- 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.
How do you remember the emergency department (ED) that trained you? Could it be that you have learned a lot more than just medicine there? Between worrying about the delayed laboratory report and explaining the need to rule out a myocardial injury to a visitor of a patient with peptic ulcer disease, you might have picked up other attributes. Subtle traits that have nudged your personality. Remembering the ED where I did my internship sparks nostalgia and makes me want to speed up my typing. As if I need to attend to something else right after this. Hopefully, I’ll give you a glimpse of what putting on different lenses can show even when we look at the same object.
Peeling yellow paint, some old cracks in the wall, and an acute sense of urgency lingering in the air are what I remember of the department. Patan Academy of Health Sciences has an ED where confused students scratching their heads to the witty professors’ question takes you to your own golden days. A subtle grin on the wise face of a grey-haired professor eagerly waiting for the next wrong answer makes you want to reach out to your old mentor. A know it all student on the verge of blurting out the answer physically holding himself behind makes you wonder what that one classmate of yours is doing these days. It is a place where teaching, helping people, running against time and having fun while at it, blends into an experience of a lifetime. Stories of eased pain, dodged suffering and narrow escapes from grave aliments enrich the history of the department.
One fine evening in the department as an intern I found myself seated in the doctor’s station, a rare but insightful experience. I found myself pondering about the lessons I can take from this part of the hospital: not just medical knowledge but lessons I can share with people from different facets of life. Below I list the common situations or sayings used in a typical ED and try to translate it for use in day to day life.
Think horses before zebras but watch out for zebras that can fly
A patient with mild fever, chest pain, and some respiratory distress probably has some sort of URTI. But the very fact that he/she landed up in the ED makes the doctor order an ECG because of the chest pain. The doctor will, of course, be leaning towards a more common diagnosis. Ruling out a diagnosis with grave prognosis, however, will be among the top priorities.
This can translate into studying common exam materials while also being aware of the zebras. Zebras show up rarely, but when they do, they tend to be stubborn. Be aware of the topics that don’t usually show up in your exam but impact the outcome when they do. We can also borrow this idea while thinking about anything in general. We tend to assume the worst, but when your date is late to dinner, it probably is just the busy traffic.
Communication is the key
A medical officer reads the patient’s history to the professor using as few words as possible, pertinent negatives and a precise format. The information and condition of the patient are conveyed very accurately. When reporting history, we aim for effective communication at its best.
I wonder how many day-to-day problems can be solved if only we communicated that efficiently outside of history taking and reporting. Using clear words, very few fillers and addressing what we don’t mean beforehand can help in getting the intended message across.
The most critical patients that visit Patan Hospital head for the ED. Recognizing them and treating the ones who need immediate attention is the second nature of a good emergency physician. Likewise, being able to focus on the most critical aspects of one’s life can be an attribute worth borrowing from the department.
How many times do we complain that we just do not have enough time to do things that are important to us? It’s mostly about deciding what comes first.
This sort of ties into the previous one. Most experienced physician attends the most critical patient. More nurses are allocated to and the best USG machine is used in the red triage area. Time, money, physical or mental effort all are resources we use to get tasks done. Sometimes success differs from failure, not in how much effort is put but where it is used. Determining which task is most resource-intensive or most productive can be a worthwhile idea to learn from the ED.
Did you check your tools?
Monitor connected to a gradually stabilizing patient beeps rapidly, indicating a sudden collapse. As you run towards the patient with your ACLS neurons firing at a rate more rapid than the patient’s declining pulse, do take a look if the pulse oximeter is connected correctly. Translated in the world where things go south more frequently than not, decide if it is a perceived problem or a real one. How many times have you let yourself go into flight or fight mode only to realize that the threat wasn’t even there?
Give thiamine before glucose
Hypoglycemia kills. Glucose save lives. Even then, giving thiamine before glucose is the norm in most EDs. The biochemistry behind is simple; thiamine is a cofactor used by many enzymes in glucose metabolism and depleting more thiamine can cause Wernicke Korsakoff disease. Look at it with the lens of a student who needs to start preparing for an exam. Determine your thiamine (proper sleep, good food, exercise, enough water and probably mindfulness). Only then glucose supplementation (studying) will yield results.
The loudest screamer isn’t always suffering the most
“How do you triage when there are more people than you can attend to?” asked a professor. The answer was funny but made a point firmly. “You should ask the most critical patients to come forward. Then you attend those that are left behind!”. The idea being; sickest of them all won’t even be able to advocate for themselves. Similarly, we can be tactful when overwhelmed by problems. Try to come up with ideas to segregate the screamers (problems that seem to be the biggest) from the sickest (actual problems).
Know your limits and ask for help
We manage acute exacerbation of COPD in the ED. Not all patients that feel relieved are discharged from there. Some patients require medical consultation and transfer. This, in no way, means that the ER physicians are incompetent in managing the disease throughout. Rather it is the evidence of understanding the job description and trust in the system as a whole. Asking for help when need be is critical to our wellbeing. Being able to ask for help shows courage and humility above all.
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.
Reflections by Vijay Nagpal and Bret A. Nicks
While many believe the environment of care is the greatest limiting factor as opposed to quality communication, literature would suggest otherwise. Establishing a positive patient-provider relationship is essential for patient care. One must recognize that while you may not be able to solve the patient’s condition or chronic illness, using effective communication skills and providing a positive patient experience will assuage many patient fears (Mole, 2016). Keep in mind, in general, patients remember less than 10% of the content (what was actually said), 38% of how you say it (verbal liking), and 55% of how you look saying it (body language) (Helman, 2015).
Effective provider communicators routinely employ these 5 Steps
We know it. People can sense the disingenuous person – whether it is a gut feeling or through other senses. Try to see the situation from the patient’s perspective, and it will ensure that you are acting in his best interest and with integrity.
As emergency providers, we are interrupted more than perhaps any other specialty. However, for the few moments that we are engaged with the patient or his family, be all in. If there is a planned interruption upcoming, make it known prior to starting a discussion. Be focused on them and the conversation; value what they have to share. At the end of your encounter, briefly summarizing what the patient has told you can help to reassure the patient that you were listening and also give them the chance to clarify discrepancies.
To effectively communicate, one must listen more than he talks. After introducing yourself, inquire about the patient’s medical concern; give them 60 seconds of uninterrupted time. Most patients are amazed and provide unique insights that would otherwise not be obtained. Once the patient has provided you with his concerns, begin asking the specific questions needed to further differentiate the care needed. By asking questions and allowing for answers, you make it about them and give them an avenue to share with you what they are most concerned about, enabling you to address those concerns.
Given the nature of the patient-provider relationship in emergency medicine, building trust is essential but often difficult. Building trust is like building a fire; it starts with the initial contact and builds with each interaction. Trust is also built on engaging in culturally acceptable interactions (Chan, 2012) such as a handshake, affirming node, hand-on-shoulder, or engaging posture.
Ensure that at the end of your initial encounter you have established a clear plan of care, what the patient can expect, how long it may take, and when you will return to reassess or provide additional information. Doing this also allows the patient to be more involved in his care and ask further questions regarding his workup and treatment plan. Additionally, helping the patient to understand what to expect while in the department can help to alleviate fear associated with unannounced tests or imaging studies, especially when these tests may require him or her to be temporarily taken out of the department (e.g., a trip to the CT scanner).
Many of these concepts have been identified in patient satisfaction and operational metrics. In one study, wait times were not associated with the perception of quality of care, but empathy by the provider with the initial interaction was clearly associated (Helman, 2015). In addition, patient dissatisfaction with delays to care is less linked to the actual time spent in the ED and more with a to set time expectations about the care process, a perceived lack of personal attention, and a perceived lack of staff communication and concern for the patient’s comfort.
To learn more about it
- Nagpal V, Nicks BA. Communication and Interpersonal Interactions. In: Cevik AA, Quek LS, Noureldin A, Cakal ED (eds) iEmergency Medicine for Medical Students and Interns – 2018. Retrieved February 15, 2019, from https://iem-student.org/communication-and-interpersonal-interactions/
- Mole TB, Begum H, Cooper-Moss N, et al. Limits of ‘patient-centeredness’: valuing contextually specific communication patterns. Med Educ. 2016 Mar; 50(3):359-69.
- Helman A. Effective Patient Communication. Available at: http://emergencymedicinecases.com/episode-49-patient-centered-care/ Accessed December 18, 2015.
- Chan EM, Wallner C, Swoboda TK, et al. Assessing Interpersonal and Communication Skills in Emergency Medicine. Acad Emerg Med 2012; 19:1390-1402.