Mount Sinai Hospital, New York
Trauma Unit, Cook County Hospital, Illinois
University of California San Diego (UCSD)

Mount Sinai School of Medicine has a very comprehensive elective programme. I went there and did my elective in Emergency Medicine. They placed me at Elmhurst City Hospital, which is in Queens. However, I lived in their student accommodation, which is near Mount Sinai Hospital. The apartment had 24-hour security with video cameras everywhere. It is expensive, but really posh.

Emergency Medicine was exciting. Initially I didn’t expect to be able to do much, being the USA with their obsession with litigation. However, I was in for a big surprise. I saw everything, from cardiac arrest, DKA, patients with AIDS, threatened abortions, ectopic pregnancies, etc. The patients were anything from the homeless, gangsters with gunshot wounds, prisoners in handcuffs, etc. IT was exciting!

I was responsible for the patient from the moment I picked up their notes and took their history. I had to decide if they needed an x-ray, what bloods to take, what fluids to give, and what medication they should be receiving, e.g. insulin etc. I then had to get the approval of the attending consultant, make sure the patient got all these things.

If it was a more complicated case, such as Gynaecology or Neurological care, then I had to call the relevant specialist for a consult. That was the most shocking part of the attachment - giving a concise, relevant history to a doctor over the phone to get their advice. If you are interested, they will let you do anything. I did LPs, intubation, CPR, I even nearly put in a CV line.

The people are nice; New York is very lively. I mostly went out with other elective students, the American students work too hard - on nearly every night. In short, this was the best experience of my life.

Nik Abdul Raschid, 1996

An addict of the worlds Best TV programme, ER, I wanted to base my elective in an ER in the USA. Cook County Hospital is a large, scruffy, 8-storey building, 3 miles west of the Sears Tower. In stark contrast to the lush private North Western, Rush and University of Illinois hospitals, Cook County is the government institution, obliged to provide medical care to those without health insurance. It is very basic. Each large ward has an armed policeman! The patient population is mainly poor; 85% black, 10% Hispanic; 10% of patients are estimated to be HIV positive.

The trauma team consists of emergency physicians and trauma surgeons; 7 consultants oversee the unit, while 14 residents on 1-2 month rotations do all the work. Residents do not get a single day off in their rotation, and are on call 1 in 3. In addition to the Trauma unit, a large Emergency Room (22 doctors per shift) deals with non-trauma medical emergencies. Gunshot wounds (5-10 per night) and stabbings top the bill, but this trauma centre also deals with victims of RTAs, falls, assaults, burns and other trauma. Adult and paediatric patients alike are resuscitated in the Trauma receiving room.

When on call (every 3rd or 4th night), students assess patients coming in, and are then expected to devise investigation and treatment plans, and ensure that these are performed. Protocols rule; the 20-page protocol guide was a big help, but perhaps fostered over-reliance on diagnostic investigations at the expense of clinical judgement. On admission, all conscious patients sign a form consenting to physical examination and treatment by all staff and students of Cook County Hospital. All patients assumed I was a doctor, and, refreshingly enough, I did not have to introduce myself as “Nick, the medical student” once.

Students learn procedures including 3 layer suturing, arterial and central venous cannulation, saphenous vein cutdowns, and diagnostic peritoneal lavage, and get to practice intubation and the CPR/ALS bit a few times. The residents show you once, and then you are on your own. IT is great experience, a true confidence builder, although hard work - don’t expect to sleep when on call.

Once admitted to either the 16-bed trauma ICU or one of the 3 wards, the patient is still the student's responsibility entirely. They must be seen before the 8am meeting every morning. Follow them, write up their notes, prescriptions, fluids, order further investigations, present them to the rest of the team on morning rounds, discharge them, see them in clinic. Patients may also require orthopaedic, neurosurgical and rehabilitation medicine consults arranging.

The 16-bed trauma ICU was where I learnt most - ventilators, Hickman lines, and Swan Ganz catheters are bread and butter here. This extensive role with continuous responsibility for patients was a big leap from my med school experience in Nottingham, and something I found humbling and very stressful. American students expect this responsibility - with their 4-year post-graduate course costing them $40,000 per year in tuition alone, they seem intently focused.

Nick Berry, 1997

Applying
A virtually impossible task. Apply 4-6 months in advance. Paperwork is a nightmare. It is a great advantage if you have access to a FAX (1 exchanged a total of 32 faxes before the final placement!). The major problem is obtaining a liability insurance. No UK company can help you with that (and of course our medical school will smile and send you away!). Only one US company can help you with your quest but be warned that the minimum insurance you will have to pay is for a year and the price is a hefty $400. So if you are looking for a cheap elective stay in Nottingham. Let me save you 15 pounds of calling and give you the contact’s fax number: 615-889-6569 (Att Less Sommars-Willis Corron Insurance).

Ms Barbara Swapp, (619-534 8556 FAX only) is the lady in charge of the UCSD student affairs (aka Judith Franklin). She is a wonderful lady and very helpful, but when it comes to documentation, she is very strict.

Necessary documentation: letter of recommendation from the dean (Faculty office), vaccinations (Cripps health centre get top marks for this), travel insurance (James Hampden 01530 416369 does a cheap annual insurance that is valid for travels up to 3 months duration) and a letter of recommendation by a consultant you have worked with. The latter is the key letter and I had mine returned several times as it was inadequate. This letter should state amongst other things how long you spent with this consultant, that your knowledge is above average, that you are competent in taking a history and presenting it to a senior and that your examination skills are very good and that you are able to come up with a reasonable diagnosis.. Also there should be a statement that your attire is proper when you are with patients and that you have a good rapport with patients as well as other medical professionals. If any of the above statements is missing.... Expect delays!

A list of clerkships on offer are available through Barbara Swapp once most of your documentation has been submitted. These clerkships last for 4 weeks and an administration fee of $250 per clerkship is due on the first day you attend.

VISA: UK nationals do not need a VISA (just ask for a letter from UCSD stating your status). Others need a BI/B2 VISA

Accommodation
Barbara Swapp will send you a list of people who will be willing to rent you a room for -$300 a month. Make sure that you are near the University or the hospital that you will be working. Unless your attachment is only based in either Thornton Hospital, or the VA (who are found on the UCSD campus) then expect another 30 minutes of travel to UCSD Medical Centre, Hilerest using the free Shuttle bus. Renting a car would also be a wise option (hence go to AA and get an international driver’s license). DO NOT USE PUBLIC TRANSPORT if you want to stay young. A trip that will take you 15-20 mins by car is likely to take 2.5 hours by bus!

The Elective
Although the clerkship description on paper sounds very well organised and busy, it is not always like that however it is not far from it either. You will need 1 week to get acquainted with US terminology/drugs during which you will feel like you have just started your junior medicine. It is very interesting to see the big difrerences an ocean can create. Do not expect to carry out an operation yourself, but you might be allowed to stitch somebody up if it’s your lucky day.

Summary
San Diego is great place, great weather, lots to see and you are almost guaranteed to have a good time. I think that this elective destination is worth every penny.

Marios Nicolaou