Exposure to new techniques or treatment strategies – how did that go?

• During this rotation, I was fortunate to have a very broad range of experiences at Staten Island University Hospital – 2 weeks in the main ED at the north site, 1 week in the south site ED, and 1 week in the critical care unit. In the main ED, I was able to see many patients on my own and present to different PAs, attendings, and chief residents. Due to the pace with which patients would come in and need to be seen, it was a challenge to obtain patients’ histories and present succinct yet comprehensive, coherent HPIs in such a short turn-around. Nonetheless, I practiced taking histories in less time and doing more focused physical exams, as many patients presented with abdominal pain, RUQ pain, chest pain, and different types of MSK pain. In critical care, I had the opportunity to put in my first IV and draw blood. I also observed a hip dislocation reduction where I was responsible for lifting the patient’s chin to help maintain his airway and helped with multiple ultrasound-guided IVs. In addition, I saw many stroke codes and trauma alerts as well as a code STEMI and NSTEMI. At the south site, I was able to do my first laceration repair on my own under a chief resident’s supervision. Thereafter, I was able to do two more laceration repairs with two other PAs back in the main ED. I also lost count of how many COVID swabs I administered.
• In contrast to my previous rotations, I saw patients who presented DNR/DNI, which changed the management very much as comfort care was the main goal. Sadly, I also experienced the loss of these patients, which can not only be difficult to witness but also difficult to watch family members and caretakers experience that loss in real time. These experiences were very new to me and forced me to manage my own emotions in those moments, though I found them very tough.

Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them.

• As mentioned, the quick turn around between seeing patients and immediately presenting to PAs, residents, and/or attendings was a challenge for me initially. I felt as though my presentations were incoherent and all over the place, making me feel self-conscious – even during the actual act of presenting. It was as if everything I knew about presenting had washed from my memory when I was put on the spot. However, the PAs I had followed reassured me that there would be many more opportunities to re-fine the art of presenting, and there is no perfect way to do it. As the weeks went on, I became more and more comfortable presenting and answering questions providers would ask as follow-up or in terms of what I want to do for the work-up and management of the patient. On one particular instance, I presented to an attending unexpectedly, and she asked me what my differential was. She then asked what I would order for the patient and what I am specifically looking for in the CBC, for instance, to rule in or rule out certain diagnoses. This patient presented with jaundice and elevated liver enzymes. Therefore, my differential included choledocholithiasis, cholangitis, hepatitis, and pancreatic cancer. However, upon asking about what I was looking for in the CBC, she asked me what specific diagnosis presents with anemia and jaundice. I could not think of the answer, but she eventually said hemolytic uremia. While that diagnosis for the patient was probably unlikely, she stressed the importance of keeping the differential very broad because otherwise diagnoses, such as hemolytic uremia, will otherwise be missed because they are not thought of. In addition, she asked me where I would see jaundice, and while I answered with the eyes and tongue, she gave me more specific direction. Namely, she taught me to look at the bottom of the eye where it meets the conjunctiva as well as the palms. Sure enough, there were more yellow areas on the palms of the patient, which is not something I remembered learning before. This was a situation I found difficult and uncomfortable especially in that it occurred in a room full of other attendings and PAs within earshot. However, it was definitely a learning experience I appreciated very much.

How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc).

• As a result of this rotation, my perspective has changed with respect to patients who are DNR/DNI because it was one thing to see on paper as an advanced directive and another to see in real life in terms of patient management and how it affects loved ones. Some patients who present with stable vitals can decompensate and become unresponsive very quickly, however, later demonstrate full decisional making capacity and refuse resuscitation and intubation – just as a provider is ready to put a central line in because there is no MOLST form documented in their chart and their health care proxy cannot be reached. From this experience, I have learned how important it is to make every effort to make sure to respect patients’ wishes. I have also learned how challenging it can be to call family members who are on their way but do not make it in time to say goodbye. Moreover, I have also learned how difficult it can be for family members and caretakers who watch their loved ones [who are DNR/DNI] become increasingly unstable over time until it is their time and they pass. I had felt an ache in my heart for these loved ones and can only imagine how they feel themselves.
• Additionally, after more exposure to patients who present with alcohol or drug use disorders, I have also realized how difficult it can be for patients to talk about their alcohol or substance use even if they are in rehab seeking treatment. Some patients carry shame, and it is important to be sensitive and non-judgmental in such cases.

What did you learn about yourself during this 4-week rotation?

• In retrospect, I have learned that even if I feel very much out of my comfort zone and overwhelmed in the moment, I am able to show up every day and continue to learn and have really positive experiences. Additionally, even though there is considerably less time to spend with patients in the ED, I have found that there are opportunities to connect with patients and their loved ones in really meaningful ways. Moreover, I learned that it was OK to not know every answer to every question I was asked. Learning to take that constant pressure off of myself allowed me to think in a clearer way because I was more relaxed and not holding my breath with fear. Lastly, I have found that I value being more involved in patient care rather than the stabilization of patients before discharging them or admitting them to what ever service they are in need of. I feel that the latter gives me a sense of feeling unfinished, and I prefer being able to see things through.