Welcome to your emergency medicine clerkship! This clinical rotation should be an exhilarating time during your medical training. Emergency medicine (EM) is a broad field that involves the acute recognition, management, stabilization, and disposition of life-threatening conditions. In addition, the emergency room (ER) or department (ED) serves as a cornerstone for treating acute care conditions ranging from patching up simple lacerations (cuts) to ocular (eye) issues and sore throats.
Be prepared to work in a fast-paced environment where you’ll take care of critically ill patients as well as urgent care issues. Shifts occur throughout the week and weekend, including early morning and afternoon (swing shifts) and some overnight shifts.
Excelling on this rotation will be fundamental to your success as a future physician no matter what field you enter—emergency medicine serves as a bridge to all other specialties. There’s no doubt that you should expect to receive a call from the ER sometime in your career!
Understand the Fundamentals of Emergency Medicine
On the first day of your emergency medicine rotation, be sure that you clearly understand the goals of the emergency physician. Most medical specialists start with a top-down approach, e.g., what is the most likely diagnosis? However, many patients leave the emergency department without a clear diagnosis every day. That’s because the goal of an emergency physician is not to figure out the exact disease process the patient has but to rule out life-threatening conditions.
As experts in resuscitation, emergency medicine clinicians focus on rapid patient evaluations that involve airway, breathing, and circulation assessments. Patients are typically assigned a triage ESI or Emergency Severity Index, based on their chief complaint and vital signs, with five (5) being the lowest and one (1) being the most ill. Patients are subsequently evaluated in order of their ESI and placed in the most appropriate area of the emergency department. For example, a patient with an ESI 1 (e.g., heart attack or major trauma) will generally get evaluated in a large resuscitation bay so that the necessary equipment is close at hand.
Once you understand the broad goals of an emergency physician and the general flow of the emergency department (ED), it’s time to get familiar with common emergencies. Learn about the ED’s chief complaints and the key differentials considered for each. For example, the most common chief complaints often include chest pain, abdominal pain, generalized weakness, shortness of breath, or musculoskeletal injury (broken bones).
Become familiar with specific disease processes such as acute stroke management, acute coronary syndrome, and traumatic injuries. In addition, take some time to learn the relevant guidelines and protocols such as advanced cardiac life support (ACLS), advanced trauma life support (ATLS), pediatric advanced life support (PALS), and clinical decision rules such as the criteria to rule out a pulmonary embolis (PERC), or the HEART score for risk stratification of acute coronary syndrome. Consulting the case studies referenced in this blog can enhance your understanding of this topic.
Along with learning those specific disease processes, be sure to become proficient in interpreting basic lab results, imaging studies, and electrocardiograms. For example, understand what an anterior, posterior, or inferior STEMI looks like on an EKG. Learn the difference between what a subdural, epidural, or subarachnoid hemorrhage looks like on a CT scan. Don’t be surprised to see point-of-care (bedside) ultrasounds frequently used in the emergency department for a variety of conditions. Make sure to become familiar with its use in trauma (e.g., FAST exam), cardiac, pulmonary, and renal assessments.
Engage with Your Emergency Medicine Attending
During your rotation, you’ll work with a variety of attendings with different styles, each bringing their own approach to clinical care. Set your expectations from the start and take a moment to introduce yourself at the beginning of each shift to establish clear expectations. You’ll also encounter residents of different seniority levels, so introduce yourself to them as well, as the senior resident may be your primary supervisor.
Keep in mind that you’re there as a learner. Ask questions, stay engaged, and be helpful. Don’t see patients without first asking if it’s an appropriate patient for you to see. Remember that the emergency department can be an uncontrolled, chaotic environment, and your safety is paramount.
How to Handle Patient Interactions in the Emergency Department
Before you enter a patient’s room or space, perform a quick chart biopsy. Review their pertinent medical history, recent visits, labs, and imaging studies. Preparing for your first discussion will help you prepare questions after you enter a patient’s room or space. A good rule of thumb is to spend no longer than ten (10) minutes assessing a patient.
When you see patients, start by introducing yourself as a medical student and ask permission to take a history and perform a physical examination (some patients may only want to be evaluated by an attending or resident). If a patient requires a sensitive exam (e.g., a pelvic or rectal exam), ensure you have supervision, such as a nurse present. If you walk into a room and a patient appears unstable or in distress, do not hesitate to call for help. Emergency medicine is a team sport; we’re all there to help each other!
While evaluating patients, demonstrate mindful communication using empathy, active listening, and answering their questions to the best of your ability. Avoid medical jargon or acronyms, and explain any medical terms or procedures in a layperson’s terms. Take a moment to remember that patients in the ER are often experiencing one of the worst days of their lives, so being kind, empathic, and providing gentle support by doing things like providing a warm blanket or a kind word goes a long way.
Additional guidance and advice for excelling during your clerkships > The Osmosis Ultimate Guide to Thriving in Clinical Rotations
When You’re Working in the Emergency Room
When presenting patients to your attending, start with sharing the patient’s name, age, pertinent past medical history, social history, chief complaint, and a brief history of present illness. Note their pertinent positive physical exam findings and pertinent negative exam findings. Then, offer your differential diagnosis, starting with the most life-threatening conditions and why you think the patient may or may not have them. Listing their most likely diagnosis is reasonable, but only once you have considered life-threatening conditions. Listing an interesting differential, or “Zebra” disease, is also acceptable.
Once their care is complete, list your workup, management, and disposition, but remember that your attending won’t appreciate an internal medicine presentation. EM physicians usually manage multiple patients simultaneously, are frequently interrupted, and often have short attention spans. So, it’s imperative to keep your presentations brief (think one to three minutes at most).
Put aside some time to regularly reassess your patient’s response to medical management. For example, if you administer analgesia (pain relievers), check the patient’s pain level. If you provide albuterol to an asthmatic, pull out your stethoscope to auscultate (listen to) their lungs after treatment and see how their breathing has changed. You’ll be surprised at how often a patient’s clinical condition can change during an ED stay, for better or worse.
Update your team regarding these responses, along with the patient’s overall clinical status. In addition to caring for your patients, offer to help out with the care of other patients—this might be as easy as getting a glass of water or performing a simple procedure like suturing a minor laceration (cut). Your other team members will often be swamped and will surely appreciate extra help.
Practical strategies to write clear and effective progress notes > 3 Tips to Write Progress Notes
Emergency Medicine Skills Development
Before and during your emergency medicine rotation, you should be able to perform basic emergency medicine procedures such as basic life support techniques (e.g., CPR, providing supplemental oxygen via a bag valve mask) and IV placement. Get familiar with basic suturing skills since you’ll likely suture multiple patients during your rotation. You’ll need to perform critical procedures such as intubation or central line placement, so be familiar with these as well. You can find several online videos and resources to help you familiarize yourself with these procedures, with some listed at the end of this blog post. Additionally, many emergency medicine rotations enhance this learning through simulation labs.
How to Study Emergency Medicine Efficiently
Like other clerkships, you’ll likely have to take an end-of-rotation or shelf exam.
Here are some tips to get the most out of your EM rotation:
- Prepare an action plan and create a study schedule so you don’t fall behind!
- Use at least one case review book or emergency medicine textbook during your clerkship rotation to integrate case reviews, practice questions, and relevant literature. Doing this will help you do well on the EM shelf exam, which can significantly impact your clerkship grade.
- Do your best to integrate the patients you see on shift with your studying—it will help solidify the material.
Don’t Forget About Self-Care
The emergency department is a high-stakes environment and can be physically, emotionally, and mentally stressful. Take good care of yourself by eating healthfully, maintaining a sleep schedule, and exercising. When you have a tough case, reach out to your team members and discuss it; they’re there to support you.
Key Takeaways for a Successful Emergency Medicine Rotation
Thriving during your emergency medicine rotation comes down to a few factors: understanding your role, being an effective team member, and developing the ability to communicate skillfully with patients. Take the time to be nice to everyone, including nurses, techs, support staff, and your attending and resident team. By fostering positive relationships and maintaining a collaborative spirit, you’ll enhance your learning experience and contribute to a more upbeat, supportive environment that benefits everyone involved.
Wishing you the best of luck on your emergency medicine clerkship! Embrace this clinical experience as an opportunity to learn and grow—you’ve got this!
References & Resources
Textbooks
- Emergency Medicine – A Comprehensive Study Guide edited by Tintinalli
- Rosen’s Emergency Medicine – Concepts and Clinical Practice edited by Marx
- Harwood-Nuss’ Clinical Practice of Emergency Medicine, edited by Wolfson and Hendey.
- Clinical Procedures in Emergency Medicine, edited by Roberts and Hedges
- Emergency Medicine: Clinical Essentials: James Adams
Pocketbook/Case Files
- First Aid for the Emergency Medicine Clerkship by Stead and Stead
- Case Files Emergency Medicine by Toy and Simon
- EM Fundamentals: An Essential Handbook for Emergency Medicine by Welsh, with Aaronson, Eicken, and Geyer (Included with your EMRA New Membership Kit for Students and Residents)
- 5 Minute Emergency Medicine Consult edited by Schaider and Hayden
- Emergency Medicine Secrets, edited by Markovchick
Additional Student Resources
- Emergency Medicine Residents’ Association (EMRA)
- American College of Emergency Physicians (ACEP)
- Society for Academic Emergency Medicine (SAEM)
- American Academy of Emergency Medicine (AAEM)
About the Author
Sean Watts, MD, Osmosis Clinical Content Editor, is a board-certified emergency medicine physician who practices community and academic emergency medicine. He completed his residency training at McGaw Medical Center of Northwestern University in 2022 and received his medical degree from Rush Medical College in 2018. Dr. Watts’ interests include curating medical education content with an emphasis on clinical relevance—for success on the USMLE, core clerkships, and residency in training examinations. He is actively involved in teaching residents in addition to his clinical duties and work with Osmosis.
Try Osmosis by Elsevier today! Access your free trial and discover why millions of current and future clinicians and caregivers love learning with us.
Leave a Reply