End of rotation reflection- Woodhull-ED
Jinjin Lin
During 5 weeks rotation at Woodhull hospital emergency department, the most important thing I learned is to identify and manage acute situations. Woodhull hospital’s emergency department has 4 brunches, EZ care, acute care, critical care, and trauma services. It is crucial to identify how serious the patient’s presentation is and how soon to get medical care and place these patients in the correct spots. For EZ care, patients have a medical condition or illness, but it is not a life-threatening condition. For acute care, patients with signs of heart attack, fainting, stroke, severe abdominal pain, asthma attack, shortness of breath, severe diarrhea or vomiting. For critical care, loss of consciousness or situations cannot be managed in the acute care. For trauma services, traumatic car crashes injuries, stab wounds, major burns, serious falls, blunt trauma, traumatic brain injuries.
For HPI, it is different from what I learned from pediatric rotation. In the pediatrics rotation, it is important to include patient’s immunization status, sick contact, and recent travel in the HPI. For the patients who are under 12 months old, HPI should also include delivery information, such as, which hospital, virginal delivery, C-section delivery, full-termed infant, pre-termed infant, NICU stay, and any complications. In the emergency department, I learned that HPI should be very concise, and only include pertinent negatives and positives. Not to address patient’s chronic issues, but will need to know the patient’s medical history and medications list. I also did a couple of trauma services in the ED. Sometimes, the patient is too sick to talk about their history, but it will be crucial to know the patient’s allergy before given anything. And I also learned how to document procedures we did in the trauma service. For example, for patient had sutures, presentation before the procedure; how many stitches placed with material; patient tolerant procedure well; and after procedure, also need to document patient’s presentations; make sure patient is not in acute distress; and also advise patient if any concern symptoms, for examples, tingling, numbness, worsening pain, swelling, patient need to return to emergency room right away.
Sometimes, it is really hard to interview patients who are angry and agitated. In the emergency room, these patients are brought in by EMS and NYPD is involved. When they are being asked why they involved in these issues, they will keep cursing and say we cannot help them. For example, there was a patient brought in with handcuff and was complaining of pain in the wrist, forearm, and numbness over the full arm. He kept cursing at police officers and made the interview really hard to process. For these patients, I learned that do not rush to get into questions about why they behave in this way. First, provide them food and water, leave the room and let them calm down a bit. Second, when we come back and approach them with empathy, and start questions by asking them how they feel right now. After patients calm down a bit, I will explain that we are the medical providers and here to help and make sure they are medically cleared.
In this acute setting, I saw lots of interesting cases. I still remember one case. The patient is 20 years old female, no past medical history presents states “I think I was sexually assaulted”. The patient states she was out drinking with her friends and brothers’ friends last night and fell asleep on the couch at her brother’s house with five of his friends. She woke up and found her underwear and pants were at her ankles and she felt as if she had been vaginally assaulted. We explained to her about prophylaxis medications and labs regarding STDs, HIV, Hepatitis, and the collection of specimens. She was tearful and agreed with the SART team to be involved. She came to the emergency room alone, and there was no one there. In the beginning, she was not sure if she wanted to report the case and she was also worried about confidentiality. We informed her that she may undergo forensic examination without a requirement for reporting, and we will keep her information safe and only use them with her consent. The physician assistant told me that an in-depth discussion of the forensic examination will be omitted, as requirements regarding healthcare provider training, tools contained within forensic collection kits, the time allotted between alleged assault and court-admissible evidence collection, and chain of custody legislation vary according to individual state law.
For the procedure part, in the acute part, I practiced a lot with IV placements by myself with one hand, blood works, EKG, injections, rectal exam, pelvic exam, obtain ABGs, foley catheter, assist in reduction, also digital blocks, place sutures and perform I&D in the trauma service. Since this is my last rotation, I did a lot in the emergency room. The PAs I followed are really great and allow me to do most parts of jobs under their names. I saw the patients by myself, wrote the entire notes with assessment and plan, order imaging and blood tests, order medications, and present the case to attending. After seeing the patients, PAs will give me feedback, like how to make the documentation better and what medications they will use. I feel more confident about working by myself.
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