Thinking Like an Emergency Physician (2023)

Emergency Medicine is the most interesting 15 minutes of every other specialty.

Everyone in medicine knows that Emergency Medicine is different, even if they can’t put the reason into words.  We know why.  We work in an environment that is different, in hours that are different, and with patients who are different more than any other medical specialty.  Our motto is “Anyone, anything, anytime.”  No other specialty of medicine makes that claim.

While other doctors dwell on “What does this patient have? – that is, “What’s the diagnosis?” – emergency physicians are instead thinking “What does this patient need right now?  In 5 minutes?  In two hours?”  

The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues. Yet we do it on a daily basis, many times during a shift.  The idea of juggling decisions for several sick people simultaneously is beyond the capabilities of almost everyone else in medicine.  They are used to working with one patient at a time in a linear fashion.

I retired a few years ago after more than 45 years in Emergency Medicine, dating back to my time as an Army medic in Vietnam.  Every time I introduced myself to a patient, I never knew in advance which direction things were going to head.  I never knew whether I could help the patient in 30 seconds or 30 minutes, if at all.  I felt like I should have given this disclaimer.

Hello stranger, I am Doctor Joe Lex.  I will spend as much time with you as it takes to determine whether you are trying to die on me, and whether I should admit you to the hospital so you can try to die on one of my colleagues.  

You and I have never met before today.  You must trust me with your life and secrets, and I must trust that the answers you give me are honest.  

After today, we may never see one another again.  It may turn out to be one of the worst days of your life.  For me, it is another workday.  I may forget you minutes after you leave the department, but you will probably remember me for many days or months, possibly even for the rest of your life.  I will ask you many, many questions.  I will do the best I can to ask the right questions in the right order so that I come to a correct decision.  I want you to tell me your story, and for me to understand that story, I may have to interrupt you to clarify your answers.

Each question I ask you is a conscious decision on my part.  In an average 8-hour shift I will make about 10,000 conscious and subconscious decisions – who should I see next, what question should I ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, and is that really an infiltrate, which consultant will give me the least pushback about caring for you, is your nurse one whom I can trust with the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home?  And so on…  So even if I screw up just 0.1% of these decisions, I will make about ten mistakes today.

I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio.  Gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG, shingles, a dental abscess, an eye foreign body … I can recognize and treat those things without even thinking.  If, on the other hand, your problem has a lot of background noise and vague signs and symptoms, I am more likely to be led down the wrong path and come to the wrong conclusion.  

I am glad to report that the human body is very resilient.  We as humans have evolved over millennia to survive, so even if I screw up, the odds are very, very good that you will be fine.  Voltaire told us back in the 18th century that “The art of medicine consists of amusing the patient while nature cures the disease.”  For the most part, this has not changed.  And Lewis Thomas wrote: “The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves.  Most things, in fact, are better by morning.” On the other hand, the path to dying is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.

Remember, you don’t come to me with a diagnosis: you come to me with symptoms.  You may have any one of more than 10,000 diseases or conditions that we know about, and – truth be told – the odds of me getting the absolute correct diagnosis are small.  You may have an uncommon presentation of a common disease or a common presentation of an uncommon disease.  If you are early in your disease process, I may even miss such life-threatening conditions as heart attack or sepsis.  If you neglect to truthfully tell me your sexual history or your use of drugs and alcohol, I may not follow through with appropriate questions and might come to a totally incorrect conclusion about what you need or what you have.

You may be disappointed when you feel that you are not being seen by a “specialist.”  Many people believe that when they have their heart attack, they should be cared for by a cardiologist.  They think that the symptom of “chest pain” is their ticket to the heart specialist.  But what if the heart attack is not chest pain, but nausea and breathlessness?  And what if the chest pain is aortic dissection?  Or a pneumothorax?  Or a ruptured esophagus?  So, you are being treated by a specialist – one who can discern the life-threatening from the trivial, and the medical from the surgical.  We are the specialty trained to think like this.

We started our training in a state of unconscious incompetence – we were so poor at what we did that we did not even know how bad we were.  We were lucky if we could care for four patients in an 8-hour shift.  But we quickly learned and reached a level of conscious incompetence and multi-tasking – we knew that we were inadequate, but we felt ourselves getting better at our job on a day-to-day basis.  By the time we finished our training we had reached the next level: conscious competence.  We could deal with almost anything, but we still had to think hard about much of our decision making.  After a few more years of practice, we reached our pinnacle of unconscious competence

If you insist on asking “What do I have, Doctor Lex?” you may be disappointed when I tell you “I don’t know what you have, but I do know it is safe for you to go home.”  Sometimes I can do this without doing a single test.  I do know that if I give you a made-up diagnosis like “gastritis” or “walking pneumonia,” you will think the problem is solved.  Worse yet, other doctors will anchor on my false diagnosis, and you may never get the right answers.

Here’s some good news: we are probably both thinking of the worst-case scenario. You get a sudden headache and wonder “Do I have a brain tumor?”  You get some belly pain and worry “Is this cancer?”  The good news is that I am thinking exactly the same thing.  And if you do not hear me say the word “stroke” or “cancer,” then you will think I am an idiot for not reading your mind to determine that is what you are worried about.  I understand that no matter how trivial your complaint, you have a fear that something bad is happening.

While we are talking, I may be interrupted once or twice.  See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, clarifying orders for nurses and technicians.  Or I may get suddenly called away to care for someone far sicker than you.  I will try very hard to not let these interruptions derail me from doing what is best for you today.

I will use my knowledge and experience to reach the right decisions for you.  I know that I am biased, but knowledge of bias is not enough to change it.  I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this condition at least half the time it occurs.

And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by pattern recognition or use analytical reason.  Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking).  Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking).  It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.

After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you.  This is to document what I have found and how I have worked up your complaint, so the hospital and I can get paid.  The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier.  But that chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process.  In my eight-hour shift today I will click about 4000 times.

What’s that?  You say you don’t have insurance?  Well, that’s okay too.  The U.S. government and many other governments in the world have mandated that I have to see you anyway without asking you how you will pay.  No, they haven’t guaranteed me any money for doing this – in fact, I can be fined a hefty amount if I don’t do it.  A 2003 article estimated I give away more than $138,000 per year worth of free care because of this law.

But if you are having an emergency, you have come to the right place.  If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracotomy, I’ll do it.  If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too.  I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter. I can float your temporary pacemaker, I can get that pesky foreign body out of your eye or ear or rectum, I can stop your seizure or your nosebleed, and I can talk you through your bad trip.

Emergency medicine really annoys a lot of the other specialists.  I think that it is primarily because we are there 24 hours a day, 7 days a week.  And we really expect our consultants to be there when we need them.  Yes, we are fully prepared to annoy a consultant if that is what you need.

I saw thousands of patients, each unique, in my near-50 years of experience.  But every time I thought about writing a book telling of my wondrous career, I quickly stopped short and told myself “You will just be adding more blather to what is already out there – what you have learned cannot easily be taught and will not be easily learned by others.  What you see as wisdom, others will see as platitudes.”

As author Norman Douglas once wrote: “What is all wisdom save a collection of platitudes.  Take fifty of our current proverbial sayings– they are so trite, so threadbare.  None the less they embody the concentrated experience of the race, and the man who orders his life according to their teachings cannot be far wrong.  Has any man ever attained to inner harmony by pondering the experience of others?  Not since the world began!  He must pass through fire.”

Have you ever heard of John Coltrane?  He was an astonishing musician who became one of the premiere creators of the 20th century.  He started as an imitator of older musicians but quickly changed into his own man.  He listened to and borrowed from Miles Davis and Thelonious Monk, Coleman Hawkins and Lester Young, African music and Indian music, Christianity and Hinduism and Buddhism.  And from these seemingly unrelated parts he created something unique, something no one had ever heard before.  Coltrane not only changed music, but he changed people’s expectations of what music could be.  In the same way, emergency medicine has taken ideas from surgery and pediatrics, critical care and obstetrics, endocrinology and psychiatry, and orthopedics, and we have created something unique.  And in doing so, we altered the world’s expectations of what medicine should be.

Now, how can I help you today?

Author

Joe LEX

Joe LEX

Joe Lex was involved in Emergency Medicine for more than 49 years – as a Vietnam combat medic, ER Tech, Certified Emergency Nurse, and Emergency Physician. For five years he was Education Chair for the American Academy of Emergency Medicine, which renamed their Educator of the Year Award the “Joe Lex Award.” After 14 years in the community, he joined the Emergency Medicine faculty at Temple University in Philadelphia. He is a “godfather” of free electronic open-access medical education and his website (www.FreeEmergencyTalks.net) taught thousands of people worldwide.

Since he retired in 2016 as a Professor of Emergency Medicine, he does a weekly radio show called “Dr. Joe’s Groove,” featuring 60-year-old news and jazz. He writes an occasional blog called “Notes from Nam” based on 170 letters he wrote home in 1968 and 1969. He is also an amateur cemetery historian and volunteer tour guide for Laurel Hill Cemetery in Philadelphia and West Laurel Hill Cemetery in Bala Cynwyd, in addition to researching and producing their monthly podcasts “All Bones Considered: Laurel Hill Stories” and “Biographical Bytes from Bala: West Laurel Hill Stories.”

Joe and his wife Andrea celebrate 50 years together in June. His publicity picture is quite old – add 15 years and 40 pounds.

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Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Thinking Like an Emergency Physician (2023)," in International Emergency Medicine Education Project, March 20, 2023, https://iem-student.org/2023/03/20/thinking-like-an-emergency-physician-2023/, date accessed: April 1, 2023

Why is emergency medicine training important in medical schools?

Why is emergency medicine training important in medical schools?

The ability to promptly and accurately diagnose and treat patients in critical condition is a crucial skill that students learn in emergency medicine programs. This exposure is especially important for doctors who practice in fast-paced environments like emergency rooms, urgent care clinics, and hospitals immediately after their graduation in some countries.

The ability to promptly recognize and stabilize critically sick patients is a key skill that is taught to prospective doctors as part of emergency medical training. This entails not only the ability to see the warning indications of illnesses like heart attacks, strokes, and septic shock, but also to initiate life-saving treatments like cardiopulmonary resuscitation (CPR) and the administration of antibiotics.

Medical students can learn to function well under pressure by participating in emergency medicine rotations. It’s very common for emergency departments to be noisy and hectic due to the high volume of people who are there for immediate attention. So, in order to offer the best treatment for their patients in situations where time and resources are limited, and many distractors in the environment, all doctors need to be able to think fast and make choices on the fly.

Learning to work with other medical professionals is also a crucial part of emergency medicine education. Patients in emergency departments are usually cared for by a multidisciplinary group consisting of doctors, nurses, and other medical experts. Medical students learn how to interact and coordinate with these other clinicians as part of their emergency medicine training.

In addition, emergency medicine education is crucial because it prepares future doctors to treat patients with a wide variety of acute and chronic disorders. Every doctor should be able to treat patients of different ages, ethnicities, and economic statuses, and they should do so in a way that is respectful of their cultural origins. Therefore, emergency departments create great opportunities with its unique learning environment for medical students.

Last but not least, emergency medicine education is critical since it helps students get a feel for the field. Physicians who have completed emergency medicine training are better equipped to deal with the high-stakes, high-stress scenarios they will experience in practice, as emergency medicine is one of the most rigorous and demanding specialties in medicine. All medical students, including those who want to specialize elsewhere, should acquire emergency medicine skills, familiarize themselves with how the emergency health care system operates, and be prepared to work in this field if necessary.

IFEM, or the International Federation for Emergency Medicine (ifem.cc), is an organization that supports the advancement of emergency medicine globally. One way that IFEM supports emergency medicine training in medical schools is by providing resources and guidelines for curriculum development. IFEM has created a set of guidelines for emergency medicine training, which can serve as a framework for medical schools to develop their own curricula. Additionally, IFEM offers training opportunities and conferences for medical educators to learn from each other and share best practices.

To improve emergency medicine training in their own countries, other nations can look to IFEM’s guidelines as a starting point for developing their own curricula. They can also seek out partnerships with IFEM and other organizations, to share knowledge and resources. Providing opportunities for medical students to gain hands-on experience in emergency medicine, such as through clinical rotations or simulation training, can definitely be effective in preparing them for the challenges they may face in the future clinical practice. Finally, investing in the development of emergency medicine residency programs can help to ensure that there is a pipeline of well-trained emergency physicians to serve the needs of the community.

In conclusion, emergency medicine training is a crucial part of a medical education because it prepares students for the realities of practice by teaching them how to quickly and accurately assess and treat critically ill patients, how to work effectively in high-stress environments, how to collaborate with other healthcare providers, how to care for patients from a wide variety of backgrounds and with a wide variety of medical conditions. Without this exposure, medical students would be less equipped to deal with complicated and challenging circumstances in clinical practice. Therefore, we highly recommend medical schools consider opening emergency medicine rotations or increasing the time of exposure to emergency medicine education.

Further Reading

  • Rybarczyk MM, Ludmer N, Broccoli MC, Kivlehan SM, Niescierenko M, Bisanzo M, Checkett KA, Rouhani SA, Tenner AG, Geduld H, Reynolds T. Emergency Medicine Training Programs in Low- and Middle-Income Countries: A Systematic Review. Ann Glob Health. 2020 Jun 16;86(1):60. doi: 10.5334/aogh.2681. PMID: 32587810; PMCID: PMC7304456.
  • International EM Core Curriculum and Education Committee for the International Federation for Emergency Medicine. International Federation for Emergency Medicine model curriculum for emergency medicine specialists. CJEM. 2011 Mar;13(2):109-21. PMID: 21435317.
  • Arnold JL, Holliman CJ. Lessons learned from international emergency medicine development. Emerg Med Clin North Am. 2005 Feb;23(1):133-47. doi: 10.1016/j.emc.2004.10.001. PMID: 15663978.
  • Beyene T, Tupesis JP, Azazh A. Attitude of interns towards implementation and contribution of undergraduate Emergency Medicine training: Experience of an Ethiopian Medical School. Afr J Emerg Med. 2017 Sep;7(3):108-112. doi: 10.1016/j.afjem.2017.04.008. Epub 2017 Apr 20. Erratum in: Afr J Emerg Med. 2017 Dec;7(4):189. PMID: 30456120; PMCID: PMC6234139.
  • Beckers SK, Timmermann A, Müller MP, Angstwurm M, Walcher F. Undergraduate medical education in emergency medical care: a nationwide survey at German medical schools. BMC Emerg Med. 2009 May 12;9:7. doi: 10.1186/1471-227X-9-7. PMID: 19435518; PMCID: PMC2689168.
  • Wald DA, Lin M, Manthey DE, Rogers RL, Zun LS, Christopher T. Emergency medicine in the medical school curriculum. Acad Emerg Med. 2010 Oct;17 Suppl 2:S26-30. doi: 10.1111/j.1553-2712.2010.00896.x. PMID: 21199080.

Related iEM Articles

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Cite this article as: iEM Education Project Team, "Why is emergency medicine training important in medical schools?," in International Emergency Medicine Education Project, February 24, 2023, https://iem-student.org/2023/02/24/why-is-emergency-medicine-training-important-in-medical-schools/, date accessed: April 1, 2023

Key recommendations for medical students interested in pursuing a career in emergency medicine

Key recommendations for medical students interested in pursuing a career in emergency medicine.

Emergency Medicine is a popular speciality among students, and residency programs are receiving an increased amount of applications year by year. However, high competition to get into the residency programs requires successful preparation for the speciality training. In addition, choosing this speciality as a future professional career may fit some individuals while it can not be suitable for others. 

Here are some recommendations to be prepared and understand whether emergency medicine is a good fit for you.

  1. Get involved in emergency medicine early: Try to find ways to get involved during medical school, such as volunteering at an emergency department or shadowing an emergency medicine physician. This will give you a better understanding of the field and help you determine if it is a good fit for you.
  2. Seek out opportunities to develop clinical skills: Emergency medicine is a highly clinical field, and you will need to be comfortable managing patients with a wide range of medical conditions. Participating in clinical rotations and other hands-on learning experiences can help you build your clinical skills and prepare you for a career in emergency medicine.
  3. Network with emergency medicine professionals: Building relationships with emergency medicine physicians and other healthcare professionals can help you learn about different career paths in the field and gain valuable insight into the daily challenges and rewards of working in emergency medicine.
  4. Stay up-to-date on the latest developments: Emergency medicine is a rapidly evolving field, and it is important to stay informed about the latest developments in patient care and medical technology. Attending conferences and workshops, reading professional journals, and participating in online communities can help you stay current.
  5. Consider a residency program: Many emergency medicine physicians complete a residency program in the field, which provides in-depth training and hands-on experience in emergency medicine. Consider applying to a residency program if you are serious about pursuing a career in emergency medicine.
  6. Focus on developing your interpersonal skills: Effective communication and interpersonal skills are essential for success in emergency medicine, as you will be working with patients, families, and other healthcare professionals in high-pressure situations. Make an effort to develop your interpersonal skills, and seek feedback from others on how you can improve.
  7. Stay passionate: Emergency medicine can be challenging, but it can also be incredibly rewarding. Make sure to stay passionate about your chosen field and continue to seek out opportunities for growth and learning.

Emergency medicine is a challenging but rewarding field that requires a strong foundation in clinical skills, a commitment to staying current with the latest developments, and excellent interpersonal skills. If you are passionate about helping patients in high-pressure situations and are willing to work hard to develop your skills, a career in emergency medicine may be a great fit for you.

Further Reading

  • Huang RD, Lutfy-Clayton L, Franzen D, Pelletier-Bui A, Gordon DC, Jarou Z, Cranford J, Hopson LR. More Is More: Drivers of the Increase in Emergency Medicine Residency Applications. West J Emerg Med. 2020 Dec 10;22(1):77-85. doi: 10.5811/westjem.2020.10.48210. PMID: 33439811; PMCID: PMC7806335.
  • Blackshaw AM, Watson SC, Bush JS. The Cost and Burden of the Residency Match in Emergency Medicine. West J Emerg Med. 2017 Jan;18(1):169-173. doi: 10.5811/westjem.2016.10.31277. Epub 2016 Dec 19. PMID: 28116032; PMCID: PMC5226755.
  • Pianosi K, Stewart SA, Hurley K. Medical Students’ Perceptions of Emergency Medicine Careers. Cureus. 2017 Aug 24;9(8):e1608. doi: 10.7759/cureus.1608. PMID: 29075586; PMCID: PMC5655118.
  • Alkhaneen H, Alhusain F, Alshahri K, Al Jerian N. Factors influencing medical students’ choice of emergency medicine as a career specialty-a descriptive study of Saudi medical students [published correction appears in Int J Emerg Med. 2018 Dec 17;11(1):56]. Int J Emerg Med. 2018;11(1):14. Published 2018 Mar 7. doi:10.1186/s12245-018-0174-y
  • Boyd JS, Clyne B, Reinert SE, Zink BJ. Emergency medicine career choice: a profile of factors and influences from the Association of American Medical Colleges (AAMC) graduation questionnaires. Acad Emerg Med. 2009;16(6):544-549. doi:10.1111/j.1553-2712.2009.00385.x

Related iEM Articles

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Cite this article as: iEM Education Project Team, "Key recommendations for medical students interested in pursuing a career in emergency medicine," in International Emergency Medicine Education Project, February 15, 2023, https://iem-student.org/2023/02/15/key-recommendations-for-medical-students-interested-in-pursuing-a-career-in-emergency-medicine/, date accessed: April 1, 2023

Why do medical students favour emergency medicine experience?

Why do medical students favour emergency medicine experience?

Emergency Medicine is a challenging and fast-paced speciality that is often considered one of the most popular clerkships among medical students. The appeal of emergency medicine stems from its dynamic nature, which requires medical students to be versatile, adaptable and able to make quick decisions.

One of the primary reasons that medical students like emergency medicine is the opportunity to learn the care for a wide range of patients. In the emergency department, medical students are exposed to a diverse patient population that includes individuals with acute illnesses and injuries, as well as those with chronic conditions that have taken a turn for the worse. This exposure to a wide range of patients allows medical students to develop a broad knowledge base and gain a deeper understanding of the complexities of medical care.

Another factor that attracts medical students to emergency medicine is the fast-paced environment. The emergency department is often the first point of contact for patients experiencing an acute illness or injury, and medical students must be able to assess, diagnose, and treat patients quickly. In addition, this challenging and fast-paced environment helps medical students to develop strong critical thinking and decision-making skills, which are essential for success in any medical speciality.

In addition to the opportunities for hands-on patient care, emergency medicine also provides medical students with the opportunity to work closely with other healthcare professionals. In the emergency department, medical students interact with nurses, paramedics, radiologists, and other specialists and learn to provide comprehensive care to patients. This interdisciplinary approach to care allows medical students to gain a deeper understanding of the role of each healthcare professional and to develop strong collaborative skills.

Emergency medicine is also a highly rewarding speciality for medical students, as it provides the opportunity to make a significant impact on a patient’s health in a short amount of time. Whether being in a team stabilizing a critically ill patient, providing pain relief, or simply offering emotional support, medical students in the emergency department have the opportunity to make a real difference in the lives of patients.

Finally, the training and education opportunities available in emergency medicine are another reason why medical students often favour this clerkship. Emergency medicine residency programs, with a robust training structure, are designed to provide medical students with extensive exposure to the most challenging cases and to provide a strong foundation in critical thinking and decision-making skills. Additionally, emergency medicine residency programs often offer a variety of elective rotations, which allow medical students to tailor their training to their specific interests and career goals.

In conclusion, emergency medicine is a popular clerkship among medical students for many reasons. From the fast-paced and challenging environment to the opportunities for hands-on patient care and interdisciplinary collaboration to the training and education opportunities available, emergency medicine provides medical students with a well-rounded and rewarding clerkship experience. Whether they go on to specialize in emergency medicine or another medical speciality, the skills, knowledge and experience gained in the emergency department will serve medical students well throughout their careers.

Further Reading

  • Pianosi K, Stewart SA, Hurley K. Medical Students’ Perceptions of Emergency Medicine Careers. Cureus. 2017 Aug 24;9(8):e1608. doi: 10.7759/cureus.1608. PMID: 29075586; PMCID: PMC5655118.
  • Langlo NM, Orvik AB, Dale J, Uleberg O, Bjørnsen LP. The acute sick and injured patients: an overview of the emergency department patient population at a Norwegian University Hospital Emergency Department. Eur J Emerg Med. 2014 Jun;21(3):175-80. doi: 10.1097/MEJ.0b013e3283629c18. PMID: 23680865.
  • Ray JC, Hopson LR, Peterson W, Santen SA, Khandelwal S, Gallahue FE, White M, Burkhardt JC. Choosing emergency medicine: Influences on medical students’ choice of emergency medicine. PLoS One. 2018 May 9;13(5):e0196639. doi: 10.1371/journal.pone.0196639. PMID: 29742116; PMCID: PMC5942813.
  • Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2643/

Related iEM Articles

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Cite this article as: iEM Education Project Team, "Why do medical students favour emergency medicine experience?," in International Emergency Medicine Education Project, February 8, 2023, https://iem-student.org/2023/02/08/why-do-medical-students-favour-emergency-medicine-experience/, date accessed: April 1, 2023

Two Roads, One Path: Academic vs. Non-Academic EM – Part 1

academic emergency medicine vs non-academic emergency medicine

Are academic and non-academic emergency medicine (EM) really two completely different worlds?

With this post I want to start a short series on this topic, hopefully with a little twist in the approach.

Why even question?

How and why do you question a distinction that is on the one hand very apparent and real, and on the other is very customary and traditional and may be true for all medical specialties?

Part of the answer is that in order to plan a fulfilling life in EM (not everyone believes in a “career”), it is best to understand the entire landscape – not only regionally and nationally, but also globally. To this end, perhaps more innovation, ingenuity and out-of-the-box thinking is needed to benefit future EM trainees than what habitual teachings on the subject offer.

Are we really committed for life to whatever we pick out of residency?  Is the decision regarding a fellowship for a senior registrar a now-or-never decision? Is there such an age as “too late” for academics and vice versa? Is the connection between academic and non-academic EM a one-way street? Is it true that once in EM you cannot do anything else because “you don’t know how to do anything else”, according to some?

Today we will begin by looking at a few labels and presuppositions that may be cemented in the collective EM subconscious. It is my intuitive suspicion that only by uncorking, uncovering or by altogether removing some of these, will we be able to get to the real deal underneath.

As they say, the devil is in the details.

Discussion One:  Smoke and Mirrors

Where will you work at and who will you work for?

First, academic vs. non-academic EM identity can to a large extent be affected by how your nation’s overall healthcare system is set up.

In countries with predominantly socialized medicine, “community practice” – very possibly a US-driven term – may simply indicate not being employed at one of the largest tertiary urban centers available, which carry all the prestige and concentrate all of research efforts. In such nations a classically proposed counterpart to academic medicine, a business-driven private EM enterprise, may be lacking completely.

If everyone works for the government, be it local or federal, then becoming “academic”, equally or more so than due to one’s personal talents and inclinations, may be the outcome of having urbanization, luck, connections or some other ability to find a bigger place to work. At one point or another one simply wins the lucky lottery ticket to move and “move up”. In essence, the EM physician is a large capital city’s teaching hospital worker first, and an academician largely by default. Such career aiming of course succumbs to the philosophy that urban and central is always better than rural and peripheral.

Second, let’s consider “community practice” as a kind of a weird term: if you are in academic EM, who else are you serving if not some community or communities? These may be communities of colleagues, trainees, organizations and researchers in addition to patients, but they are communities nonetheless.

Equally, if an EM physician is truly and solely in non-academic practice, does she really envision and lead her professional life without any engagement in research, publications, teaching, administration, local and international networking? What would the website “Life in non-academic EM” look like – a steady picture of a work mule without links or content?

Both terms academic and non-academic EM may be infused and muddied with other meanings like institutional- or government-affiliated practice, private practice, non-teaching, and so on.

In real life, both type of endeavors (if the distinction between academic and non-academic is genuine) can be conducted in very urban or in rather rural environments; and either practice type may be institutionally affiliated or tied to NGOs, governments or businesses. In the United States some recent criticism has sprung related to the so-called inbred residencies – EM training programs created and operated by large corporate entities.

More importantly for a future trainee: both types of EM practices may or may not involve exclusive night shifts, overtime, faraway travel, being underpaid, unfair seniority, feeling unappreciated and cogwheelish (new word for you), without a clear sense of direction or belonging.

Don’t get ridiculous with cliches.

Now to some cliches, most of which are from the trainees themselves.

One: the sigh “I love teaching, but I hate research” from those choosing non-academics.

Let me ask a provocative question: are all of the globally famous EM research superstars you and I know necessarily brilliant teachers? It appears that “I love research, but I hate teaching” never stopped anyone from an academic road. This, of course, is poor logic either way.

Teaching is a hard thing to do well, and there is a distinction between bedside and classroom teaching, but so is research! Just like the so-called charisma of say a journalist, perhaps some abilities one can be born with (in the words of Professor Snape, “possess the predisposition”). Yet, vast majority of skills can be and have to be acquired.

So instead of anguishing over your inborn leanings and phobias, think rather of what you would prefer to be doing, once you learn it, during any typical week of the next five or more years after residency. Now, how can you realistically translate that into life, given the types of attainable EM jobs out there in your current or anticipated environment?

Two: “get in, get out (of the ED), and enjoy the rest of your life!”

Often the EM backpack mentality, as bumper-stickered above, is sold as the prime appeal of non-academic work.

All true – academicians, when not at work, do not enjoy their lives to any significant extent. They spend most of their free time in dusky library dungeons and at other EM-bound noble activities, while those outside of academics enjoy hundreds of free hours sailing the high seas or YouTube.

As a very weak truism, non-academic EM may sometimes open up more free time for non-EM related activities of one’s life. But is wastage of time laying on a couch an activity, and are you susceptible?

On the contrary, it may be plausible that academicians may enjoy fewer and shorter shifts, more diverse practices, more immediate access to cutting edge innovations and articles, fuller specialist call panels and fewer unfinished charts to review and sign at home.

Three: “One should only do a fellowship if planning an academic career…in which case, you better get into one!”

No, you should probably do a fellowship primarily because you are very interested in what the fellowship is about. Everything else is an extra, albeit a welcome one – like perhaps natural entry into an academic institution or a network of contacts for expanded career options.

It is also completely legitimate to consider the burden and the years of your medical training so far. In some countries just getting to a recognized EM residency (which may be abroad!) has already cost you several years post medical graduation. In such cases, ambivalent feelings towards adding even more years via a fellowship to the perpetual student status are fully valid.

On the other hand, it may very well be that in the near future (if not already), all EM docs without a fellowship, whether entrepreneurial or in public service, academic or not, will become non-competitive for best jobs.

Is doing a fellowship straight off the bat after residency the only option? What if you are not interested in any during training, but become interested later?

To be fair, right after residency makes not only intuitive sense, but typically the system is set up that way, especially fellowship funding. Still, one has to be careful, as not all of fellowships are funded, nor are all fellowships accredited. Viewed in a constructive light, this creates not only constraints but also degrees of freedom for making choices.

True, if years pass, an entire family’s lifestyle dependent on attending level salary may not be very compatible with the salary of a fellow even with all the moonlighting in the world. But is the latter income difference profound in your country, or are the main barriers to a delayed fellowship of a different sort – e.g., government rules written in stone, the mass competition from the youngsters or some unspoken negative culture towards old-timers in their forties among fellowship directors?

Overall, nothing is insurmountable if given enough will, persistence and preparation. Otherwise, there would have been no people in their forties in my medical school class or residency.

Which professional currency would you rather deal in?

All mentioned above is not to be construed to say that some harsh realities do not exist.  One problem with cliches is that they are very zonal, while proclaiming to be universals.

The simple overhanging truth is that every field has its own currency, and both academic and non-academic EM are no exceptions.

For future EM trainees this is pertinent and applicable not only because of the obvious choices you will have to make after formal training, but also because of the need to gear and adjust your preferences while still in training.

Grant funding and publications are absolutely the ubiquitous currency in academics. Productivity, billing and people management (aka “leadership”) skills are the hardcore coinage in business-driven EM. Advancement and promotion within socialized medicine systems may call for yet another set of valuables altogether.

Still, thinking in terms of such hard constraints will tend to corner you in at least two ways.

First, it is not to be implied that ability to generate grants or publications never helps or is not useful in non-academics, or that no academician has to keep track of her billing and productivity metrics.

Second, if cornered, you will be liable to forget the correct reasons for choosing a certain path – the ones that spring from your deep interests and curiosities. These reasons miraculously happen to be the same ones to keep you out of burnout and disappointment years later, no matter what type of practice.

I am proposing a much simpler approach to the above dilemma. Choose currencies that will create the least disdain and subconscious resistance (manifested by nausea and wanting to do what your dog does after it gets wet), and then ones for which you think you already have more inborn propensity if not talent.

Finally, are you really ego-, career- and promotion-driven?  How would you define your own future success in EM?

Enough from me for now.

In future discussions and interviews we will try to elicit opinions of other EM physicians to shine different shades of light on the intriguing sub-topics this topic uncovers.

Stay tuned!

 

Intern Survival Guide – ER Edition

Intern Survival Guide - ER Edition
In some parts of the world, Internships consist of rotating in different departments of a hospital over a period of one or two years depending on the location. In others, interns are first-year Emergency Medicine residents. Whichever country you practice in, an emergency rotation may be mandatory to get the most exposure, and often the most hands-on. Often, junior doctors (including myself)  find ourselves confused and lost as to what is expected of us, and how we can learn and work efficiently in a fast-paced environment such as the ER. It can be overwhelming as you may be expected to know and do a lot of things such as taking a short yet precise history, doing a quick but essential physical exam and performing practical procedures. I’ve gathered some tips from fellow interns and myself, from what we experienced, what we did right, what we could’ve done better and what we wish we knew before starting. These tips may have some points specific to your Emergency Medicine Rotation, but overall can be applied in any department you work in.
  • First things first – Always try to be on time. Try to reach your work a couple of minutes before your shift starts, so you have enough time to wear your PPE and feel comfortable before starting your shift.
  • Know your patients! Unlike other departments, ER does not always have rounds, and you do not know any of the patients beforehand, but it always helps to get a handover from the previous shift, and know if any of the patients have any results, treatment plans or discharges pending, to prevent chaos later on!
  • Always be around, inform your supervising doctor when you want to go for a break, and always volunteer to do more than what you’re asked for. The best way to learn is to make yourself known, ask the nurses to allow you to practice IV Cannulation, Intramuscular injections, anything and everything that goes around the department, remember the ER is the best place to learn.
  • Admit when you feel uncomfortable doing something, or if you’ve done a mistake. This makes you appear trustworthy and everyone respects someone who can own up to their mistake and keeps their patients first.
  • Breath sounds and pulses need to be checked in every patient!
  • Address pain before anything else, if their pain is in control, the patient will be able to answer your questions better.
  • Never think any work is below you, and this is one thing which I admired about ED physicians, you do not need someone to bring the Ultrasound machine to you, you do not need someone to plug in the machine, you do not need someone to place the blood pressure cuff if you can do it yourself. Time is essential, and if you’re the first person seeing the patient, do all that you can to make their care as efficient as possible.
  • Care for patients because you want to, and not for show. Often junior doctors get caught up in the fact that they are being evaluated and try to “look” like the best version of themselves. While it may be true, remember this is the year where you are shaping yourself for the future, and starting off by placing your patients first, doing things for their benefit will not only make it a habit, the right people will always notice and will know when you do things to provide patient-focused care, or when you do them to show that you are providing patient-focused care.
  • Teamwork will help you grow. Not everything in life has to be a competition, try to work with your colleagues, share knowledge, take chances on doing things, learn together, trying to win against everyone else only makes an easier task even more stressful and can endanger lives.
  • Learn the names of the people you work with! In the ER, you may across different people on each and every shift and it may be difficult to remember everyone’s names, but it’s always nice to try, and addressing people by their names instantly makes you more likable and pleasant to work with!
  • Keep track of your patients and make a logbook of all the cases you see and all the procedures you observe/assist in/perform. This not only helps in building your portfolio, but also in going back and reading about the vast variety of cases you must have seen.
  • Always ask yourself what could the differential diagnosis be? How would you treat the patient?
  • Ask questions! No question is worth not asking, clear your doubts. Remember to not ask too much just for the sake of looking interested, but never shy away from asking, you’d be surprised to see how many doctors would be willing to answer your queries.
  • Don’t make up facts and information. If you forgot to ask something in history, admit the mistake, and it’s never too late, you can almost always go back and ask. It’s quite normal to forget when you’re trying to gather a lot of information in a short span of time.
  • Check up on the patients from time to time. The first consultation till the time you hand them the discharge papers or refer them to a specialty shouldn’t be the only time you see the patient. Go in between whenever you get a chance, ask them if they feel better, if they need something. Sometimes just by having someone asking their health and mental wellbeing is just what they need.
  • Take breaks, drink water and know your limits. Do not overwork yourself. Stretching yourself till you break is not a sign of strength.
  • Sleep! Sleep well before every shift. Your sleep cycles will be affected, but sleeping when you can is the best advice you can get.
  • Read! Pick your favorite resource and hold onto it. A page of reading every day can go a long way. The IEM book can be a perfect resource that you can refer to even during your shifts! (https://iem-student.org/2019/04/17/download-now-iem-book-ibook-and-pdf/)
  • Practice as many practical skills as you can. The ER teaches you more than a book can, and instead of looking at pictures, you can actually learn on the job. Practice ultrasound techniques, suturing, ECG interpretation, see as many radiology images as you can, learn to distinguish between what’s normal and what’s not.
  • Last but most important, Enjoy! The ER rotation is usually amongst the best rotations an intern goes through, one where you actually feel like you are a doctor and have an impact on someone’s life! So make the best of it.
If you are a medical student starting your emergency medicine rotation, make sure to read this post for your emergency medicine clerkship, and be a step ahead! https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/  
Cite this article as: Sumaiya Hafiz, UAE, "Intern Survival Guide – ER Edition," in International Emergency Medicine Education Project, May 26, 2021, https://iem-student.org/2021/05/26/intern-survival-guide-er-edition/, date accessed: April 1, 2023

Recent Blog Posts By Sumaiya Hafiz

Knee Jerk, Shotgun and Kitchen Sink in Emergency Medicine

Knee Jerk, Shotgun and Kitchen Sink in Emergency Medicine

For a trainee in EM, it is useful to know about three types of cognitive practice that require caution.

While a knee jerk reaction may sometimes save time, a shotgun investigation may improve billing and a kitchen sink therapy may create the illusion of therapeutic rigor, arguably that’s all there is to it.

In reality, there is not much true value to any of these three missed approaches.

We will look at each one with a few examples and then briefly discuss below.

Knee Jerk

When I was rotating in the ED as an MS4, a visiting EM attending once told me that “adding a Type and Rh should become a knee jerk” for any patient with vaginal bleeding in early pregnancy. Whether or not taking the extra 30 seconds to scroll through the EMR for a previously documented Rh likely to be on file is a better strategy, this one is fairly simple.

Not all of our knee jerk reactions are equally simple or harmless.

I have seen adenosine being pushed before one could say “Mama” for anything from sinus tach to atrial flutter and A-fib with RVR: paramedics, physicians and even unsupervised nurses all being equally guilty. Why? Because a sustained heart rate above 180 is scary to some. And the reflex is to do something quickly because we don’t like to remain scared.

Nursing staff going straight for IV placement while forgetting not only the basic ABCs of resuscitation but even to disrobe the patient is another example. Starting any patient at 100% oxygen saturation who is short of breath on nasal cannula oxygen is yet another.

We like to do what we are trained to do well and/or what is easy. Our brains then compel us to prioritize doing it.

Once my ED team halted a verbal order for a whopping dose of colchicine blurted out to nursing by a careless consulting cardiology fellow – the patient had mentioned his ankle pain to the fellow in passing. The man was in acute renal failure and ended up with a septic ankle joint diagnosed later. Knee jerk is in part responsible for well-perpetuated ED mental formulas such as “gout = colchicine”, “fever = paracetamol”, “wheezing = albuterol” and “hypotension = 2 liter IV fluid bolus”.

The knee jerk is how we pick from our favorite antibiotics and how we generally prescribe, how we diagnose and order things on lobby and triage patients and how we even decide on CT scans and dispositions. Frequently, our hospitalist medicine colleagues will utilize the same reflex and unnecessarily or prematurely consult specialists.

On occasion, when the arrow released via a knee jerk reaction hits the bull’s eye, it feels and looks great. Knee jerk, unfortunately, is also how we assume, stereotype, over-simplify, ignore and ultimately miss.

Shotgun

This one does not have to be shot from the hip, though it certainly looks cooler that way. Often this is done thoughtfully, with a pseudo-scientific aroma to it.

I was on my MS3 internal medicine rotation when one day, the dreaded ED handed us an elderly female with a congratulatory thick paper chart, a bouquet of vague complaints and no clear diagnosis. When I asked my senior resident what we should do, the answer was a shoulder shrug and a confident “Lab ‘er up!”.

Shotgunning is not just about shooting out labs in the dark, however. It usually refers to a much wider “strategy” (actually, a lack thereof) of checking anyone for “anything” so as to not miss “something”.

Consider an ED evaluation of a headache involving some component of facial pain. Let’s order a migraine cocktail, CT and CTA of the head and neck, ESR to check for temporal arteritis; and when we find nothing, let’s do antibiotics in case of possible dental caries, otitis, mastoiditis or sinusitis. Sounds pretty thorough and terrific, doesn’t it? In fact, many patients would tend to think so. Clearly, after all that, we just could not miss something real badTM. We should remember that in EM you are worth every test that you order.

Hyperlaboratoremia and panscanosis are not the only clinical manifestations of the shotgun approach.

Though in all places, it is well-intended, there is a more buried shotgun in standardized chest pain workups, ED triage scales, pre-conceived clinical pathways and universal screenings than you may think.

Kitchen Sink

One might say that kitchen sink is the therapeutic twin of shotgun diagnostics, though one does not need to stem from the other.

The kitchen sink is how you and I treat most non-threatening and hence not easily identifiable ED rashes. As one of my professors once said: the rule of dermatology is that “if it is dry, use a wetting agent, if it is wet, use a drying agent, plus steroids and antibiotics for everyone”.

At its core, any kitchen sink approach violates two key pillars of modern medicine – evidence-based practice and personalized therapy.

Another example is the kitchen sink phase of resuscitation in a soon to be aborted CPR effort. While in the beginning, we do tend to follow certain parameters and algorithms, towards the end and well into the “futile” stage of CPR remedies like calcium, magnesium, bicarbonate, second and third anti-arrhythmic and so on all inevitably flow one after another regardless of the suspected cause of cardiac arrest or objective facts known.

While benign rashes are benign, and futile CPR is futile, most of the kitchen sink does not involve such obvious extremes. In fact, some of it is perfectly legitimized and even justified – have you ever thought of what “broad-spectrum antibiotics” in sepsis really implies?

Reasons For Need To Know

Why is knowing about the knee jerk, the shotgun and the kitchen sink ahead of time important?

First, the cognitive action patterns described are unavoidable and inescapable. It is precise because we will not be able to fully stop using all three on occasion, that we should know about them ahead of time.

Second, there is something positive and well-thought-out corresponding to the other side of each of the three behaviors:

Fundamentally, knee-jerk reactions rest on pattern recognition as the predominant cognitive pathway at work – something that physicians start to rely upon more and more as they mature. While risking the error of premature diagnostic closure (among others), pattern recognition does save time and resources. This mode is why, as some studies suggest, senior-most providers may be more effective in triage.

On the opposing side of the shotgun coin are the well-accepted mantras of keeping one’s differentials broad and of thinking outside the box. Such forced mental efforts help avoid anchoring among other cognitive errors.

Last, kitchen sink elements may indeed be acceptable in salvage type of situations or in uncharted waters, given multiple paucities in our scientific evidence and in our full understanding of physiologic processes. In such select cases, we humbly admit our limits and hope that something unknown may work at the last minute, while there is no further harm that can be done.

It would be a mistake, however, to confuse each of the positives described with the three patterns we started with when taken in their pure form.

Third, the limitations and harms encountered by not keeping the three tendencies in check are real and immediate:

  • Knee-jerk reactions do not yield beneficial results when the situation encountered is new and principally different from those experienced before, yet it has the external appearance of something familiar. Think of COVID.
  • Shotgun-galore practices subject multiple patients to unnecessary tests and to potentially harmful procedures and interventions that inevitably follow, further inflating the costs of healthcare.
  • Perpetuating myths and unmerited traditional practices, kitchen sink therapies also coach our patients into expecting both the unreasonable and the unnecessary for the next visit, undermining any accepted standard of care at its very core.

What Next?

A more in-depth discussion of all three phenomena presented would indeed be appropriate, including an investigation into any viable alternatives.

For now, I encourage all trainees to look further into the general and well-researched topic of cognitive errors in emergency medicine. 

We should also all strive to practice based on best available evidence and not to be coerced into questionable behaviors by external pressures such as performance metrics that may lurk as false substitutes for quality.

References and Further Reading

  • Frye KL, Adewale A, Martinez Martinez CJ, Mora Montero C. Cognitive Errors and Risks Associated with Provider Handoffs. Cureus. 2018;10(10):e3442. Published 2018 Oct 12. doi:10.7759/cureus.3442
  • Oliver G, Oliver G, Body R. BET 2: Poor evidence on whether teaching cognitive debiasing, or cognitive forcing strategies, lead to a reduction in errors attributable to cognition in emergency medicine students or doctors. Emerg Med J. 2017;34(8):553-554. doi:10.1136/emermed-2017-206976.2
  • Schnapp BH, Sun JE, Kim JL, Strayer RJ, Shah KH. Cognitive error in an academic emergency department. Diagnosis (Berl). 2018;5(3):135-142. doi:10.1515/dx-2018-0011
Cite this article as: Anthony Rodigin, USA, "Knee Jerk, Shotgun and Kitchen Sink in Emergency Medicine," in International Emergency Medicine Education Project, July 20, 2020, https://iem-student.org/2020/07/20/knee-jerk-shotgun-and-kitchen-sink-in-emergency-medicine/, date accessed: April 1, 2023

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: April 1, 2023

Core EM Clerkship Topics

Core EM Clerkship Topics

In the last ten years, there are few published undergraduate emergency medicine curriculum recommendations (Hobgood et al., 2009; Manthey et al., 2010; Penciner et al., 2013; Santen et al., 2014).

Current undergraduate curriculum trends recommend longitudinal and horizontal integration, and the topic lists related to emergency medicine are extensive for medical students.

In this post, we provide International Federation for Emergency Medicine and Society for Academic Emergency Medicine’s recommendations (Manthey et al., 2010; Hobgood et al., 2009).

The chosen topics can ideally be re-discussed in the clerkship during the senior years of medical school.

  • Abdominal pain
  • Altered mental status
  • Cardiac arrest and arrhythmias
  • Chest pain
  • GI bleeding
  • Headache
  • Multiple trauma
  • Poisoning
  • Respiratory distress
  • Shock

Because the length of the rotations can vary between institutions, the topics list can be extended according to the length of the clerkship and local needs.

References and Further Reading

  • Hobgood, C., Anantharaman, V., Bandiera, G., Cameron, P., Halperin, P., Holliman, J., … & International Federation for Emergency Medicine. (2009). International Federation for Emergency Medicine model curriculum for medical student education in emergency medicine. Canadian Journal of Emergency Medicine, 11(4), 349-354.
  • Manthey, D. E., Ander, D. S., Gordon, D. C., Morrissey, T., Sherman, S. C., Smith, M. D., … & Clerkship Directors in Emergency Medicine (CDEM) Curriculum Revision Group. (2010). Emergency medicine clerkship curriculum: an update and revision. Academic Emergency Medicine, 17(6), 638-643.
  • Penciner, R. (2009). Emergency medicine preclerkship observerships: evaluation of a structured experience. Canadian Journal of Emergency Medicine, 11(3), 235-239.
  • Santen, S. A., Peterson, W. J., Khandelwal, S., House, J. B., Manthey, D. E., & Sozener, C. B. (2014). Medical student milestones in emergency medicine. Academic Emergency Medicine, 21(8), 905-911.

How to make the most of your EM Clerkship

How to make the most of your EM Clerkship

Emergency Medicine has something for everyone!

Starting the Emergency Medicine (EM) Clerkship is one of the most exciting times of any medical student’s life, regardless of whichever specialty they plan on specializing in because EM has something for everyone. It is like solving all those questions that begin with ‘A patient presents to the Emergency Department with…’ but in reality, at a faster pace and with more tricky situations. This can make students feel overwhelmed, as they find themselves juggling between books and resources as to which one to follow or which topics to learn, and I am here for just that! To share the approach that helps many students get the hang of EM and make the most of their time in one of the best learning environments of any hospital.

Prepare a list of common conditions

The basic approach would be first to jot down all the problems you can think of.

Here is a list to help you get started: Core EM Clerkship Topics

There are problems that you may be heard a lot such as Chest Pain, Heart Failure, Shock (and it’s types), Acute Coronary Syndrome, Sepsis, Pulmonary edema, Respiratory Failure, Coma, Stroke, Hypoglycemia, Subarachnoid Hemorrhage, Fractures, Head Trauma, Status Epilepticus, Diabetic Ketoacidosis, and Anaphylaxis.

As every doctor you meet will always say, common is common, so always focus on things that you have heard and seen most about, read about them, make notes on their clinical features, differentials, investigations and management. Most importantly, do not forget to read about the ABCDE approach in every critically ill and trauma patient.

Brush up on your history taking and examination skills

Know what to ask and when to ask. Patients in the ED are not in their most comfortable composure, so try to practice and frame questions that provide you with just enough information to make a diagnosis in the least possible time.
The same goes for examination, never forget the basics of examination and their importance. Practice examination as much as you can and you will automatically see it come to you naturally at a faster pace. Also, do not forget focused history and physical examination is a cornerstone of EM practice and saves a lot of time.
Where investigations can help you exclude a differential, 80% of your diagnosis will be built from what you ask, what you see and what you feel. Keep in mind that if you are not thinking or looking for something, you will not see and find it. So, be suspicious of life, organ and limb-threatening problems.

Read about common ED procedures

ABG, Intubation, Central Lines, FAST Scan, Suturing, Catheter and Cannula placement are some of them. As a medical student, you will probably not be required to perform any, but it is good to have an idea about the procedures when you see them. If you can practice, then that is even better, ask a resident or intern to show you how and you can have a go yourself under their supervision! Remember, “see one, do one, teach one.”

Watch videos on examination, interpreting X-rays, & procedural skills

Youtube is an asset when it comes to medical education, make good use of it. There are also plenty of videos on the iEM website that you can watch and learn from.

Interpretation of ECG & X-rays

Google is your best friend for this! You have the list of common conditions, all you need to do is a google search on the most common ECG findings and x-rays in medical emergencies and you will be good to go. You can also always learn these from the doctors around you in the ED, as the more you see and try to interpret, the better you get at differentiating the normal from abnormal.

Books

Before the rotation

Before the rotation, read a review book, recall your basic knowledge from internal medicine/family medicine and surgery because EM almost covers all of the acute problems of those fields. Moreover, do not forget, EM is an independent specialty and has its’ own textbooks.

iEM Clerkship book is a very good source to get started with! Download Now! – iEM Book (iBook and pdf)

If you are the kind, who likes solving questions, the Pretest Emergency Medicine is a great source.

During the rotation

During the rotation – Learning what you see is the best way to keep things in your long term memory. After your shift ends, and you go home, get some rest, recall the cases of the day and read about them on Up to Date/ Medscape or any resource that you prefer, this will help you relate what you saw with what you are reading and will help you recall it better later on.

These are just a few tips to help in making the most of your EM rotation. Remember to study hard, but also practice, brush up on your communication skills, talk to patients, be there for them. The EM Clerkship prepares you for life as a doctor, as you practice every aspect of medicine during this time and learn to answer questions about acute medical problems and their severity when asked by those around you.

Cite this article as: Sumaiya Hafiz, UAE, "How to make the most of your EM Clerkship," in International Emergency Medicine Education Project, October 4, 2019, https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/, date accessed: April 1, 2023

An upside-down cake: the EM differential diagnosis

An upside-down cake: the EM differential diagnosis

How we’re different

When I was rotating on surgery as a medical student, our attending once asked of our small group what may be concerning in the differential for right upper quadrant abdominal pain. A very eager and a somewhat brash student blurted immediately: “Echinococcal cyst!” The attending replied, “Well, that’s true, but if Echinococcal cyst is the first thing you think of as a surgical consultant, you’re crazy!”

On the other hand, take a practicing internal medicine physician like my Dad. He formulates his differentials with a very different strategy, which is: what is the most likely? A chronic cough is bronchitis (even with hemoptysis), pneumonia, GERD or postnasal drip. Shoulder pain is, of course, a sprain, bursitis, or some referred cervical impingement. And so on.

Unfortunately, neither hunting for zebras (an unofficial US name for exciting but rare diagnoses) nor settling for the most common works for emergency medicine. In fact, that is how true diagnoses may get missed and patients may start dying. 

Why we are different

The EM differential diagnosis is a pyramid tipped on its head. It is therefore different from how differentials are approached by many other specialties.

In EM, we first have to think of and rule out the most severe or threatening pathology. That’s a given. But our choices have to come from among the common killers, not Martian viruses or unheard of tumors from a medical encyclopedia. 

Amoebic meningitis is exciting to encounter in your practice. But guess what? Your patient won’t have it. At the same time, for EM physicians things like pulmonary embolus, aneurysm of the abdominal aorta, subarachnoid hemorrhage and necrotizing fasciitis are everyday icons on our cognitive desktops. While less common than a common cold, these things are by no means rare.

Why it is difficult

In EM, one can rest assured that common pathology will present atypically and not quite like the textbook.

Things are further complicated by confounders, mimics and the disjunction of concern.
 
Confounders are concurrent pathologic processes that the patient already has, which tend to get worse due to any new significant disease process or general body stress. CHF and COPD get exacerbated, kidneys become insufficient, anxiety and psychoses go florid and atrial fibrillation accelerates to rapid. How do you spot sepsis or an MI, which is the true cause of it all, underneath layers and layers of abnormal vitals and test results?
 
Mimics are things that pretend to be other diseases. PE presenting with a low-grade fever and a cough, carbon monoxide poisoning posing as geriatric altered mental status, and severe sepsis arriving as chest pain, dizziness and a bumped troponin. Such has happened many times in the past and continues to happen daily at all EDs globally.
 
The disjunction of concern is when your patient is not worried about what you are worried about. They don’t want to get cancer like their neighbor, but they have never heard of a TIA or an AAA. Kawasaki disease? Why don’t you just give my daughter better antibiotics? My uncle died of a heart attack at 35, not a “bisection” or whatever you called it…So I don’t want a CT scan!
 
An EM physician’s focus on ruling out worst-case scenarios may paradoxically contribute to a patient’s distrust at the end of the encounter. The patient’s agenda is to leave knowing what disease they have, while we are often satisfied knowing which horrible things a patient does do not have.

It may take years of practice to be able to persuade someone that you have done due diligence and your professional duty by excluding a whole lot of deadly things, while the exact diagnosis still remains elusive.

Secretly paranoid, openly confident and always nice

We are confident, but also afraid. We have to think of the worst yet possible scenario for any complaint, yet of course anticipate that the actual diagnosis will hopefully be something less severe and quite common – like a migraine. After all, after most CT scans and lumbar punctures, it is not a subarachnoid hemorrhage.

In EM, we are in this perpetual struggle with having to be professionally pessimistic and paranoid on the one hand, yet emotionally supportive and reassuring for the patient on the other. I always teach my students, even nursing trainees, that no one should be leaving an emergency department more scared or anxious than when they came in.

Your job as a rotating trainee in EM is to understand and learn this exact interplay.

Homework

For your attending, but more importantly for yourself and your patients, you have to be as concerned with sepsis from PID on a 16-year-old young woman with fever and abdominal pain as you are with appendicitis. The 86 year old grandmother with Afib but on no anti-coagulation, because she falls a lot is not just TIA or CVA prone. Her embolic clots may just as well be traveling downstream, causing that intermittent or out of proportion abdominal pain called mesenteric ischemia – for which you do not have a good lab test or imaging, by the way.

Here is a brief checklist:

  • For any anatomic complaint or a chief complaint type

    think of several real worst-case scenarios that are not zebras. Can something horrible yet by no means unheard of be presenting atypically? What steps can you take to prove or disprove it?

  • Think of confounders and mimics.

    What else could be going on? Like a stack of dominoes: what happened first, what happened next?

  • Address the patient’s concerns

    while carefully and patiently pursuing your own professional agenda.

  • When it turns out to be something common or benign,

    don’t forget to discuss worrisome signs for which to return. What if you’re still wrong?

If you liked this story, you may like these too!

Cite this article as: Anthony Rodigin, USA, "An upside-down cake: the EM differential diagnosis," in International Emergency Medicine Education Project, August 26, 2019, https://iem-student.org/2019/08/26/an-upside-down-cake-the-em-differential-diagnosis/, date accessed: April 1, 2023

Core Topics for EM Clerkship

Core EM clerkship topics recommended by SAEM are ready for students. Feel free to read or listen. And, do not forget to share with your colleagues or students. Sharing is caring!

Shock

by Maryam AlBadwawi Introduction Shock, in simple terms, is a reduced circulatory blood flow state within the body. The inadequate circulation deprives the tissues of its

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Chest Pain

by Asaad S Shujaa Introduction Chest pain is one of the most common symptoms presented in the emergency department (ED), and it is worrisome because

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Gastrointestinal Bleeding

by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley Case Presentation A 61-year-old man with a history of liver cirrhosis secondary to chronic EtOH abuse presents to

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Headache

by Matevz Privsek and Gregor Prosen Introduction Headache is a subjective feeling of pain, crushing, squeezing or stabbing anywhere in the head. They are typically

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Respiratory Distress

by Ebru Unal Akoglu Case Presentation A 40-year-old female with a history of diabetes mellitus presents with a complaint of 6 days cough and muscle

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Multiple Trauma

by Pia Jerot and Gregor Prosen Case Presentation A 28-year old male was a restrained driver in a head-on motor vehicle collision. He was entrapped and

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Poisonings

by Harajeshwar Kohli and Ziad Kazzi Case An 18-year-old, previously healthy female, presents to the Emergency Department with nausea, vomiting, and tremors. She states 45

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Cardiac Arrest

by Abdel Noureldin and Falak Sayed Quick link to Spanish Version Introduction A 23-year-old female was brought into the emergency department. Her frantic family members

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Altered Mental Status

by Murat Cetin, Begum Oktem, Mustafa Emin Canakci  Case Presentation An 80-year-old female presents to the emergency department with a tendency to sleep (altered mental

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Abdominal Pain

by Shaza Karrar Case Presentation A 39-year-old female presented to the emergency department (ED) complaining of right-lower-quadrant (RLQ) pain; pain duration was for 1-day, associated

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