EM Didactic: 10 commandments for being a stellar intern/ medical student in the ED

Monday, September 5, 2016

10 commandments for being a stellar intern/ medical student in the ED

1. Be pro active

Study about the ED (Prior to your first day, gather some info and do a bit of home work. Learn about the residents, attendings, speak to your colleagues about their experiences who have been through the rotation already. If possible, spend sometime in the ED a day before you intend to start)
Be upfront - Go out and introduce yourself and tell why you are here. ED is usually a busy place often congested with patients. Be proactive about doing things - always ask if you can assist with something - may be a procedure or working up a new patient. Don't stand in a corner like an spectator, this can be annoying for most of the people around.

2. Develop H and P skills (Ask what is required, be succinct, skip the exams and history portions that are not required)

H&P-->Differentials-->Labs--Treatment plan : This is the order! Don't jump to labs.
Life threats first: When you hear hoofing beats, think of lions, tigers and bears..i.e. Think of ACS, PE, Dissection first when dealing with chest pain (Think twice before sending someone home with a label of GERD)
Know how to briefly present a case within 2-3 minutes. Most ED docs will not pay attention if you don't get to the point within 2 minutes. Tailor your history and get to the point ASAP.

3. Keep Reading (common presentations, creating a list of problems/DDs, read about the cases that you see everyday)
This is what I did for the first few months of my training. Read about every case that you saw from a standard textbook like Rosens or Tintinalli. I would also recommend "An Introduction to Clinical Emergency Medicine" by Mahadevan. Learn about the common presentations of common diseases and also start construing atypical presentations. I promise you that if you do this for say 6 months - you will see yourself getting transformed and developing the EM mindset. The more you read, the more confident you will be while managing patients, speaking to attendings from various other specialities.

4. Procedures

This is something that I was really fond of (Central Lines, Chest tubes, Intubations..) and here is what I did - I always thought that I am not getting enough procedures. So I fixed a note on the ED notice board in the resus area where I requested my contemporaries to call me for any procedure 24X7. It was always busy and my colleagues were kind enough to call me for various procedures. So I was called for doing lines even when I was not on shift, sometimes at 2AM and in the long run it proved to be very useful. Find out your way of doing this.

5. Follow up patients (recheck your patients frequently and update them on the progress of their evaluations. Tell them what is happening and what are you/they waiting for. Care about them and are attentive to their needs (pain control, warm blankets, meals if appropriate). And if you follow them up until discharge, you will end up developing a great connection with them in addition to a much better understanding of what they went throughout the in-hospital course.

6. Documentation
Write legibly and comprehensively. Your chart should give a good picture about the patient. Address abnormal vitals, write down your concerns and a treatment plan. Always and always mention the date/time and discussion that too place with the specialists. If you are working on Electronic Medical Records, spend a few extra hours during the first couple of days to learn the software better.

7. Learn how to ask for a consult
This is something that you are going to do for quite a lot of your patients and as a medical student/intern, it can be daunting. Observe how attendings interact with other specialists. How they persuade IP doctors, how they develop relationships and make things go smooth. Read more on asking a consult here.

8. Be Professional

Attire - Dress up like a physician that you would want to consult and be honest i.e don't cook up vitals or parts of the history that you did not really ask for. It is better to accept that you missed a certain portion and get back to the patient to fill the gaps.
Respect others - EM is all about teamwork. Be respectful and courteous towards all your team members (nurses, paramedics, technicians, housekeeping).
Know your limitations - If you are in doubt, let the patient know that you need to speak to an attending/ consultant about it. This is not a sign of incompetence but making sure that you want to do the best for your patient.

9. Ask for feedback
This is pivotal. Rather than one single feedback, ask for weekly (for 1 month rotation) feedback from your preceptor. Multiple sessions provide you with opportunities to reflect back and fix the issues. The power of a appropriately given feedback is PHENOMENAL.
More on feedback here.