- 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.
Cough is one of the most common complaints presenting to any emergency physician or primary care practitioner – whether it is the chief complaint or an associated symptom. An acute cough is one that has been present for less than three weeks. In the era of COVID-19, a patient presenting with an acute cough can be alarming and scary. So, now more than ever, it is important to develop a strong diagnostic approach to the acute cough, which is largely a clinical diagnosis.
Differential Diagnosis of Acute Cough*Indicates the most common causes of acute cough.
|Cause||Example||Symptoms / warning signs|
|Infectious (viral/bacterial)||Upper respiratory tract infection aka common cold*||Rhinorrhea, nasal obstruction, sneezing, scratchy/sore throat, malaise, headache, and no signs of consolidation|
|Acute bronchitis*||Recent upper respiratory tract infection, and absence of COPD, and absence of high fever or other systemic signs|
|Influenza||Fever, sore throat, nasal congestion, myalgia, headache, and no signs of consolidation|
|Pneumonia*||Fever, tachycardia, tachypnea, consolidation signs on respiratory exam, and mental status change in patients >75y old|
|Pertussis||Whooping cough and cough-emesis|
|COVID-19||Fever, non-productive cough, fatigue, dyspnea, and/or other less common symptoms such as sore throat, diarrhea, headache, skin rash, and anosmia|
|Post-nasal drip aka upper airway cough syndrome||Post-nasal drainage sensation, need to clear throat, and rhinorrhea|
|Allergic rhinitis aka hay fever||Itching and watering of eyes, rhinorrhea, pruritis|
|Exacerbation of a pre-existing chronic disease||Exacerbation of Asthma||History of episodic wheezing, non-productive cough, dyspnea, reversible air-flow obstruction, allergen exposure or triggered by exercise|
|Exacerbation of COPD||Smoking history, dyspnea, signs of obstruction on respiratory exam i.e. decreased breath sounds, and irreversible air-flow obstruction|
|Exacerbation of CHF||Dyspnea, orthopnea, peripheral edema, gallop rhythm on cardiac exam, and elevated JVP|
|Drug-induced||ACE inhibitor use||Non-productive cough, tickling or scratchy sensation in throat typically arising within 1 week of starting medication|
reflux disorder (GERD)
|Heartburn, regurgitation, dysphagia, and cough is more prominent at night|
|Other pulmonary causes||Pulmonary embolism||Clinical signs and symptoms of DVT, dyspnea, tachypnea, tachycardia, pleuritic chest pain, immobilization for 3 or more days, surgery in the past 4 weeks, history of DVT/PE, hemoptysis, and malignancy with active treatment in the past 6 months|
|Lung cancer||Smoking history, new change in cough, hemoptysis, dyspnea, night sweats, weight loss, and signs of focal obstruction on respiratory exam i.e. decreased breath sounds|
|Foreign body aspiration||Dyspnea, inspiratory stridor, choking, and elevated risk in children|
|Acute inhalation injury||History of exposure to smoke (e.g. in firefighters, thermal burn victims) or chemicals (e.g. chlorine, ammonia)|
|Bronchiectasis||Large volumes of purulent sputum, dyspnea, wheezing, and chest pain|
|Interstitial lung disease||Non-productive cough, dyspnea, fatigue, weight loss|
Picture the scene: A 23-year-old female presents to the emergency department with a cough that has been ongoing for one week. What are your next steps?
- Confirm the duration and timing of cough
- Nature of cough, i.e. whooping, hemoptysis, and productive vs non-productive?
- Presence of the following associated symptoms: fever, dyspnea, sore throat, headache, chest pain, heartburn, rhinorrhea, facial pressure/pain, nasal congestion, or weight loss
- History of any chronic lung disease (i.e. asthma, COPD), allergies, CHF, or immunosuppression?
- Smoking history?
- Medication history, i.e. ACE inhibitor use?
- HEENT exam (head, eyes, ears, nose, and throat)
- Respiratory exam
- Cardiac exam, including JVP
- Send for COVID-19 swab according to your hospital’s guidelines
- Order CBC if suspecting infection
- Order ABG if dyspnea present or life-threatening cause of acute cough suspected
- Order sputum culture if suspecting bacterial pneumonia
- Spirometry if need to differentiate between obstructive lung disease (e.g., asthma, COPD) and restrictive lung disease (e.g., interstitial lung disease)
- Consider starting with a Chest X-ray if red flags for serious pathology are present >> dyspnea, hemoptysis, chest pain, weight loss, immunosuppression, significant smoking history, elderly or at risk of aspiration, tachypnea or hypoxemia, abnormal cardiac or respiratory exam, or sepsis.
- If suspecting foreign body aspiration, need to order bronchoscopy
Please note that treatment of the conditions that may cause acute cough are not discussed in this blog post, but can be found through medical resources such as those in the references section. Treatment for acute cough often requires treating the underlying cause.
- Boujaoude ZC, Pratter MR. Clinical approach to acute cough. Lung. 2010;188 Suppl 1(Suppl 1):S41-S46. doi:10.1007/s00408-009-9170-6
- Holzinger F, Beck S, Dini L, Stöter C, Heintze C. The diagnosis and treatment of acute cough in adults. Dtsch Arztebl Int. 2014;111(20):356-363. doi:10.3238/arztebl.2014.0356
- Madison JM, Irwin RS. Cough: A worldwide problem. Otolarynogol Clin North Am. 2010 Feb;43(1):1-13, vii.
- Strong Medicine. An Approach to Cough. Published 25 March, 2018. https://www.youtube.com/watch?v=LDMEtNXik-A
- University of Toronto. Cough and Dyspnea. 2015. http://thehub.utoronto.ca/family/cough-and-dyspnea/ Accessed 17 August, 2020.
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
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
Fever + Headache + Neck Stiffness
24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex
25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia
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
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.
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.
Emergency Medicine Clerkship: Things to Know selected from SAEM and IFEM undergraduate curriculum recommendations are uploaded into the website. More specific disease entities are on the way.
by Linda Katirji, Farhad Aziz, Rob Rogers Introduction The Emergency Medicine (EM) clerkship typically takes place during the fourth year of medical school. However, some