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Emergency Medicine Rotation\\
Clinical Clerkship Clues: Emergency Medicine

Posted on November 21, 2007
Filed Under Medical (MD, DO), Medical Students

by Alison Hayward, MD
SDN Staff Writer

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.

bility 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!

6 Responses to “Clinical Clerkship Clues: Emergency Medicine”

1. Global One on November 22nd, 2007 10:40 am Interesting article, I have did a pediatric emergency room elective, and loved the pace of patients, i.e. seeing 15-20 patients on a shift, and the diagnostic algorithms that must be employed. Some ER doctors do seem a little rough around the edges, maybe this is the whole job vs. calling, I am still interested in all the details and workup of medicine patients, and mostly I’ve seen only 2-3 page medicine notes recently, even less for subpspecialties that we consult, in the past I’ve seen maybe 8 page notes at the longest, but the words “See previous note” help as I guess these days we just need to document what changes for the patient on the service. Anyway, my viewpoint it seemed that the pediatric ER attendings I worked with had a great job, not just in terms of lifestyle, but they get to see the patient first, initiate the workup, and talked to worried patients, but they all (maybe 4 out of 5) seemed to HATE their job and complained frequently . . . but at least they don’t have to deal with tracking down charts, nurses, patients, scheduling for procedures etc. . . an ED patient always gets first dibs for that x-ray or CT. Also, ED physicians seem less academic than other physicians, i.e. less likely to look up the latest article, even though they seem to have alot of time in between patients, . . . I loved heading into my peds ER shift each day, and got excellent evaluations, but the work seems isolating if all you see is the ER and don’t get the interaction with residents on rounds and going to grand rounds or really investigating your patient’s condition in depth.
2. Alison Hayward on November 23rd, 2007 10:13 am Hi G1, thanks for your comments!
I will be the first to agree with you that EM physicians face less frustration than other physicians and that the job is highly satisfying. However, it is a matter of the type of frustrations people don’t want to deal with, and for some people, not being able to work up the patient’s complaint in depth is more frustrating than having to worry about the kinds of things you have to deal with on the floors – though we DO still have to deal with tracking down nurses and charts (where was this magic land where you did not have to worry about that?)!
Anyway, I cannot speak for the doctors you work with, but I would say on the whole EM physicians love their jobs and are happier than other docs in the hospital. Those grousing folks you worked with sound like they had a bad attitude and should not be mistaken for being representative of the specialty. It sounds like this may have been a community ED? I can assure you that in EM we do look up current articles etc, though oftentimes we would be doing that at home rather than at work – the pediatric ED may give you time between patients for looking up questions, but in a busy adult ED that is definitely not the case.
In short, I think you need to do another rotation in the ED, definitely in an academic center, if you think you may be interested – so you can meet some EM physicians who enjoy their work and read on a variety of subjects. At my program we have teaching rounds every morning in the adult ED, as well as the standard 5 hours of lecture time per week (and monthly simulations in the sim lab) for furthering our knowledge base. We also take an EM test every month on subjects like trauma or toxicology or OB/GYN to review diagnosis and management. The attendings in our program are very sharp and in fact, one is on the staff of UpToDate (UpToDate and eMedicine both have many of EM physicians on staff!- did you know the founder/CEO of eMedicine is an EM physician?). So the degree of being academic really depends on the person and the place.
If you want to be able to see your patients day after day and to really investigate their conditions in depth, you should be going into internal medicine, not emergency medicine. If you like being able to have a lot of face time with patients all day at work and not needing to worry much about writing 2-8 page notes, consider EM! And if you really can’t decide, consider an EM/IM program – you can find such combined residencies on the SAEM website, and you can search this topic in the SDN forums for more information on whether it is for you.
3. Global One on November 23rd, 2007 11:05 am That is really interesting that there are some ERs that have teaching rounds, and I guess with computer technology it would be possible to watch EM lectures from a computer during downtime in the ED, which I agree doesn’t happen in the adult EDs I have seen during my time on medicine. Obviously there are some EDs that are a bit more academic than others. I would be interested to know your opinion of Family Medicine doctors who work partly in the ED and then the rest of the time on the floors, from what I hear this is becoming less and less of a possibility. I have used uptodate and more frequently emedicne. . . and personally I don’t find them to be the end all and be all of medical reference, i.e. there is alot they leave out and in the end if in medicine you have a difficult clincial decision with a patient I would use articles and textbooks to generate my own uptodate opinion (which often varies from the uptodate opinion), . . .so in the end I don’t think just using or primarily using uptodate will make someone knowledgeable, . . . this is probably just me as everyone seems to love these resources, but I guess it is a good starting point and perhaps somewhat helpful for ED physicians who have a more acute focus.
4. Alison Hayward on November 23rd, 2007 12:50 pm Hi G1:
No, in EM residency the residents generally get one morning off per week to attend lectures. No one has to watch them from afar – an attending/midlevels cover the department alone in the meantime.
My opinion of family medicine doctors who work in the ED – in rural areas, if there are no EM trained/boarded doctors available, that is the standard of care. However, family medicine and emergency medicine are very different fields, and so having all EDs staffed by board certified EPs would definitely be the ideal. Take a look at family medicine residency rotations vs. emergency medicine residency rotations and you will see what I mean. We do numerous months of critical care/ICU time to gain these skills. (though I have the highest respect for family physicians, my mom is one! I certainly know I couldn’t do her job as well as she can)
UpToDate and eMedicine are certainly not the end-all or the be-all, but I just cited them to point out that emergency physicians are heavily involved in a lot of the most common online medical references, which is what I thought you were referring to the doctors you worked with not using at work. You generally can’t go extensively researching in textbooks and performing literature searches while you’re on shift in the ED. Luckily we have plenty of time outside work to do that kind of thing.
5. Amy B on November 29th, 2007 5:54 am I enjoyed your article. I am going to be going into EM and am quite excited about that. Luckily my school (Virginia College of Osteopathic Medicine) has a mandatory EM rotation in our 3rd year. It was the catalyst that took my interest from internal Medicine to EM.
I just finished a EM 4th year elective in a rural but very busy ER. There were a number of Family med docs as well as EM trained. There was definitely a difference in EM verses FP. One example was a patient that had an anterior dislocated shoulder and the FP would not try to deal with it. He called in a surgeon. He was not comfortable in treating it because this patient had a shoulder joint replacement and it made the FP nervous. After hearing this patient crying for hours as he sat waiting for the surgeon, my attending, who is EM trained asked the FP if she could try and pop the shoulder back . The FP agree reluctently and thankfully she was able to pop in back. This is just one of many examples where the FPs were not able to do things that the EM docs were able to do at that location.
6. zac on July 28th, 2008 4:16 pm Hey Doc-
What an awesome article! I’m starting my EM rotation in 1 week and though I’ve enjoyed most of my other rotations, none of them have quite done it for me. You just described my personality to a T… Can’t wait to start my rotation! Just linked your article from my blog.




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