Clinical Clerkship Clues: Emergency Medicine

Are you suffering from roundsitis? Hypercaffeinemia? Overnight call adjustment disorder? Scutworkophobia? My friend, there is hope. I strongly advise you to look into the specialty of emergency medicine – in which the medicine you practice is practical, your time is spent saving lives rather than writing notes, and you miraculously find yourself at home at the end of every workday, wondering how you got to be so lucky.

In emergency medicine, as in all specialties, there are rough days and difficult patients, and you will still end up cursing our broken healthcare system as you struggle to get paid for what you do. However, EM is known for its humane work hours, diverse patient population, and efficiency.

As a medical student or even a resident, working in emergency medicine can be a breath of fresh air. To go from toiling through paperwork on the wards and spending more time with a patient’s lab values than with the patient, to seeing and treating patients one-on-one with an attending can be an exhilarating experience. Somehow, knowing you have tweaked a floor patient’s magnesium value just doesn’t have the same thrill as halting a seizure with Ativan, waking up an apneic patient with Narcan, or cardioverting a patient in atrial fibrillation. Even the little things in emergency medicine can be very satisfying: relieving pain and nausea, repairing lacerations, splinting fractures, and draining abscesses are all easy ways that you can instantly fix a patient’s problem. If you like procedures but fall asleep in the operating room, you really need to try emergency medicine.

Sadly, many medical schools do not allow students an opportunity to rotate in the emergency department until fourth year. This leaves a very short amount of time to pull together your residency application if you fall in love with it. If you suspect you would be happy in EM, you should definitely try shadowing an emergency physician for several days (or even better, nights) as a first or second year student.

Consider the following list which I have always found very helpful – credit goes to Desperado in the EM Forum here on SDN:

1. The Emergency Physician (EP) sees his profession as a job, not a calling. You will notice in your medical school class that there are those who live, eat, and sleep medicine. Those people typically do not go into EM. EPs typically have many outside interests, and are interested in a job that allows them to pursue those interests as well as medicine.
2. EPs love working up undifferentiated complaints. They got upset in their third year medicine rotations when they were told to go down to the ED and work up the guy with the COPD exacerbation. They wondered, “If I already know he has a COPD exacerbation, what’s left to work up?”
3. EPs think a doctor-patient relationship is what you have when someone gives you a chart with a patient’s name on it, not what happens after following someone’s hypertension for 10 years.
4. EPs like to do procedures. They think sticking people with needles is fun.
5. EPs aren’t afraid to make a decision on limited information.
6. EPs like to work as a team. They know what their nurses do outside of the hospital, and nurses call them by their first names.
7. EPs like to multi-task. EPs prefer to work while they’re at work.
8. EPs prefer a specialty of breadth to a specialty of depth. They enjoy learning practical information, and using common sense.
9. EPs enjoy being able to take care of people from all walks of life, rich, poor, old, young, smart, stupid, etc., without having to worry about whether they can pay you.
10. EPs typically enjoy a large percentage of their medical school rotations. They often think psychiatry is interesting, just not necessarily something they’d like to do all day. They enjoyed surgery, they enjoyed ICU, they may even have liked OB/GYN. They usually liked internal medicine, but detested rounding for hours and writing 10-page-long notes.

How to Succeed on Your EM Rotation

So you’ve decided to go into EM, and you want to ace your rotation. As on any rotation, the biggest keys to success are being enthusiastic and hard-working. Importantly, though, there will also be a few other personality traits that your residents and attendings will be looking for.

You should develop the ability to get a brief H&P that still includes all the pertinent details. Aim for your H&Ps to take about 10 minutes if possible. Remember, this means you need to work on skills like re-directing patients during interviews. You can still start with an open-ended question, but after that try to focus in and get the positives and negatives that will help narrow your differential, and focus on your CODIERS questions (Course, Onset, Duration, Intensity, Exacerbation/Remission, associated Symptoms). One of the hardest things to remember as a medical student is that you are there to identify potential urgent/emergent causes of pathology. This means that you will have to set aside items that are non-emergent for the discharge instructions to be worked up as outpatients.

As a follow-up to getting a brief H&P, you must be able to present the patient in a concise manner. Try to take a few moments to organize your thoughts before launching into your presentation. Lead with a statement including age, gender, and chief complaint, potentially adding any significant medical history. For example “35-year-old woman presenting with leg pain” is not the same as “35-year-old woman with past medical history of tobacco abuse and Factor 5 Leiden deficiency presenting with leg pain”. A good opening statement should ideally put a differential into the listener’s head. After presenting CODIERS, pertinent positives and negatives from the review of systems, and past medical history, go to physical exam and only mention pertinent findings. Leading with vital signs is a good idea (i.e. “afebrile, tachycardic in the 110s”) then hit the high points. Always include cardiac and lung exams (i.e. “lungs were clear, heart exam normal, no murmurs”) and then try to stick to anything unusual or relevant to the chief complaint.

Have a differential and plan. It doesn’t have to be extensive. Have at least 3 differential items, and definitely include the most dangerous possibility as well as the most common. For example: chest pain – acute coronary syndrome and reflux (aortic dissection would be another good one to add). Don’t forget, the patient does not have to fit the diagnosis perfectly, the important part is that you are actively considering the possible diagnoses. Don’t overthink things. For the plan you can always order the cheap, easy tests. Think of orders in common sets like “CBC, Chem 7, EKG, chest X-ray, cardiac enzymes” or “CBC, Chem 7, KUB, U/A, pregnancy test, LFTs”.

Come early, stay late, and give good sign out. Don’t leave without ensuring that your patients are being followed up on.

Be courageous, but not foolhardy, about volunteering for procedures. If you’ve never seen a procedure, ask if you can see one first. If you’ve seen it, ask that someone to walk you through it. When you feel comfortable with trying it on your own, be aggressive about asking for the opportunity to do it. Try to get experience with lumbar punctures, suturing, A-lines, paracentesis, and splinting, and observing procedural sedations, dislocation reductions, and central lines. Do as many ultrasounds as you possibly can. If you have a good attending or resident, try to attempt a central line or intubation. Always ask if you can attempt the procedure – the worst that can happen is that they say no, and at least you will appear eager to learn.
Don’t overextend yourself. No one should expect you to do the work of a resident. Just take two patients, or maximally three patients, and try to do your best job on them.

Best Books for Your EM Rotation

It is hard to recommend books, because different personalities may mesh better with different types of books. Here are the things I recommend to any intern or medical student in the emergency department:

• A general reference for your pocket: my suggestion is either the “Tarascon Emergency Medicine Handbook” or the “Pocket Medicine: Emergency Medicine” book (the little black book). Another one I like is “Emergency Medicine Pearls.” As a medical student having a book like the Pocket Medicine book or the EMRA pocket book will be key to acing your rotation, because you can look up the patient’s chief complaint and have a plan for tests and treatments when you present to the attending – crucial!
• A general drug reference: you have to prescribe and think about many different medications in EM. I recommend having ePocrates on your Palm or carrying Tarascon Pharmacopoeia if you don’t have a Palm. You don’t have time to use the computer.
• A specific antibiotic reference: I think the Sanford Guide is equivalent to hieroglyphics. If you really like ID, carry Sanford, otherwise, download the JHU Antibiotic program free for your Palm or carry the EMRA Antibiotic Guide, which is more like “Antibiotics for Dummies.”
• The ACLS algorithm cards — because you never know. Don’t enter the ED without them.
• The EM Rules Palm program — another excellent free download. Be able to run many important EM algorithms “in your head”! The creator is right here on SDN.

You do not need to buy an EM textbook for your rotation, it is too much information, and when you are a resident, your program will usually give you its preferred text.

If you have further questions about your rotation in EM, the SAEM website is a wonderful resource.

Also, the SDN Emergency Medicine Forum is full of fabulous residents and a number of attendings who are happy to answer questions – as long as they haven’t been asked a million times before. Visiting the EM forum requires strict forum etiquette, so search your query first, and read the FAQ, or you may find your question buried in a sea of witty retorts and Chuck Norris jokes!