HOW TO DO WELL ON YOUR EM SUB-I
Congratulations on picking the best specialty! Like every rotation you do, doing well in emergency medicine is dependent on your attitude and work ethic. Get to each shift 15 minutes before start time, stay for signout unless told otherwise, show enthusiasm, say “yes” to any procedure offered to you, be nice to everyone, and stay late on your shift if there’s a good learning opportunity (procedure, big trauma coming in, etc.). Bare minimum, every shift you should come prepared with your stethoscope, notebook, pens, and trauma shears. I like Madison Supply, available on amazon, for cheap trauma shears.
Before we begin with specific advice, let’s talk resources. Some of these are pricier than others. If you’re not going into EM, feel free to ignore the more costly options.
Apps:
MD Calc: Free.
You probably already have this app. If you don’t, download it now because it is absurdly useful. There are a million different scoring systems, but these are the
ones you must know for EM:
PERC (rules out PE. A PERC negative patient still has a 2% risk of PE, which is considered equipoise, meaning the risk of treatment=risk of missed PE. Therefore missing 2% of PEs is considered acceptable)
Wells (risk stratifies possible PE patients to either recommend CTA, D-dimer, or using PERC to rule out PE without testing)
Heart Score (risk of major cardiac event in the next 6 weeks. Should be used for chest pain patients)
Canadian Head CT (Scoring system on whether to use CT head for patients with head trauma)
Canadian C-spine (Scoring system on whether to use C-spine CT on trauma patients)
Nexus criteria (Similar to Canadian C spine. At my institution, it’s considered worse than Canadian C-spine, especially in older patients)
PECARN (whether to use head CT in pediatric trauma patients)
Ottawa Ankle (Whether to use imaging in ankle injuries)
Ottawa Knee (Whether to use imaging in knee injuries)
Ottawa Foot (Whether to use imaging in foot injuries)
Glasgow Coma Scale (Fine to have this on MDCalc, but you should also memorize the criteria)
Curb-65 (Scoring system on whether to admit pneumonia patients)
Epocrates: Free
Another app you should already have. Drug dosages, contraindications, side effects, etc.
WikiEM: Free
A great app for information on diagnosis and management for different EM complaints. Simply search the diagnosis you’re worried about into the search bar and see how to proceed.
Diagnosaurus: $5
Not 100% necessary, but I use it frequently and find it helpful. Essentially, it gives you most of the differential diagnoses for a given chief complaint. So, for example, if you have a patient with epigastric pain and you want to make sure you’re not missing a dx, search “epigastric pain” and you can pick out differential diagnoses from the list that you hadn’t thought of and find reasonable. It also differentiates between regular diagnoses and “can’t miss” diagnoses.
Orthoflow: $5
Essentially, how to handle ortho complaints for people (like me) who suck at ortho. Simply identify the fractured bone, and orthoflow will ask you questions (such as location of fracture, displacement of fracture, etc.) about the fracture to ultimately give you your work up, plan, and dispo.
Sublux: Free
An app that gives you the basics on how to read different x-rays.
Pedistat: $5
Never bought this one, but EM residents swear by it so I’ll list it here in case anyone is doing Peds EM. Essentially, it gives different dosages/ equipment sizes for the critically ill child.
Non-App resources:
EMRA Membership: $60
EMRA is the Emergency Medicine Residents’ Association. While normally I don’t see the value in joining professional societies, this one is an exception. When you sign up, they will send you a ton of resources that are super helpful to doing an EM rotation. Especially valuable is the EM Fundamentals book, a chief complaint based guide that fits in your white coat and gives you all the high yield history, physical exam, red flag symptoms, workup, and dispo for a given chief complaint. This is literally my most used resource on any EM rotation, which is why I recommend it so highly. They will also send you the EMRA Antibiotic Guide, which gives you the preferred antibiotic choices for basically every infectious complaint you’ll see. EMRA membership also includes a monthly EM academic journal and newsletter to your house, and it gives you a discounted price on some of the other helpful EMRA books, like the EKG guide or the new ortho guide coming out.
Note: If you want the EM Fundamentals book (and trust me, you do) but don’t want to buy a $60 membership, you can buy just the book for $27 on Amazon. Though for people going into EM, I’d still recommend the membership because of the other stuff you get.
Rosh Review: $99 for 1 month, $149 for 3 months
UWorld, but for EM. If you have an EM shelf, I’d absolutely recommend it. If you don’t have an EM shelf, you can probably get away with not using it.
Quizlet: Free
Someone made a bunch of old SAEM (an EM organization who is responsible for some shelf exams) questions into a quizlet. Great for shelf studying, though some outdated information. Here’s the link:
https://quizlet.com/297081941/flashcards
Tintanelli’s Emergency Medicine Manual: $60
The bible for EM. You don’t absolutely need it as a student, but you will eventually need to buy it if you’re going EM and it is more comprehensive and has more chief complaints than the EM Fundamentals book I mentioned earlier.
Suture Man: For lac repairs. Save to phone.
Notebook:$10
I have bought this notebook 4 times now. Each page has a template for HPI, PMH, PSxH, Social, Meds, Family, ROS, Physical Exam, Vitals, Assessment, and Plan. Part of being a good EM student is giving a great presentation, so you need to be organized in your history taking. If you already have a system for that, then great. If you need a system, this is the one I recommend. Link:
Amazon product
5minuteSono: Free
5 minute videos on the basics of reading certain ultrasounds.
5 Minute Sono
So now that you (hopefully) have the resources needed to set yourself up for success, here is how to actually approach seeing a patient in the emergency room:
Before you see the patient, I recommend looking in their chart. Caveat: if the ED is slammed or your resident/institution doesn't want you to chart review, then you don't have to. I would, however, at least recommend checking the vitals and seeing if any important labs have come back. I recommend this because if you have to present right after walking out of the room, your attending is going to want to know the vitals and it's best not to list a dx that's already been ruled out by labs as your #1 diagnosis.
A chart review should really take no more than 5 minutes.
Write down the following:
Patient name, age, chief complaint, Room #
Vitals
PMH relevant to the chief complaint
Look over the following:
Triage note (it’s usually just 1-2 sentences of what the patient told the nurse)
Meds. You do not have to write down every med, but sometimes there will be meds the patient is taking that are 1)unusual 2) have side effects that could explain cc or 3)indicate that the PMH is not complete, such as if pt is taking amlodipine but no HTN listed in PMH
Labs. Many patients will have labs ordered by triage which may or may not be back by the time you see them. Again, you do not have to write out each lab value, but you should write down anything that was abnormal and if a certain lab test was totally fine. I usually just write down something like “CBC wnl” or “Lipase wnl”
Last Visit(s). Is the patient here constantly for CHF, now presenting with SOB? Are they almost never here? Do they always come in with vague pain requesting pain meds? These things are good to take a mental note of.
In addition, if there’s time I would recommend very briefly looking up the patient’s CC in the resource of your choice. For me, this is usually EM Fundamentals. Look over the high yield history and physical exam info you must know, and write down anything you think you may forget to ask about. For example, for back pain, you should really be asking about trauma, saddle anesthesia, bowel/ bladder incontinence, numbness or weakness, IVDA history, any history of osteoporosis (if old), and fevers. If you’re likely to forget any of these red flags, then write it down so you can be sure you’ll ask.
Alright, now that you’re prepared, go into the room. Make note of anyone else in the room, and ask about their relationship to the patient. Be polite and professional, take the history and do the physical. Generally, save the sensitive parts of a physical exam until a resident is with you unless told otherwise. Try to keep the whole encounter to 10-15 minutes.
Presenting:
Presenting in the emergency room is difficult and has a steep learning curve. Here is a great 10 minute video that gives the basics:
Making the Most of Patient Presentations
You should watch it. Seriously. However, if you can’t spare the 10 minutes here are the basics you must remember:
EM presents in a SOAP style presentation, and the presentation should be brief. Keep it somewhere between 1-3 minutes
For subjective, use OPQRST for pain. Make sure to list the pertinent negatives as well when you’re presenting.
For objective, start with vitals. You generally don’t have to list out numbers unless they’re abnormal. Say if they’re well appearing or if they look ill. Don’t list each and every part of the exam you did. It’s usually fine to say something like “Physical exam was remarkable for epigastric tenderness to palpation with voluntary guarding. The rest of the exam, including cardiac exam, was unremarkable.” If there is anything in the DDx that needs scoring, you should calculate the score for the patient for that differential. For example, if patient presented with syncope and you thought about PE, you can say something like ‘Wells score was 1 indicating low risk, and the patient was PERC negative”
Assessment should be divided into two parts. “Most likely” and “Can’t miss.” For example, “Ms. Jones is a 45 yo female presenting with a 2 hour history of lower abdominal pain, fever, and nausea most likely secondary to diverticulitis due to her known history but could also be UTI. Can’t miss diagnoses for her would include ectopic pregnancy, PID with TOA, and appendicitis” If you don’t think you have a broad enough ddx, use diagnosarus or another resource of your choosing to try to supplement your differential.
DO NOT JUST GUESS ON THE PLAN. As soon as you leave the room, check your preferred resource to guide you on what you should be ordering and what dispo is. Again, for me, this is EM Fundamentals. If there are 2 options that seem reasonable (“To scan, or not to scan?”) ask your resident if they’re chill and have a second what they think the right answer is before you present to the attending. Plan should often be conditional on the outcomes of tests, if possible. “For Ms. Jones, I think we should order a CBC, Chem 7, UA, pregnancy test and lactate. In addition, I think we should get a CT abdomen and pelvis to assess for possible diverticulitis or appendicitis. If the CT is negative, we’ll need to do a pelvic exam with GC/Chlamydia testing to look for PID.”
The Plan should also include Dispo. Say whether the patient should go to ICU, floors, observation, or home. It is also fine to say “Dispo is dependent on the outcomes of the testing we’ve ordered.”
VERY, VERY IMPORTANT: you are not done with the patient after you present. Keep checking on your patients, at least once an hour or so, for the entirety of the time you are both in the ED. You should follow up on any labs/ imaging that comes back and keep the patient updated as appropriate (i.e. probably fine to say “the CT scan did not show appendicitis.” Much less ok to say “the CT scan showed you probably have cancer.” Save tough conversations for the attending/resident). You should also be checking for clinical improvement after any treatment has been given to the patient, and let your attending know how they’re doing if there’s been a change, i.e. “Ms. Jones says her headache is ‘100% better’ now that she’s gotten fluids.”
Notes: I don’t want to do a deep dive here on how to write a note, since you should already have a pretty good idea. Basically, your note should look an awful lot like your presentation, and in your “Plan” or “Medical Decision Making” section, you need to justify why you made the decisions you did in terms or ordering/ dispo. For example “Ms. Jones’ SOB is likely 2/2 an asthma exacerbation due to her prior hx of asthma, wheezing on physical exam, clear CXR, and improvement after brochodilator treatment. It is most likely not PE because she is PERC negative has no hx of prior DVT/PE, no leg swelling, no travel hx, no tachycardia, and her symptoms resolved after duonebs were given.”
In addition, most EM notes have a “reevaluation” section. This is where you write clinical changes in the patients as well as updates for labs/imaging. Include the time. Example:
“At 5:01, reevaluated Ms. Jones who was still SOB and had new onset tachycardia. Ordered a CTA due to emerging clinical suspicion of PE.”
“7:04 CTA read showed segmental PE in L lower lobe. Pt started on heparin.”
Calling an Admitting Team
You may be asked to call an admitting team about a patient you've been seeing if they'll be staying in the hospital. This presentation is different than a regular ED presentation. You're going to want to introduce yourself, give a one liner that includes the suspected dx and the reason for hospitalization, and then a super brief story of what happened as well as what you've done so far for workup and treatment.
Example: "Hi this is Suzie calling from the ED in regards to a patient Ms. Jones in room 11. She's a 45 yo F with PMH of HTN here with perforated appendicitis seen on CT scan, in need of hospitalization for IV abx and possible operative management. She's been having RLQ pain, nausea, and fevers for 4 days, with more severe symptoms beginning yesterday. On physical exam, she's febrile and very tender but she's well appearing and vitals are stable. She has a WBC of 14, labs are otherwise unremarkable. A CT scan showed a 3cm fluid collection around an inflamed, enlarged appendix. We've already started her on fluids as well as CTX and flagyl."
SPECIFIC CLINICAL SCENARIOS
Trauma:
At most institutions, your job is to help expose the patient and maybe help with compressions. Stand at the foot of the bed if it’s free and expose the patient with your trauma shears (after getting the ok from the residents or after seeing the nurses start exposing the patient). If you don’t have to cut the clothes off and the patient is stable, there is often an effort to not cut off their clothes so keep that in mind before you go cutting everything. After the patient is exposed, generally you want to get out of the way. You may also consider helping to turn the patient when needed, but your goal here is to not impede anyone from doing their job by being in the way. If you want to do compressions (and are certified to do so), go to the person doing compressions and just say “let me know if you get tired and want to switch.” It's also helpful to have the cardiac arrest ACLS algorithm memorized, so I'll include it here.
Chest pain:
You have to learn to systematically read EKGs. For this, you’ll need a strategy. Most people go in order or “Rate Rhythm Axis Intervals Morphology Assessment”. I am not good enough at EKGs to teach in this guide, but here’s some resources from smarter people:
If the person has suspicious chest pain that started in the last few hours, they made need a delta troponin, meaning a troponin that was drawn 3 hours after their first negative troponin to rule out a false negative troponin that we often see in the setting of early MI. If their chest pain started 2 days ago, they only need 1 troponin. As stated earlier, use the Heart Score on chest pain patients. Generally, patients who are “moderate risk” on the heart score get admitted regardless of their lab results/ ekg results.
PE:
Possibly the most annoying differential diagnosis in emergency medicine, you should at least think about PE in nearly everyone with syncope, SOB, and chest pain. Make sure that you look up the actual criteria for Wells and PERC before you enter the room so you can make sure you have enough info to score them. Lastly, generally the correct way to do things is to use Wells first. Do not use PERC first and do not use it alone.
If low risk on Wells, use PERC to exclude them. If they can’t be excluded with PERC, the correct (but controversial answer) is to dimer them.
If moderate risk on Wells-> dimer
If high risk on Wells -> CTA
I’ve included the algorithm below. Note that this is an extremely controversial area of EM, some docs may use a different algorithm, and some may choose to dimer/ CTA/ do nothing solely on clinical gestalt.
CHF vs COPD
If someone with a history of COPD and CHF comes in with SOB, tie breaker goes to the lung exam.
Poor Historians
Generally speaking, poor historians get aggressive workups even if their baseline is altered. Old demented people and alcoholics get scans.
