EM Clerkship

L→ Episode Summary

O→ Episode Summary

A→ Episode Summary

S→ Episode Summary

Tip #26

Update your attending when the nurse is having difficulty with your patient’s IV or drawing blood.

Tip #27

Get the urine sample from your patient (there is no greater delay in patient flow than waiting on urine)

Tip #28

Round on your patients and repeat your initial scripting.

* “It’s Zack the medical student again”* “Anything I can do to make you more comfortable?”* “Do you have any questions?”* “I’m doing my best to keep things moving fast for you, here’s an update”

Tip #29

Perform one of the 4 most important reexamination protocols.

* The ambulation trial* Best for patients with low oxygen on arrival or geriatric patients with weakness/dizziness/etc* The repeat physical exam* Best for patients with abdominal pain or respiratory complaints* The repeat vital signs* Best for patients with multiple abnormal vitals documented in triage, hypertension, fever, etc* The PO Challenge* Best for patients with nausea and vomiting or pediatric patients

Tip #30

Update your attending the MOMENT everything is back (and choose one of 3 dispositions)

* Admit them* Best when you have confirmed a specific, bad diagnosis* Discharge them * If everything is normal, including your reexamination* Recommend follow up in 1-2 days* Observe them* Best for patients with concerning symptoms, risk factors, or red flags but reassuring testing or no clear diagnosis

Tip #21

Review and note if the patient has any IMPORTANT old records.

* Any ED visit within the last month for a similar complaint (aka “Bouncebacks” and frequent fliers)* Any echocardiogram or catheterization reports for a patient with cardiac symptoms* H&P and discharge summary for recent hospitalizations* Any large imaging studies (CT, MRI, etc) that have been obtained in last few months

Tip #22

Give a “Snowy Blizzard” presentation

* Step by step by step MARCH through your presentation in a clear, concise, confident manner (please refer to presentation episode for typical presentation format)

Tip #23

Do not forget to give at least a basic treatment plan. Some basic options include…

* Pain Medicine* Nausea Medicine* Fluids

Tip #24

Introduce your attending to the patient (demonstrates massive ownership)

Tip #25

Get something set up for your attending

* Laceration kits* I&D kits* Consent forms* Ultrasound machine* Language line

Additional Reading

* How to give a basic patient presentation in EM (EM Clerkship)

Tip #16

Recheck the patient’s heart rate and respiratory rate (and put in your presentation that you did so)

* Heart rate frequently falsely elevated when being triaged* Respiratory rate frequently falsely normal when being triaged

Tip #17

Fully examine the specific complaint. Some common misses include…

* Neurologic complaints (headache, paresthesias, dizziness, asymptomatic hypertension, seizures, visual complaints)* Finger-Nose* Heel-Shin* Gait (if possible)* Visual FIELDS* Spinal complaints (neck pain, back pain)* Straight leg raise* Crossed straight leg raise* Achilles and patellar reflexes* Midline tenderness

Tip #18

Independently OBTAIN stool sample (if clearly appropriate) or articulate in your presentation that you are WILLING to get it

* Elderly syncope* Abdominal pain with dark stool/melena* Severe anemia or large drops in hemoglobin/hematocrit

Note: You should NOT be doing full pelvic exams, rectal exams, GU exams INSTEAD of your attending (stool samples probably fine in my opinion), and you should NOT be doing these exams without a CHAPERONE.

Tip #19

Get the patient into a gown (at a minimum you should expose the area of concern)

Tip #20

Bring the ultrasound, gel, and towels to bedside. Appropriate chief complaints for this would include…

* Patients over 50 with back/flank pain (AAA exam)* Patients with severe hypotension/shock (RUSH exam)

Tip #11

Give 4 descriptors/adjectives for each complaint

* Location* Quality* Duration* Modifying Factors* Severity* Context* Timing* Associated Symptoms

Tip #12

Get the ACTUAL story. Why did the patient come NOW?

* Did something change or worsen?* Did family force them to come?* Do they have a family history of something similar?

Tip #13

Present the pertinent RED FLAGS for each complaint (some examples)…

* Headache* Sudden and Severe* Fever* Neck Stiffness* Neurologic Complaints* Back Pain* Saddle Anesthesia* Bowel/Bladder Incontinence* Fever* Trauma* Chest Pain* Exertional* Family history of MI at same age* PE risk factors* Sudden and Maximal/Tearing

Tip #14

Get their doctor’s names

* Primary care provider* Pertinent specialists

Tip #15

Don’t get bogged down giving too much medical history during your presentation. Simply write down the important facts for reference and present a few notable items in your opening sentence.

C→ Episode Summary

Tip #6

Make your patient remember your name.

* Introduce yourself clearly* Show the patient your badge* Use a nickname if your name is difficult for people to remember/understand* Repeat your name again and again

Tip #7

Keep the patient informed about…

* Diagnosis* Anticipated ED course/timeline* Delays

Tip #8

Keep your patient comfortable.

* Get them blankets* Show them how to use the remote/call light* Adjust the bed* Turn down the lights* Get them something to drink

Tip #9

Move fast.

* Spend no more than 10 minutes with the patient* Immediately grab your attending if the patient is ill appearing

Tip #10

Use a translator.

* Learn how to use a medical translator in your department (phone vs consult vs video consult)* INDEPENDENTLY use a translator to obtain your history when appropriate