What do medical students do during their summers? Well for me, I did not take the usual route of research (~50% of UT medical students), traveling, rural electives, etc. Instead, I dedicated my last summer in achieving 2 objectives:

1) Start MedChatter
2) Shadow physicians from various specialties and decide a specialization for myself.

Since my life hasn't been interesting lately, I've decided to look back to my past shadowing experiences and share it with you guys. I will try to post on all of my experiences, so this post is the first of many to come.

First shadowing experience:  Pediatric ER at Hospital for Sick Children (SickKids), Toronto

For those who don't know, SickKids is the largest pediatric hospital and the most research-intensive hospital in Canada.  Located in Downtown Toronto, it is world-renowned and boasts a lustrous history of scientific discoveries.

For me, neither pediatrics or ER appealed to me as a career choice. The former deals with a very challenging population, while the latter demands incredible stamina, ability to multi-task, and has a high burnout rate. However, my limited exposure to these specialties motivated me to explore these fields and see whether my pre-conceived notions about these specialties were valid. Luckily, University of Toronto offers ER shadowing opportunities to its medical students through an established shadowing program. So I contacted the program director, and I was quickly matched with a ER physician. I was given a few days to choose from:

    June 12 : 11p - 9a
    June 22: 11p - 9a
    July 1: 11p - 9a
    July 10: 8a - 6p
    July 13: 5p - 1a
    July 14: 11p - 9a
    July 23: 11p - 9a
    July 29: 8a - 6p
    July 31: 5p - 1a
    August 8: 5p - 1a
    August 9: 11p - 9a
    August 14: 8a - 6p
    August 22: 8a - 6p

I had figured that if I was going to experience ER, I might as well experience the worst of ER - the night shift. If I was ever to chose a career in ER, I'd better know that I'll be able to handle working through the night, so I went with the 11pm - 9am shift.

Before starting my shift, I was told to submit 3 learning objectives. Mine were to:

1) Gain an understanding of the nature of the work.
2) Learn about the associated lifestyle.
3) Learn about the training process and the different training options.

On the day of my shift, I took a nap from 7-10pm, and then walked into the hospital ER in full anticipation. I had a stethoscope around my neck, a clipboard ready to take notes, and a sheepish grin. Everything about me that day said "newbie". After reporting to the nursing station, I was told to have a seat. A few residents walked by and asked who I was. I responded, "oh, I'm a first year medical student shadowing Dr.X today." She then turned to another resident and said, "look at that, a 1st year student doing a night shift. Talk about being keen. LoL" Being keen has always had a poor connotation in highschool and undergrad. For some reason, the word takes a more positive meaning once you are in medical school. I think it may have to do with the fact that being keen = competent = better to work with.

Few minutes later, my preceptor walks in. To keep things anonymous, I will not disclose his name or physical appearance. Let's just call him Dr.Tim.  He shook my hand, welcomed me to the department, and said, "it looks like we have a busy night, so let's get going." The previous attending informed Dr.Tim of all the unfinished businesses as a part of the "handover".

The next few hours involved me following Tim back and forth in the ER like an idiot, seeing patients on different beds. Since this happened few months ago, my memory is a bit hazy, but I remember that a majority (over 50%) of the kids where in for fevers. And here I was expecting lacerations from fist fights and gunshot wounds (I know, in a pediatric population? What was I thinking).

In cases of fever, the biggest thing to rule out is meningitis, as it is often lethal. Common symptoms include fever, irritibility, tense or bulging fontanelle, stiff neck, dislike of bright light, confusion, etc. Few physical exams can help with identifying meningitis in older kids. For diagnostic purposes, often a lumbar puncture is required.

For those who are unfamiliar with lumbar punctures (LP), you stick a needle between two vertebrae (usually L3/L4) and draw out cerebral spinal fluid (CSF). The CSF then may be analyzed and cultured. In meningitis CSF will show increased white blood cells and proteins, and decreased glucose. CSF culture will show bacterial growth.

This was painful to watch as it is a fairly invasive procedure. As you can imagine this can be quite traumatic for babies. I saw about 8 LPs this evening. Some where done very quickly and successfully, while others where simply terrible to watch. In one case, a resident performed a LP on an infant. The mother chose to be in the room while it was done. This particular LP was what's known as a "dry tap".  The needle went in, but no fluid came out. After a few tries, there was still no CSF. During the whole process, the baby was screaming her lungs out, letting the whole ER know of her excruciating pain. The resident gave up and Dr. Tim immediately took over. But to no avail, the tap was still dry. After inflicting so much pain to the infant and her mother, the whole procedure yielded no useful results. I believe that eventually, antibiotics for meningitis was prescibed as empiric therapy.  Sometimes in medicine, you treat it even if you are not sure what it is.

In another case, a boy with severe abdominal pain was brought to the ER by his parents. They had already been waiting for around 3 hours before an error in care had occurred. The boy was waiting for the radiology department to image his abdomen when one of the nurses had mistakenly informed the radiologist that the patient had left the ER for another hospital. Another few hours passed before the staff had realized what had happened. Needless to say, the parents where frustrated with the staff for the unnecessary wait and started accusing the nurse (who was not responsible for the incident) for being incompetent and unable to offer care. The nurse retorted with accusations of her own. The whole professional atmosphere just broke down into a silly confrontation. Fortunately, Dr.Tim maintained his composure and was able to calm the parents by acknowledging all of their complaints/concerns despite whether they were valid or not. In a matter of minutes, the ER was back in order. Dr. Tim was definitely a smooth operator.

At around 4 am, I was about to pass out... things after that were pretty much a blur for me. I remember a resident asking me to find the fracture on a X-ray of a foot, and I pointed at the epiphyseal plate. Dr. Tim asked me to explain the function of Von Willebrand Factor. Since I studied clotting recently, I quickly answered "when the endothelium is damaged, Von Willebrand Factor attaches to the subendothelium and anchors/activates platelets via GPIb." He gave me a blank stare and said, "you could've just said clotting." I had expected to be "pimped" by Dr.Tim (for those who don't know medical terms, pimping refers to the staff physician grilling you with questions). I think Dr. Tim was too busy to bother.

Anyway, my recollection fails me at this point. At the end of the shift (9am), I quickly rushed home and crashed on my bed. Overall, it was a good experience. Although it was a limited exposure based on a very specific population, here is what I think of ER:

Pros:

-   Great hours. ER physicians probably have the lowest number of working hours out of all specialties (approximately 40 hrs /week). On average, they work around 3-4 shifts a week plus some teaching or research commitments.
-   VERY flexible! You can really choose when you work. I know some physicians who take months off to travel, do work overseas, etc. Vincent Lam, the author of "bloodletting and miraculous cures" is a ER physician at Toronto. He traveled to the arctic and antarctic as a ship doctor.  This amount of flexibility is very rare in the field of medicine.
-   Exciting! You never know what's going to happen. Exciting things happen every day.
-  Quick results - when you see a patient, it's whether you can treat him or not. If you can, the results are often immediate. If not, just refer the patient to someone else! There is nothing in between. Unlike internal medicine, there is no sense of lingering uncertainty regarding patient management.

Cons:

-  Fast-paced/intense work (this may be a plus for you, but not for me). This is where the high burnout rate comes from.
-  Night-shifts - I'm not sure how I feel about this since it was my first night shift. However, I'm sure that anyone can get used to it with time. Some may prefer night-shift since it frees up your day. I think I'd rather have more structured working days.

The residency program for ER is 5 years, but nowadays, you can go into ER through family medicine (2 years family medicine + 1 year ER = total of 3 years). I believe the salary of an average ER physician is in the low to mid-range ($200,000 - $300,000/year).

Anyway, it's Christmas day and I've just spent the last 2 hours blogging. I hope you guys enjoyed this.

Next shadowing experience will be:  plastic surgery

So stay tuned....

Kev out.