First Shifts: Intern Mini-Series Pt. 1 ၏ စာသားမှတ်တမ်းအပြည့်အစုံ

in as an intern because I had only done literally 8 weeks in the E. D. 2 clerkships. Right? But it was a gamble that I was willing to take because it was the only 1 that kept my attention and I enjoyed it it was very patient facing. And so with actually came across Ohio State University as I am part of, American Academy of Emergency Medicine and they actually do virtual emergency medicine residency fairs and the program director did a two minute presentation on Ohio State. I was like, wow, there's a lot of resources. There's everything you can get into every fellowship. I love to get into a lot of things So those resources are here. I said, that sounds like a great institution to develop my skills So very happy to be here coming from Chicago. It's only a drive away and I do that drive with my daughter multiple times in a semester. So that is how. I got here and I thought, you know, going through intern year again with only eight weeks of emergency medicine, the things that I wish I had known, right? I really hope that this podcast series helps our fellow interns and other interns that are starting EM and other residencies. So, with that, most of our discussion will be focused in terms of, rotations, a lot of our information most likely can be applied to other interns. We'll start with the 1st question, Nick, and it is. What was the transition from medical student? to resident physician like for you? Nick: Yeah. So, where I was in med school for my four year, I did not see a patient from early October until July 1st of intern year. I had a little bit of a sabbatical I had other endeavors I was doing like traveling and taking bird courses at my med school, my last rotation my away rotation where we had a real day where you worked as an intern. You were not with any residents. You were just with the med ed fellows and you did a full shift where you saw the patient wrote the note, did X, did Y, made all the calls, everything. I think I saw two people that day. I had no idea what I was doing, and was trying to figure everything out. I was like, wow, intern year is going to be a mountain. then we got to OSU in June. they did the best job they could getting us,ready for our orientation block. when that all started, we're kind of thrown in, but there's so much staffing and they overstaff us so. there's a lot of room to grow and a lot of room for learning, thankfully. I think I had been so nervous about my experience earlier that I was overcompensating for making sure I was on top of everything. Plus having the added resources of people there who want to help you and want you to succeed and tell you how to get things done really made things run well. so I think the transition right into intern year was not as bad, as I was expecting, or maybe I was just catastrophizing things a little bit in my brain, it wasn't easy, but it was very manageable. there's this misnomer in medicine that everything is, like drinking from a firehose. that's impossible. no one can physically do that. the way I was taught to look at it early in med school was like pancakes. You have 70 pancakes to eat in a week. Anybody can do that. do I want to do that? Probably not. but that is an attainable goal. drink from a fire hose is not attainable. You cannot do that no matter how hard you try unless your cheeks are made of steel. if you can tell yourself, Okay, I'm gonna eat ten pancakes a day, You can do that and get through 70 pancakes in a week. So I think that's what medicine is like instead of this hyperbole of drink from a fire hose. it's more manageable and just like starting M1 year. it's an uphill battle. You got to learn quick about how to get things done and how to be successful. But we all got to this stage. So I think, you know, everyone's ready for it. Edleda: I appreciate that. I didn't know you were such a comedian,I really appreciate it. Really? You Nick: didn't know that? Edleda: Maybe I did actually. I just forgot how comical you are. But, um, I will say my transition was actually quite rough. I think, um, realizing I was leaving my husband in Chicago and thinking, Oh, with my mother and my daughter, we'll be all right. then, you're an intern now and these are your hours and responsibilities and you also need to study. it's not that I didn't know those things. I think it was the weight of balancing or at least attempting to maneuver this new role. I'm no longer the med student my identification had been for years, right? There was always someone above you. And I think for me, as exciting as it was graduating, moving into that role of responsibility. To be honest, not knowing what EM fully looked like only with eight weeks it felt painful to show up because I was like, Oh my gosh, I'm actually still learning. What EM encompasses, you know, I don't have a two year, three year mentorship with an EM physician to know the land. And so for me, I think intern year was very much. This is EM. This is what we do. This is what you chose and let's move through it. So Transitioning the question, what were the best and what were the hardest parts of intern year Nick Nick: I think that, our residency and our faculty are very supportive and I never felt like I was being judged in a negative way for being a little bit like, I don't know what to do in the first few months of residency. we do a very good job at that. I also think that, I'm sure this is, universal around all programs, but all the faculty know that July, August, September, these are all interns who are just trying their best and don't always know what they're doing but are trying to put their best foot forward. This is not their first rodeo with all of this. the grace that was given was very nice. that was a very good part of it. I think that having a great class, that everybody, wanted to be at this program and was happy with being here and being together, made things really, good as well. I'm also thankful that I got pretty lucky and had a pretty

stable personal life outside of work. There were no major tragedies. no major hardships. so that is something that, you know, that can make the transition very rough. And I was fortunate to have a pretty steady year. and yeah, then I think having a good community and then just realizing that this is the time to learn and, you know, I only have three years and I don't want to waste a whole year of just trying to be nervous. About whatever's going on let's take advantage of the moment and let's learn a lot I think also, was very helpful in making it a successful year Some of the hardships I think it's just getting used to the increased physical and mental demands of residency As I had said previously, I didn't see a patient between October and July 1st. So my M4 year was pretty easy. I wasn't really trying too hard. And then you go from that to working, 60 hours a week automatically. I'm grateful to be in emergency medicine where that's pretty much our cap, compared to some other residency programs. That was just difficult having to switch to nights every two weeks. having to go through, long didactic sessions and then go to shift and then also feel like, I need to study some more. And then also the existential crisis of what am I doing? I'm trying my best, but my plans aren't always congruent with what the attending feels. I think that there's some isolationism that we get in emergency medicine in our intern year because we have so many off service rotations, which is pretty universal. we go to, our peds er, we go to the sicu, we go to EMS, we go to ortho. And we go to cardiology that's just you for a few months and it's like, wow, I am not seeing my friends. I am in this new city and I really don't know a lot of people. so I just feel like I'm kind of on my own. which is really hard for a lot of people. and also trying to feel like you fit in with the program itself. cause you know, for me, I was lucky that I had the first block of intern year in the emergency department, but for a lot of people, they didn't see the ER until January of intern year. Thank you. best parts of intern year for me, I think was when you're going to laugh. But when I was on vacation, take a break, um, and go back to Chicago or Nashville, also in our cardiology consults, it was a plan 9 to 5 or 8 to 5. Edleda: you could plan life a little bit more.where I could see my daughter more and interact more. With the outside world outside of changing shifts constantly, I think the stress of trying to learn the job and then you're rotating shifts, mentally and physically, I was always lagging behind trying to get those things in line. whenever there was a moment where I could Choose my schedule in a way. outside of work I realized I just needed that break during those times. there were rotations that I enjoyed and especially the one that you and I Nick were on the anesthesiology ultrasound. It was really great. just being collaborative and having fun while learning is best. And that's what we did. Um, hardest parts, like I said, was with rotations I'm having to explain to my daughter why today I'm at the hospital until this time and tomorrow you might not see me. I think that was actually really hard. cause again, that is new to our life. or it was, and now she's more used to it and more inclined to understand that you may not see me tonight, but I'll see you when you get off from the bus tomorrow. And I think I had to learn you know, give myself grace as a mother. and really as a wife, and also ask for that grace from others, Marker --- Edleda: so now we move into rotations. our goal with identifying these rotations is not only to identify Nick, but to tell people what you think main learning points or takeaways could be from the rotation that interns should look forward to, if they've not already, move through these rotations we'll start with, our emergency medicine blocks, which we have four of them at Ohio State with an additional month at Nationwide Children's Hospital And then our community site, our Ohio State University East Hospital. So Those Ian blocks consists of half of our year. they equal 6 months in total. Nick, what did you find to be good resources great apps to share with in turns or in force who will be matching next May as well as any resources you have. Nick: Let's see, for resources, I'll just go to my phone really quick, to, look at the apps that I have on my main screen. I have UpToDate, I have Medscape, a big drug app that, you can just plug in anything and be like, okay, this sounds like a reasonable dose when, you're like, I have. No idea what the dose of Aztreonam is, also calling your pharmacist is very important, and you should be doing that. But, you know, Medscape is, uh, is a good resource MDCalc has a lot of good, calculators and scales. However, you should make sure that they're properly vetted and been in the right clinical context as well, because they can be a little misleading sometimes and they don't know everything. Kim: and I think some of the good tools that are on there are like PERC, WELLS PE, WELLS DVT, and the HEART score are stuff that we use very frequently. Nick: but others like the Alvarado Appendicitis score might not be all telling. there's also this, differential app that I downloaded in my third year of med school. walking into intern year, just,being able to plug in hematuria and make sure I'm not forgetting a lot of stuff was really helpful. I haven't used it in a while, but it's a very helpful tool, especially if you have, a weird, Chief complaint or a weird symptom that you're like, I just need to get a better differential for and just make sure I'm not missing anything big in my head. That's a good one. having Haiku on your phone or whatever EMR app your hospital uses is really good because being able to take pictures of rashes and Not have to walk, what seems like a half mile back to your desk. If you're in a very large emergency department, it is nice on

the fly. I have, the WIC EM, which is not the best website, but if you just need a quick, you know, what's the main idea of our management here intern year that, uh, that would be really good. I have an NIH Stroke Scale, app, and I also have Full Code Pro, from, one of the cardiology, services that helps me run a code. It has a metronome on there, and keeps track of all the medications that have been given, I have the safe local app, which, uh, you can plug in height, weight, and what local anesthetic you want to use. And it tells you how much you can use. PETAstat is also a big one, for when, stuff hits the fan, when you're at Nationwide, and just having something kind of there will help you out a lot. then there's also two that I like a lot called suture and fractures. Uh, they're from the same company. for suture, it's just an app where you point to where on the body it is what its shape is and how deep it is. And it tells you what type of sutures to use. Fantastic. And then fractures is a, you point to the bone and where on the bone and what kind of fracture, and it tells you basic management that way you know,we need to call ortho right now, or this could be an outpatient clinic one. and then there's also the Emra app that has the antibiotics and a lot of other stuff on there. I have a couple of those books in my backpack, so I don't use the app, but the Emra antibiotic guide. is very helpful. It is mostly up to date. and can be a good refresher So. Those are the apps that I use mostly when I'm at work. some of the other things that I've used while on shift is corium. I believe it's from the makers of MA and it's like a quick, handy dandy, outline of basic management for most things that come into the er. they have a, Hey, someone is crashing in front of you. What should I do right now? tab at the top, which is really nice. when you just need a quick reference. they also have a deeper dive if you keep scrolling and. Here, you know, here are the labs. TTP, don't forget to get the LDH, or stuff like that, and the haptoglobin, And then it walks you through basic managementthose have been really helpful, and that's mostly what I've used, on shift. also, nursing staff, RT, pharmacy, social work, and everyone else at my disposal, being at a large academic center, we are very blessed to have a lot of very smart people who know what they're doing that are not doctors in the emergency department. asking a nurse hey, what am I looking at right now? They probably have an idea sincethey've been there for a lot of years. and they know how to help you out. Pharmacy as well. but of course, there's always caution that this could be a newer person And making sure that you always, fact check, you know, everything once you hear something. Edleda: I agree, I mean, you've given us a whole list of apps I don't have much to add. I try to minimize how many things I use because it overwhelms me to have so many, but I also have a stat. The suture, the fracture apps. I do use love their podcasting. Corp Indium. Also, of course, our textbooks are 10 to Rosen's. And so I think I like 10 to Nellie's. that's what I use. And here at OSU, and other academic institutions, you can access a lot of the resources online through the library system. You may not have to go out and purchase these books yourself, they are already purchased through the university system. And so I actually, checked out Tintin Alley's physical copy, from the library most people don't recognize that your university and academic institutions, may have Physical copies of these books. there's also Ross review and, OSU, has blessed us with purchasing that for us. there are other residencies that allow you to purchase these, Nick, you really exhausted the list. I'm sure there are a lot more. I also have, An app called Palm Em. it is not a bad idea to have an app that will, jog your memory of differentials and being very inclusive. there is nothing wrong with using what's been created to help you learn and really to help you not, have premature closure Nick: I believe that one of our attendings, Marcus Wooten is really good about pushing people on those differentials. Because he'll say, you'll say, oh, you know, XYZ, you know, walks like a dog, talks like a dog, is probably a dog. Oh, well, what else? What else? And he really pushes you to,make sure that you're thinking of a lot of other things. Edleda: I think 1 of our attending sector, Dan Martin, he's very big on making, us exercise this thought process of not closing. So, soon, like, he very much emphasizes that in didactics on multiple occasions. I actually really do appreciate that. He highlights that fact. we're going to move on to the next rotation, which is orthopedics we're able to do our orthopedics at either grant hospital, which is part of doctor's health and is a level one trauma center Here at OSU, ofthey have an orthopedic residency program as well. the intern class is divided and goes to either the two places. So we both were, at OSU. my question to you, Nick, is what. Were goals in terms of what you wanted to take away from that rotation. Nick: Yeah, so we have the ACGME goals of getting your 10 dislocation reductions. that's something we have to check off while we're on ortho. I just wanted to get comfortable with splinting. that is not something that I was taught in med school very well. and then, just more comfortable with doing my reductions and trying to figure out, what do the orthopedists want when they see this patient in clinic the next day? those were the main goals that I had, was just trying to get what are the pet peeves of orthopedics when they see something come in. either as a consultant or the outpatient provider, and then,what are best practices that we can do here, in the ER that really, make them Edleda: I agree. I also was focused on wanting to get the dexterity and, The feel behind reduction, as well as splinting. knowing what you need to bring into

the room to do these things and how they do it. I think any tapping of joints. So, seeing and doing a lot of those arthrosynthesis, I think that's really important for him, especially if we're practicing in the community, also, like you said, Nick, I always paid attention to what, or so wanted from the E. M. department when they were consulted. So, did you already get those inflammatory markers and the imaging? If you're, you know, suspecting, a septic jointit really helped me when I got back to the department. what resources, Nick, if any, outside of Ross review, you Did you use or? Nick: during that block, I read all of the tensionalis ortho chapters and the musculoskeletal chapters as well, just trying to, make sure that I was trying to take it all in, in my month on that rotation. And then when I had questions about something, I could just lean over to the resident and be like, Hey, I saw this. Edleda: Is this real? Is this not real? What are your thoughts about this? And then get like the insider scoop on whatever phrase that I read into now that I was a little confused by.I enjoyed, looking things up with radiopedia.I very much use Roche during that time, focusing on musculoskeletal ortho, and patients that we saw. Like you said, I would ask the resident. What do you guys do? What type of surgery is this and that's a little bit beyond but I do like knowing what's next it reminds me of how important our job is to be honest And then also I noticed that there are orthopedic case files some EM programs do. They have like blogs on it and what they saw, and what the final diagnosis was. while I was on that rotation, I was looking at blogs from Cook County I think that really helps put things together. I like, for those interns that do not know we have an orthopedic guidebook that's found on our phone list a link for the various fractures and how to handle the management to help us and help guide consulting orthopedics. All right, make you sick. You neck. What were you trying to get out of those rotations? Nick: so I did not have a required, I see you exposure, in my, in my med school nor did I seek it out my fourth year. So, uh, Walking into MICU around Labor Day was the first time I had any ICU exposure, ever. you know, it's a different beast, especially in the SICU here at OSU. You are systems based rounding versus problem based like on the floor, and you know, there was a lot of words that I hadn't really heard before, like vasopressin, and propofol, and presidex, and trying to figure out sedation, and this, that, and the third. there was a lot to learn, and a lot to digest all at one time. However, having a senior on with me who was very, happy to help guide what I thought was the right thing to do that day. And then also we had, some very nice fellows, and the attendings were also very helpful. And then the ATPs that were also on the service for MICU, were also a good resource, because this is what they do all day long. a resource I really leaned on was the nursing staff. the ICU nurses, are there for a reason and they're at an academic center in an ICU for a reason. they know what they're doing and they know the basic flow of how these things go. Uh, but I also think that believing in yourself and your instincts goes a long way in the ICU. a lot of interns know more than they realize. looking back I definitely knew more than I realized in the first semester. when I needed to talk to the fellow about a patient that was like, uh, kind of sick, kind of not sick,I felt like I was able to master that pretty well. when I had a question, like, can I figure that out? or do I really need to talk to the fellow about that or my senior? and so trying to figure things out yourself, but also having a low threshold to fact check yourself with someone above, I think is really important. Adlita, I don't believe you've done grant yet, but that's something else that in the SICU, overnight, it's just you and the attending is only a vocera call away, but you know, you're just trying to manage things, uh, by yourself. So getting that footing, and trying to practice that confidence in the SICU in your intern year, is really important. I had a very good time, learned a lot about myself, especially in the surgical ICU. you learn a lot. a lot of the ICUs, especially the surgical ICUs from what I've heard from different places across the country are, a little bit more letting you do what you think is best and you're probably not too far off. having that, level of autonomy really helped me, develop more professionally in our field of emergency medicine. I also think that getting to know my other residents in the SICU was very important. I'm still close with the two surgery residents I was with as well as the orthopedics resident and now when I see some of the faculty like Dr. Eiferman, in the ER, He knows me I'm probably going to tell him the right thing when like there's a trauma that came in and he was walking in like halfway through. and so having face to face time with those other residents, is very important. trying to be congenial with the nursing staff and learning from them. having friends in your back pocket when you need to consult someone is also very helpful. Edleda: I think those are great points. I definitely echo when you're on off service rotations. That is a time to build your network within the hospital among all staff and co residents it makes work. Less work and more like community, right? for those who love teamwork and need that to work such as myself. I look forward to having connections with people. Just like you said, you'll find those same trauma surgeons are downstairs in the trauma bay. So they recognize you, you recognize them as well as the surgical residents.I was looking forward to placing a lines placing CVC is just more of that hands on skill of just putting in lines. and I think some people as interns, that's the thought process. And it is true. It's not all you

do, but it is some of what you do. And I think I enjoyed that. you also learn about vent settings and you learn more of the critical care pathology, that is part of the goal, right? As you are taking care of critical care in the E. D. that will move up to the next step. The ICU and so I always try to connect back, what we see in the E. D. And where they move to if they get admitted and how they manage them? I think that's part of the learning as we become more of the physician that we want to be. were there any resources you use outside of the fellows and co residents, nurses, staff, Kim: one resource that a lot of people use is MCRIT. They have a lot of good, pages about different pathologies, vent settings, you name it, it's on there. That was a very good supplemental resource to try to see how I could apply that to, the patient care, the real world. Nick: and another big resource is yourself trying to see what am I seeing a lot of, what am I not seeing a lot of, and where can I learn from different patients in the unit? Because someone like me who has, I would say, subclinical ADHD, It's kind of hard to, stay, focused on rounds. That's why I'm doing emergency medicine. staying focused on rounds is not always the easiest thing for me. making sure that I'm trying to learn something from each patient every day. if there's just some pathology that you're curious about, when there's downtime talking to your fellow or your attendings and saying, Hey, I've wanted to learn more about this. I haven't seen a lot of this yet in my time here. what are your pearls, for taking care of this kind of patient when I see them in the ER? I think that goes a long way to ingratiating yourself, with your co workers, and then trying to get the most out of your rotation. a lot of people realize that we're only here for three years, but at the same time don't realize we're only here for three years. using resources while we can, I think is very important. Edleda: I definitely second that. you're very busy in the ICU just coming even in the second year out of CVICU. those respiratory therapists, those ECMO specialists were amazing and great teachers. even the pharmacists that rounded with us, and other teams, you know, if you're taking care of patients with bilateral pulmonary transplants, and you have the pulmonary transplant team or the transplant infectious disease team. These people are resources and gold mines to understanding the pathology and management of these patients. I thoroughly enjoy talking to the intensivists in the C. B. I. C. U. they are A textbook I think that's something as interns to not shy away from. we're going to move on to the next rotation toxicology. we spend 2 weeks with 1 week at the. Poison Center. and then another week where we go to Nationwide, as part of the toxicology consult team. So,were there any takeaways and any resources, if any, outside of Ross Review that you used? Nick: Yeah. first for resources, the book that they gave us,

was Gold Franks to use as a guide and that was very helpful, in just having that in our pocket, that way when we came across things we were able to look things up very quickly that was the main resource that I used. In Columbus, we have the Central Ohio Poison Center, which is kind of a rarity among cities to have. My med school was in Memphis and the only poison center in all of Tennessee is in Nashville. and so having them, in our backyard or literally 10 minute walk from my apartment, is a privilege , not a right that we are lucky to have here. and so, It's a good time to see how the toxicologists think and how the people answering the phone to the general public, who are nurses and pharmacists think about things and their algorithm for helping people when they call in from the general populace or when a terrified resident calls from the children's hospital, or the emergency department when someone is very ill with some type of poisoning. It's also cool that, two of my co residents want to go into toxicology, and that. I don't think really knew a lot about toxicology before they got here. actually found it very fascinating and became very appreciative of what toxicology is. I appreciate it speaking to health care workers when we would call in the check on patients, throughout Ohio, at the various hospitals, Edleda: So it wasn't just the E. D. It was once they were up in the I. C. U. you're checking on them daily to see how they are. at any point where I'm questioning things, that's a resource purposefully there for us to use. Marker --- Edleda: the next rotation was OBGYN. we spent two weeks there.everyone was at OSU. what did you take from or were you looking, to gain from that experience? Nick? Nick: so kind of like what I said with ortho, we have a requirement with OB 10 vaginal deliveries We see a lot of ortho come through, but labor and delivery is not something we see a lot of, in the emergency department. something that I found very helpful was to go over to the other two residents that were on consults, and say, Hey. Let me know if there's any consults that come in from the ER that, you think would be, appropriate for me to go help out with. Obviously, I'm not going to be doing consults for them, but being able to see how they think about things, the way they staff things. And when I call them about something, I want to know what happens on the back end and what their thought processes are. that was a very good experience as well. And I think another, pearl for, our interns depending on how OB rotations work at other programs is, trying to get in good with the midwives because, a lot of the times the residents are working with, more complex patients, that may have been seen in an MFM clinic. or that may be more high risk and have other things going on and they usually take the more low risk, more run of the mill, deliveries that come in. those are a little bit more simple. sometimes when I was in with the residents, things were a

little more complicated than I had expected or they were expecting. this patient had a history of complicated deliveries in the past. So it might not be the best one for someone who honestly really didn't know what they were doing for the first few deliveries. but being with the midwives, I got more deliveries that way and I got a lot more routine deliveries that way. What probably most of them are like in the real world. so that was a very good experience. And I think also just hearing all of the jargon that I had completely thought I had forgotten, after M3 year. Edleda: was also really good, just to know how my consultants speak. and so being able to use the word AROM in a sentence, I think, and a lot of other vocabulary has been very important and a very good learning point that I gained from that rotation. and then also how to talk to the nursing staff as well over there because we sit with the nursing staff, Yes, I think for that rotation I was really focused on dexterity. where are you placing your hand on this head? how are you helping this mom push? I was in there, counting with them, looking at the tracings. though we're not responsible for those tracings, can we talk about those early decels, getting in the mindset of what we typically don't do in terms of OB, I really appreciated getting hands in on everything. Like I want to know what our residents are looking at, what they're concerned about. They're running back to the room. very much for me, it was more about placement, and when things don't go right. So we did have a shoulder dystocia, like, what do you do? Right. also for interns, especially at OSU, feel free to talk with the OB attendings. They're very kind and approachable. and they don't mind going through, the cases, and I encourage the interns to do the same, um, Marker --- Edleda: in terms of cardiology. what we can say from cardiology in general, or at least I can speak on is, I really appreciated seeing many of the patients coming through the emergency department. and looking at the typical symptoms that they have and what we did to work them up and why we consulted cards. But more importantly, I love seeing on the cardiology side, the various, ways of working a patient up additionally. So are we doing a coronary CT versus, just getting the echo? Or do we need to take them back to the cath lab? so I appreciate what we do because we are very much. the patient facing, you know, I'm coming in with atypical symptoms of chest pain random right shoulder pain, you know, and you think it's random it's not the most random when you see from the other side, that, Hey, they needed, a cabbage your second year at OSU, if you do CVICU, then you're taking care of those, post cabbage patients, you're seeing From the E. D. Through. so I really appreciated that. I think, resources, there is definitely the E. C. G. Weekly. It's an annual paid subscription where, Dr. many people know for cardiology. He's an E. M. Physician, at University of Maryland. he actually has a. videos now to go through the EKGs with you. And it's a very nice resource to have as a resident, really trying to work on their EKG reading skills. Nick, did you have anything to add for cardiology? Kim: so things that I got from my cardiology rotation, was being able to pick my fellow's brain Nick: how things work once they get up to the cardiology service, what they're looking for in the emergency department versus what they're looking for, as a floor consult. I wanted to shout out, especially. walking through, uh, weird and pretty standard EKGs with my attending and my fellow. we would look at the telemetry boxes a lot, and then also looking at the patient's, EKG while in the department and on the floor. I also wanted to shout out one of our program directors, Jeremiah Emerson, who is a fantastic resource about EKGs. I did his two week elective where there was a book that I tried to read from cover to cover and also his super high yield, lectures anything about EKGs, this man knows. trying to learn from him all that I can in three years has been great. a few weeks ago when I was over at OSU East, we had a very unique EKG that was a surrogate for complete heart block. and it was nice to have that knowledge in the back of my head that how this person needs to be seen by EP kind of like right now. something that I might not have noticed, prior to intern year on my is elective second year.