start 3rd-year EM clerkship tomorrow - any advice?

[asianpride]

Hello,

I start my 3rd-year EM clerkship tomorrow. I don't have any specific questions but if anybody has any advice as to how to do well during a 3rd-year EM clerkship I would greatly appreciate it. Thank you.


PS: It's my first 3rd year clerkship

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[Apollyon]

1. BE ON TIME!
2. Get some sleep tonight, so you are on your game
3. Be eager, but don't be a spaz - if you look and act like you want to be there, more people will gravitate towards you. Some residents will grab you even if you are asleep, and, at the other end, others won't do anything, even if you are standing between the res and the patient. Just don't get underfoot.
4. Jump at every procedure - if you haven't done it (which is likely), the answer is, "I've never done it, but I want to learn!" It's even better if you've gone over - just once - some basic procedures, so you can say you've read about it, but haven't done it.
5. If they tell you you can leave early, don't ask twice. Likewise, if you are offered a lunch break, take it (but don't take a long time - just make sure you eat!).
6. If you don't know the answer, just say you don't. EM are a laid back bunch, and won't bite your head off.

 

[asianpride]

1. BE ON TIME!
2. Get some sleep tonight, so you are on your game
3. Be eager, but don't be a spaz - if you look and act like you want to be there, more people will gravitate towards you. Some residents will grab you even if you are asleep, and, at the other end, others won't do anything, even if you are standing between the res and the patient. Just don't get underfoot.
4. Jump at every procedure - if you haven't done it (which is likely), the answer is, "I've never done it, but I want to learn!" It's even better if you've gone over - just once - some basic procedures, so you can say you've read about it, but haven't done it.
5. If they tell you you can leave early, don't ask twice. Likewise, if you are offered a lunch break, take it (but don't take a long time - just make sure you eat!).
6. If you don't know the answer, just say you don't. EM are a laid back bunch, and won't bite your head off.

thanks

 

[Paws]

Enjoy it!! I have two years to go before I am in your shoes - dang, I love ED stuff!!

 

[EMDrMoe]

thanks

ditto - I start Wednesday

 

[dlung]

ditto - I start Wednesday

Have fun maureen. Just follow Brickman's "5-minute rule" and be anal about making sure everything was ordered/labs are back, and they'll love you. Once they trust you, they give you tons of independence, so take advantage of it!!! You might not get this level of clinical decision-making all year!

 

[mikecwru]

Hello,

I start my 3rd-year EM clerkship tomorrow. I don't have any specific questions but if anybody has any advice as to how to do well during a 3rd-year EM clerkship I would greatly appreciate it. Thank you.


PS: It's my first 3rd year clerkship

Don't waffle or use a lot of "I think," "He's kinda" as in "He's maybe a little tender..." You need to make decisions on these things. Remember what is part of the history (pain) and what you objectively see on physical exam (tenderness). This has been my most recent issue with a student.

mike

 

[roja]

Can't be emphasized enough: BE ON TIME.

Ask to see patients... sometimes people forget you are there, but don't be a pest.

Let residents/attendings know you want to see stuff... (if you have any procedures, etc I would like to observe/learn).

A safe way to talk about exams, even when you aren't sure: 'on my exam, there was X'. Kind of covers the well, i'm just a med student and not really sure... without you having to waffle.

Bring an EM study guide to read for down times. Offer to do IV's.


Good luck! enjoy.. em is great stuff

 

[Homunculus]

in addition to what everyone else has said, it will help to change your frame of mind that was taught in medical school or even other rotations you've had so far of "most commons". the ED is for ruling out what will kill you now or what will kill you a little later, not what will kill you after you can see your PCP. it's not hard to switch to this mind set, but i've seen students struggle for weeks before it finally clicks with them.

and take the time to remember the cases-- the ER is fantastic board prep.

--your friendly neighborhood not ED-phobic caveman

 

[Febrifuge]

Equipment: Always keep one or two pairs of exam gloves in your pocket. If you have trauma shears, carry them too. If you don't, consider picking some up. (They're like $5, and even if you decide you're done for life in the ED, they're handy in the kitchen.) Your stethoscope will actually be used in the ED, unlike on some rotations, so be sure it's got a name tag stuck to it. Even better, get one of those little holsters for it.
Staff: As someone said, ED people are pretty laid back. And sometimes, this can blur the lines of the heirarchy (which I tend to think is good.) So be as nice to everybody as you think you should be to the person who's writing your evaluation. You never know who's a student, who's a tech, who's a respiratory therapist, and who's the chief resident.

 

[Seaglass]

Even better, get one of those little holsters for it.

Only if you don't mind being mocked mercilessly.

 

[Febrifuge]

Depends on the program. At Hennepin, most residents have 'em. (Though yes, they are a little dorky. Still better than clocking a patient in the forehead.)

Keep in mind, the trend lately is a tablet PC for wireless charting, so we are totally comfortable with geekiness.

 

[roja]

*mock*

 

[DrMom]

Can't be emphasized enough: BE ON TIME.

I've been told this same thing by an EM residency director. I'm amazed that something this simple can make one look good. I haven't heard this emphasized in the other specialties, though. Do the other services not notice this so much or are people slacking off when they get to EM?

 

[roja]

Dr.Mom-

EM is shift based, which probably makes it even more important.. I have seen people shunned for being chronically late but not nearly so much. In the ED, it is really annoying to be all ready to sign out and get home and not have your relief at hand.

It usually only takes being late once or twice for our offservice rotators (medicine being the most notorious) to figure out that when shift starts at 7 it means 7. Not 7:15.

 

[DrMom]

That makes some sense, roja. It just struck me as odd that it doesn't seem to be as big of an issue on the other services.

I'm good at being on-time so I'll be working for that gold star

btw: the input from all of you is much appreciated

 

[Febrifuge]

I've been told this same thing by an EM residency director. I'm amazed that something this simple can make one look good. I haven't heard this emphasized in the other specialties, though. Do the other services not notice this so much or are people slacking off when they get to EM?

My tech's-eye view is really informative, when it comes to students. There are some who behave, especially when they think there's no one important around, as though they find the very idea of EM to be too... something. Uncivilized, or crazy, or icky, or (in very rare cases) beneath their superior intellect. Some appear to think of EM as not very challenging, and a good 4-week rotation to schedule when they'd rather be doing something else.

Many of them may just be overwhelmed, or fearful of making a mistake, but when they're late to arrive -- or just plain don't show up -- it really makes them look like they're dismissing the specialty. Those who are excited about and interested in EM have a totally different vibe. A med student who is competent, smart, willing to work a little, and able to get along with people will become a superstar without too much of the traditional hustle/ pimp/ sweat nonsense.

 

[cooldreams]

man.. em jus sounds so much nicer than all the other areas, why more ppl dont try to go em completely baffels me...

 

[roja]

Its the best.


And not to scare any newbies, but one of the finer points you can look into...

while the focus of EM is definately to rule out the life threatening illness, there is still a lot of 'common is common', stuff. The IMPORTANT thing (and if you start thinking like this early in EM you will look uber smart) is to always THINK of those life threatening things adn then figure out if they are likely in your patient...


quick example:

CC sharp chest pain worse with deep inspiration x 2 days.... VSS, 19 yo male, no recent travel, no fh, no PMH. No trauma

Most likely diagnosis: pleuritic chest pain.

Most important thing to rule out: PE


Now this is a simplified case but here is the key to presenting it... You can say, I think its pleuritic chest pain (insert all the reasons.. inspiratory, vss, recent uri, blah blah blah) but add in- unlikely PE secondary to ... VSS, no travel, no risk factors, etc etc.

So, its okay to come up with a common diagnosis.. but its important to let the person you are presenting to know WHY you don't think its XY and Z fatal things...

And if you want a good book that quickly summarizes these things, the EMRA 30 Most Common ED book is really good...

 

[kungfufishing]

that book is great

another good basic thing is to try and think ahead about things that will need to be known about the patient anyway - who's their doctor? tetanus? meds? recent workups (cath, mps, echo, style consultant, etc)
and while sticking to a focused visit/presentation is certainly important, probably best to try to know everything about your patients, at least at first, and start thinning your presentations as you go along - simply because your idea of 'what's important' and the resident's/attending's might be somewhat different.

 

[EMDrMoe]

that book is great

while sticking to a focused visit/presentation is certainly important, probably best to try to know everything about your patients, at least at first, and start thinning your presentations as you go along - simply because your idea of 'what's important' and the resident's/attending's might be somewhat different.

What would you guys suggest doing to speed up h&p's without missing important info?

Also, what would be the best way to use the EMRA book to focus more with a patient? Thanks!

 

[roja]

You should use that book to guide what you include in your presentation. If the patient is complaining of Knee pain, then the social history isn't reallyt hat important (know it but don't present it, in case they ask).

However, if they have chest pain (young or old) drug use becomes important, etc.

This will take practice.. the key point is, include what you think is important and be ready to awnsesr other questions.

 

[Apollyon]

You should use that book to guide what you include in your presentation. If the patient is complaining of Knee pain, then the social history isn't really that important (know it but don't present it, in case they ask).

However, if they have chest pain (young or old) drug use becomes important, etc.

This will take practice.. the key point is, include what you think is important and be ready to answer other questions.

But you gotta use your head - knee pain in a teenager or someone in their 20's - trauma vs. arthritis. If you think it's arthritis, you think septic, and the #1,2, and 3 thing is gonococcal; that's when the social history - succinctly - is important. Your attending WILL ask you why don't you think it's septic arthritis.

 

[realruby2000]

And if you want a good book that quickly summarizes these things, the EMRA 30 Most Common ED book is really good...

where can one get this book?

 

[roja]

*sigh* I knew this would happen. apollyon this was not used to open up a discussion on the management of knee pain. It was really a quick example of how an EM3 should try to filter out what is important, in their mind, but make sure they have all the information. IE, have the social history for a young knee pain just in case its asked. I certainly didn't want to discuss the intricacies of knee pain..... (however, I would say if the knee is not swollen, red, warm or tender and pt is afebrile, septic knee still wouldn't concern me. )

ruby You can find this book at the emra website: www.emra.org

good luck.

 

[Apollyon]

*sigh* I knew this would happen. apollyon this was not used to open up a discussion on the management of knee pain. It was really a quick example of how an EM3 should try to filter out what is important, in their mind, but make sure they have all the information. IE, have the social history for a young knee pain just in case its asked. I certainly didn't want to discuss the intricacies of knee pain..... (however, I would say if the knee is not swollen, red, warm or tender and pt is afebrile, septic knee still wouldn't concern me. )

ruby You can find this book at the emra website: www.emra.org

good luck.

roja My comment on yours was germane - the knee part was generic. All I was pointing out was another way of looking at it (and, am I wrong?). My point was how something that seems immaterial may well not be.

That's all.

 

[sweetfynesse]

That makes some sense, roja. It just struck me as odd that it doesn't seem to be as big of an issue on the other services.

I'm good at being on-time so I'll be working for that gold star

btw: the input from all of you is much appreciated

I think being on time is important for all rotations. It's just that for other rotations it isn't as important to be on the floor at a given time, as it is in having all of your patients seen by the time rounds start. That's all.

The only other thing that hasn't been said, and usually only applies to women, is don't forget to smile from time to time. I know that sounds crazy. But as a female resident, I have noticed that the only people who notariously get criticized for being too serious are women.

Also, learn everyone's name from the attendings down to the techs. When you need something done, ask that person to do it by name. The sweetest sound to a person is their name, and I guarantee you will earn points and it will make your life easier. If you find it hard to learn names, then write it on a piece of paper with a description.

And, last but not least, ask intelligent questions? No matter what anyone says, some questions are just dumb. And when a resident/attending is swamped, there's nothing more frustrating that having to take time to answer a dumb question.

Best of luck

 

[roja]

roja My comment on yours was germane - the knee part was generic. All I was pointing out was another way of looking at it (and, am I wrong?). My point was how something that seems immaterial may well not be.

That's all.

Which is why I said, get the information, but pick out what you think is important. It was not meant to open up a discussion on knee management or even ways of looking at knee pain. But illustrating, that as a 3rd year, you get ALL the info and try and figure out what to present.

 

[EMDrMoe]

Thanks roja and Apollyon! Both points of view (which I believe are two sides of the same coin) are noted

 

[Febrifuge]

So... a week later. AP, how are things going for you so far?