Clinical Rounds

     You've spent the last 12 Wednesday nights and Saturdays with your local fire department, practicing splinting and bandaging. You've read your EMT textbook. You've passed the practical and written tests. Now you're ready for your clinical rotation. You're scheduled for the overnight shift at your local hospital's emergency department. Your course coordinator has given you the list: vaccination records, name tag, dress code. But what do you do when you arrive?

     Most EMT training programs require students to work in emergency departments to gain clinical experience. Few provide any advice or orientation on what to do once students get to the ED. This article offers guidance on how to get the most out of your ED rotation.

FIRST IMPRESSIONS
     Before you get to the ED for your shift, do some homework. Ask your course coordinator to tell you to whom you should report at the start of your shift. People like to be called by name. If you walk in and ask for a specific person, you are more likely to be absorbed into the team. If your coordinator doesn't have the information you need, call the ED prior to the start of your shift and ask for the nursing supervisor. These are busy people, so be brief and to the point. Explain that you're an EMT student scheduled to work a specific shift and ask to whom you should report when you arrive. You may still get told to "show up and talk to anybody," but at least you have the name of the person who answered the phone. Plan what you're going to wear. Some EDs have specific requirements. Meet such standards in a professional way. Wear a name tag. If your class or hospital doesn't provide them, make your own.

     First impressions are important. This is no time to be timid. Walk up to the desk or nurses' station, make eye contact and stick out your hand and introduce yourself: "Good morning, my name is Matt. I'm an EMT student at the local community college, and I'm here for ED clinical time." Smile pleasantly and wait. If you were able to get the name of the nursing supervisor, ask for him or her.

     Once you get past the initial introductions, you need to start identifying the players. More than likely you've met the ED clerk. This person keeps track of patients. They bring them in from the waiting area and put them in rooms. The ED clerk is a good person to get to know. Large EDs will have EMTs or paramedics on staff. Make friends with them. They get paid to do the job you're studying to do. Ask them to teach you things. The ED nurses should be next; ask the clerk to introduce you. Again, make a good impression. Remember their names. If you have to, write them down. You will be asking the nurses to let you work on their patients. Most small to medium-size EDs will only have one doctor on shift. They may also have a physician assistant (PA) or nurse practitioner (NP). Get introduced to these folks.

     Your goal is to meet that one person who is going to take an interest in you and your education. You don't know whom that is going to be. In a perfect world, everyone in the ED will be looking for opportunities to teach you things and will instantly think of you when they're about to start a procedure you could do. The reality is that people are used to doing their own work. One or two people on the shift will really embrace the idea of working with you—find them.

     Your next big project is to get oriented to the ED. If somebody seems to have the time, ask them to show you around. You want to know how the rooms are numbered and what types of patients go in which rooms. Usually there's a white board on which room assignments, chief complaints and orders are written. You'll also want to see what's stored where. If somebody asks you to put oxygen on a patient, you should know where the non-rebreathers are stored.

GETTING TO WORK
     Every patient who gets put in a room needs a set of vitals taken. Follow the clerk or nurse into each room and ask if you can get the vitals. Take a complete set: pulse rate and quality, blood pressure, respiration rate and quality, lung sounds, capillary refill, skin tone and color. Some nurses won't want you to write on the chart. Write your results on a piece of paper and give them to the nurse. Once you've proven you can get a set of vitals that seem correct, you will probably be trusted to write them on the chart.

     When you interact with a patient, introduce yourself. I usually say "Hi, my name is Matt. I'm an EMT student, and your nurse has asked me to take your blood pressure. May I?" By asking permission, you give the patient a sense of control in a situation that probably seems out of control to them. And patients would rather understand you're a student instead of assuming you're just bad at your job if you appear nervous.

     Look for opportunities to help with interesting cases. If a major trauma is coming in, get in the room. The staff will need help lifting the patient, cutting off clothes and taking vitals. The NP or PA will usually need somebody to assist if they're applying a splint to a fracture or suturing a laceration. Conscious chest pain patients provide a good chance to practice getting a history. If you explain that you're a student, the patient shouldn't mind you repeating questions they've already answered. If the ED is busy, try to avoid being assigned to one patient. You are there to get as much experience as you can.

     Study the work done by other EMTs. If an ambulance brings in a patient with C-spine precautions, look at what's been done. This will let you see what the "real world" is like. Rarely does the work done in the backseat of an overturned sedan measure up to the results of practice sessions back at the firehouse. Keep your observations to yourself. Learn what you can without negative comments on the work of field EMTs.

     Sometimes traffic into and out of the ED will be slow. Spend this time productively. Pitch in with the staff to clean and restock rooms. Bring your textbook to study when the chores are finished. You will continue to impress the staff if you're available to work and learn but not hovering over them as they catch up on paperwork. Pick one spot that's out of the way but can be seen from the nurses' station. Go there whenever there is nothing to do. If you're easy to find, you'll get more interesting assignments.

     When your shift is over, go home. Don't hang around because you're just starting to "get it." There will probably be another student coming in for the next shift. If you have time and the staff isn't changing shifts, introduce your fellow student to the key players in the ED. Thank the people who helped you. You want to be remembered as that polite EMT student, not the guy who just disappeared. Your program probably requires more than one shift, so you'll be back.

CONCLUSION
     You may not be able to put all of these tips to work on your first shift. Expect to feel overwhelmed and work to stay productive despite the apparent chaos. Your second shift is usually better than your first. Practice good people skills, and you should be able to make the most of your time in the ED.

Matt Vandzura started working in EMS for the National Park Service in 1998 as an EMT. Currently he is a park ranger in Yellowstone National Park and provides care at the Intermediate EMT level.