Category: Resident Doctor

A Simplified Guide into Emergency Medicine – UK

A Simplified Guide into Emergency Medicine
~ Nadine Schottler, Great Britain ~ Leave a comment

The great thing about going into emergency medicine (EM) is that it allows entry into the program at various points of your career. So whether you know right off the bat following your two foundations years or whether it takes you a couple of years to make a choice, there is a straight pathway into the speciality (give or take a bit more competition!).

Acute care common stem (ACCS)

The most common entry route into emergency medicine from your foundation years is through the Acute care common stem (ACCS). This will be a 3-year training program and so becomes your CT1-3 years. This will comprise four six-month rotations in Intensive care medicine (ICM), emergency medicine (EM), anesthesia, and acute medicine (AM). Following this, there will be a one-year focus on EM and pediatric emergency medicine (PEM). In terms of examinations, the major ones that need to be completed are the MCEM Part A before the CT3 year and the MCEM Parts B and C before progressing to higher specialty training (ST4).

Defined route of entry into EM training (DRE-EM)

If one doesn’t do the ACCS and decides they want to enter EM in their ST3 year, this can be done view the DRE-EM. For the two years before entry into the DRE-EM at ST3, you need to have a minimum of 2 years of experience in substantive EM posts (which exclude any done during your foundation years). In addition, one of these posts needs to have been in the UK in the previous four years. Examples of such posts could be a core trainee level in an ACCS specialty (anesthesia, EM, ICM, AM), which at the end of the pathway would give you a Certificate of Completion of Training (CCT), or in core surgical training, which would give you a Certificate of Eligibility for Specialist Registration by the combined program route (CESR CP). Your ST3 year following acceptance into the DRE-EM can take 18 to 24 months, depending on how quickly competencies are met to enter ST4. 
 
Before entry into their ST4 years, trainees will be required to have completed the EM specialty-specific examinations before progressing into ST4:
• MCEM Part A or MRCS (Latter for DRE-EM trainees only) 
• MCEM Parts B and C
 
At the end of this training, all trainees will be required to complete the FCEM exit example before their awarded their CCT.  

Higher Specialty training (HST) in EM

This is one of the pathways into EM that can be taken following CT3/ST3. Entry at this point is by a selection through a national recruitment process. From this point, HST trainees can also apply for subspecialty training posts, such as PEM or prehospital emergency medicine. This training post doesn’t have to be full-time (i.e., done over two years instead of one year).

This simplified pathway can be seen in the figure below.

However, your route into EM isn’t always straightforward; you might be considering taking a detour, so it’s important to remember that there are backways into EM as well, and not everything will have been covered here! So make sure to check out the ACCS 2021 curriculum guide or the RCEM website for more details.

Further Reading

Cite this article as: Nadine Schottler, Great Britain, "A Simplified Guide into Emergency Medicine – UK," in International Emergency Medicine Education Project, November 8, 2021, https://iem-student.org/2021/11/08/a-simplified-guide-into-emergency-medicine-uk/, date accessed: March 24, 2023

Intern Survival Guide – ER Edition

Intern Survival Guide - ER Edition
~ 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: March 24, 2023

Recent Blog Posts By Sumaiya Hafiz

Things You Should Know Before Your First ED Shift

Things You Should Know Before Your First ED Shift
~ Ibrahim Sarbay, Turkey ~ Leave a comment

I recently posted a question to the Twitterverse:

“Imagine that an Emergency Medicine intern asked you for advice before his/her FIRST SHIFT. What would be your FIRST ADVICE?”

I also raised the same question in Turkish. In a couple of days, I received nearly 100 answers from reputable names of Emergency Medicine working worldwide. I highly benefited from these advice, and I think that our site’s valuable readers can also benefit. I tried to select the most inspiring ones and divided them into main categories. Under each advice, you can find the name of the tweet owner and the link to the original tweet. Let’s start.

Core

Enjoy being on the frontline by helping patients who are seeking your help in their most difficult time. This is a great privilege and responsibility that we should never forget.

Arif Alper Cevik (@drcevik) Tweet

Never forget what a privilege and responsibility it is that people don’t know you ask for your help on the WORST DAY OF THEIR LIFE.

Amal Mattu (@amalmattu) Tweet

In the Emergency Department, you may be worried about 'why am I here?' one day, but you may think that you are doing the best job in the world another day. Now you have a lifetime which every day and every patient is different. Love your profession EVERY WAY, glorify knowledge and skill, and always be at peace with your job.

Başak Bayram (@basakdr) Tweet

Education

Never be afraid to say, "I don't know." It's why you're here to be taught. If you already knew everything, then you wouldn't need residency.

Justin Hensley, (@EBMgoneWILD) Tweet

Trust yourself as if you know everything, try to learn as if you know nothing.

@cear_slan Tweet

Want to get smart? Do 2 things: 1) Read up on at least 1 patient every shift. 2) Ask lots of questions to residents, attendings and consultants.

Amal Mattu (@amalmattu) Tweet

Feel free to ask me (or another senior) about anything (/everything). When I was at that stage I wish I’d asked more. I suspect some people think asking is a sign of ignorance or weakness. Actually, it helps us to be safe & to appreciate other perspectives.

Rick Body (@richardbody) Tweet

This is the Emergency Room; this is the lion’s den; first, you have to protect yourself, and you will do this with your knowledge. So don't think ‘I'll practice, I'll fill my knowledge gap in 3-5 months', sit down, and read the textbook.

Göksu Afacan Öztürk (@Goksu_Afacan) Tweet

First compel yourself to read at specific points, and gradually you will find your appetite for reading. You are the one primarily responsible for your education!

@ChannelAziz Tweet

Never feel shy to ask or say I don't know. It's your chance to make mistakes and learn, share the knowledge you have and don't keep it to yourself.

Lara Sulaiman (@Dr_Lara) Tweet

Of course, you cannot know everything, but you can start learning.

Ozlem Guneysel (@oguneysel) Tweet

80% of “KNOWLEDGE” is "INTEREST"

Ayhan Özhasenekler (@Aozhasenekler) Tweet
Resilience

Resilience

The Emergency Medicine career is a marathon, not just the first few years of residency. Don't waste your energy inordinately for things you can't fix. Invest in the future self.

Can Özen (@cozenmd) Tweet

When you dance with the bear you can't stop until the bear wants to stop.

Nurettin Özgür Doğan (@DrOzgurDogan) Tweet

Calm down. Every shift eventually ends.

Mustafa Ercan Günel (@mercangu) Tweet

Rest and eat, whenever you get the opportunity. The Emergency Room is like a HIIT, you need to slow down first to speed up.

Burcu Yılmaz (@Burcu_Yilmazzz) Tweet

If you are a parent, sleep when the child sleeps.

@pekinipeklisi Tweet
Empathy

Empathy

Don’t judge patients or consultants without walking a mile in their shoes.

Amal Mattu (@amalmattu) Tweet

Think of every patient as your relative. Balance your professional authority with your kindness.

@damkmiyenses Tweet

Communication is important. Tell the patient and one of his/her relatives what you already did and what you plan to do, and ask if there is anything they want to ask.

Altuğ Kanbakan (@prothemanes) Tweet

Peter Rosen once said, “Nobody woke up this AM decided to ruin your day.” Happiness is YOUR choice. Be happy, stay positive.

Amal Mattu (@amalmattu) Tweet

Remember, when you see a patient in the middle of the night who requests you to apply his/her prescribed topical cream on his/her back because –apparently- he/she can’t, that person is the joy of the night.

@dogu6 Tweet

Follow up on your patients. This will reinforce your learning. Call patients at home to see how they’re doing. They will love it, and it reminds you of why you chose this profession.

Steve Richards (@srichmd) Tweet

Remember to acknowledge that you most likely are a stranger to your patient. It only takes a few minutes to reassure someone that you are there to help them through their ER experience as a team. We tend to forget this in the busy ER.

Anél Pelser (@PelserAnel) Tweet
Values

Values

Nobody expects you to know much (yet). But it is expected you to be 100% reliable. Never EVER EVER EVER lie. If you don’t know something or you don’t do something, be honest.

Amal Mattu (@amalmattu) Tweet

Your attitude to this advice will determine your path through our specialty. The blindingly following advice will bring as much peril as ignoring it all. Emergency Medicine requires you to consider impacts on patients, professionals & the populations - no one approach fits all.

Damian Roland (@Damian_Roland) Tweet

Never EVER EVER EVER be arrogant. You will be wrong many times in your career. Learn humility NOW.

Amal Mattu (@amalmattu) Tweet

What I like most about emergency medicine is how it allows us new perspectives every day. In the pandemic, we are treating the same disease all the time, but each patient and their family brings a different story, and every time I feel more humble in the face of life, the disease, and the future. Being in a LIMC country can be so challenging, so painful to treat and suffer along with inequalities and lack of resources... But we have the opportunity to be our best, as I said yesterday to my residents: we don’t have the best hospital, but we can be our best and give the patient what they may not have in the best hospital: treatment with dignity and respect and love. For me, being able to show my patients that I care, and receiving their gratitude has been undoubtedly the only possible prevention of Burnout. So I would say: Our specialty is beautiful, the opportunity for growth is vast, but it takes humility and perseverance to complete this journey.

Jule Santos (@julesantosER) Tweet

Never allow senior residents of other departments to treat you as if you are their junior.

Dr Erdi Kadir Y. (@DrEKYacil) Tweet

Our fingers are not equal, and so are the attendings whose hands you train on are not the same nature. There is the gentle one who loves you and there are critics who believe that development comes only with criticism and a dose of pain. Your job is not to try to classify them but to do what is required of you and to benefit from everyone.

@ChannelAziz Tweet

We want you to be the brain of a machine in which none of its cogs can work properly. Sometimes, even if you don't know how to swim, you will find yourself in the ocean surrounded by the waves, but most of the time, in the hardest moments, you will find a huge army with you. Welcome...

Barış Murat Ayvacı (@emresuspack) Tweet

If you think a senior is wrong about something, give him evidence, but don’t be obstinate...

Ali Kaan Ataman (@erdrkaan) Tweet

You may be untutored, but never be uninterested. Because knowledge definitely comes to those who have interest.

Mustafa Ipek (@dr_mustafaipek) Tweet

Appear weak when you are strong and strong when you are weak. Look weak when strong; look strong when weak. Also don't forget to look at vital signs 😉

Osman Avşar Gül (@mefisto_avsar) Tweet

Don’t be a d*ck.

Rob Rogers (@EM_Educator) Tweet

Enjoy your junior days, qualify for your senior days.

Agit Akgül (@DrAgitAkgul) Tweet
Patient Records

Patient Records

(Carefully) Fill out the patient records. What will save you from everything are these records.

@dferek Tweet

Spoken words fly away, written words remain. Record everything...

Şervan Gökhan (@servangokhan) Tweet

What is not written is deemed not done. First, protect yourself and then protect the patient. Choose a good role model.

Ozge Duman Atilla (@ozgedumanatilla) Tweet

Workup

No workup can replace a good physical examination.

Erdal Demirtaş (@Erdal_DD) Tweet

Never order a test that you won’t check the results.

Eyupkaraoglu (@drekaraoglu) Tweet

Know your tests! Know their rough sens/spec and when to trust them (and more importantly, when NOT to trust them)!! No test is 100%, and all are context-dependent!

Elias Jaffa MD MS (@jaffa_md) Tweet

Decision Making

Being efficient should never be at the expense of being thorough. You will eventually have to waste more time making things right.

Danya Khoujah (@DanyaKhoujah) Tweet

If someone brings up a concern, go to the bedside.

Sunny Elagandhala (@elegantdolla) Tweet

Think simple, make a quick decision. Determine the senior you will take as a model.

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Once you suspect about a diagnosis, be sure to rule it out.

Ilker Akbaş (@ilkerakbas) Tweet

Do not forget to consider emergencies and other diseases while focusing on frequent diseases of the period, such as COVID. The most important thing that the emergency doctor needs to do is to look at the case from a wide perspective from the very beginning.

Gaziantep Acil Tıp (@AcilGaziantep) Tweet

Watch out for the last patient who came just before your shift ends.

Meltem Şahin (@onlakonusmayin) Tweet

In emergency medicine [and in life :)] the possibilities are 0% or 100% only in limited scenarios. You need to quickly learn managing probabilities, setting priorities, distinguishing acceptable and unacceptable risks. Also you need to learn reading the environment; because it usually gives many signs before the problem emerges.

Elif Dilek Çakal (@DrEDCakal) Tweet

Patient in the Resus is easy. Spotting the patient with a real emergency in minors is the tough one.

@fakuna_matata Tweet

First rule of emergency response is to ensure your own safety!

SALİH KARABULUT (@drskbulut) Tweet

When in doubt or worried about someone, talk to floor senior physicians EARLY.

Rahul Goswami (@Rahul_Goswami_) Tweet

I would say to try your best to remain open-minded and try to be aware of your biases and blindspots. This applies especially to patients with psychiatric illness and substance use disorders. If you're explaining X symptom on Y problem, always ask yourself, "Does this actually make sense?

Elias Jaffa MD MS (@jaffa_md) Tweet

The most frequently overlooked diagnosis in the emergency room is the second diagnosis! Do not limit your perspective to one diagnosis. Most frequently missed fracture in the emergency room? The second one! Remember that the patient may have a second fracture!

Mehmet Ergin (@drmehmetergin) Tweet

While assessing only isolated parts, don’t miss to assess the patient as a whole. Do not evaluate the patient on a single system, single organ basis. Emergency Medicine requires ‘holistic assessment’.

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Discharging

No hospital bed belongs to you. If in doubt, do not discharge the patient.

Haldun Akoglu (@IstanbulEMDoc) Tweet

Do not discharge the patient relying on what someone else is telling you without assessing by yourself!

Emre Salçın (@emresalcin) Tweet

Do not discharge the patient after midnight: You may be tired, you may overlook something, the patient and his relatives may not find a car or money to leave, or they may try to go to the town or another city but have an accident on the road, etc. Those all happened (Not my personal experience, but I have seen them), evidence based...

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Before discharging the patient whose treatment is completed, make sure to think like that: ‘Is there any possibility that this patient will come back with a cardiac arrest before the shift ends?’ If you are hesitant, prolong the process.

@fakuna_matata Tweet

The patient at the hospital is better than the patient at home’. Do not discharge if you are not sure.

Belgin Akilli (@AkilliBelgin) Tweet

Team Play

Emergency Medicine is teamwork. Get along well with your colleagues, your nurse, your intern, your staff and your secretary. Find yourself a role model, try to be a good example for others. And enjoy the Emergency Medicine.

Melih İmamoğlu (@melihimam) Tweet

You may learn a lot of thing from your nurse, act like a teammate.

Yusuf Ali Altuncı (@draltunci) Tweet

That’s all for now. By the way, what would your advice be?

Cite this article as: Ibrahim Sarbay, Turkey, "Things You Should Know Before Your First ED Shift," in International Emergency Medicine Education Project, July 13, 2020, https://iem-student.org/2020/07/13/things-you-should-know-before-your-first-ed-shift/, date accessed: March 24, 2023