by Linda Katirji, Farhad Aziz, Rob Rogers
The Emergency Medicine (EM) clerkship typically takes place during the fourth year of medical school. However, some programs may have an optional elective during the third year. Whether or not you plan to specialize in Emergency Medicine, the rotation is an important aspect of your medical education. 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. 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 particular 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 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 seeing the patient. A majority 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 or not you plan on a career in EM. 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 have to 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 should not go home, where as a consultant, or admitting service, does not want to admit a patient who shouldn’t 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 at the bedside or at the time the student or resident presents the patient. Many times, attending physicians will pick out “teaching points” for each patient. Each physician will have a different teaching style, and your learning will, in general, be more active than passive.
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 not matter what the diagnosis may be.
Unique Skills To Take Away From EM Clerkships
Emergency medicine is a wonderful rotation that exposes you to different patient populations but also a variety of pathology. 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 and performing ultrasounds and much more.
Often you may be busy doing different tasks when you have to drop everything and 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 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 a which may include 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 a chest x-ray or a CT scan of the abdomen, 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. Everyday you will meet patients on the worst day of their life. Realizing this and comforting them and their families is paramount to your success as a physician. You will also encounter a variety of consulting physicians. Some are nice and professional while others are not. 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 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.
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.
References and Further Reading
- CDEM Emergency Medicine Student Podcast (https://cdemcurriculum.com/2016/02/22/em-stud-podcast-now-brought-to-you-by-cdem/)
- Emergency Medicine Clerkship Primer (http://www.ucdenver.edu/academics/colleges/medicalschool/departments/EmergencyMedicine/Education/Documents/EM%20Clerkship%20Primer.pdf)
- Comment on Emergency Medicine Clerkship Primer (https://lifeinthefastlane.com/emergency-medicine-clerkship-primer/)
- EMRA Medical Student Page (https://www.emra.org/students/)