ER Clinicals = More Stress than Experience

[Bieber]

Other sign offs happen in the classroom (like intubation on a dummy) and we are then allowed to practice live in the field but, I've heard it's rare that students actually get to intubate during clinicals.

Whoa! You guys aren't getting time practicing live intubations in the OR? That's something you need to be talking to your program director about. Intubation is a difficult technique that requires a lot of practice (and a lot of continual practice) to maintain your skill level. You don't want your first live intubation to be on a code blue patient in the field where it's hectic, you want it to be on a sedated patient in a calm OR with an anesthesiologist and a CRNA at your side.

Edited January 31, 2011 by Bieber

[Andrea]

Whoa! You guys aren't getting time practicing live intubations in the OR? That's something you need to be talking to your program director about. Intubation is a difficult technique that requires a lot of practice (and a lot of continual practice) to maintain your skill level. You don't want your first live intubation to be on a code blue patient in the field where it's hectic, you want it to be on a sedated patient in a calm OR with an anesthesiologist and a CRNA at your side.

We do not have anything scheduled where we'd be likely to get a calm sedated intubation, no. If we can get in good enough with physicians or Paramedic preceptors in the field we might be allowed the opportunity. It's very unfortunate and the program chair doesn't plan to make changes to this any time soon. I practice as much as I can in the classroom lab but, doing it live is far different. Many students have asked to do it when an intubation was needed and all have been denied. One student was about ready to intubate but, the patient began vomiting and the ER doc took over. I've been flat out told it won't happen in the ER by some because of hospital policy or some such and other times, I'm just the low man on the chain... Flight medics helping out in the ER, PA students and even RN students come before EMS students. My fingers are crossed that I'll be lucky to get even one in the next 11 months but, I'm not too hopeful!

[Just Plain Ruff]

We do not have anything scheduled where we'd be likely to get a calm sedated intubation, no. If we can get in good enough with physicians or Paramedic preceptors in the field we might be allowed the opportunity. It's very unfortunate and the program chair doesn't plan to make changes to this any time soon. I practice as much as I can in the classroom lab but, doing it live is far different. Many students have asked to do it when an intubation was needed and all have been denied. One student was about ready to intubate but, the patient began vomiting and the ER doc took over. I've been flat out told it won't happen in the ER by some because of hospital policy or some such and other times, I'm just the low man on the chain... Flight medics helping out in the ER, PA students and even RN students come before EMS students. My fingers are crossed that I'll be lucky to get even one in the next 11 months but, I'm not too hopeful!

WOW, my hospital rotations required 12 intubations. Most if not all were done in the OR. Rarely did I get to intubate in the ER because there were always people higher on the pay scale to do that.

But in the OR is a great place.

ONe of the best intubation days I had was the bariatric surgery days. I was able to intubate several 400-800 pound patients which we all know are nightmare intubations. I had a incredible CRNA and Anesthetist to work with. They walked me through everything and I got the tube every time.

Unfortunately live endotracheal intubations are becoming harder to get with the LMA being used so extensively in the OR setting these days.

I just had a procedure done where they used a LMA On me. Woke up without the scratchy throat unlike the last intubation I had a number of years ago.

[Andrea]

You guys make me so jealous! I might try talking to the program chair again, there has to be a better way than standing in line for a tube and hoping to be the lucky one. Practicing on dummies is really only good for practicing the set up and technique, eventually you've gotta move on.

[HERBIE1]

You guys make me so jealous! I might try talking to the program chair again, there has to be a better way than standing in line for a tube and hoping to be the lucky one. Practicing on dummies is really only good for practicing the set up and technique, eventually you've gotta move on.

I agree that the mannequins are fine for set up and technique and getting a rough idea what the anatomy looks like, but it only goes so far.

Yeah, intubation in the OR is great, but it still doesn't really prepare you for the real deal in the field. Nobody is ever NPO, nobody's secretions have been dried up, and they have not been paralyzed. You do the best you can until you get your shot. Be as prepared as possible. It's a skill that takes time to master and be comfortable with.

[BoCat9]

I went through my ER clinicals last year, and I know what you mean. What I started doing was when I walked in the door and got my assignment for my nurse preceptor, I would immediately go up to him/her and introduce myself (as long as they weren't in the middle of trying to get something done). The next thing I would do is ask them if were any duties they would like me to do on each patient during the day. Most of the time they would ask me if there were any skills I needed to work on. The main things I did during my clinicals were IV's, drawing blood and administering medications.

The best piece of advice I can give to you is be proactive. If there is a procedure that you would like to observe or try, if it is in your list of approved skills, ask! The worst thing they can tell you is no. I asked if I could observe on quite a few things and after a few days, I was invited to observe or try things and the doctors on duty would take time to show me things.

[Timmy]

I can understand your frustration! I to have been pushed around on placement and not given the full opportunity to learn. Were often pushed into doing all the showers and vital signs while the RN does all the medications and various clinical aspects of the job. There seem to be a lot of stigma associated with students coming onto placement, that being we will lighten up there workload. I do admit, I have been on placement were the shift has been nothing more than insane, tense, frightening and in fact, dare I say the nursing to patient ratio was dangerous. It’s not fair at all to expect an RN to care for 10 post operative patients who require close observation and monitoring, strict analgesia, we had multiple patients on PCA fent and everyone required opioid analgesia whether that being as breakthrough, stat or routine administration, had an insulin infusion running, neurovascular observations, we had a medical emergency call, all post op patients are on strict fluid balance monitoring and IV fluids. The level of staffing this hospital had was nothing short of distressful and by the end of the shift you just felt nauseated.

That being said, the majority of placements are sensational and well organised.

Your clinical placements sound interesting... Coming from a nursing perspective our placements seem to be a little different. At the start of placement were allocated a clinical educator who is responsible for our overall learning and how we spend our time on the placement. This person’s job is to supervise a group of students (normally 4 at a time) and there our major reference point for the whole placement. At the start of every shift were allocated a preceptor, generally a senior RN or clinical nurse specialist who have undertaken preceptor training, these people are to supervise and direct us on the floor and give feedback to the clinical educator.

Normally we spend most of the shift on the ward but spend the last few hours with the clinical educator and the other students in a learning type forum on a daily basis. In these forums we have to pick a medication that were not familiar with and write a short essay on its pharmacology, pharmacodynamics, adverse reactions, indications, precautions, dosages ect and present it at the forum the next day, likewise we also have to select a disease, procedure or condition and explain its pathophysiology, symptoms and treatment. This is the time we can also ask any questions or address any concerns we may have.

The clinical educator will generally float around the wards, watching us like a hawk, any areas we seem to be lacking in confidence or knowledge they’ll step in and take over from the preceptor to offer more intensive mentoring.

While were on placement the requirement from the universities perspective is generally an assignment associated to a clinical case study, normally 2000 or so words. We also have a clinical learning tool which is about 15 pages long of competencies that need to be signed off by the clinical educator, these competencies range from communication skills, research skills, clinical skills, acute care skills and so on…

A few times on placement we’ve done ‘clinical education series’ on various topics, we then have to research the chosen topic, construct a presentation and deliver it to the staff of the hospital. We did a series on alcohol withdrawal as it was identified that patients were being mismanaged in the clinical setting. We had to research alcohol withdrawal, its signs and symptoms, pathophysiology, management and treatment and present it to about 150 nurses, doctors and various other clinical staff. Quiet nerve racking indeed!

I’m always excited and look forward to clinical placement but it’s very intensive, draining and tiring. We normally head out on blocks of 4 weeks, after we get home from a 9 hour shift were often up to all hours researching our university and hospital theoretical requirements only to be back into it a few hours later.

[DwayneEMTP]

Holy shit Andrea, I'll tell you what, the way you present yourself here bodes well for your paramedic future..

Smart, introspective, you evaluate each piece of advice and accept or reject it on what appear to be very rational, logical premises removed from your personal feelings. And your 13 years as a nursing assistant? Are you kidding me? You had very little, if anything to gain from Basic experience, so if there is any of that nonsense floating around in your head, let it go, you have more important things for those brain cells to do.

I feel like I'm in the twilight zone these last few weeks, watching you, and Beiber, and....damn it, their names escape me at the moment, but you'll know who I mean when you read their posts. (Speaking of which, where the hell is Ugly?) You all are like, what, about 12 years old? Smart, strong, super committed! I'm not sure if it's the rash of "Screw the grammar nazis! I want to spell like I'm 6!!" that has caused me to lower my bar a lot or if we are just being blessed with a bunch of wickedly smart new folks? I guess it doesn't matter in the end. Anyway...

Another thing occurred to me from Herbie's post, and that was about being useful. I decided just for shits and grins to jump on the rooms of the nurses that seemed to be more inclined to teach, clean and decon them as soon as the pt was out if I wasn't busy doing something else on the theory that if they had less other work to do then perhaps they would have more time to teach me things. And it worked out just that way for me. I was soon being called to push meds, or insert IVs, etc, etc. Now, the danger here, is that it's not your job to clean rooms and you need to not allow anyone to come to believe that it is. I did this simply by ignoring anyone that ordered me to.. :-) I would clean like crazy for sweet nurse A, Asshole nurse B would say, "When you're done with that one, get my taken care of quick." But I just couldn't hear him/her. It really wasn't very long before many learned that the way to activate my hearing aids was to teach me something...anything! Within my scope, outside, didn't matter...It worked perfect for me.

Also, I don't know if you have to deliver babies during your clinicals? We had to be present for a minimum of two live vaginal births. I didn't go to this clinical until later, not sure why, but I got to see most of my classmates come to hate it as they would sometimes have to go 5-10 12 hr shifts to have the vaginal births happening, and have the mother consent to allow them to watch...I was dreading it. But, I got really lucky. At the time I smoked, and I went out to smoke and noticed most of the expectant fathers were coming and going on a pretty regular basis, so I would watch for them to go out to smoke, follow them out, and say, "Hi! Hey, isn't it your girl that's giving birth inside? Yeah? You know, I"m a paramedic student and we're here to observe deliveries as it's out job to give lifesaving care to the mothers and new babies if they deliver outside of the hospital. But man, most people don't like to let us help. They don't seem to think that someday it may be their wives or kids I'll need to be smart enough to care for.." And every one said, "Well, do you want to watch our delivery? That would be great!" Then we'd go back into the hospital where the hubby would introduce me as some kind of mother/child saving hero that they should feel obligated to help educated, and all were. I participated in 5 live vaginal deliveries in my first 6 hrs of clinicals including one woman screaming the whole time to the doctor, "If he's never dropped a baby let Dwayne do it God damn it!" Which of course didn't happen, but I appreciated her vigor.

Anyway, in my terribly long winded way what I'm trying to say is be creative. I've not seen you in a medical discussion yet, or one on morals and/or ethics, but I'm really looking forward to it as you're obviously smart. This is another game, just like medicine. Step back, take a look, think it through and figure out how to win it. There is not question in my mind that you are absolutely capable of doing so.

Good luck. Keep posting, keep participating, you're going to be really good at this...

Dwayne

[Andrea]

@ Timmy....... Your clinical experience sounds pretty involved and seems to really incorporate the book work during the clinical rotation as well as a bit of a guarantee to get in on some of the action with someone there to facilitate it. I'd love to have a bit of that in my program! Since I'm not required to do those fun extras your program requires, I do test myself where I can. Any time I push a drug, if time allows, I go back and read up on it for memorization purposes. Even if it's a drug I'm already familiar with, it doesn't hurt to learn a few more side effects and whatnot.

@ Dwayne........ I've been working what seems to be a slow shift... Sunday mornings. It's not uncommon that we spend the first couple hours of the day stocking and cleaning rooms, which I'm happy to do until the "after church rush" begins. I'm definitely going at my next shift with a little more aggression and if they think me a pest, so be it. I'm almost done with my ER time and there's quite a bit more I want to know and practice before I head on to specialty areas and ambulance time.

Love the OB story! We aren't required to actually deliver as it is up to the mother if we can be present, but I think I will spend 16 hours in OB, so there is hope! I've heard it's easier for women to get into the delivery room than men so, my fingers are crossed! As for my CNA experience, the only thing I'm holding onto there is patient interaction. It was nice knowing a few basics like how to take vitals and some of the drugs I use to give in the group homes but, that's as far as it went.

I've been stalking some of the more medical related posts but, haven't had the urge to toss in my three cents yet. Some of it is still a little over my head and I'm taking it all in... all in due time.