How to Succeed on your EM Away Rotations

Author: Hilary Fairbrother, MD, MPH, FACEP, Associate Professor, Director of Undergraduate Medical Education, Department of Emergency Medicine, University of Texas McGovern Medical School

Away rotations. What once was an option is now essentially mandatory if you want to match in emergency medicine (EM). In order to have a “complete” ERAS application, most students will get a SLOE (Standardized Letter of Evaluation) from their home program after a month-long rotation. Students are also expected to go to an outside institution, spend a month working in the ED, and obtain a second SLOE based on this performance. In fact, this “away SLOE” is the #1 indicator of residency matching success. Basically, if you are judged to be exceptional by an institution who did not raise you (i.e. not your medical school who is biased because they want to successfully match you into residency) then everyone else believes that you are exceptional.

Each year, starting as early as January, programs start accepting applications for away rotations. Some through VLSO (Visiting Student Learning Opportunities – formerly VSAS) and some not. The key to getting an away rotation is to apply early. Plan on applying to at least three programs to land a single away rotation. There are not as many spots as students seeking spots, so rotations fill quickly. This is a chaotic process, which is difficult for everyone… but you made it, and now you are getting ready for your away rotation. You find yourself stressed about this month-long audition. Here are some points to keep in mind.

  1. Show up early, stay late. Professionalism 101. Be excited to learn. Try to be a master of always being present and easy to find and yet never in the way. It is an art.
  2. Minimize any schedule requests.If you have some important life events in August (a wedding, a trip, etc.) then don’t do a rotation in August! Remember, most of the time the scheduler for your rotation will have a BIG say in whether you match at that program. They are typically the Clerkship Director or the Course Administrator. If you are interviewing during your visiting rotation, be very clear about the days that you need for interviews (this is OBVIOUSLY an acceptable ask) but then offer to work whenever they want you to, to make up for multiple schedule requests.
  3. Be honest. A. DON’T LIE. If you didn’t check the TM’s, don’t say that you did. If you didn’t ask a smoking history, don’t say that you did… eventually you will be caught and even minor transgressions are big red flags.
  4. Listen to your patients, their families, listen to the residents and attendings… listen for overhead pages. Everyone is different, and they will ask you to see and present patients in different ways. And then they will act like this is OBVIOUSLY the ONLY way that ANYONE could ever see this patient or make this differential diagnosis. Clearly, this is not true. Humor us, we want to teach you, and so we want you to model our behavior during the shift.
  5. Buy some trauma shears. Every time there is a trauma code/medical code the clothes need to be cut off. If you don’t have shears, then BUY some and have them in your pocket. If you see your resident or attending doesn’t have shears, GIVE THEM YOUR SHEARS. Every critical patient needs an IV. Even if you can’t put in the IV, get all of the stuff together. Anticipate the needs of your team. Make yourself useful. Is some of this scut work? Sure, but someone has to collect the supplies for the foley. Make yourself indispensable, and you will get more opportunities for education and procedures during your rotation.
  6. Know where to find stuff.At your home institution this should be easy. On an away rotation, that first day of orientation… go look and find stuff. You should know where the basic stuff is. If someone asks you to go get something and you don’t know where to find it, TELL THEM immediately. Offer to get help finding said object, or go with the resident/attending to see where the object is located so you know for the future.
  7. Vital signs are vital.Totally cheesy, but true. You go to see a patient, and their heart at triage was 120, but you note during your exam that it is 85. This is important and should be part of your presentation. Also, vital signs are never stable until you have at least two sets showing no change. A single set of VS can be “within normal limits” but in order to assess for stability, you must show the delta.
  8. Re-assess your patient.Are they still in pain after the medication? Has their breathing and breath sounds improved after the nebulizer treatment? If a patient is getting worse or needs something that you can’t provide, TELL SOMEONE right away.
  9. Determine pregnancy status. If you are seeing a woman between 12 years of age and 55, then chances are good that they will need a urine pregnancy test. If you have the ability to do this yourself in the ED, then do it. This should not delay your presentation of the patient, but often can occur concomitantly. Same with any rapid ED testing, urine dip-sticks, or any non-invasive point of care testing that is applicable to your patient. If you don’t have the availability of doing the test yourself, then make sure that the patient has a cup to pee in.
  10. Know everyone’s names.At the start of every shift, introduce yourself to the attending (duh) and the residents (double duh) and the nurses and techs and ancillary staff. What do you think works better? “Sally, can you help me put in this IV?” OR “Hey… can ‘you’ help me put in this IV?” If you know someone’s name, they will learn yours, and you can bet that they will let others know (in a positive way).
  11. Learn how to start an IV/draw blood from a patient, suture a simple laceration, and do an ABG before you go to your away rotation.These are basic skills, but if you can reliably do them, you can bet that your team will allow you to do new and better procedures. When more complicated procedures are being performed (LP, central line, paracentesis, chest tube), ask if you can scrub in and be the assistant. Practice suturing at home on bananas, practice instrument ties and one-handed ties, because those are what we use in the ED.
  12. Take ownership of your patients and show your team that you are doing so.You should be the FIRST to know when results are back. You should also know if your patient’s care has been delayed in some way (i.e. labs aren’t drawn because no one can get blood from the patient. CT head wasn’t done because the drunk patient refused to go with the transporter). No one needs Q5 minute updates, but an update to your attending or resident every so often, or when patients are ready for disposition is very useful and will secure your position on the team and build trust with your teammates.
  13. Work hard. This is a month-long audition and now is your time to shine. Don’t try to study for Step 2 or be asking for extra days off for a birthday.

Finally, the 4th year rotation allows the program to decide whether they want you, but it should also give you information about whether you want to go to residency there. Each EM program is different and suits different types of learners. Have fun and work hard. Remember, your EM faculty and residents are excited to have you around. They want to teach you. Occasionally you will come across people who don’t love teaching, but ignore those people; they are in the vast minority. You have already made the awesome decision to join us in EM. Good job making excellent life choices. Now the fun begins!

References

How to Excel in your 4th year Clerkship. https://coreem.net/blog/med-student-blog/how-to-do-well-4th-year/

Click here – for trauma shears that are decent and cost less than $10.

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