Welcome to your Emergency Medicine Clerkship Rotation!
We hope you will find your experience challenging and exciting. It is unlikely to ever be boring! Clinical experience in an Emergency Department is highly valuable to all physicians and surgeons as this is where acute and undifferentiated illnesses and injuries usually first present. Whatever your career goals are in medicine, you will likely have some interaction with Emergency Departments; if, in no other way, because your patients will sometimes go there. To understand the role that this course takes in your overall training, it is helpful to understand the role of the Emergency Department in our Health Care System and society.
The Emergency Department is by definition an open door … the “front door” to the hospital and to the health care system in general. Open 24 hours a day every day of the year, the ED attracts a large and diverse population to its portals. Emergency Physicians provide initial care to patients who are critically ill or injured, as well as those less acute. We provide consultations and care to patients who have been referred from the community by both medical and non-medical sources. The ED also provides a safety net for patients who develop complications of therapy or surgical procedures, and for discharged hospital patients who may deteriorate, as well as patients who do not have a primary care physician.
Your clinical experience in the Emergency Department will be quite different than your experience in other rotations. You will get an opportunity at the front-line to develop your skills in the “symptom pursuit” approach to undifferentiated patients. One of the most important abilities that you should develop while in the ED is the ability to distinguish sick patients from well patients. You will also need to think on your feet and perform rapid assessments, set priorities and make quick decisions. You will be called upon to manage multiple patients simultaneously and concentrate in a noisy environment with frequent interruptions. You will have to be practical and you must master certain technical skills and procedures. The first 15-60 minutes of emergency situations from all of the specialties are usually dealt with by Emergency Physicians. Clinical experience in these situations is invaluable.
(If this sounds intimidating, don’t worry.) You will be functioning as a member of a team and working closely with the Staff ED Physician. Never hesitate to get the staff physician involved in a case that you are worried about. The ED is a place where patients can get very sick, very fast. As soon as you think a patient that you are seeing may have a life threatening condition, you should inform the Staff ED Physician. S/he will then ensure that things get done in a timely fashion. Of course, you will continue to be involved with the case. Patient care will come before education. (Lives may depend upon it!)
It is essential to remember that the Staff Physician is working with skills based on years of experience and knowledge – you are not. There will be times when s/he takes what appear to be “shortcuts”, treats patients without having any history and what appears to be no physical examination. Things are sometimes backwards in Emergency Medicine – treat first and ask questions later. You cannot expect that you will function at this level, and to attempt to do so is dangerous. Decisions made in this fashion are based on observation and experience, and four weeks in the ED will not provide this sort of expertise.
You will need to recognize sick patients and call for help. After the crisis, ask the Staff Physician what it was about the patient that indicated heart failure, not COPD was the cause of their shortness of breath, why they knew the patient had renal colic as they walked down the hall to a room.
Focus on identifying “sick” from “well”; but, also use this opportunity to take advantage of doing a proper history and physical, and gaining experience from the wealth of clinical findings available. A patient with a minor head injury will not have papilloedema; however, look at the fundi – the more normals you see, the more readily you will recognise the abnormal. Do not attempt to perform “shortcuts”, with the exception of calling for assistance with a sick patient. These are “experienced shortcuts” – you need to master the basics before you can eliminate any of them!
Don’t be afraid to ask the Staff Emergency Physician questions. If we can’t answer, we will know where to direct you to find the answer. Much of what we do is based on experience, and we will be only too happy to advise you on how to proceed with challenging cases. The Emergency Medicine faculty are also well poised to provide education in those acute presentations that cross traditional specialty lines. Our primary goal is to provide you with a good clinical education in Emergency Medicine while ensuring excellent care to our patients.
Recognize the time to ask questions. The middle of a cardiac arrest, with 30 patients waiting to be seen, is not the time! Be prepared to be ignored in that situation. The Staff Physician has a primary responsibility for patient care but will be pleased to hear your questions when the Department is settled and in order. Write down questions you have related to a specific case, and ask them at an appropriate time. The Emergency department can generate stress for even the most experienced physician.