After 30 short days and 165 seemingly even shorter hours spent at Baylor University Medical Center’s Emergency Department, I have completed my emergency medicine requirement and have a solid list of things I wish I had been told on how to prepare and what to expect. After learning the hard way, I’m excited to pass on this new knowledge to anyone who is anxiously awaiting their EM rotation like I was! I have a strong interest in emergency medicine and couldn’t wait to get started however, it was my very first rotation and I was extremely nervous. Luckily, BUMC threw me in head first and on the very first night I got to reduce multiple fractures, perform hematoma blocks, and see patients on my own before presenting. By the third week, I was suturing and performing I&Ds solo and on my last week, my preceptor let me get a taste of being an actual provider by putting in my own orders for labs and imaging, deciding whether or not to admit my patients, and perhaps the most commonly used skill for any medical provider → charting, charting, charting. (CYA, am I right!?)

How To Prepare

First let’s talk about the things you learned in school (& probably forgot like I did) that I used almost every day and that my preceptors asked me about specifically. I’m not going to explain the tests and topics, look them up on your own (this will help it stick in your brain!) but I’ll tell you why each one is important!

 SIRS criteria – All patients should be screened at triage (and again by you!) for signs of sepsis. You’d be surprised at how many patients look totally stable and non-toxic but actually meet 2 or more SIRS criteria. This prompts you to check labs specifically for….

Lactate – Why is this such an important lab value? What are things that can cause it to be high? Just as importantly, what can cause a falsely high value? Remember that lactate is not included in a CBC/CMP/BMP and has to be ordered and drawn separately.

Critical electrolyte values – If you haven’t done so already, do yourself a favor a just commit these to memory. It is time-consuming (and embarrassing!) to be flipping through your pocket guide in front of your preceptor because you don’t remember the range for sodium (which I also learned the hard way).

Special tests and signs –  I kept a running list of tests and signs that my preceptors asked me if I checked after seeing patients. I kicked myself often for forgetting these (or remembering their names but not what they were for) so be sure to review them! Even though many of them are non-specific, they really help support your differential (& make you look like a rockstar if you can say “Murphys & Boas was positive, I’d like to send this patient to sono.”)

• Levine sign

• Homans sign

• Boas sign

• Psoas sign

• Murphy sign

• Kehrs sign

• Cullens sign

• Battle sign

• Brudinski sign

• Thompson test

• Dix Halpike test

• Tinels test

• Phalen test

• Fluid Wave test

• Apley Maneuver

• This is not a comprehensive list of all of the signs and tests you can use to guide diagnosis but these are the ones that I saw most often!

Overdose antidotes. Unfortunately, ODs are common in the ED. Review guidelines and meds used to reverse and manage ODs on opioids, heroin, benzos, tylenol, beta blockers, iron, PCP, etc. These are just the substances I witnessed over the month. There are many more.

H&P. Lastly and perhaps most importantly, review your notes from when you took your H&P courses. In your mind (or at least my mind) it seems like you wouldn’t forget how to perform a good abdominal exam or MSK exam but it’s easy to forget things when you have real patients talking through their symptoms or writhing in pain while you try to auscultate. Also, patients can quickly swing from belly pain to neuro symptoms in which case you need to be able to do a quick but thorough exam of both systems. A good rule of thumb I learned is to examine the system or anatomy above and below their complaint. For example, if they have chest pain, be sure to do a neuro exam as well as abdominal exam. If they have knee pain, you’ll evaluate the ankle and hip. You get the idea.

What To Expect

Be independent. In my experience, there wasn’t really anyone able to hold your hand. It’s not because they were mean or didn’t care, it’s just that in a downtown metro emergency department with over 70 rooms and 4 trauma bays that are always full, there’s no time. Expect to hit the ground running and be prepared to see patients by yourself, even the first day. Be sure to take a detailed history of the problem (don’t skip any part of OLDCARTS), find out what medications they’re on, and remember your exam findings. This makes your preceptor’s job easy when you present the patient, and they can continue focusing on what they were doing. If you forgot to ask something, don’t worry. It’s inevitable. Whatever you do, don’t make anything up and simply say, “I forgot to ask. I’ll go do that right now.”

Closed mouths don’t get fed. This is perhaps the most important thing to remember if you want to practice hands-on clinical skills. The ED is a great place to be if, like me, you love procedures. It is routine for providers to do intubations, central line placement, EJs, suturing, I&Ds, paracentesis, lumbar punctures, and more. If you want to be the one to do these things, TELL THEM! I had to remind not only my preceptors, but the other providers who were working that day that I really wanted to get practice in and to call me if anything procedural came up. My best memory of the rotation was the opportunity to intubate! If you don’t keep yourself fresh on their minds, they’ll forget and just do it themselves. Don’t take it personally and don’t be afraid to SPEAK UP about the skills you want to practice. I also got to practice IVs and foleys by asking the nurses to teach me. They were happy to do it and let me put in every single IV they had on a shift.

Be involved, but not in the way. This is especially important in trauma situations when there are 10 people in the room, the patient is coding, and everyone seems to be in their own world. Whenever we got a trauma, I would prepare accordingly (gown and glove) and wait in the trauma bay for how I could be helpful. Sometimes that meant just watching and learning. Other times it meant chest compressions or applying pressure to wounds. Try to jump in and help out where you can (in any situation) just be sure not to be overbearing or get in the way of saving a life.

If you don’t know, look it up. If you are taking a patient history and don’t recognize a medicine on their list, take a second and google it before presenting. If their PMH includes a syndrome you’re unfamiliar with, just do yourself a favor and learn a little about it. This is an easy way to gain new information “on the job” and save your preceptor a little time as you move through your patients. I had to do this countless times (particularly for medications) but as the month progressed I began seeing a lot of the same ones and knew right away what they were for! Never doubt the power of UpToDate!

Be able to explain WHY you want to run every test. Pretty much every time I presented a patient my preceptor would ask “so what do you want to do?” Sometimes I would throw out “CBC and CMP” just to have an answer but that wasn’t enough. Be able to say why you feel lab work is important. Are you checking for anemia? Do you suspect their liver enzymes are up? Why? If you want imaging be able to say why. Do they need it according to the Ottawa rules or NEXUS criteria? The MDCalc app is your best friend here!

Tackling the EOR. The emergency medicine EOR from PAEA is notoriously difficult because they can ask about such a broad range of topics. It’s true that you never know what will come through the doors of that emergency department and must have a thorough knowledge of every system, every age, massive trauma to minor earaches, OB complaints to broken toes. The exam reflects this by presenting a long list of topics and I found some questions that weren’t even on the PAEA blueprint. To prepare, I used the exam blueprints on PAEA and focused on the largest topics (cardio, ortho). I went through it systematically and read each topic in my Pance Prep Pearls book and took practice tests through both ExamMaster and PAEasy. I passed the test using this method but I didn’t do as well as I would’ve wanted. It’s hard to study while on a rotation so be sure to plan for that along the way. I found myself cramming during the last weekend. If your biggest worry is the EOR, check out my better study tips!

If you’ve made it this far on such a long entry, I imagine you’re the type of person who already prepared for the EM rotation and are gonna be just fine! If you have any questions or helpful suggestions, drop them in the comments below!

Love and light,

Asia

PS - If you’re looking for the scoop on other rotations, check out Inpatient Medicine, Pediatrics, General Surgery, Psyche, Trauma ICU, Cardiothoracic Surgery, Plastic Surgery, Family Medicine, and OBGYN!