Adapted from Morning Report by Chief Resident Rushabh Shah.
Public fear regarding COVID-19 has caused the unexpected consequence of decreased ED volume in hospitals around the country. The much-needed breath of fresh air is appreciated, but fewer patients means fewer direct learning opportunities for EM residents. Here are some suggestions to keep learning on your next low volume shift.
Go the Extra Mile
The most important part of residency is building your individual practice. Not only do we need to build our medical knowledge (including EBM, procedures, and the other 10,000 skills rocked by your average EM doc), but we need to practice how to manage volume, logistics, and personalities. Basically, as residents, we need to tackle the not-so-subtle challenge of mastering the art of medicine.
While most of us strive to weave the suggestions below into our daily practice, sometimes a busy ED means we put less effort into our communication skills. Take the time now to practice with the suggestions listed below, so that when the ED ramps up again, you can weave these skills seamlessly into your individual practice no matter how packed the waiting room looks that day.
Be thorough and practice discussing your thought process and medical decision-making in detail with your patients, nurses, attendings, and peers.
With patients: Give them time and listen to them. Develop the art of translating medical jargon into English for patients with varying levels of health literacy. When you encounter someone with low health literacy, spend the time to think about the best way to translate complicated medical terminology. For your next highly educated and anxious patient or parent, practice choosing the right words to communicate medical terms that they find frightening.
With nurses: Involve them in rounds and engage them during procedures like your bedside sono. Ask them if they have time to teach you tricks of the trade, like how to manipulate all the tubing during procedural sedation.
With attendings: Cite clinical scoring tools and appropriate references. Ask for feedback on your differential diagnosis. Be goal-directed in your learning – announce what you’re working on at the beginning of the shift and elicit feedback at the end.
With yourself: Perform “full” exams and practice those that you may not do routinely. Test those reflexes! Perform a fundoscopic exam. Look in the ears and get to know normal vs. abnormal. Think about which labs really help narrow the differential, and be thorough with considering abnormalities that you might be tempted to write off (A.K.A. punt to medicine) such as acid-base status. Push your consultants to share their insights, and ask to be involved in bedside procedures. Discuss goals of care for patients (especially if over 65 or terminal). Establish a health care proxy and discuss desires for invasive procedures.
With families: Some hospitals may still have limited visitation policies. Imagine how you would feel if your parents were in the hospital. Take the time to FaceTime boarding patients with family.
Mock codes and resuscitation
Practice mock codes, especially on your trauma rotations or in pediatrics. Involve the nurses and techs so that you can reenact cases in real-time. The opportunity to perform SIM in a realistic environment is invaluable. PEM folks are especially eager to be involved and review uncommon presentations such as neonatal resuscitations. Allow your juniors to practice “running the room”, especially as we wrap up another year of residency.
Ultrasound
Refine your ultrasound skills (although be cautious with COVID-19 patients and clean the devices thoroughly afterward). Some common exams to practice include the Lung/cardiac, FAST, FRAGLE, and RUSH exams. Utilize ultrasound for procedures such as IV catheterization, nerve blocks, and dislocated shoulders. For our readers facing a surge in COVID-19 patients, consider the bedside transthoracic sono to appreciate pathologic findings and practice differentiating patterns of pneumonia from those of acute heart failure.
Procedures & Equipment
Take the time to review locations for equipment storage, and depending on resource availability in your hospital, explore procedure kits, especially for those that are performed infrequently or are technically complicated. Here are some ideas of procedures to review and practice with SIM or kits:
- Subclavian central line placement
- Thoracotomy
- Chest tube and pleuravac setup
- Defibrillator settings
- Transvenous/transcutaneous pacing equipment
- Slit-lamp exam
- Lateral canthotomy
- Crich kits
- Trach kits
- Casting and splinting
Read Things!
Last but not least, learn how to do an effective literature search and read things – books, blogs, PubMed, that amazing EBM article with all the great pictures of hand pathology that you’ve been dying to load onto your Anki ortho deck. Whether you are a PGY1 preparing for Step 3, PGY2 preparing to be awesome, or PGY3/4 prepping for the board exams, use the time to study! Start here with Dr. Allen’s recipe for efficient learning in residency. Lay the FOAMed on thick, catch up on landmark literature, and throw in those Airpods for some long EM:RAP sessions. Residency is a marathon, not a sprint!
Andrea Greene
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