Reflection: EM Rotation
Emergency medicine as a first rotation provided as many exciting learning opportunities as it did challenges. Advancing from skills learned in the classroom to real world application on real life patients was thrilling, as was generally observing the structure and flow of the emergency department setting. The staff of NYP Queens were welcoming and patient with a student just starting out on rotations and provided an environment that was conducive to branching out and trying new things with plenty of constructive feedback. While initially unsure if I would get the most out of the ED without any prior rotation experiences, I found that jumping right in helped to hone many skills that will help me on my future rotations as well.
One of the first skills I was able to practice was suturing laceration repairs. I enjoyed practicing this quite a bit during didactic and was looking forward to attempting the real thing. While we had a bit of practice with our rubber pads, there was the benefit of being able to place the pad directly in front of us at a level of our comfort. Obviously, this isn’t the case in real life, which I appreciated immediately when placing sutures in a patient’s brow while they reclined in a stretcher. With time I learned to adjust myself and the patient in order to place the sutures more comfortably and to use a more accommodating grip on the needle driver. A patient I’ll remember for quite a while was a 5 year old boy with a laceration to his forehead who, despite his dad and I doing our best to make him comfortable (along with generous amounts of lidocaine), was silently crying under the sterile field through the procedure. Needless to say this also was very different from suturing a rubber practice pad. He felt better and proud of his stitches just a few minutes later. Along with more sutures, placing staples, and blood draws and IV’s, I placed my first NG tube on this rotation and in that case was able to coach another patient through an unpleasant procedure.
Of all the places to practice delivering a concise and to-the-point patient history, the emergency department has to be one of the best. This was a big adjustment for me, and one that still needs plenty of work in the future. The ED is of course a “fast-paced environment” if there ever was one, and it immediately became clear that the presented history must be fat-free and focused. As a student I have to say this was extremely challenging as the skill of absorbing, boiling down, and reconstituting a patient interaction into a crystal-clear presentation is only just developing. In my upcoming rotations I will make improving this skill a top priority. Other challenges included an extremely diverse patient population where a translator was often necessary. For some reason this intimidated me going in, and I’m glad to say now that I quickly became comfortable with the process, and in a way the start-stop nature of using a translator helped me to focus my questions to pertinent points and make a point of phrasing them as clearly and simply as possible.
As with learning to focus questions when using translation services, I found my experience in the ED to be one where recognizing opportunities to improve despite challenges (or even in light of them) was paramount. Working closely with the different teams really brought to light how medical professionals are continuously learning and improving upon the skills they already have. Even as a student I never felt completely on the outside so much as someone just starting down the same road they’re already on. The attendings, residents, and nurses of NYPQ were more than happy to share their knowledge and lend opportunities to attempt skills, and for that reason I’ll remember it fondly as my first rotation of the clinical year.
Journal Article With Summary
Mäkäräinen-Uhlbäck E, Vironen J, Falenius V, et al. Parastomal Hernia: A Retrospective Nationwide Cohort Study Comparing Different Techniques with Long-Term Follow-Up. World J Surg. 2021;45(6):1742-1749. doi:10.1007/s00268-021-05990-z
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093171/
Background: Parastomal hernia repair is a complex surgical procedure with high recurrence and complication rates. This retrospective nationwide cohort study presents the results of different parastomal hernia repair techniques in Finland.
Methods: All patients who underwent a primary end ostomy parastomal hernia repair in the nine participating hospitals during 2007-2017 were included in the study. The primary outcome measure was recurrence rate. Secondary outcomes were complications and re-operation rate.
Results: In total, 235 primary elective parastomal hernia repairs were performed in five university hospitals and four central hospitals in Finland during 2007-2017. The major techniques used were the Sugarbaker (38.8%), keyhole (16.3%), and sandwich techniques (15.4%). In addition, a specific intra-abdominal keyhole technique with a funnel-shaped mesh was utilized in 8.3% of the techniques; other parastomal hernia repair techniques were used in 21.3% of the cases. The median follow-up time was 39.0 months (0-146, SD 35.3). The recurrence rates after the keyhole, Sugarbaker, sandwich, specific funnel-shaped mesh, and other techniques were 35.9%, 21.5%, 13.5%, 15%, and 35.3%, respectively. The overall re-operation rate was 20.4%, while complications occurred in 26.3% of patients.
Conclusion: The recurrence rate after parastomal hernia repair is unacceptable in this nationwide cohort study. As PSH repair volumes are low, further multinational, randomized controlled trials and hernia registry data are needed to improve the results.
My Summary:
This study assessed the primary outcome of recurrence rate in patients with parastomal hernia repair between the years 2007 and 2017. 235 parastomal hernia repairs were included in this retrospective cohort study that evaluated the various major techniques of the hernia repair, with the most common being the sugarbaker technique in 38.5% of cases. There was found to be an overall recurrence rate among all techniques of 24.7% with a median time from operation to recurrence of 24.6 months. There was determined to be an overall complication rate of 26.4% with a re-operation rate of 20.4%. The study determined that the rate of recurrence is unacceptable despite flaws in the study which include a relatively small number of operations using each respective technique that were included in the study. For this reason they are unable to draw conclusions regarding the superiority or inferiority of any one technique over the other. They further suggest that parastomal hernia prevention techniques are rarely utilized and have poor evidence for efficacy, reinforcing the argument for better techniques to repair these hernias.
Why I Chose This Article:
I chose this article after an encounter with a patient who had a long history of numerous health issues, not least of which was rectal cancer which ultimately resulted in a colostomy bag being placed. The patient was obese and had a history of multiple herniations while presenting with a significantly distended abdomen and pronounced parastomal hernia. Their main complaint was vomiting and abdominal pain and were later determined to be suffering from a small bowel obstruction. I was curious if the combination of abdominal surgery and a history of herniations (including his current parastomal hernia) could have further predisposed him to this obstruction and wondered what could be done for the parastomal herniation. I also wondered why nothing had been done for it up to this point as he seemed to feel it was ‘normal’ for him at this point and had been that way for some time. From the findings in this study it seems that repairs of this type of herniation come with significant risk of complications and recurrences that may leave some hesitant to intervene if there are no immediate concerns.
Site Evaluation Summary
My site evaluations were with Andrea Pizarro, PA-C who works in surgery at NYPQ. From these meeting I was able to get feedback on what was done well and what could use some work regarding my H&Ps, review my pharmacology cards, and assess my journal article selection. My H&Ps consisted of 3 full history and physicals that were conducted on patients in the emergency department, which was challenging to achieve at times, but for the most part I was able to extract the information needed from my relatively brief first encounters with patients. My evaluator helped me to see the benefit of providing a patient education segment at the end of my documents which I found to be an interesting way of shifting my perspective. By creating these hypothetical patient education conversations I was able to boil down findings and communicate what the patient themselves can do to better help their healing process or to better manage their chronic illnesses.
My first H&P presented a patient complaining of lower leg weakness and lower back pain following the lifting of a heavy object days earlier. We went over the red flags for back pain and how that was reflected in the treatment decisions made by the providers that particular day. I was sure to include an appropriate patient education segment on her request, along with a list of differential diagnoses. We debated the benefits and potential harms of prescribing Percocet for this patient, even if just for single administration in the ED. In my second evaluation I presented a patient with epigastric pain and a past medical history of inguinal hernia and rectal cancer with subsequent colostomy. The patient was found to have a small bowel obstruction. Since my evaluator is a surgical PA, we were able to go over my journal article (which addressed a parastomal herniation the patient presented with) and I was able to learn from their first-hand experience being involved in similar cases where patients undergo herniation repairs and the potential need for subsequent repairs. We also discussed education concerning signs of obstruction in patients with a colostomy. Our meetings were a great way for me to expound on my patient encounters and learn from an experienced PA as well.
