The Importance of the Emergency Medicine Clerkship (2023)

April 17, 2023May 3, 2023 ~ iEM Education Project Team ~ Leave a comment

by Linda Katirji and Farhad Aziz

Introduction

The emergency medicine (EM) clerkship typically takes place during the fourth year of medical school. However, some medical schools may have an optional elective or a core rotation during the third year. Whether or not you plan to specialize in emergency medicine, the rotation is an important part of your medical education that will help you develop unique skills. The emergency room is a unique learning environment which is different than any other setting in the hospital. It provides clinical opportunities that are largely unavailable in other clerkships and rotations, and one of the few places you will encounter a completely undifferentiated patient. During residency, many specialties will also spend a significant amount of time in the Emergency Department (ED). This may be within a structured EM rotation, or while admitting or seeing patients for a certain medical or surgical service. Therefore, it is important to gain an understanding of the flow of the ED as well as the unique thought process that must be employed with emergency department patients. This chapter will discuss some of the unique aspects of the emergency department, some of the skills to acquire during the EM clerkship, as well as how to best be successful and take the most away from your rotation.

Unique Aspects of The Emergency Department Environment

The high volume and acuity of patients in the ED create a time pressure and forces physicians to employ a different style of practice than in most other settings. A steady stream of patients, some of whom may require immediate life-saving measures, means that many times there is little to no time to review history or any medical records prior to evaluating a patient. Most of the time you will need to assess a patient without knowing anything about their background. Therefore, it is important to gain an understanding of what the most important pieces of information to gather are for each patient. This can be difficult since most patients will arrive with completely undifferentiated complaints. Some common examples of these undifferentiated complaints are “chest pain” and “abdominal pain”, where the etiology can range from completely benign to immediately life-threatening, or “weakness”, where the differential diagnosis includes essentially the entire spectrum of medical pathology.

This undifferentiated patient is the standard in the ED. However, they can present in any medical setting. It is important to learn the thought process and develop a strategy for thinking through these types of patients whether you plan on a career in EM or not. Emergency physicians (EPs) must employ and master a completely different style of practice than most physicians. EPs must always think worst case scenarios for each chief complaint and must be knowledgeable and comfortable with associated the workup and treatment. A good example of this is chest pain. Even though many times the complaint of “chest pain” is found to be caused by a non-acutely life threatening etiology, EPs must immediately think of six fatal causes of chest pain: acute coronary syndromes, aortic dissection, pulmonary embolism, pericardial tamponade, pneumothorax, esophageal rupture. Additionally, ED doctors must use a different thought process in determining the disposition, or outcome, of the patient. The ED doctor essentially wants to avoid sending a patient home that is not safe to go home, where as a consultant, or admitting service, does not want to admit a patient who does not need be admitted. This may seem trivial, however this difference in thought process can occasionally create tension between the ED and admitting services.

Teaching in the ED is different than most other settings in the hospital as well. There is usually no time set aside for formal rounds, so most teaching is done actively at the bedside or at the time the student or resident presents the patient to the attending physician. Many times, attending physicians will pick out “teaching points” for each patient. Each physician will have a different teaching style. Your learning will generally be more active than passive, and likely more short and frequent rather than one long teaching sessions or lecture on rounds.

Lastly, the ED is a great place for medical students and first-year residents to learn to take responsibility for their patients. Students often time have an increased level of autonomy compared to other rotations. Many times, the student will be the first person to assess the patient, which is a very important role. It is important to learn to distinguish whether a patient is “sick” or “not sick”, and whether or not at first glance you think this patient could go home or needs to be admitted no matter what the diagnosis may be.

Unique Skills To Take Away From EM Clerkships

Emergency medicine is a wonderful rotation that exposes you to not only different patient populations but also a variety of pathology and diseases. This diverse collection of patients and pathology lends emergency medicine residents and students a unique opportunity to gain a mastery of different skills. These skills range from a knowledge of how to approach critically ill patients, gaining procedural skills, reading radiographs and CT scans, performing ultrasounds and much more.

Often you may be busy doing different tasks when you must drop everything to manage a critically ill patient. This is one of the exciting aspects of emergency medicine. These patients offer students a great opportunity to learn the principles of resuscitation, such as managing airways and circulatory collapse, identifying causes for the patient’s decompensation, and instituting the appropriate treatment. Whether you pursue a career in emergency medicine or choose to pursue a different specialty, critically ill patients will likely always be a part of your patient population. Understanding how to approach and stabilize these patients is an important part of being a physician.

Though learning the art of resuscitation is a vital part of the EM rotation, this is also an opportunity to gain competence in a variety of procedures. Whether you intend to pursue a career in pediatrics, internal medicine, orthopedics, general surgery or any other specialty, your rotation through the ED will expose you to a wide array of procedural skills ranging from intubating and placing central lines and arterial lines in the critically ill to performing lumbar punctures and fracture reductions in children. Autonomy is encouraged with procedures, and you will have the opportunity to improve your skills and techniques under the guidance of residents and attendings. EM is a very hands-on specialty. You should take advantage of medical student and resident didactics as an opportunity to learn. These usually consist of lectures on different subjects but also may include ultrasound practice, procedure labs on mannikins or cadavers and simulation. This will give you an opportunity to practice and provide better patient care during your rotation.

In addition to becoming familiar with a wide array of procedures, your EM clerkship will also allow you to familiarize yourself with a variety of imaging modalities ordered in the ED. There is a tremendous amount of pathology found in the ED which lends itself to a range of imaging. Whether it be learning to perform bedside ultrasonography on a crashing patient or simply learning how to approach reading a chest x-ray or a CT scan of the abdomen on your own, your EM rotation will give you plenty of opportunities to become proficient in a skill you will need later in your career.

Though your EM clerkship gives you exposure to a tremendous amount of skills which will help you become a savvy doctor, no skill is more important than compassion and humility. Every day, you will meet patients on the worst day of their life. Many will have gone through traumatizing experiences, or have a life changing chronic condition, or be in a severe amount of physical or emotional pain. Realizing this and comforting patients and their families is paramount to your success as a physician. You will also encounter a variety of consulting physicians. Speaking with consulting physicians about a patient is an art form in itself that EM physicians must master. While most consultants will be polite and professional, its not uncommon in to meet push-back from a consultant. Occasionally, some may be out right rude. Having a general understanding that they all have knowledge that you can learn from will set you up for a successful career in medicine.

How To Be Successful on Your EM Clerkship

Many of the of the same qualities that allow you to be successful in other rotations will help you to be successful in the ED. It is important to be hardworking, proactive, and knowledgeable. Keep a close eye on your patients, re-evaluate them frequently, and make sure to follow up on any results, including labs, imaging, and any recommendations by consultants. The unique aspects of the ED and EM clerkship discussed previously mean the first few shifts may be stressful and seem chaotic and hectic. For every student and resident that rotates through the ED there is a significant learning curve – with each shift you spend in the ED, things will feel less and less daunting. It’s important during this time that you know your limitations and what you are comfortable and not comfortable with. Many times you will be the first person to assess the patient. You should have a low threshold for alerting an upper-level resident or attending if the patient appears to be sick, or if they present with a complaint you are uncomfortable with. At the same time, you should be confident in what you do know and take the opportunity to learn how to diagnose, treat, and manage your patient.

The best way to build confidence during your EM rotation is to gain experience and knowledge. Try to be proactive in learning new procedures or treatments with attending or resident assistance. Additionally, it’s very important to keep up with reading and studying. In the emergency room, you may see medical pathology you’ve only read about and will be expected to know how to diagnose and treat these diseases properly. When you have the time, use the resources you have at your disposal and look things up before presenting to your resident or an attending, and have a plan to disposition (ie, admission or discharge) already made for the patient.

Good communication is essential for a physician in any specialty, and in the ED, it is an imperative skill to have. You will be working with a large team of nurses, technicians, consulting doctors, social workers, and paramedics, just to name a few. When you see a patient, it is a good idea to speak with the nurse before you enter the room to gain a better understanding of the patient’s complaint, as well as gather any information that was relayed by EMS. By communicating the plan of care to the nurse and supporting staff, you will not only improve patient care and reduce mistakes but also forge relationships that will enrich your experience in the ED. In acute settings such as a patient code or rapidly decompensating patient, good communication with the entire team is critical. As a medical student or rotating resident, this is a great time to practice and improve your communication skills in these acute settings under the direction of residents and attendings.

Your EM rotation will be an exciting, unique experience during medical school and residency. Whether you plan to specialize in EM or not, you will learn many procedural skills, improve your own method of diagnosing and treating patients and be able to practice a different method of medical decision making.

Authors

Linda KATIRJI

University of Kentucky, Department of Emergency Medicine

Farhad AZIZ

The Ohio State University, Department of Emergency Medicine

Listen to the chapter

Cite This Article

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

Cite this article as: iEM Education Project Team, "The Importance of the Emergency Medicine Clerkship (2023)," in International Emergency Medicine Education Project, April 17, 2023, https://iem-student.org/2023/04/17/the-importance-of-the-emergency-medicine-clerkship-2023/, date accessed: October 1, 2023

2018 version of this topic – https://iem-student.org/the-importance-of-the-emergency-medicine-clerkship/

References

EMRA and CORD Student Advising Guide (https://www.emra.org/books/msadvisingguide/msag/)
EMRA Medical Student Page (https://www.emra.org/students/)
The Emergency Medicine Clerkship Primer (https://www.saem.org/docs/default-source/saem-documents/students/em-clerkship-primer_0_0.pdf)

Reviewed By

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.

Thinking Like an Emergency Physician (2023)

March 20, 2023May 3, 2023 ~ iEM Education Project Team ~ Leave a comment

by Joe Lex

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

Dan Sandberg, BEEM Conference, 2014

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 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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Cite this article

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: October 1, 2023

2018 version of this topic – https://iem-student.org/thinking-like-an-emergency-physician/

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Intern Survival Guide – ER Edition

May 26, 2021April 30, 2021 ~ Sumaiya Hafiz, UAE ~ Leave a comment

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: October 1, 2023

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Approach to Acute Cough in Adults

November 4, 2020October 30, 2020 ~ Sheza Qayyum, Canada ~ Leave a comment

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
Gastroesophageal 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?

History

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?

Physical Exam

Vitals
HEENT exam (head, eyes, ears, nose, and throat)
Respiratory exam
Cardiac exam, including JVP

Laboratory Tests

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)

Imaging

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.

References

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.

Cite this article as: Sheza Qayyum, Canada, "Approach to Acute Cough in Adults," in International Emergency Medicine Education Project, November 4, 2020, https://iem-student.org/2020/11/04/approach-to-acute-cough-in-adults/, date accessed: October 1, 2023

Triads in Medicine – Rapid Review for Medical Students

June 12, 2020June 7, 2020 ~ Sumaiya Hafiz, UAE ~ Leave a comment

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

How to make the most of your EM Clerkship

October 4, 2019October 4, 2019 ~ Sumaiya Hafiz, UAE ~ Leave a comment

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

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.”

list of selected procedures

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.

How to read c-spine x-rays

How to read chest x-rays

How to read pelvic x-ray

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.

FREE DOWNLOAD

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: October 1, 2023

New Section is Uploaded – Emergency Medicine Clerkship: Things to Know

August 29, 2018August 28, 2018 ~ iEM Education Project Team ~ Leave a comment

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.