Emergency Medicine Rotation

 Not even going to try to hide it, I was terrified about my Emergency Medicine (EM) rotation. Why? Besides our didactic course, I had no experience in it prior to PA school (all my patient care hours were in family medicine/primary care). My EM rotation was supposed to be towards the end of my clinical year. But, when my first rotation fell through (this happens often), my schedule got switched around & there I was…going into my first clinical rotation in the Emergency Department. Eeek! In hindsight, being in the ER my first rotation was a blessing in disguise.

​The weeks leading up to it, all I could tell myself was “It’s only 6 weeks. I just have to get through it.” I knew I would learn so much medicine, but I would also picture myself fainting or freezing at the sight of a motor vehicle accident (MVA), trauma, etc. Luckily I didn't faint, ha! And, once in the ER, running a code, intubating, suturing….I LOVED it! I found myself looking forward to each day & the rush of being in the ER.
 
Prior to my first shift & throughout the rotation, I spent hours reading, working up differentials for common complaints, learning dispositions, and listening to podcasts. Below you’ll find what worked for me & also amazing advice from Josh & Mike, two fellowship trained ER PA-Cs. I wish I had their advice prior to starting my own rotation! Be sure to check out their blogs about this too

If you’re scared about EM (like I was)…just breathe, take a moment to process everything, and keep on reading. Trust me, you’re way more prepared than you think!
 
What is it like? 
I spent most of my rotation in the main ED, with little to no time in the fast track. I was also at a stroke/STEMI center in the middle of downtown Los Angeles, so we were busy! ER’s are noisy, and anyone in the ER will tell you that you come to embrace the constant beeping of machines, yelling, and running in the hallway. Controlled chaos. If you feel out of place on the first day, this is normal. It gets better with time.
 
Hours: 
I usually worked four 10 hour shifts, or three-four 12 hour shifts. The majority being early morning (4 or 5 am starts) or night shifts. No matter what, they’re long shifts. Invest in some comfortable shoes and/or compression socks. Also, if you’re doing night shifts, earplugs, dark curtains, and eye covers go a long way! Coffee/tea also isn’t a bad idea! 
 
Websites/Links: 

• EM in 5
  • High yield videos in Emergency Medicine for residents and students...all in 5 minutes!
• Emergency Medicine Cases
• Emergency Ultrasound Cases
  • ​Provides foundation for a basic understanding of Emergency Ultrasound (EUS). Contains lectures, tutorials, cases.
• Emergency Board Review
  • Lectures, tutorials to prep you for exams

Reference Books: 
By reference books, I mean they’re slightly big to lug around

• Step up to Emergency Medicine (~$35)
• Tintinalli’s Emergency Medicine Manual (accessed from school library) 
• Current Diagnosis & Treatment Emergency Medicine (accessed from school library)

 
Books that fit in your white coat pocket:
I have mixed feelings about pocket resources, mainly because there is very little time to open up a book & look up a topic during your shift. I did carry either one of these around & came in handy a couple times but these were mainly used these as a means to solidify/review info for my end of rotation exam. They're straight to the point, so I found it helpful. Take a look at these if you're interested

• Pocket Emergency Medicine (~$45)
• Tarascon Emergency Pocketbook (~$16)

What I carried in my white coat pocket every shift: 

• Pocket EM or Tarascon Emergency pocketbook 
• Phone—to access apps/UpToDate. Consult with your preceptor to make sure it is OK to use your phone.
• Gloves
  • When running a code, you often need to have your gloves on ASAP. The patient is rushed in, everyone is running different places, IVs are being placed, cords are everywhere, chest compressions are starting. Have your gloves in your pocket & you’ll be ready as ever! 
• Blank piece of paper for a "To-do List"
  • My preceptor usually taught residents, so he passed on this tidbit onto me. Kept us organized/made sure each patient was taken care of!
  • Blank paper folded into 8 rectangles, each rectangle corresponding to a patient
    • Sample: Bed #1, CC, labs/imaging ordered, dispo
    • As each lab/imaging came back, it would be checked off
  • Thrown out at the end of the shift! Be cautious of using patient identifiers
• Small notepad
  • For notes and topics to look up later
• Pens (multiple)
• Protein bar—often didn’t have a formal lunch! 
• Gun/mints/hard candy—for those long night shifts

 
Apps: 

1. MDCalc—I was often asked about Wells, PERC, etc. You can calculate each score nicely on here! 
2. Epocrates—for dosing
3. UptoDate—a must for every rotation

 
PodCasts: 

• EM Rap
  • If you have the extra cash (skip on some Starbucks coffee runs if you have to!), definitely recommend this one!
  • HUGE fan of it & anyone in EM will tell you how incredibly valuable it is. I learned so much from this podcast & easily worth every penny.
• EM Basic 
  • Free podcast
  • What I love: Will go through each chief complaint (chest pain, abdominal pain, first trimester headache), its differential, work-up & WHY you’re ordering different labs. Cannot say enough great things about this one! There’s also a corresponding PDF with each episode. Must get!
• EM clerkship—EM for Students
  • Free podcast
  • What I love: 10-15 min episodes, but all high yield information! Also, I've sent Zach Olsen (creator of EM clerkship) a couple of questions via email & he responds every time!
• Pediatric Emergency Playbook 
  • Free podcast
  • What I love: very few podcasts focus on the peds patient. Some episodes start off a bit slow, but continue listening. Lots of great mnemonics & tips for dealing with the little ones in the ER.

Know:

• EKGs
• Basic suturing/laceration repairs
• Key Workups
  • ​Abdominal pain (#1 Chief Complaint)
  • Chest pain/MI
  • Stroke
• When to order imaging/which imaging is best
  •  X-rays (ottowa rules, etc)
  • CT with or without contrast 
    • EM clerkship has a great episode about this!

and now...

"Top Tips to Crush your EM rotation"
by: Mike G. & Josh F, fellowship trained ER PA-Cs
On Instagram: @PAlifeinEM
Website: PAlifeinEM

1. FOCUSED HPI, physical exam, and review of systems. Your encounter with the patient in the Emergency Department should be directly focused at their chief complaint and building your differential diagnosis. Each question should be asked with a purpose. The goal is to weave your way through the patient's story to rule in or out a specific diagnosis. When presenting your patient to either the PA or MD, your differential diagnosis should start with the most life threatening disease process. 
2. When you want to order an imaging test or labs, start trying to FIGURE OUT THE SPECIFICS of exactly you want to order. Instead of saying, “I want to order labs and a ultrasound”, be more specific, “I want to order a CBC, CMP, Lipase, and a right upper quadrant ultrasound”.
3. When you see a patient, TAKE OWNERSHIP. This does not mean you are going to be the one making all the decisions (you will not have to), but try and follow the patient all the way through their ED course. 
4. KNOW THE DISPOSITION. This is one one of the most difficult tasks in emergency medicine, even for practicing PAs and MDs. As you leave the patient’s room you should try to have a general idea if the patient is someone who can be discharged or will they need to be admitted.
5. PICK TWO TOPICS on each shift to read about. 
6. BE INVOLVED with as many cases at possible. Even if you are not going to be seeing the patient, try to be be exposed to as many different patient cases and procedures as possible

​Alright, that's all! Let me know if this helped you on your rotation! ​