage detects stone expulsion as accurately as follow-up computed tomography (CT) scan. This study was a secondary analysis of a multi-center prospective trial of patients diagnosed by a CT scan with a symptomatic ureteral stone <9 mm in diameter. Patient-reported stone passage, defined as capture or visualization of the stone, was compared to CT scan-confirmed passage performed 29-36 days after initial presentation. Four-hundred-three patients were randomized in the original study and 21 were excluded from this analysis because they were lost to follow-up or received ureteroscopic surgery. Of the 382 remaining evaluable patients, 237 (62.0%) underwent a follow-up CT scan. The mean (standard deviation) diameter of the symptomatic kidney stone was 3.8 mm (1.4). In those who reported stone passage, 93.8% (91/97) demonstrated passage of the symptomatic ureteral stone on follow-up CT. Of patients who did not report stone passage, 72.1% (101/140) demonstrated passage of their stone on follow-up CT. The conclusion was that for patients who report capture or visualization of a ureteral stone, a follow-up CT scan may not be needed to verify stone passage. For patients who do not capture their stone or visualize stone passage, imaging should be considered to confirm passage.

 

Typhon:

EM Typhon Log

 

Self-Reflection:

I say this with every reflection, and I don’t think it’ll change but, going into this rotation was the most intimidating so far. However, it was my favorite rotation so far because it was the most involved I felt with my patients.

This rotation helped me the most with overcoming my fear of seeing patients by myself. Whenever, a patient popped up on the board, I would try to go see them as soon as I can. I liked that there were “end of shift evaluations” done every shift by the attending because it made me work harder and show more initiative, which is something I have struggled with. One thing that really helped me feel comfortable with seeing patients alone is that when I would come back to present to the attending/senior resident, they were never too harsh on me or made me feel like I didn’t do a good job. They were always very nice and the residents never made me feel like a burden, and were always willing to help and teach me whether I had questions or not.

I also liked when they asked me for my own assessment and plan, although I may have not liked it in the moment, but I found it helpful in the long-run because this is something I will have to do if I’m working. This rotation really forced me to create a list of differentials and how to work through them. I also had to learn how to think differently and have the emergency mindset of emergency medicine and think “what can kill this patient.” This was not easy at first but after a couple of shifts, I saw improvement in myself.

One of my weeks for this rotation was all nights, 4 in a row, and that was very tough for me at first because I could not get myself to do much but I ended up loving the night shift because there were more PA’s around and they treated me like they’re coworker and were also very nice and liked teaching.

I got to place a couple of IVs, suture twice, place stables in someone’s head, be bedside for intubations and more. I was able to observe/somewhat participate in traumas that came in. This was probably when the rotation felt the most intimidating, but I loved the concept of a team gathering right before the patient gets there and prepping for every possibility. The teamwork that I saw during this rotation made me want to do emergency medicine.

I don’t have much negative feedback about the rotation, as I genuinely enjoyed it, but one thing I wish was different was that residents/attendings would acknowledge there’s a student working and that they would come grab them for interesting cases that they might not be aware of. I also wish every attending and resident required students to give their own assessment and plan so that they can get comfortable with thinking on their own.