Chances are that if you are reading this blog post you already have an interest in emergency medicine. In fact, you’ve probably spent countless hours learning about the field, perhaps by reading articles on this very blog. My hope is that this post will give you some tips and tricks to help you survive and thrive during those all-important core and elective emergency medicine clerkship rotations.
On the off chance you’re thinking of specialising in another field, this article will hopefully pump you up and give you useful advice to help you stay afloat. The emergency department set-up will inevitably vary among health centers, hospitals and curriculums, but there is some consistent information that should be applicable regardless of location.
ED Team Dynamic
Are you ready for fun, variety in cases, and a high-paced environment? In most emerg rotations, you are given a lot of autonomy in completing your history and physical and developing an initial plan of action (to be reviewed with your staff), making for a lot of learning and independent research.
In the emergency department, you generally work closely with an attending, but it is extremely important to maintain good communication with the nurses and other staff in your area. I cannot stress enough how much these people can really help facilitate your experience.
You should be functioning fairly efficiently by the end of the rotation, but your primary goal is to learn, not to see as many patients as possible. There may also be a resident working under the same staff. You will discuss patients directly with the staff and follow up on patient issues on your own. This is a good experience as you are directly interacting with the staff, and managing your own patients, unlike on wards where often decisions are made about your patients for you. This also means that you must be able to present your cases efficiently and in an organized and concise manner as you will be presenting to the staff. There is an excellent article that is located below in the resources section that will give you tips on how to do this well.
The staff will have his or her own cases and will be extremely busy so it is important that you know your case, be concise, and have a preliminary plan. Staff may want you to write orders before you review with them, but this is very much site- and staff-dependent, so ask your staff at the beginning of the shift.
Your Task and Roles
When you are oriented at the start of your rotation, you should learn about the specific expectations for the site you are assigned to. Each physician you work with will likely have his or her own preferences for how you organize your time. Arriving a little early for each shift will give you a chance to introduce yourself and set objectives This is a great time to think back to the feedback you got on previous shifts and let your attending know up front what you need to work on. Also, find out if they have a special niche interest within EM; if you are working with someone who also works for poison control, for example, this may be a good opportunity to review some toxicology with an expert.
At the beginning of each shift, the previous team will (sometimes) give report on all the patients to the incoming team. This usually happens in the night-to-morning change over, and often occurs attending-to-attending. As a student, you should listen attentively and take notes. Usually you will be seeing new patients for the majority of your shift, but you also may be asked to reassess patients who have already been seen or you may hear of an interesting physical finding, EKG, or x-ray that would be worth checking out. This process differs a bit at sites where there is overlap amongst physicians or where residents or students start shifts at different times than do attendings, but it can still be helpful to keep an ear open when you hear staff handing over to one another. Signover is also a great opportunity to learn how to safely and efficiently hand over the care of your patients.. Even if your attendings prefer to give the signover themselves, you can still pay attention to how they do it and ask questions..
Seeing new patients:
There are almost always new patients to be seen. That is the fun of the ED. Most ED charts consist of a triage form, vitals, and a progress note section for you to write your notes (some or all elements of the chart may be electronic, depending on the centre). Communicate with the attending as to how they want you to take cases. Some attendings will want to select appropriate med student cases, and some will let you choose your own or they may expect you to see the patients in the order that they arrive (adjusted for their acuity level at triage). If you have a certain interest you can let them know and try to take cases that will give you more exposure that area. It is essential to make a list of your patients and what tests and consults you are waiting for so you can remember to check them as you go. You will continue to follow up on patients’ tests, consults and imaging throughout your shift to determine the appropriate course for the patient, and you will perform and write re-assessments on these patients. This list is also handy for keeping track of key learning points from each case, and for writing down questions you want to ask the staff later or look up on your own later.
Initial Patient Assessment:
The best part of ED is you often get first crack at fresh cases. The ED has a rapid pace, but make sure you take your time and get an excellent past medical history and history of the presenting illness, as initial investigations and other services will rely heavily on this information. Keep your history specific to the chief complaint, and be as concise as possible. Ruling out life-threatening causes of illness is a priority. If someone comes in with chest pain, ask questions to rule out a MI and look at their EKG and troponin before you start asking detailed questions about pain or infections. A useful trick is to read the triage sheet before seeing the patient and take a moment to list the most important diagnoses to consider in a patient with this chief complaint. Then, use this list to direct your history and physical.
No need to regurgitate everything from your initial assessment, just the key points such as chief complaint, then comment on what has been done so far (such as bloodwork and imaging that has now come back), how the patient is doing (including your reassessment exam) and whether things are worsening or improving, and what the impression and plan are now (including what is still waiting to be done). Remember to re-evaluate sick patients often, and always leave a written record of your re-checks (including the date and time). Think about this as ’rounding’ on your patients again like you would on a second day of stay if they were an in patient – drop a quick SOAP note! (NB: SOAP = Subjective, Objective, Assessment, Plan.)
Emerg will often have to consult other medical specialties. This is done differently at different sites; some use a telephone system or physical pagers, while others use computer software. Develop a friendly rapport with your consultants and learn how to give a strong and relevant oral history for maximum effectiveness. Stay tuned for a piece on how to improve your consultations in the next few weeks!
Learning in the ED:
The ED is a great place for learning. You see patients of all ages with a variety of presentations. Patients usually arrive without a diagnosis, so you will benefit from the challenge of unravelling an undifferentiated chief complaint. You will have plenty of opportunity to do procedures, including bedside ultrasounds. On the other hand, there are plenty of obstacles to teaching in the ED. The most important is lack of time. Another is the lack of continuity between teacher and learner, since you may work with a different attending each shift. Self-direction is key to making the most of your experience. Help the attending use their small amount of teaching time with you as efficiently as possible by openly revealing the aspect of the case that you found the most challenging or confusing. This means you need to make a habit of honestly reflecting on your performance after each shift (or even each case!) Often you will identify gaps in your knowledge or technical skills that can easily be remediated with a short teaching session or self-study. Remember that the key learning point for some cases may not be within the realm of “medical expert” – often the pearl that you will take away from the case lies in another CanMEDS role (communicator, collaborator, advocate, manager, scholar, or professional). Usually it is the case that left you feeling frustrated or uneasy from which you can learn the most. Reenacting those moments in your mind or dissecting them with your attending or a colleague can help you manage a similar problem better next time.
What to read before you start…
How to present:
The 3-Minute Emergency Medicine Medical Student Presentation: A Variation on a Theme. Davenport, Honingman and Druk. 2008.
The outstanding medical student in EM: http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2001.tb02123.x/epdf
This is a free PDF from U of T which covers topics you should be familiar with before starting your rotation such as Chest Pain, Dyspnea, Syncope and Altered Mental Status.
The ABCs of Emergency Medicine. Divisions of Emergency Medicine, 12th edition, University of Toronto.
Other online resources include BoringEM, Life in the Fastlane and the New England Journal of Medicine has a series of short videos about procedures commonly done in the ED.
Find a resource to review EKG reading (such as Dubin) as this will come up a lot.
Key Tips for this Rotation:
1) Always reflect on your performance: after each shift, try to identify what went well and what you could have done better Ask for feedback andwhen you identify weaknesses, ask for specific advice on how to improve.
2) Always check a patient’s vitals and eyeball a patient before reading through their chart; patients can be much sicker than their chart describes, vitals can be very telling, and patients can deteriorate quickly. Pay attention to the triage time – if you are seeing the patient hours later, the vitals may need to be repeated.
3) If you are worried about a patient, go get your staff ASAP! Never be afraid to ask for help.
4) Try to get experience dealing with as many different types of cases possible; even though there may be things you don’t like dealing with or that are not as interesting, this is your time to develop an approach to all sorts of different cases and broad experiences will make you a more competent doctor.
5) If there is something you are particularly interested in (such as trauma), let your staff know because often they will then involve you in those cases
6) Be punctual. Pay attention to the clock as the shift nears its end, so you can be sure to have reassessed your patients to be ready to give a complete report at signover. Don’t leave until you have completed all your documentation, especially reassessment notes.
7) Have a positive attitude and be enthusiastic. If you strive to be helpful and friendly, you will be well-liked and given many opportunities for extra teaching and learning.
Reviewing with the Staff | Dr. Christine Meyers
Dr. Meyers is a Faculty Lecturer at McGill University Health Centre.
The emergency department offers a unique learning experience that all medical students can benefit from, regardless of which specialty they hope to match into. For most students, it is the first time they encounter totally undifferentiated cases of all stages of acuity, with no way of predicting what they will be called upon to do next. Within the few hours of each shift, you will have the privilege of getting to make a tangible difference in the lives of several people, whether through simple reassurance, advice for healthier living, or a quick decision to secure an airway. Whether you are trying to get in to an EM program or simply want to get the most out of your rotation, the key is to reflect upon these moments and actively seek to learn something new from every case. Don’t stop asking questions, and accept the fact that the answers are probably going to keep evolving.
This piece has been edited by Drs. T. Chan & S. Luckett-Gatopoulos.