CEimpact Podcast

Precepting Your Way Through Trauma

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Traumatic patient interactions may not occur very often, depending on where you practice, but they are important teaching opportunities on many levels. It’s not just how you navigate trauma with a pharmacy learner that matters, but how you support them in processing what has occurred.

In this episode, we bring together a preceptor and her former resident for an impactful conversation on how to best assess, navigate, and process traumatic patient interactions with pharmacy residents or student pharmacists, and how those learnings transfer to other areas of pharmacy practice after the fact.

Host
Kathy Schott, PhD
Vice President, Education & Operations
CEimpact

Guests
Samantha Katzman, PharmD, BCEMP
Clinical Pharmacy Specialist – Emergency Medicine
University of Louisville Health – Jewish Hospital
Louisville, KY

McKenzie Packard, PharmD, BCPPS
Pediatric Clinical Pharmacist
Atrium Health Wake Forest Baptist
Winston-Salem, NC


Get CE: CLICK HERE TO CPE CREDIT FOR THE COURSE!

CPE Information
 
Learning Objectives
At the end of this course, preceptors will be able to:
1. Discuss strategies to assess pharmacy resident or student pharmacist readiness for a potentially traumatic patient interaction
2. Describe strategies preceptors can use to support pharmacy learners after a traumatic patient interaction

0.05 CEU/0.5 Hr
UAN: 0107-0000-24-177-H99-P
Initial release date: 5/15/2024
Expiration date: 5/15/2027
Additional CPE details can be found here.

The speakers have no relevant financial relationships with ineligible companies to disclose.

This program has been:
Approved by the Minnesota Board of Pharmacy as education for Minnesota pharmacy preceptors.

Reviewed by the Texas Consortium on Experiential Programs and has been designated as preceptor education and training for Texas preceptors.


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Speaker 1:

Hello. If you are a regular listener, welcome back. If you're new to Preceptive Practice, then welcome. We're glad you're here.

Speaker 1:

Ce Impact brings you this podcast each month, typically on the third Wednesday. Each episode engages insightful guests who share resources and ideas to help you improve your precepting practice, become a more effective teacher and mentor and balance your work with these additional but important responsibilities. We've received multiple requests in recent months for a conversation around how preceptors can best support their learners during and after experiencing traumatic patient situations. These may or may not occur every day, depending on where you practice, but they are important teaching opportunities on many levels. It's not just how you navigate trauma with a pharmacy learner that matters, but how you support them in processing what has occurred. In this episode. I talked with Dr Samantha Katzman, an emergency medicine pharmacist at University of Louisville Health, and Dr Mackenzie Packard, a pediatric clinical pharmacist at Atrium Health, wake Forest Baptist in North Carolina. They were PGY-2 and PGY-1 residents together for four years. About four years ago, actually, in the same health system here in Iowa, dr Kassman precepted Dr Packard as part of a required emergency medicine rotation, where Dr Packard was completing her PGY1 residency. This unique opportunity to bring them together resulted in an impactful conversation about how to best assess, navigate and process traumatic patient interactions with pharmacy residents or student pharmacists, and how those learnings transfer to other areas of pharmacy practice. After the fact, dr Katzman and Dr Packard do discuss a couple of acute and traumatic patient interactions as part of this episode.

Speaker 1:

While they're not terribly graphic, necessarily this may not be for you. If that's the case, take a break and we'll see you back on the next episode. Well, welcome, sam and Kenzie. I'm super pleased to have you here today to talk with me about precepting in what can be traumatic situations sometimes in our teaching environments. I know today is a little bit of a more serious topic and maybe a little heavier in some respects, so I'm really grateful for both of you being willing to to chat with me. Sam, I'm wondering if we can maybe start with the introductions, if you could just sort of share a little bit about your background and and you know what you're doing now and maybe what what brought you here to this conversation?

Speaker 2:

Yeah, no problem. Um so hi, everyone that's going to be on. My name is Sam. I am an emergency medicine pharmacist. Currently I'm located in Louisville, kentucky. I did PGY1 and then PGY-2 in emergency medicine and I've been practicing in the ER for three years now total, if you want to count PGY-2. I precept students. I precept residents, both for our current PGY-2 EM residency and our PGY-1s. We do have ER experiences as well, so something that I'm passionate about. I very much enjoy precepting students in residence and kind of acclimating them to the ER and helping them grow as clinicians.

Speaker 1:

Awesome Thanks. Yeah, we've been working with you for a long time on different projects, so it's nice to reconnect. Kinsey, welcome. Can you introduce yourself? Share a little bit about your, your background and your current practice.

Speaker 3:

Yeah, um, so my name is Kenzie. I am a current uh pediatric pharmacist in Winston-Salem, north Carolina, at Atrium Health um Brenner Children's Hospital. Um, I did a PG01 in Des Moines, which is where Sam and I met Um, and then I did my PGY two in Indianapolis, specifically in peds, before um heading to this job that I'm currently in, which I took great out of residency, um, so I have been out of residency for it'll be, I guess, two coming up on two years, um, and so I I'm a new person, kind of, so to speak, when it comes to precepting. You know you take students as residents, but being the lead preceptor has been something I've only done for just about a year now.

Speaker 1:

So great, yeah, so getting your feet wet and all that, all that fun stuff, yeah, and you alluded to this Kenzie, but this is not obviously the first time you've met. Um, you uh work together as kind of as co-residents, so I don't know, sam, maybe share a little bit about you know, your former connection and and how, how you worked with Kenzie when you were both on residency.

Speaker 2:

yeah, I guess I kind of I can't understand that part. So yeah, I did my uh PGY2 emergency medicine at in Des Moines as well, at the same time that Ken's was a PGY1. And so we worked very closely, we shared an office together and I think we really grew together just as friends during residency. But the precepting exposure that we shared during my PGY2, I precepted her emergency medicine elective, actually it was required, I think it was required for our PGY1s there. So I got to kind of help acclimate her to the ER and it was one of those experiences.

Speaker 2:

Going into it I knew she wasn't a huge fan of because we kind of had talked about it and how it was kind of stressful and not a comfort area. So we spent a lot of time together trying to kind of get her feet wet and just be more comfortable with okay, well, what do you just do with critical situations and not. Our goal with the experience for her wasn't necessarily like I want you to be an independent ER pharmacist by the end of it, but I want you to just feel more comfortable with what do I do in certain situations and what are my good resources to go to. And I felt like that was a very good experience for both of us, and we've stayed in contact too every once in a while after residency was completed for both of us, and I was very happy that she went on to do peds, because I think it's definitely her happy area.

Speaker 1:

Her sweet spot. Yeah, that's great. That's great. Yeah, well, thanks for sharing that. I'm so thrilled that we could get you both together and obviously you've maintained that connection, which is great. It sounds like you both did a lot of growing and learning together, so that's awesome.

Speaker 1:

Stan, let's start with you. With several years spent exclusively in EM at this point, you've no doubt had multiple patient care experiences that have probably involved certain levels of trauma, sometimes significant trauma. I know that you and Kenzie share one of those experiences, and so I'm really grateful that you're both willing to be here and talk with me about it today, because I know that might not be easy. You know, the focus of today's session really comes out of requests that I've had from experiential programs and some residency programs.

Speaker 1:

I think this is a topic that doesn't get discussed, maybe a lot in general as a you know, as a sort of a skill for preceptors, but you know, helping students and residents navigate traumatic situations, whether that's you know, the kind of trauma we're going to talk about today, or maybe just you know dealing with the loss of a patient.

Speaker 1:

You know, even in the community pharmacy, you know the kind of trauma we're going to talk about today, or maybe just, you know, dealing with the loss of a patient. You know, even in the community pharmacy, you know those are serious things that can really impact learners, you know, who are just getting their feet wet with some of these life experiences. So I'm really grateful that you're willing to come together and talk about it, and I think it's a topic that, like I said, it's been requested and I think it's something that's probably not talked about as often as maybe we should. So thank you. So, sam, with that, can you describe an emergency room situation that you and I know, particularly one that you and Kenzie have shared? To sort of lay that groundwork?

Speaker 1:

for us and then we'll dive deeper into you. Know that as sort of a teaching moment, but just to maybe lay out the situation for us and then we'll dive deeper into you. Know that as sort of a teaching moment, but just maybe lay out the situation for us.

Speaker 2:

Yeah. So if I'm remembering the timeline correctly, it was just about like the last chunk of rotation experience and we'd had several trauma activations. So the hospital we did PGY1 and PGY2 at was a level two adult and pediatric trauma center. So we had a lot of learning experience that, a lot of exposure to traumas that would come in and so at that time we had had several level two, level one activations. And when we got the call ahead for this particular one, I initially told Kenz I said, okay, I'm just going to be here for support when this rolls in, like you're going to take primary and I'm going to try to let you run the show and just see how it goes. And at the time the information we had gotten was that they were bringing in an 18 year old stabbing victim and I think that was just about all that we had gotten, and he was very critical, hypotensive at the time. So we all went to the trauma bay, got our lead on, got everything set up. We had like a brief conversation beforehand, like I said, like, okay, we're just going to run through really quick all the things that you might need. I'm just going to be here for backup.

Speaker 2:

However, when the ambulance arrived and the paramedics actually brought the patient in. They were actively doing CPR, which wasn't what we had gotten beforehand, and kind of looked at Ken's. We looked at each other and I could tell she was a little bit like whoa. That's not what I expected and as the preceptor in that instance and just knowing kind of again at the beginning of the rotation what our goal was, I could assess at that point like this may not be the one for her to run on her own. So I kind of changed it to more of a okay, you stand here, you hold what I tell you to hold, we'll talk about it. You're going to do what I tell you to do. You're not going to run this one, because I don't think we had had any trauma codes yet in her rotation.

Speaker 2:

Ken's can probably correct me if that's not true. So again, those are more of a really unique situation when you're talking about different traumas, even as a pharmacist, that you're involved in just because the care is different. So when they did get him onto the bed and we started doing things again switched more to a kind of like modeling, coaching role instead of a just background observation role from a precepting standpoint. He ended up with a complete clamshell thoracotomy. We did actually call time of death at one point and then did get some cardiac function back, but we were involved with him all the way from arrival to the trauma bay. Ken's and I were responsible for administering all the medications during the code process, in addition to helping with some other stuff and some like intracardiac epi and some other very crazy things, Got him all the way to the operating room where we handed him off to the OR staff and then tried to come back to the ER.

Speaker 2:

to debrief at that point, as far as you know, okay, how did you think that went? How are you feeling right now? What? What do we need to talk about, in terms of either what you don't understand you do understand, or what are you even feeling? And it was a pretty stressful, even for me, it was a pretty stressful situation to be in, but it was good to see that we could get him to the OR and he actually did make it out of the OR with a lot of resources so.

Speaker 2:

But we were very heavily involved with that and I think, at least for myself too, it was a good precepting experience. And Kenza, I was texting her before this and I was like what did I say to you? I know I said some things and like at the time when they called it, I kind of made a comment about like oh good, and then I was like wait, wait, wait as a teaching experience, like not good that somebody is coming in stab, but like good, we haven't had a penetrating trauma. I don't think like this will be a good teaching experience.

Speaker 2:

So I tried to be in that mindset right off the bat. But again, sometimes it's very difficult to balance what do I try to teach you in the moment while trying to critically stabilize the patient, especially seeing kind of how significant his injuries were when he finally did arrive. And obviously I think I learned a lot from that. I'm hoping, like when Kenz and I talked about it afterwards, I think she learned a lot too and had a lot of respect for just the whole entire trauma process and she's going to get to speak to it but hopefully I think took some kind of learning points from that that she can implement with a lot of other practice areas.

Speaker 1:

Yeah, yeah, it was there. What? What was the point at which you realized that the teaching moment was not going to happen now, it was going to happen after?

Speaker 2:

I would say honestly, when I saw the ambulance come in with the Lucas actively running which I don't know if our listeners, if everybody's familiar with what that is but theas is like an automated uh cpr compression machine that a lot of ems services are starting to carry, because then it frees up somebody from doing compressions um, and then there was a medic standing next to him that had his hand like actively pushed into the staff injury I'm trying to prevent blood coming out. And when I saw that and I looked at Ken's and I remember her kind of having just this white shocked face and I was like, okay, scratch what I said, you're not running this one.

Speaker 2:

You're going to be my support. We'll handle this together. So I think, just as preceptors, I think it's really hard and it's definitely a skill that I've been continuing to try to work on is really trying to pick up on the nonverbal cues from your learners. Continuing to try to work on is really trying to pick up on the nonverbal cues from your learners, because I've noticed now precepting more students. Specifically, I find that students oftentimes will verbally tell you like, yeah, I'll go do that, yeah, I can do this, yeah, I'm fine, because they don't want to let you down or risk potentially getting a bad grade or whatever it is. But if I can look at somebody and pick up on their nonverbal cues of okay, this person's really uncomfortable. Now I just tell them and just change the plan and say, no, nevermind, like you're going to come with me and watch how I handle a certain situation and then we'll talk about it afterwards and then you know like see one teach, do one, teach one.

Speaker 1:

is kind of how I try to incorporate from then on Right, right, yeah, which can be a challenge in the environment you're in, probably because you don't like. You know, like that day you didn't know what you were going to have necessarily until you walked in, right, I mean, you were anticipating something different than what you got, and I'm sure that's just probably the average day. You know how you were feeling that day and you know what actions did Dr Katzman take that were most helpful to you during the patient interaction, you know. And then later we can talk a little bit about some of the longer term conversations that you guys had. But in that moment you know how were you feeling and you know how did she handle that in a way that was and you know how did she handle that in a way that was appreciated.

Speaker 3:

Yeah. So as Sam weighed out the situation, I also wanted to just add one detail. We actually I think it was like late in the afternoon when this had come in, and so I technically was off of rotation at the time that this rolled in came overhead that they were, you know, having this activation in the ER, and so Sam looked at me as I was, you know, not technically no longer on like rotation for the day, I was just in the office trying to get some other things done.

Speaker 3:

But she also was there, and so she looked at me and she was, like we haven't had one yet. Like do you want to go? It's totally up to you. Like I understand, understand, you know we're at the end of the day, you have some other things you have to get done, but throughout my entire emergency medicine, I was with Sam for I think six weeks was my rotation and so throughout that entire time I would say that that was probably the rotation I learned the most on. Sam has a very good way of like looking at her learner, ask them like, how do they learn best? And for me that was being asked questions. So she questioned me every single day that I was with her for six weeks and so I learned probably more on that rotation than I did, you know, throughout any of my other experiences PGY, one year so that was very helpful. So it was very helpful. You know that she just looked at me in that moment and she was like, hey, you want to, you want to go learn some more things? Like I don't know exactly what this is, um, but we can go see what's coming in and we can, you know, work through it. So, knowing that, you know we had that relationship as like preceptor with her, as my preceptor but also like as co-residents, it makes it maybe a little. It made me maybe a little more comfortable to be in that situation. You know she was only one year ahead of me but she still knew so much more than me for those situations but you feel maybe a little bit closer to those peers as co-residents than you do with, you know, a preceptor who you're, you know, just meeting and don't spend every day in the office with and don't talk to every day. So I think the situation was very unique but I think that it, you know, led to a very comfortable teaching moment for her and then for me obviously as well.

Speaker 3:

When the call initially went over, like Sam said, we went to the ER. We didn't really know what was coming in, just that it was a trauma. And then you know we got all the information when we got to the ED. So we talked through a few things before EMS got there. You know what things we would maybe need, where they would be located, and so we I was prepped a little bit ahead of time before you know we actually needed some of those things, which is also always helpful when you're in a less familiar environment, especially trying to know if someone asks you for something, where do you get it.

Speaker 3:

Because it's, I think, the worst feeling in those situations is feeling like you could be helpful but you can't be because you don't know what you're doing or you don't know where to go to get something to get something. So I think you know, in the moment when they initially rolled in, it was lots of feelings of you know, nervousness and what's going to happen and what, what are they going to need? What are they going to ask us for. But talking through some of those things beforehand definitely helped to calm the nerves a little bit. Know that. You know I was there to help and Sam was going to also be there to direct me. If any questions were directed towards us that I couldn't answer, she was going to be there to answer them as well.

Speaker 1:

Yeah, it sounds like she made it as safe a space as possible for you. Yes, after the, after the, you know the situation. What, what interventions did you maybe receive from Sam that helped you sort of process the situation and what had occurred?

Speaker 3:

Yeah, I think the most helpful piece of advice or information that she had shared with me is that really anything I mean with someone coming in with CPR in progress anything that you're doing for them or to help them is really just to try to get them back to living. And so I think when you think about those situations, you know, while it's very traumatic for everyone in the situation, you know the patient is essentially not living anymore. Knowing that everything that you are doing is trying to help the patient come back to living is probably the like thing that helped me the most is that you know I was just there trying to get them, trying to get them back.

Speaker 2:

So anything I was doing wasn't necessarily going to be harmful to the patient, but only helpful. Yeah. I think the way that I think the way that I said it cause I hence maybe doesn't want to say it, but when she brought it up I was like, yeah, I remember that I looked at her at one point and I said we can't make him any more dead, so let's just focus on following our algorithms, doing what people are saying we should do, like we cannot make the situation any worse than it already is.

Speaker 2:

And I say that to a lot of my students even now, if we have codes that come into the ER and they want to be involved and they have questions that are like, but what about compatibilities? Or what about can I put this in a line we can't make it worse, like there's very few. I can only think of maybe a couple of things that could really make the situation worse, and it's nothing that we're going to be doing. So I'm glad that that was helpful. It has been yeah that's a really good.

Speaker 1:

You and I had kind of talked about that, you know, when we were prepping last week for this conversation, and I thought that that was a really. That stuck out to me too, sam, the idea of sort of level setting the expectations and the role that you're playing in a traumatic situation, so that, I don't know, making it less scary but I mean kind of making it less scary, right, like you are not going to single-handedly mess this thing up. You know we're we're in a tough situation and our role here is not not to achieve a hundred percent health. It's, you know, like it might be in a different pharmacy setting this is a whole different ball game. And level setting the expectations, right.

Speaker 1:

Yeah, that's really important, sam. Was there anything you know long-term that you? You know? I know you said this was at the end of the kind of the end of the experience, but even thinking about other situations that you maybe have been in, you know what are, what are some other sort of longer term steps that you've taken with learners who've maybe experienced some trauma, to just make sure that you're keeping a pulse on that with them and helping them process?

Speaker 2:

Yeah, I try. So, like Ken says, I ask a lot of questions and sometimes I try to do that during whatever the experience is as well, for two reasons One, so I can try to assess their level of where they're at and what their comfort level is and what they know how to do during, whether it's a code or, you know, like a non emergent resuscitation things like that. But also to try to I think, especially if you're going to practice in the ER, we have to be very good to a certain degree at compartmentalizing and being able to still think clinically and critically. And so if I can kind of distract them but also try to keep them on task, I find that that helps them not get overwhelmed in the moment. And I've had that as feedback from especially my PGY-2s that I precepted now for the last couple years that it can be tricky to find those moments during the resuscitation to ask questions. But when I notice that they come up, I try to kind of do that to detract from the situation a little bit and to also keep them on track with like thinking clinically from a learning standpoint. And, like Ken said, I like to if I have an idea of what's coming in or what's going on. I try to touch base with the learner beforehand and say, okay, well, have you seen one of these before? Do you want to try to run it yourself? If not, how do you? How involved do you want to be? Because sometimes I'll have students who are like, oh yeah, like I want to help, like give meds, I want to help do things, and then there's others that are not quite as comfortable and maybe just want to stand back and watch. But I also definitely had students that have been exceptionally uncomfortable with any type of kind of code, situation or blood, and I also give them the option of yes, this is an ER rotation. I get that. But if you really just want to step out of the room and I can talk you through what we did in there afterwards, that is also an option, and I let them know that they can leave the room at any point in time. Because, especially if it's a learning appy experience or even a PGY1, and it's not something that they're going to be doing long term or it's not an interest area that they want to do forever, there's really no reason in my mind that they would have to be exposed to that type of experience, because at a certain point if your learner is too distracted or too distressed or too upset or doesn't feel good, they're not going to learn anything from that situation anyhow, right.

Speaker 2:

Um, and especially for like my pgy2 is now I have like another recent example. We had a walk-in pediatric trauma, uh, and the hospital that I currently practice at mainly is not we're not a trauma center at all, but we do like transplants. We get a lot of of really sick cardiac patients and we're right next to a children's hospital. So every once in a while we do get PEDs that get brought in kind of by accident. And I had one of our PGY-2s that I was precepting in.

Speaker 2:

I was kind of making the rounds handing some meds out, didn't realize we had this walk-in. I found her in our resuscitation room and she just kind of looked a little shell-shocked and I took her aside really quick and asked her kind of those similar questions like how many PEDS traumas have you had so far? And she's like I've only had maybe one other one. I said, okay, do you want to try to do the things? And like, what are we going to be anticipating right now, or do you want me to just kind of like stand here and tell you what we're going to, especially with peds. I think everybody that's in emergency medicine can agree that pediatric emergencies and traumas are probably the most stressful that you can deal with.

Speaker 2:

So in that situation again, I kind of touched base with her at that time and then, even while the doctors were doing their initial assessment, I was like okay, it was a hit and run. What injuries would we be anticipating? It looks like there's a hematoma on her head. What types of head injuries are we going to be expecting If that happens? Are we going to need Keppra? What if we don't have that? What are our alternatives? Um, and then after we kind of got the child stabilized, I sat down with her too and like kind of asked like how are you feeling? How do you think that went? Um, was there anything I could do? Your support and preceptor, so that you can be successful not only in helping with the patient but also, like, actually learn something from the encounter. Cause, again, that's, I think, always kind of like the hard part for learners, especially if they haven't had a lot of traumatic experiences, is to really stay focused in the moment. So that's kind of how I try to approach it.

Speaker 1:

Yeah, yeah, no, that makes a lot of sense. I mean it just sounds like you've really relied on that opportunity to sort of reassess and level set and then focusing on the debrief after, but in that middle time really just focusing on delivering the care and compartmentalizing some of the other things for later. That makes a lot of sense. Kinsey, can we talk a little bit about? I mean I love that you said you learned, you know so much in this experience and you know so often that happens, I think, where you learn the most, where you don't expect to, because you know you were pretty clear about the fact that this maybe wasn't, you know, going to be your long term. You know practice setting. How have you, how do you see yourself using some of the things that you've learned and you know as a result of some of these kinds of patient interactions and those teaching moments with Sam? How is that playing out now in your own teaching? Do you have any sense of how that's?

Speaker 3:

happening or some examples that you could share. So, as far as like, from a precepting standpoint, I am not really in an emergency setting anymore. I cover our pediatric ICU a few times, but I actually just had my first code be called while I was actually covering the PICU just a few weeks ago, and they had actually it was a child that was in imaging when it was called and so by the time I got there they actually had already achieved, you know, raw skin. The child was back, so they really just had to be taken to the PICU in order to be intubated at that point, but otherwise they weren't actively doing CPR.

Speaker 3:

I did do a lot of practicing and then I went to all of the pediatric codes, whether they came through the ED, they were called on the PICU or called on the SPOR during my PGY-2. Thankfully we didn't have too many of those that were, you know, real. Most of them were actually like a simulation, but still very helpful. As far as you know learning goes. Most of the time I didn't have a learner with me, but you know, taking the things that I learned from Sam, from you know, that day and the whole emergency department experience that I had was really helpful, again, knowing that everything that you're doing is can only really be helpful and at that point it is hard to be harmful.

Speaker 3:

It's something that I continue to pass on um with all of my learners A lot of people, especially if you're at a hospital that doesn't have a lot of codes or that doesn't you're not in. Like, we don't have a pediatric emergency department um rotation for our PGY2 currently. Um, so sometimes that can be hard when you know they're going to those things and they're like I don't, you know, I went to this today and this is what happened. So when people talk to me about it learners talk to me about it I just try to remind them.

Speaker 3:

You know everything that you're doing is only helping the patient. You take the mistakes or not mistakes, but the some of the mistakes that you know you see people do in simulations and then you can apply those to real life so that they don't happen again in the future. Um, and then also some of the things that happen in simulations, such as you know someone's asking you for dosing and you don't know what the dosing of that drug is. Um, you remember it very quickly the next time someone asks you for that when you forget it the first time.

Speaker 3:

So you know, just being exposed to those situations I think is really like the most helpful thing, especially for a learner. And then I think the other thing is that you are sometimes you are only one person. It can be very high stress in those situations. You can have people yelling at you, asking you for 7 million different medications all at the same time and at some point you know you have to kind of prioritize which ones they're going to need first, which ones are more important, and then sometimes you have to look at whoever's standing in the room and you have to say I am only one person, I can only drop one medication at a time. I'm working on that. I will be to you shortly.

Speaker 3:

But you know, everyone you know handles high stress situations differently. So just trying to stay calm, the most calm you can in that situation I think is helpful. As far as you know. Trying to be a preceptor, helping which in any way you can, your learner, especially if they want to try to take it on themselves. Being there for support, I think is also another thing that's very helpful.

Speaker 1:

Right, right, yeah, that's great. Right, right, yeah, that's great. Sam, how much tailoring. You know how much have you had to kind of tailor your approach based on the range of learners that you've worked with. But you know you've got to have a whole range of folks coming through there. Yeah, and I think even students who choose an EM rotation don't always know what they're getting into, so maybe you could chat a little bit about what that looks like.

Speaker 2:

Yeah. So I try to start off like the first day of my rotation and I feel like it's good practice and probably everybody always talks about doing it, but I'm not sure how much actually gets done. But I really sit down with them with the syllabus and like what my expectations are and then I really ask them like why did you choose to do this rotation? Like, if it's a student, and actually for our PGY1 starting this year at University of Louisville, em is going to be required for all eight of them, so we'll rotate through our various community sites with me, um, with the main trauma center and things like that. But I really like to sit down the first day and get a feeling of what do you want to get out of this rotation, um, and why did you pick to do it if you're a student? Because for me that really helps.

Speaker 2:

I don't want to waste time. And when I say that I mean in the sense of I don't want to waste time, and when I say that I mean in the sense of I don't want to try to teach them something that one they're not interested in because they're not going to retain it and it's going to be a very unpleasant experience for both of us. And two, what can I help them learn? Skill wise and knowledge wise? It's going to help them in the future, depending on what they want to do, whether it's go into community practice, go in and do residency, pgy1, pgy2, whatever it is. So I really try to have that conversation on day one as far as what are your expectations for me?

Speaker 2:

These are my bare minimum expectations from a rotation, passing standpoint. And what types of patient experiences can I try to optimize for you and like pick out and try to send them to? Because what I found too is like with students, I've had a variety now of ones that either they literally had no interest in EM, had never been exposed to even a hospital before, and they just picked it just because and sometimes those can be challenging learners from a precepting standpoint again, depending on their kind of attitude and interest level be the most rewarding experiences, especially when they're engaged and then they find out wow, I'd never really realized this was a practice area and now I get to learn so much. And then I've had students too that are like I want to go into residency, I want to do critical care, em and those kinds of like high-performing learners. I really again try to push them more like here's some literature to read, we're going to discuss literature, and I really drill them down on specifics of like acute DKA management and acute chest pain and like things like that, and really try to get more into the weeds with somebody who's very engaged and interested, whereas, like I said, for students that take it just because they didn't want to do any of the other electives offering through their experiential office.

Speaker 2:

I try to focus more on well, where are you going to go after this? I try to focus more on well, where are you going to go after this? Okay, if you're going to probably go into community or you're interested in AmCare, okay. Let's focus on more patients that come in with poorly managed chronic disease states and not necessarily like the high acuity critical care level patients Cause. At the end of the day and I tell this to my students too I try to circle back on the end of the day and say tell me two or three things that you learned today. I just want to make sure that you're learning at least one thing every day. So then by the end of rotation, you at least you feel accomplished. I feel accomplished and we haven't wasted you know, three, six weeks, however long the experience is. But I try to establish that right away on day one.

Speaker 1:

Yeah, no, that's, that's great. Have you ever had a situation, you know, you know. You know we've talked about your, your interaction with Kinsey and you know sort of that immediate debrief. Have you ever worked with students where students or residents, you know where, the, where there was sort of a longer term concern about their wellbeing? After, you know, after an experience and as the preceptor, you can't be the sole source of support right, so you know, were an experience and as the preceptor, you can't be the sole source of support, right? So you know, were you able to connect them to other resources or what you know? What's the next thing when it, you know, when it goes beyond that situation and you just don't, you know you can't continue to be the only support that they have.

Speaker 2:

Yeah. So I thankfully haven't had a lot again, I think, because I try to establish day one what their expectation is and also to giving the especially the students the option of if I know something really bad is coming in or they really don't want to be in a code situation, like I honestly don't. I don't force them to do that because, like I said, depending on what their long-term career goals are, I don't feel that everybody needs to be exposed to those situations are I don't feel that everybody needs to be exposed to those situations if it's not something that they want to be engaged in. However, I did recently have a student that she was interested in like hospital practice, was considering PGY1. I don't remember exactly. She had like cardiology, critical care, em as kind of her interest areas and we had an unexpected code called in our cardiac observation unit and at my current hospital that falls under my purview because it's right next to the ER, most of it's staffed by our ER nurses and so when they called the code blue cardiac ops, I was like all right, we're going to go to this, and it was kind of a weird situation where the patient had been had decided to transfer from a different hospital by personal vehicle instead of EMS, knew he had like an elevated troponin. Didn't think he was a STEMI at the time. However, by the time he got over to us, even in his own car, he ended up coding in our OBS unit. So cardiology was already there, thankfully, and we didn't have to code him for very long. But he did have to get defibrillated and I drew up meds and kind of the whole time.

Speaker 2:

She kind of stood there and looked just very shell shocked by the whole situation and I could kind of tell, like okay, we're going to have to sit down and like really talk about this afterwards because we had I hadn't had a either a walk-in trauma or a code with her yet on her rotation and this was just for like second week of four. So after that, once the patient went left to cath lab with cardiology, I was like hey, let's go sit down for a second and like what? Like tell me what, what you thought about that whole situation. Like what, what are your feelings right now? And she was, like I said I think shell shocked is probably the best phrase I can use Cause she had she was like an intern in a community practice.

Speaker 2:

This was, I think her second hospital rotation in general, but again her first like code and she was like I don't know how you stayed so calm, like I would have been shaking, and you drew up meds and it like wasn't that big of a deal and I was like okay, but you have to remember how many years have I been doing this. I've seen a lot of these and again it's just with practice. Okay, like routine, routine, because I could tell too she was feeling really upset with herself, because I had asked her like hey, do you want to go hand this med in there?

Speaker 2:

and she was like no, no, I like I, I just want to stand here and so I tried to explain to her too like it's okay to feel that way, like the only reason I seem so calm is because I've done this so many times, um, and really I'm not very calm on the inside. It's just right ready to practice. But with her too, on that particular day we kind of I could tell she was kind of stuck and kept looping back to it, so I did give her. There was a topic discussion coming up later that week, and so instead of having her continue to work up patients because after that, when she was trying to present patients to me like she was missing things that she usually didn't miss in terms of well, did you look at this lab? What do you think about this? What meds should we anticipate?

Speaker 2:

And so I could tell that she was distracted, and so I was like, well, let's stop looking at patients. You were going to prepare a topic discussion on aortic dissections for in two days. Why don't you start pulling resources and work on that and sit here and we'll just don't worry about working up patients anymore, cause that's at least less stressful to me? So, and for her to to just kind of look at literature and detract away from thinking about real people for a little bit, um, and I did send her home a little bit early that night too. She was better the next day and I did try to touch base with her and say like hey, how did you do last night, like did you want to still talk about anything from yesterday? And she still kind of expressed she was like that was a lot.

Speaker 2:

And I was like yeah, yeah, yeah, I know, and so I didn't refer to any place else. But, like at our hospital, we do have chaplains that make regular kind of walking rounds in the ER. That we do have like our student, nurse, learners and stuff. We'll talk with everyone and they serve as like a family resource and employee resource and I think most schools to also have some type of either, if not a chaplain, like a counselor resource that I have not had.

Speaker 2:

I can say I haven't had to reach out to like the experiential office coordinators for like that type of information, but I know they're also available, so that's other places you can right right people to. But that's at least how I tried to handle that situation and again touch base after those types of things with my learners, like what do you want to talk about? How can we make this a learning clinical point and try to take ourselves out of what you were feeling in your body at that point, cause that's the really hard part, especially for people that do end up practicing long-term in the ER is okay. How do I kind of detach myself in the moment and then still process the feelings afterwards, right?

Speaker 1:

Yeah, and it sounds like in. You know one thing that preceptors can do is watch for behavior change. So what was happening differently after the interaction that wasn't happening with that learner before? You know, and you mentioned missing some things and you know keeping an eye out for behavior change that you know could be tied back to that. So for both of you, you know how do you take care of yourself after navigating a difficult patient interaction. Kinsey, I know you're not in, you know in an EM situation or an ER situation, but you know you're working with sick kids so there has to be some, you know, stress and and anxiety that comes with that. What do you, what do you do to take? Just take care of yourself.

Speaker 3:

Yeah, I think, just in general, you try to compartmentalize as much as you can. I try to keep things at work and not bring them home, but that isn't always possible. Plus, when you see it all the time, you have to sit down and at least process what's happening with the patients and the families. We have patients that come in all the time, you know, that end up going to organ donation, and so I think one thing you know that helps with some of those situations is, you know, we do our honor walk for those patients and families, which is always a very, you know, sad moment as they're wheeling down to the OR. But you know, knowing that they're going on to help so many other people is always a good feeling that you can take with you Not obviously good for the patient but good for, you know, all the people that are out there waiting for organ donation and things like that.

Speaker 3:

And then we also have several chronic kids that come in. You know, sometimes they have to go home on hospice and things like that, and so I actually had a one of our pediatric hospitalist attendings just a few months ago. They had to, you know, go talk to a patient's family and ask if they wanted to do comfort care, like hospice, and they essentially had to tell them that their child was not going to make it very much longer. And then it was, you know, in the middle of rounds, and then we just continued to go on rounding and so at one point he was like I just want to take a minute to like I understand, this is not like normal, like most people don't just go tell people that their child only has a few months and then they just continue on about their day.

Speaker 3:

So he was like I'm just going to take a moment and if anyone needs to, you know, go take a break, go get some water, go get some food, take a minute to. You know a process. What just happened? Like please feel free and then we'll. You know you, it's not like that's the end of your day or it's not the last thing that you do. Um, you have to continue to take care of all of the other patients that need you as well. So, um, I think, just you know, knowing that you have some resources, we have, um, like counselors and therapists and things that employees can go see, especially after like traumatic events happen, or just from a day-to-day basis, that insurance will pay for so having those resources. Like Sam said, I think almost all hospitals, or most hospitals, have chaplains or some sort of like religion resource as well that are always in the hospital going to talk to them.

Speaker 3:

It's not something you can process yourself on your own so just you know, knowing what resources you have in order to you know process that, or talking with co-workers, I think sometimes helps to you know they sometimes have different perspectives that they can share, which might get you thinking a little bit differently about the situation and help you that way as well.

Speaker 1:

Yeah, yeah, and that's really good advice. Anything to add to that, sam? Anything you know that you try to do to keep yourself well in tough situations? Yeah, I would say pretty similar.

Speaker 2:

We did it in Iowa and I find most of the physicians and providers that I work with now we do this as well.

Speaker 2:

But if we have an unsuccessful code, we do take a moment of silence in the room, which I feel kind of is helpful from somebody who's been involved with that process standpoint, to just stand there and kind of accept the gravity of what has just happened Something else that I do every once in a while again, depending on how many people are in the room.

Speaker 2:

But I have helped the nurses kind of clean up the area, especially if family is going to be coming in to see them. So like getting a fresh feed on getting all of the garbage like you know, syringes and stuff off the bed, which for me kind of helps from like a closure standpoint, if that makes sense. Um, but really trying to just make sure that if we did bring family in to see them, that their family member doesn't look as unput together as they were during our resuscitation efforts. Um, I will also like depending on how bad it is or how kind of stressed I am for the day like I will like just get up and just take a walk from my desk and where I sit currently in the ER it's right by the ambulance bay, so like there we have a seating area outside.

Speaker 2:

Like I actually a lot of the ER nurses do this as well but like, frequently, just walk outside and sit on the curb for a few minutes just to might be the only difficult thing that they're going to have to deal with for the day, but unfortunately our job doesn't end with that acute event, so we have to kind of keep going. And again, it's unfortunate that we have to be so good at compartmentalizing, but a lot of the stuff has to get pushed to the side so that we can function. And I would say that I've kind of gotten in the last couple of years into there's a lot of really good books out there in terms of how does trauma affect you and your kind of psychosomatic connections and things like that, and I have kind of gotten into reading more of those just to have a better understanding of okay.

Speaker 2:

Why am I feeling this right now and where is that stemming from? And I will say a lot of my understanding of again, those non-verbal cues and noticing when learners are maybe not behaving normally comes from some of those books that I've read, because I recognize that in myself, as well as maybe inappropriate coping strategies to try to, like, ignore what's going on but again it's very hard to circle back and try to process some of the things that you see and feel in those situations.

Speaker 2:

And so, again, like ken said, um, we have the chaplain, there's therapy services, and also do I find that, oh, if you have good co-workers that you can go to and be like man, we have this patient. I kind of run down through it sometimes. Just verbalizing the situation and getting it out of your head is really helpful as well, especially you have somebody who has an understanding of that scenario or like what you did, so that they can really empathize with you and, you know, validate what you're feeling and have seen.

Speaker 2:

So I feel like sometimes, too, we don't want to go home and dump on our families, especially if they don't work in healthcare and, too, from a processing standpoint, if you feel like you're not being validated and from no fault of their own, but if they purely can't understand what you've dealt with in the day. Sometimes that's really hard. So I definitely rely on my coworkers and stuff to you know, if there was difficult situations to talk back with them on.

Speaker 1:

Right, help you process. Yeah Well, this has been, I know, really kind of a difficult thing to talk through, but really helpful, and I think you know we've been talking about a pretty extreme, you know trauma environment. But I think, kenzie, you've also added some good perspective on. You know how does some of this play out in other practice environments, and I think so much of it does. What would you both say is the one thing that any preceptor could start doing today that would help their learners navigate, you know, trauma in their current learning experience or in future experiences.

Speaker 2:

I would say I think I kind of have elucidated to it because I already try to do it or like be better at doing it. But if you have a type of event where you feel like wow, this probably could have been really heavy for my student, or you pick up on any of those non-verbal or even verbal cues that they express you like wow, that was a lot, really try to ask them like did you want to talk through something? Do you understand what happened right now, like do you want me to explain, like step by step, why we did x, did X, y, z or alternatives? Cause I feel like sometimes too, especially with students, when they haven't seen a lot of that and again the point that I made to Ken's, where I'm like we can't make this any worse Sometimes they get really caught up on should I have done something different? Is what we did wrong, and so I really try to like discuss it with them afterwards and have that debriefing, that dedicated debriefing moment, to just really see what did you learn from it, how are you feeling? And if they really need to be, you know, sent to an office to go work on a different project or even sent home for the day. I know we have to keep, you know, a certain number of like rotational hours and things like that for them, but I feel like at that certain point we really need to put the student, the learners kind of wellbeing and mental health above, like the hourly rotation needs, because at the end of the day, if they're really stressed out about something and they can't talk through it with you and you're still expecting them to sit there and perform like they were, they're not going to learn anything from you for the rest of that those days hours anyhow.

Speaker 2:

So I really think that the biggest, the biggest piece of advice I could give is really touch base with your learners frequently, either during whatever the acute event is, or if you notice them afterwards, like just really stop and have a moment with them to say how are you doing? Let me check in with you. What do you want to do for the rest of the day? Do you feel like you can perform or not? And then just be really kind of accepting from a precepting standpoint. If they're like man, I that was really a lot Like I I just don't know how to like do anything for the rest of the day. I think we just need to be more compassionate from the precepting standpoint and just say, okay, cool, we'll change. We'll change course. Go work on a topic discussion, go prepare your presentation, or, if you really have somebody that's struggling, like honestly, just go home. Go home, call your mom, we'll reassess tomorrow morning where you're at.

Speaker 1:

Yeah, yeah, yeah. I mean you know we've talked about compartmentalization and that has a place, but after the fact is, is not, you know, then it's. You have to be not, not be afraid to, to dig in and you know, talk through it. So, kinsey, anything from your perspective, you know, just based on your own experience, what's. You know, what's something that preceptors can and should start doing, you know, to help students navigate difficult situations making sure that they know they can talk about it, that they have resources that they can go to.

Speaker 3:

Also continuing, you know, like I said, the most helpful thing when I was in that situation was knowing that everything you're doing is really just there to be helpful to the patient. So continuing to remind them you know that what they're doing is helpful for that patient. And then I think the other thing I would add would be, like Sam had said, when she precepts, she gives her students or learners an option to go to the to. That situation, I think, is also really helpful. Just them, you know, knowing that if this isn't something that they want to do long term, it's not something that they necessarily need to expose themselves to, it is perfectly fine for them to say no, I don't think I can go into that situation. You know they have to take care of their mental health as well. So knowing that they have that choice, that choice isn't going to negatively impact them, I think, is another big thing.

Speaker 1:

Yeah, yeah, no, that makes sense. That makes sense. Well, thank you both. This was a really good conversation. I feel like my head's kind of swimming with with all of the takeaways, but I believe and hope that this will be helpful for all kinds of preceptors, you know, who have learners, who are navigating things for the first time, that you know may be at various levels of traumatic on the continuum. So, thank you both, I wish you both the best and I hope we can talk again soon.

Speaker 1:

I had so many takeaways from this conversation, but a few really stand out for me. First, recognize that all learners may not have chosen the rotation they are on and that we need to look for ways to tailor the experience to their career goals. For example, in the ER, you can focus on patients with chronic disease management issues versus acute trauma. For learners who are planning to enter ambulatory care or community practice, lay the groundwork before an anticipated traumatic situation. Think about and talk out loud what supplies might we need? What are the likely meds we will use? What is the learner's level of comfort? What role do they want to play? Transparency in all of these things seems to provide an opportunity to both assess how ready the learner is for the situation that is about to unfold, but also helps to start making the transition into patient care mode. Dr Katzman described this as beginning to compartmentalize. Stay flexible and read your learner both the spoken words and body language. Did their behavior change after the experience? In a concerning way? Sam described a student who started missing things when waking up patients after experiencing a traumatic situation. For example, students or newer residents may not be comfortable admitting that they're not ready for something for fear that the preceptor might think less of them, but if the learning plan for the day needs to change after a difficult situation, then make the change.

Speaker 1:

Next, compartmentalize in a healthy way. Focus on the patient during the experience, but be ready to debrief and process with your learner after that and take care of yourself as an individual After you've supported the learner. What do you need to do to keep yourself well and finally honor your patients and their families? Yes, you do need to get on with the workday, but it's also important to acknowledge the heaviness of what has occurred. Who will be affected and make space for those feelings.

Speaker 1:

If you'd like more education on this or related topics, check out the show notes for some. Links to the books that Dr Katzman mentioned have been helpful to her, and if you have resources that you have used, send me an email at kathy at ceimpactcom and I'll get them posted here for others. As always, be sure to check out the full library of Preceptor by Design courses available for Preceptors on the CE Impact website. As always, be sure to check out the full library of Preceptor by Design courses available for Preceptors on the CE Impact website, and be sure to ask your experiential program director or residency program director if you're a member, so that you can get access to all of it for free. Thanks again for listening and I'll see you again next time on Preceptive Practice.