Ace Your SLOEs: An Interview with EM Clerkship Podcast's Zack Olson, MD
Samuel Southgate, MSIV, University of Connecticut School of Medicine
EMRA MSC Editor 2019-20
You recently put out a series of episodes of EM Clerkship podcast focused on “How to Crush Your SLOE”. What are some of the simple things students can do to excel during their EM rotations?
One of the things I stressed in my first episode is the importance of introducing yourself. It’s really a big deal. As an attending you meet so many people and every day there are new nurses, new techs, new students. It’s hard to keep track of everyone. So even if you have good first introduction where it’s very clear, it can be easy to lose track over several shifts. It’s not like you have to introduce yourself to the attending 10 times – that would just be strange. But even if you introduce yourself to nurses and residents they will overhear your name again so the whole group will get to know who you are.
It's probably about the most important thing. Have you ever noticed that once you know a few of the nurses’ names then those become the nurses you go to; you are more prone to talking to them. It’s not the coolest tip but I really think that staying your name to make sure everyone knows you for the first couple of days goes a long way to getting them to want to talk to you. And at the end of the rotation, for your evaluation, the clerkship director will usually ask for feedback from everyone you worked with. It’s a group discussion. And just the fact that people know your name means they will feel friendlier towards you. It’s almost like a subliminal trick. I still think that’s the most important thing people should do when they start a new rotation.
That speaks to how medical students can integrate themselves into the team, be helpful, and be available in a way that people can ask them to contribute. What other ways can students become part of the team?
There are a lot of things that will happen around the emergency department where you can contribute. I’ll give you an example. Within the last few weeks I had a trauma patient, a transfer from a smaller hospital, and I found that this patient required a full trauma evaluation. They were still fully dressed and on the backboard. I had to pull aside whoever I could find to help me. In this kind of situation there are a lot of things that aren’t strictly medical that need to be done. And I’m always stepping out into the hallway to ask for help, whether that’s someone to maintain midline cervical stabilization, or helping to get clothes off. In these situations you’ve just got to get stuff done. So there are a lot of those opportunities. On the other hand, in a really intense critical care resuscitation you may feel pushed out of the way. That's probably how it's going to go. But there are certainly things that you can do, like CPR, which you should certainly get involved in as a med student.
Another simple one would be urine. If you put in ten orders, someone will go to the patient’s room, draw blood, and they’ll get nine out of ten tests. But the patient’s in bed, the side rails are up, they’re in severe pain. And before you know it all your blood work is back and they haven’t peed. That urine is almost always the hang-up. A lot of us will joke about how we wish we could hire a tech whose only job would be to get the urine. It’s a lot of work to get the patient up and have them pee or walk them to the bathroom. And it’s not like the urine is a blow-off test, either. For example, frequently urine pregnancy tests are a critical decision point in evaluation of female patients with abdominal pain. So try to help that process along.
In addition, there are the simple things like getting patients blankets and ice chips. Ice chips are almost always okay. If someone is hungry and they’re like ‘can I have something to eat or drink’ the only reason to say no is because you’re going to be sedating them. If they are going for a CT scan for suspected appendicitis you should probably hold off. But if the patient is not a critical care resuscitation and there are no impending surgeries, they should be able to drink. And, then, if you start to get along with the nurses and they begin to teach you, you become very helpful. Nurses are frequently understaffed and are running around a lot. You can get your hands on a lot of IVs and other things. The more you do, the more it will snowball and you’ll get asked to do more. All of a sudden you are just another member of the team. At that point, you’re set.
What are some of the things to keep in mind to excel when you are seeing patients?
When you are with the patient I think the big point is that you are trying to get yourself set up to give your presentation, if we’re talking purely from a SLOE perspective. Obviously there is learning there and you want to give good patient care. But from a purely strategic perspective, when you’re in the room you want to set yourself up to nail that next point of evaluation; the presentation. When you are taking your history, you really need to focus on red flags. Ask yourself: what are the red flags for this particular complaint? So for headache, red flags would include: a sudden and maximal-at-onset headache, fever, neck stiffness, a family history of brain aneurysm: really specific, yes-no, red flags. The more of those that you can knock off, the more the history component of your presentation is going to shine.
Another element is the exam. This is one of the biggest things that differentiates medical students. Everyone learns the full head-to-toe physical exam but you never do that in emergency medicine. So when you are in the room, whatever the patient complaint you need to be thinking about what physical exam you should do. And nearly always it consists of examining the area of their complaint thoroughly. So, for example, headache: it doesn’t matter what the heart and lungs sound like. Most of that stuff doesn’t belong in your presentation. What matters in this case is the neurologic exam; the more you can put in your neurologic exam, the better your presentation is going to sound. It’s really focusing on that complaint and doing a thorough focused exam. It’s not that we just do a cursory exam of everything in emergency medicine. No; we examine the complaint really thoroughly.
How do you suggest medical students build their differential diagnosis and present it to the attending?
Usually, you’re going to have a sense of what is going on with the patient, so start off with what you think it is. But immediately after that you have to go into what we look for. We in emergency medicine are very paranoid folks who chase down rare things frequently. Not rare, benign diagnoses, but rare, critical diagnoses. So in someone who comes in complaining that they tweaked their shoulder, you might think that it’s musculoskeletal shoulder pain, so you get some red flags and do a thorough focused exam. But what are some other big things that are bad that can cause shoulder pain? The big one would be MI. It can actually go on most lists: abdominal pain; weakness; dizziness; shortness of breath. So you want to make clear that you are thinking of other life-threatening diagnoses. Your differential should be what you think it is and the other stuff that you don’t want to miss.
So once you’ve got your differential, how do you suggest going about building and presenting your plan?
So the testing plan is easy, right? Anything that you can rule out with your physical exam, you can rule out. That’s totally appropriate; you don’t need to test for everything. Stroke is the perfect example; are you going to MRI every person who comes in dizzy? No. But if you are worried about someone who is dizzy you do a complete neurological exam. And then additional testing depending on the complaint.
The treatment plan in your presentation is not too fancy. Do you want to start an IV, yes or no? Do you want to give them fluids and, if so, how much? The other easy ones are pain medicine and nausea medicine. The main nausea medicine you need to know is Zofran (ondansetron). If they are at all nauseous, give them some fluids and Zofran. Phenergen (promethazine) is another good option for nausea. In terms of pain medicine, Tylenol (acetaminophen) goes a long way. It is one of the effective pain medications that exists. And then there’s ibuprofen, morphine, and Dilaudid (hydromorphone). Know a few of these and a standard dose.
So once the orders are in and you’re awaiting the test results, what should the student focus on?
From here on out - and keep in mind that you’ll have probably more than one patient - you really have just one job. Sure, you want to keep the patient updated. But really you are just keeping an eye on that patient’s results and their response to the treatments you’ve given them. What you are trying to do is to beat your attending to the reevaluation and the results. When the attending asks ‘did you see that chest x-ray?’ you want to say ‘yeah’. So I would spend a lot of energy keeping track of when results come back and being on top of it. What you want to have is not just the results in your head but a reevaluation exam done of the patient. This is something that attendings do a lot for medico-legal reasons when we’re getting ready to discharge a patient. It’s not the full exam, it’s specifically a reevaluation of the patient and a repeat focused exam once you’ve got the results. If you can do this it looks very good because you are following up and taking ownership. You’re beginning to think like an attending.
Do you have any other tips?
I think attitude goes a long way. I think it’s really hard to know what the anticipated attitude is, because you don’t necessarily want to go and just be yourself. What is the mask that you put on of being a doctor or a medical student? I always had trouble with this. It’s really a balance. You want to study really hard and get very smart so you can have some level of confidence. In a very few years you are going to be making incredibly difficult decisions and you are not going to know what to do. You have to fall back on the fact that you have worked incredibly hard, likely harder than other people around you, and you are going to trust that you are doing the best you can do. You didn’t slack and you read all the chapters on the topic. You want to have that confidence that comes from working hard. But it has to be balanced with a certain level of humility and it is sometimes hard to know how best to manifest that.
I think it’s very important to stay humble. I have been humbled so many times on this job. I don’t even know the blind spots I have. Humility goes a long way because it allows communication; having the humility to let your team influence things is big. And as soon as you get humble, things start to click because when you make a mistake it won’t eat at you when you get home. You just go home and read the chapter again and really think about it. A lot of my podcast episodes stem from mistakes I made. But you have to be confident that you are working hard.
Check out more advice from Zack at EM Clerkship Podcast and listen via all major podcast apps.