Ten Tips for Medical Students Rotating in the Emergency Department

This is it! What you’ve been waiting for, right? Navigating the Emergency Department as a learner can be exhilarating and exciting…..and terrifying and daunting. Don’t let it be. You’ve got this. Follow these tips and shine!

1. Introduce yourself to both the residents and attending physicians!

While you’re at it, introduce yourself to the nurses, paramedics and any other staff. Try to learn everyone’s names and their roles. During your rotation, you will be a part of this team. They want to get to know you and you should do the same.

It may be intimidating to introduce yourself to someone new, but think about it: it will be worse if they just see someone new and are left with the question “who is this person?”.

For people with a visual memory, it helps if you show your badge and they can see your name in writing, especially if it's a difficult one to remember. Make sure your badge is always visible, so they can refer to it in case they forget. When you work with the same attending, re-introduce yourself: “Hi Dr Manning, I’m Jessica, I worked with you yesterday and I’m working with you again today”

2. Don’t wait to be told what to do.

Every ED learning environment is structured differently. ASK! Some programs will assign you patients to see. At our program at North Florida Regional Medical Center (NFRMC), we want you to take the initiative. If you see a new patient placed in a room or rolling in through the door, you are free to let the resident or attending physician know you will be going to see the patient.

Act like the patient is your responsibility and their life depends on you! You are NOT a scribe or observer and in some cases your attention will be the one thing that helps this patient, aka your thorough history and physical exam.

Make sure you ask about pertinent risk factors and have a rolling differential diagnosis in your head as you interview the patients. Be ready to share that differential with your attending - see below!

3. Try to see patients as soon as they roll in and get the report from EMS.

First responders are the patient’s first point of contact for medical care. They are key players of the healthcare team. En route to the ED, they perform their assessment of the patient and administer medications as needed (often under very difficult situations).

Make sure you get this information; it can define our work-up and patient care.

Sometimes, when the patient has an altered mental state, it is the only information we have. If you arrive in the room after EMS has left and you weren’t able to get a report directly from them, make sure you find the nurse or staff that received the report. Some important details to report back to your resident or attendings are: chief complaint, interventions (such as medications, fluids, and oxygen), vital signs prior to and after interventions are given, and code status. (extra tip: don’t forget the EMS glucose level!)

4. Offer to call the nursing homes, family members, or poison control.

There are times that require a more detailed history, whether this is because the patient is unable to provide a full history or because you need a list of medications.

Take the initiative to call the patient’s nursing home, rehabilitation center, or family members.

Patients presenting with an overdose or with a toxidrome will require a consultation from poison control. Store poison control’s number in your phone and call them at 1-800-222-1222 (their phone number is the same wherever you go!). Take notes on the conversation. Write down the name of the person speaking to you. Make sure you get recommendations on what labs to get, how often to get them, and if there are any specific signs or symptoms to look out for.

5. Listen to Emergency Medicine podcasts.

There are several podcasts to help you prepare for your audition rotation. Dr. Stephen Carroll does an amazing job of teaching you how to be a rockstar with his podcast, EM Basic. His podcast is specifically for medical students and interns to master common chief complaints.

As a medical student I listened and took notes on every single podcast prior to my rotations; it didn’t take that long.

I had attendings and residents literally drop their jaws while listening to my presentations, differential diagnoses and plans.

Dr. Zack Olson’s podcast, EM Clerkship, is dedicated to providing high yield information for medical students to help you get the top 10% ranking on your SLOE.

6. Familiarize yourself with common EM Rules, Formulas and Criteria.

Download the MDCalc app or make sure to refer to www.MDcalc.com. Familiarize yourself with commonly used algorithms such as the HEART score, Well’s criteria, PERC rule, NEXUS criteria for C-spine, and PECARN for head CT. The HEART score is used for chest pain risk stratification and guides many emergency physicians’ decisions for disposition. When a patient presents with chest pain, calculate their HEART score, which predicts the patient’s risk for a Major Adverse Cardiac Event (MACE) in the next 6 weeks. You will know this because MDCalc has explanations of all of this on the same page you use to calculate it! Include this score in your presentation to your attending physician, and you will shine.

They will know you are thinking a step ahead and considering your patient’s disposition.

The Well’s criteria and PERC rule are used for risk stratification to guide your work up for a deep vein thrombosis (DVT) and pulmonary embolism (PE). The gold standard diagnostic test for a PE is a CT angiography of the chest, which has high doses of radiation, so we use these algorithms to risk stratify patients. If your patient meets all the PERC criteria and does not need to be further evaluated for a PE, many of us say “the patient PERCs out”. In the same vein, the NEXUS criteria and PECARN algorithm help reduce unnecessary CTs of the C-spine and pediatric brain, respectively.

Personally, when I was a medical student I used a moleskine notebook to write down these commonly used criteria.

This way, attendings and residents didn’t think I was checking Twitter or sending text messages while on shift. I used that same notebook to write any clinical pearls that I didn’t want to forget or things I wanted to look up later.

7. Don’t wait to be prompted to present a plan when presenting your history and physical.

You are NOT a scribe! You are NOT a reporter. Use your differential diagnosis to come up with a plan on how you are going to rule in or rule out what you have on your differential diagnosis.

Your plan may be wrong many times - THIS DOES NOT MATTER!

Your plan should have four components; every single one is just as important as the other.

First, you will order labs as you see fit. Most patients will require a complete blood count, a basic metabolic panel, and urine studies, while others may need more specific testing, like a D-dimer or coagulation panel. Secondly, you may need to order imaging, including electrocardiogram (ECG). Thirdly, patients may need interventions, such as supplemental oxygen, medications, and fluids. Finally, you should always have a plan for disposition. You should make an argument for whether your patient will likely need to be discharged or admitted. As a third year medical student, you were expected to provide a good history and physical exam in your presentation. As a fourth year medical student, we expect more; we want to hear your assessment and plan. Of course, you are a student and you are here to learn. Your plan will not be perfect, but it should be well thought out. (Extra tip: Don’t forget a urine pregnancy test on female patients.)

8. NEVER speak badly about other programs or specialties

Emergency Medicine is a small world. We know you may do other rotations at other programs, or have friends in other programs who give you details about their experiences. You must remember that we have friends too. Programs do not want to hear you talk negatively about other programs.

Students that talk badly about other programs raise a red flag.

Undermining and insulting other physicians, programs and specialties is a terrible stain on all of medicine. It is divisive and will only lead to negative feelings and reactions.

9. Don’t follow the resident or attending physician everywhere, and don't watch them type

Some attending physicians will want you to follow and manage your own set of patients and to accompany them to see a few patients. Unless the resident or attending physician asks you to come along, do not follow them to see every patient they will see.

They expect you to watch for your patients’ lab and imaging results, and they want you to follow up after interventions to assess for improvement.

So if you are bored and find yourself just sitting there - go check on your patient or ask the charge nurse if there are any IV’s to put in!

They will be paying attention to your time management and ability to multitask.

Furthermore, they need their privacy. Don’t follow them blindly because you might find yourself following them to the bathroom!

10. Always be willing to help, have fun and be enthusiastic!

I wish you the best of luck! If you ever need any help or have questions, feel free to reach out to me on Twitter, @DMoraMD.