Push Th(d)ose Vasopressors

Push Th(d)ose Vasopressors

Background

Since Scott Weingart first advocated for using push-dose pressors in the Emergency Department (ED) over a decade ago(1), push-dose vasopressors, also known as bolus-dose vasopressors have seemingly found their way into many EDs. However, recent studies have sought to ask more questions regarding its use and safety in the Emergency Department.

Vasopressors such as epinephrine and norepinephrine are commonly used for regulating and maintaining adequate blood pressure or mean arterial pressure (MAP). While these are usually administered as a continuous infusion via central access, administering them as a small bolus through peripheral access came to be known as push-dose vasopressor in practice.

Traditionally, this small bolus strategy was used in the operating room (OR) by anesthetists to treat transient hypotension due to sedating agents or spinal anesthesia. Multiple studies have supported the safety and efficacy of push-dose vasopressors in this clinical setting/patient population (2).

Swensen, et al. (3) studied the safety of bolus-dose phenylephrine for hypotension in the Emergency Department, however, data on the efficacy and safety of push-dose pressors remains sparse in ED and in-patient settings. Studies published in the past few years have questioned the lack of evidence regarding the safety and efficacy of push-dose pressor use in ED settings and highlighted some negative consequences of its use (4). To understand the concerns, it’s important we first understand the vasopressors, indications for use, and preparation in the ED.

Push-dose pressors in the Emergency Department

The two common vasopressors used as push-dose pressors in the Emergency Department are Epinephrine and Phenylephrine. Patients needing emergency airway, traumatic brain injury, and post-cardiac arrest with the return of spontaneous circulation may all experience hypotension which could lead to adverse outcomes. Push-does pressors have been proposed as a temporary measure to limit the hypotension while a vasopressor infusion/definitive treatment is being set up (5).

phenilephrine vs epinephrine
push dose epinephrine
push dose phenilephrine

Clinical settings in the ED where the use of push-dose pressor is proposed:

  1. Airway management: Hypotension prior, during, and post-intubation could be treated with bolus-dose vasopressors. Panchal et al. (6) did a retrospective chart review of intubated hypotensive patients in which phenylephrine was used. Bolus-dose phenylephrine demonstrated an increase in systolic blood pressure and the authors recommended further studies to understand the best use of phenylephrine for post-intubation hypotension.
  2. Return of spontaneous circulation (ROSC): In patients with ROSC, bolus-dose pressors may aid in the maintenance of end-organ perfusion, which is often impaired after ROSC (7).
  3. Traumatic brain injury: By rapidly increasing mean arterial pressure and thus cerebral perfusion pressure, bolus-dose vasopressors may help to prevent secondary brain injury.

What are the concerns regarding the use of push-dose pressors in the ED?

Acquisto and Bodkin (8) cited a few dosing errors while using push-dose pressors and highlighted that emergency physicians are less familiar with the practice of medication preparation/manipulation and hence dosing errors are expected, inadvertently causing patients more harm than benefit. They also emphasized on the lack of evidence in the literature regarding the efficacy and safety of push-dose pressors in a stressful environment like the ED.

Rotando and Picard et al. (9) in their prospective observational study of 146 patients receiving push-dose pressors in the ICU had thirteen (11.2%) patients have a dose-related medication error and seventeen (11.6%) adverse events. They concluded while push-dose pressors where efficacious, they were associated with adverse drug events and medication errors.

Cole et al (10). performed a retrospective analysis of 249 patients receiving push-dose pressors and found a higher incidence of adverse hemodynamic effects (39%) and human errors (19%). They emphasized the need for further studies to question whether push-dose pressors improve outcomes, and if so, how to safely implement them in practice.

Another concern raised is whether physicians may bypass standard resuscitation practices of fluid boluses in favor of using push-dose pressors. Schwartz et al. (11) found that only 34% of patients received an appropriate fluid challenge before using push-dose pressors in a retrospective chart review of 73 patients receiving push-dose pressors for acute hypotension in the ED. Furthermore, it appeared that patients who did not receive an appropriate fluid bolus needed more doses of bolus-dose pressors followed by the need for continuous vasopressor infusion within 30 minutes of bolus-dose pressor use.

Emergency physicians work in stressful environments which raises concerns on the ability of the physician to perform accurate dose calculations under duress (4). The prepared syringe also contains multiple individual doses, and using more concentrated solutions potentially increases the risk of overdose and extravasation injury (12).

Conclusion

While the practice of using push-dose pressors has found its way into the Emergency Department, it is crucial to acknowledge that evidence regarding its safety and benefits is limited. However, rather than disregarding the practice, high-quality research should be encouraged, which could potentially be practice-changing. Holden et al. (12) offer a framework of operational and safety considerations for the use of push-dose pressors in the ED and is a must-read for all using push-dose pressors in their current practice.

References

  1. Scott Weingart. EMCrit Podcast 6 – Push-Dose Pressors. EMCrit Blog. Published on July 10, 2009. Accessed on September 25th 2020. Available at [https://emcrit.org/emcrit/bolus-dose-pressors/ ].
  2. Lee A, Ngan Kee WD, Gin T. A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery. Anesth Analg. 2002 Apr;94(4):920-6, table of contents. doi: 10.1097/00000539-200204000-00028. PMID: 11916798.
  3. Swenson K, Rankin S, Daconti L, Villarreal T, Langsjoen J, Braude D. Safety of bolus-dose phenylephrine for hypotensive emergency department patients. Am J Emerg Med. 2018 Oct;36(10):1802-1806. doi: 10.1016/j.ajem.2018.01.095. Epub 2018 Feb 19. PMID: 29472039.
  4. Cole JB. Bolus-Dose Vasopressors in the Emergency Department: First, Do No Harm; Second, More Evidence Is Needed. Ann Emerg Med. 2018 Jan;71(1):93-95. doi: 10.1016/j.annemergmed.2017.05.039. Epub 2017 Jul 26. PMID: 28754354.
  5. Weingart S. Push-dose pressors for immediate blood pressure control. Clin Exp Emerg Med. 2015;2(2):131-132. Published 2015 Jun 30. doi:10.15441/ceem.15.010
  6. Panchal AR, Satyanarayan A, Bahadir JD, Hays D, Mosier J. Efficacy of Bolus-dose Phenylephrine for Peri-intubation Hypotension. J Emerg Med. 2015 Oct;49(4):488-94. doi: 10.1016/j.jemermed.2015.04.033. Epub 2015 Jun 20. PMID: 26104846.
  7. Gottlieb M. Bolus dose of epinephrine for refractory post-arrest hypotension. CJEM. 2018 Oct;20(S2):S9-S13. doi: 10.1017/cem.2016.409. Epub 2017 Jan 10. PMID: 28069098.
  8. Acquisto NM, Bodkin RP, Johnstone C. Medication errors with push dose pressors in the emergency department and intensive care units. Am J Emerg Med. 2017 Dec;35(12):1964-1965. doi: 10.1016/j.ajem.2017.06.013. Epub 2017 Jun 7. PMID: 28625533.
  9. Rotando A, Picard L, Delibert S, Chase K, Jones CMC, Acquisto NM. Push dose pressors: Experience in critically ill patients outside of the operating room. Am J Emerg Med. 2019 Mar;37(3):494-498. doi: 10.1016/j.ajem.2018.12.001. Epub 2018 Dec 3. PMID: 30553634.
  10. Cole JB, Knack SK, Karl ER, Horton GB, Satpathy R, Driver BE. Human Errors and Adverse Hemodynamic Events Related to “Push Dose Pressors” in the Emergency Department. J Med Toxicol. 2019 Oct;15(4):276-286. doi: 10.1007/s13181-019-00716-z. Epub 2019 Jul 3. PMID: 31270748; PMCID: PMC6825064.
  11. Schwartz MB, Ferreira JA, Aaronson PM. The impact of push-dose phenylephrine use on subsequent preload expansion in the ED setting. Am J Emerg Med. 2016 Dec;34(12):2419-2422. doi: 10.1016/j.ajem.2016.09.041. Epub 2016 Sep 22. PMID: 27720568.
  12. Holden D, Ramich J, Timm E, Pauze D, Lesar T. Safety Considerations and Guideline-Based Safe Use Recommendations for “Bolus-Dose” Vasopressors in the Emergency Department. Ann Emerg Med. 2018 Jan;71(1):83-92. doi: 10.1016/j.annemergmed.2017.04.021. PMID: 28601272.
Cite this article as: Neha Hudlikar, UAE, "Push Th(d)ose Vasopressors," in International Emergency Medicine Education Project, November 11, 2020, https://iem-student.org/2020/11/11/push-thdose-vasopressors/, date accessed: October 18, 2021

More Posts From Dr. Hudlikar

Unmasking communication during COVID-19

Unmasking communication during COVID-19

As face masks become ubiquitous in our health-care practice due to the COVID-19 pandemic, communication between the patient and health-care provider has become harder than ever before. The challenges posed by COVID-19 have highlighted various areas of deficiencies in the health care industry as well as heightened anxiety among health-care providers as well as patients. Communication with patients has become particularly challenging and ever so more important than before.

Imagine the plight of a patient struggling to breathe, being greeted by someone in full PPE, struggling to understand your muffled speech through the mask amidst the background noise of oxygen hissing through a breathing mask. Earlier, your smile would have worked to ease some of the anxiety by coming across as approachable and friendly; however, your face mask has cost you a brave soldier in your battle of gaining trust. The situation is worse in the elderly, frail, and cognitively impaired patients who may rely on lip-reading and facial expressions to communicate.

Health care workers are forced to have difficult conversations of do-not-resuscitate orders, advance care planning, and break bad news while wearing a face mask and PPE, creating a barrier for effective communication with patients and their family members.

If you have previously relied on a firm handshake and a smile to lessen the anxiety of patients but are now finding it challenging to have clear communication, here are few ways to improve communication with patients.

Unmasking communication during COVID-19
Cite this article as: Neha Hudlikar, UAE, "Unmasking communication during COVID-19," in International Emergency Medicine Education Project, August 10, 2020, https://iem-student.org/2020/08/10/unmasking-communication-during-covid-19/, date accessed: October 18, 2021

Management of Status Epilepticus in ER

References and Further Reading

  1. Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48–61. doi:10.5698/1535-7597-16.1.48
  2. Joshua G. Kornegay.  Chapter 171. Seizures. In: Tintinalli JE, ed. Tintinalli’s Emergency Medicine A Comprehensive Study Guide. 8th Edition. McGraw-Hill Education; 2016: 1176-1178
  3. Rabin E, Jagoda AS. Chapter 92. Seizures. In: Walls RM, Hockberger RS, Gausche-Hill  M, eds. Rosen’s Emergency Medicine Concepts and Clinical Practice. 9th Edition. Philadelphia: Elsevier Saunders; 2018: 1256-1264
  4. Sharma AN, Hoffman RJ. Toxin-related seizures. Emerg Med Clin North Am. 2011;29(1):125–139. doi:10.1016/j.emc.2010.08.011

 

Cite this article as: Neha Hudlikar, UAE, "Management of Status Epilepticus in ER," in International Emergency Medicine Education Project, June 1, 2020, https://iem-student.org/2020/06/01/management-of-status-epilepticus-in-er/, date accessed: October 18, 2021

Anaphylaxis in a Nutshell

anaphylaxis in a nutshell

Anaphylaxis can be broadly defined as a severe, life-threatening, generalized or systemic hypersensitivity reaction. Literature suggests that anaphylaxis is not always easily recognized in the Emergency Department (ED). One study indicates around 50% of cases being misdiagnosed and up to 80% do not receive appropriate first-line treatment.

Triggers

The most commonly identified triggers of anaphylaxis include food, drugs and venom, but it is important to note that 30% of the cases can be idiopathic. Among drugs, muscle relaxants, antibiotics, NSAIDs and aspirin are the most commonly implicated.

Which patients are at an increased risk of anaphylaxis severity and mortality?

Extremes of age

Co-morbid conditions (asthma, COPD, cardiovascular disease)

Concurrent use of beta-blockers and ACE inhibitors

While the overall prognosis of anaphylaxis is good, the key to avoiding adverse outcomes is by prompt recognition and initiation of appropriate interventions. Below are key points to guide your management of anaphylaxis in the ED.

Recognizing Anaphylaxis in the ED

Anaphylaxis reactions vary significantly in duration and severity and a single set of criteria will not identify all anaphylactic reactions. The World Allergy Organization (WAO) has suggested the following criteria to help ED physicians be more consistent in their recognition of anaphylaxis.

Anaphylaxis is highly likely when any one of the following three criteria is fulfilled

1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized urticaria, itching or flushing, swollen lips-tongue-uvula) AND AT LEAST ONE OF THE FOLLOWING

  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)
  • Reduced blood pressure or associated symptoms of end-organ dysfunction (eg. hypotonia [collapse], syncope, incontinence) OR

2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours)

  • Involvement of the skin-mucosal tissue (eg, generalized urticaria, itch-flush, swollen lips-tongue-uvula)
  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)
  • Reduced blood pressure or associated symptoms (eg, hypotonia [collapse], syncope, incontinence)
  • Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting) OR

3. Reduced blood pressure after exposure to known allergen for that patient (minutes to several hours)

  • Infants and children: low systolic blood pressure (age-specific) or greater than 30% decrease in systolic blood pressure
  • Adults: systolic blood pressure of less than 90 mm Hg or greater than 30% decrease from that person’s baseline

Management Algorithm of Anaphylaxis in the ED

Anaphylaxis algorithm
Anaphyaxis algorithm 2

Key Points in Management

References and Further Reading

Cite this article as: Neha Hudlikar, UAE, "Anaphylaxis in a Nutshell," in International Emergency Medicine Education Project, January 31, 2020, https://iem-student.org/2020/01/31/anaphylaxis-in-a-nutshell/, date accessed: October 18, 2021

Deadly ECG Patterns – 5 Can’t Miss ECG Findings

5 Can’t Miss ECG findings

An average ER physician performs around 100 tasks in an hour and gets interrupted at least every 6 minutes. One of the common interruptions in the ED is a request to “sign off” on an ECG of a patient who has been triaged but not seen by a doctor yet. Therefore, knowing deadly ECG patterns is an essential skill for emergency physicians, residents, as well as medical students who rotate in the emergency department.

Below are five ECG patterns that should raise concerns for red flag conditions.

ECG #1

A 37-years-old female patient presented to the ED with complains of dizziness and generalized fatigue. She was started on ACE inhibitors few months ago and missed her clinic appointments. Her bedside VBG revealed a K+ of 8.1

ECG source - Dr. Smith's ECG blog

The ECG shows severe bradycardia, wide QRS complexes and symmetrically peaked T waves in V2-V5.

Key Take Home Points

Hyperkalemia can present with multiple abnormalities on an ECG, including

  • Tall, peaked T waves with a narrow base (best seen in precordial leads)
  • Progressive flattening and eventually disappearance of P waves
  • Wide QRS complexes
  • Bradyarrhythmias (sinus bradycardia, slow AF, second and third-degree AV blocks)
  • Sine wave appearance (pre-terminal rhythm)
  • Endgame: Ventricular fibrillation

Always consider the diagnosis of hyperkalemia in a patient with a history of dialysis, renal failure, or treatment with drugs like ACE inhibitors, ARBs, spironolactone especially if the ECG shows bradycardia or complete heart block.

ECG #2

A 56-years-old patient presented to the ED with lightheadedness and dizziness. Initial vitals showed hypotension and tachycardia.

ECG source - Dr. Smith's ECG blog
ECG source - Dr. Smith's ECG blog

The above ECG shows low voltage, lectrical alternans: the beat-by-beat R-wave amplitude changes best appreciated in the precordial leads. A bedside ECHO completed after the initial ECG showed a large pericardial effusion.

Key Take Home Points

Massive pericardial effusion can produce a triad of:

  • Low QRS voltage
  • Tachycardia
  • Electrical alternans (consecutive, normally-conducted QRS complexes alternate in height)

Consider the possibility of pericardial effusion and a potential impending cardiac tamponade in patients with electrical alternans on ECG.

ECG #3

A 65-years-old patient was brought to the ED by family members in a disoriented state. Further history revealed that the patient was taking digoxin as one of his regular medications. His serum digoxin level was 2.7 ng/ml.

ECG Source - learntheheart.com
ECG Source - learntheheart.com

The above rhythm strip shows atrial tachycardia with 2:1 AV block.

Key Take Home Points

Always have a high suspicion of digoxin toxicity in a patient taking digoxin presenting with the disoriented state.

Digoxin toxicity can cause a wide variety of arrhythmias. It is classically associated with supraventricular tachycardias but a slow ventricular response (e.g.: atrial tachycardia with high-grade AV block).

The other common rhythms include:

  • Regularized atrial fibrillation (AF with complete heart block + accelerated junctional escape rhythm which produces a paradoxically regular rhythm)
  • Bidirectional VT (polymorphic VT with QRS complexes alternating between LBBB and RBBB morphology)

Digoxin toxicity should be separated from the normal digoxin effect that can occur in patients taking the expected dose of digoxin. The digoxin effect (image below) includes sagging ST-segment depression, abnormal T waves (flat, inverted or biphasic) and a short QT.

ECG source - Dr. Smith's ECG blog

ECG #4

A 45-years-old patient presented to the ED with a history of severe central chest pain lasting about 10 – 15 minutes. Cardiac enzymes were negative. However, with the above ECG findings, the patient was sent to the Cath lab and subsequent coronary angiography revealed proximal LAD artery occlusion.

By Jer5150 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=19598089

The above ECG shows deep T wave inversions in precordial leads. This is known as the Wellen’s sign.

Key Take Home Points

Wellens syndrome is a pattern of deeply inverted or biphasic T waves in V2-V3 which is highly specific for critical stenosis of left anterior descending (LAD) artery.

There are two patterns of T wave abnormality in Wellens syndrome

  • Type A: Biphasic T waves (initially positive and terminally negative)
  • Type B: Deep and symmetrically inverted (Most common type)

Note that patients can be completely pain-free with normal cardiac enzyme levels. Patients are, however, at extremely high risk of anterior wall MI due to the critical LAD stenosis and need appropriate Cardiology consultation and management urgently.

ECG #5

A 17-years-old previously healthy male patient who had one attack of syncope earlier in the day presented to the ED.

ECG Source - Peter Allely - liftl.com
ECG Source - Peter Allely - liftl.com

The ECG pattern is diagnostic of Brugada syndrome – coved shaped ST-elevation > 2mm followed by an inverted T wave seen in V1 and V2.

Key Take Home Points

Such finding is very serious in a patient with a recent episode of unconsciousness.

The suspicion of Brugada syndrome must be confirmed or excluded by an urgent consultation with a cardiologist.

Conclusion

ECGs in isolation are usually not enough to make a diagnosis – always correlate with clinical history and/or confirmatory investigations.

Try looking at as many ECGs as possible to improve your skills of pattern recognition and picking up subtle changes in ECGs.

Cite this article as: Neha Hudlikar, UAE, "Deadly ECG Patterns – 5 Can’t Miss ECG Findings," in International Emergency Medicine Education Project, November 22, 2019, https://iem-student.org/2019/11/22/deadly-ecg-patterns-5-cant-miss-ecg-findings/, date accessed: October 18, 2021

Decisions!

Decisions

As a medical student, I remember once watching a team of physicians and nurses resuscitating a patient who had a cardiac arrest. And while the team worked cohesively like cells that make up a multicellular organism, there was a clear team leader. The ER physician at the foot end of the bed was giving clear instructions to the team and leading the resuscitation. As time passed, I could see the expression of the ER physician change as he finally asked his team to stop resuscitating the patient. In that moment, I remember being aghast and even appalled at the decision of the doctor to stop resuscitating the patient. A few years and many exams later, having found myself in countless similar situations as an ER Resident, I have just begun to understand the complexity of making such decisions.

ER physicians make difficult decisions

Can You?

As physicians, we constantly make decisions in the best interest of our patients and while finding confidence in our decision making is a slow and steady process, it is a process which begins even before we graduate. As a medical student, the choice of medical specialty can be one of the hardest decisions to make. There is a definite finality to the decision of which specialty one decides to pursue. Those who go into medical school with an intended career path may find it easier while others may make their decision as they are exposed to different specialties through their clerkships.

Is Emergency Medicine the right specialty for me?

If you are contemplating if a particular specialty is right for you, then you are already on the right track. All specialties have advantages and disadvantages. Dermatology is often viewed as an attractive specialty by those who like a bit of calm in their lives. But, I know many dermatologists who would not mind a little change from their usual routine of patients every once in a while. (Okay, not many but a few of them).

So, what are the pros and cons of Emergency Medicine?

Pros

  • Variety Is The Spice Of Life

    The great thing about working in the ER is exposure to a variety of cases. At the end of a shift, you could have resuscitated a patient with myocardial infarction, sutured a bleeding scalp wound and even delivered a baby in the ER. If you are someone who enjoys working in a dynamic and fast-paced environment, then working in the ED will definitely be in your comfort zone.

  • No On Calls… Ever!

    Limited working hours, predictability of hours and offs during the week are some factors that attract physicians towards a life in the ER. An ER attending once joked to me that he could not predict a single minute of the shift but knew the exact time he would be sleeping in his bed comfortably. The flip side however, is managing shift schedules and disrupted sleep patterns, which will be discussed under cons.

  • Hands Off While Delivering Shock but Hands-On Otherwise

    I have to admit that not every shift will be like an episode of ‘Code Black,’ but you will still have many shifts where you would get to do hands-on procedures like chest tubes, intubations, and central lines as well as point of care ultrasound which is gaining rapid use in the ED and is an exciting area for further development in the ED.

  • Looking Into The Future

    This can be listed as an advantage or disadvantage, depending on the way you look at it. Emergency medicine, as an independent medical specialty, is relatively young. If you are planning to pursue EM in a place where it is in its nascent stages, you are likely to hit a few speed bumps on the way. This, however, provides you with plenty of opportunities to develop a new model of health-care in your community and make a difference. If you are pursuing EM in a place where there are already well-developed training programs in place (for example the US, UK, Canada or Australia), there is still a lot of potential for research and exploring new tools that will make EM more efficient.

Cons

  • Burn-out

    If you have already done a clerkship in the ER, then you would have probably heard the word ‘burnout’ at least a couple of times and if you have not then I simply do not believe you. Burnout continues to be a pervasive issue among physicians - but not just in the ER, it affects physicians from all specialties. The fact that burnout is discussed and debated so much in the ER is actually comforting as that means there are just as many people looking to fix and help with the problem.

  • Working in shifts

    If you choose to be an ER physician, then working the night shift, on public holidays and weekends is now an unspoken truth of your life. This lifestyle may particularly get more difficult as one gets older and shoulders more responsibilities, especially towards the family. Another challenge that ER physicians face is the circadian rhythm changes, constantly shifting from day to night shifts and back to day, can certainly put one’s health at risk.

  • So what happened to my patient?

    If you are someone who likes to develop long term relationships with your patients, the ER setting can be a challenge for you. However, for most ER physicians, the lack of follow up is a non-issue. Personally, I believe there are many opportunities to develop a rapport with the patient in the ER while knowing that you may never see the same patient again.

What if I am a woman wanting to work in the ER?

One of the success stories involving employment for women since the late 20th century has been the increasing proportion of women in the medical profession. Data from the US suggests that while there was a dramatic upward trend in the representation of women in EM programs (28% in 2001 to 38% in 2011), but sadly this trend has now plateaued in the last few years. Some of the reasons cited for women not choosing EM as a specialty include lifestyle in the ER (working shifts, weekends, etc.) and under-representation in EM leadership.

The reasons could be countless and influenced by the social and cultural norms of each place. The right people to guide you in your decision making are the female residents and attendings working in your local ER. So seek them out and definitely factor in their experience in your decision.

There are also many organizations and blogs which support the empowerment of women in Emergency Medicine. American Association of Women Emergency Physicians, Women in Emergency Medicine (WEM), FemInEM are few that you should definitely check out.

How do I finalize my decision?

Keeping an open mind throughout your clerkships helps. Try to experience each speciality to the maximum you can. So that by the end of medical school, you would have a fair idea of what choosing that specialty would entail.

Try to schedule electives in the speciality you would like to pursue. In the ER, use this opportunity to try working in shifts and get a taste of what it’s like to work in a fast-paced environment. Also, speak to the residents and attendings about their experiences to gain invaluable insight into the specialty.

What if I want to know more about EM?

A good way to learn more about emergency medicine is to join local and international professional emergency medicine organizations as a student. You can also sign up for newsletters, listen to podcasts and follow blogs dedicated to Emergency Medicine to keep up with the latest happenings in EM.

ISAEM is a global student organization which is a active collaborator of iEM Education Project
IFEM is a global organization aiming to improve emergency medical care and education. IFEM is the main endorsing organization of iEM Education Project

Final thoughts

I understand that the above article might portray an ER physician as a superhero/woman navigating through all that chaos, trying to make a difference in the world. But in reality, one does feel like that if lucky enough to pursue something that one is passionate about. So find your passion and do not stop until you do. If you find it in Emergency Medicine, perhaps we may cross paths in the future, if not, I still wish the best for you.

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Cite this article as: Neha Hudlikar, UAE, "Decisions!," in International Emergency Medicine Education Project, August 2, 2019, https://iem-student.org/2019/08/02/decisions/, date accessed: October 18, 2021