How to shine on your emergency medicine sub-I!

Disclaimer: This was written when I was a med student! These are my personal opinions and do not in any way reflect my residency program or my employer. I don't mean to speak on behalf of anyone other than myself! 

Emergency medicine is unlike any specialty I had rotated on before my fourth year. Our role is to identify life-threatening conditions and treat them. When a patient comes in with a headache, we don’t need to figure out what it is – we need to rule out what it’s not. We rule out the life-threatening causes of headaches, treat the patient if we suspect one of them, and then figure out their disposition. Are they safe to go home, do we want to observe them for a little while, or do we admit them to the hospital? We might never know what’s causing a patient’s concern but if we can reassure ourselves that it’s not life-threatening, then we’ve done our job.

It took me two months of sub-internships to figure out these things. You definitely don’t have to do them all, I really try to be mellow lol but all the EM people seem more mellow than me so this list is more intense than you probably need to be! Be patient with yourself and show yourself grace as you adjust to the pace of emergency medicine. It might take a few shifts or a few weeks to find your rhythm and that’s okay!

Before your rotation:

• Know the top five acute causes of the ten most common concerns: headache, abdominal pain, chest pain, back pain, shortness of breath, weakness, fever, altered mental status, nausea/vomiting, eye pain + redness. WikEM is a good place to start!
• You can also think about how you’d work up each of these concerns in terms of physical exam, labs, and imaging
• I made an Evernote note for each ddx before I started and then fleshed the notes out more during my month. 
• Some concerns were too broad for me so I started to break them down further – abdominal pain in a patient 65+, flank pain, abdominal pain in a young woman
• If you’re really trying to go hard, you can look over the eight week curriculum on ALIEM.
• EM:RAP’s C3 podcasts were so helpful for beginners but they do require an EMRA membership – the articles and EKGs are free though!
• SAEM has a 100-page primer to the EM clerkship if you want a real deep dive!

At the start of a shift:

• The first day at a new site, familiarize yourself with your new environment. Find where the social workers hang out, where the ultrasounds get plugged into, where the warm blankets and juice boxes are stored, where the staff bathrooms are! 
• Introduce yourself to EVERYONE at the start of a shift! You are a new face entering their world (and they’re only seeing half your face lol). Because I couldn’t smile at people, I would wave every time I saw someone I had introduced myself to earlier – which seems silly but I did win over some tough-looking nurses.
• Have goals but be flexible with them. Some goals you should be able to practice on a shift no matter what (get discharge paperwork done before my resident has the chance, call the consults/admit the patients myself) but some are harder to predict (practice my abdominal pain ddx, do a laceration repair). Your resident might ask what your goal for the shift is so have one ready but know that you can’t predict how a shift will go and be ready to adjust gears as needed.
• Touch base with your resident or attending at the start of the shift. One of my sub-Is paired me up with a senior resident for the whole shift, one of my sub-Is had me float around more independently. But there should be someone you should talk to about expectations on who to present to, how to write your notes. I told my resident/attending that I would love to help with any procedures that came up on other people’s cases too!
• Early is on time. Get to your shift 15-20 minutes early to do your screener and get your PPE on and then scan the board before signout starts. There will be a few patients that the outgoing team hasn’t gotten to yet so look them over and start thinking about your next case. Make sure you’re physically at signout at least five minutes before the hour. 

On shift:

• Start with the end in mind. All patients fall into one of three disposition buckets after you first meet them – definitely going home, definitely getting admitted, or pending based on labs and images. The dispo buckets are fluid but they’ll help you triage tasks. 
• If you have three hours before signout and haven’t called the admitting team, you might wanna get the ball rolling on that so you aren’t staying overtime. If your patient seems well enough to go home, you can start drafting discharge paperwork.
• Keeping dispo at the forefront helps you address what is keeping this patient here in the ED. If all their tests have come back normal, is it that they’re still in pain or haven’t been PO challenged yet? Do you need social work to help with where they’ll go after discharge? It’s easy to get bogged down by all the things happening around you but dispo is KEY!
• Your exam starts when you walk in the room. Watch the monitor for their vitals. Do they seem out of breath when they talk to you? Are they sweating or wincing in pain? Do they look comfortable? After a month in the ED, you should have a better sense of sick vs not sick (most of your patients will be “not sick”, they’re not going to hand a bunch of unstable patients to an MS4 lol).
• If you are worried for ANY reason (they’re not responding normally or if they seem altered or agitated, or if there’s serious vital sign abnormalities), go get your resident. Knowing when you need help is a sign of maturity!
• (Semi-related but important point: tell your team if you feel uncomfortable. I had a male patient with belly pain who told me how beautiful I was, then said he had groin pain when I was examining his abdomen.... ya I told my resident lol who then did the groin exam for me)
• Don’t wait for some orders. If a patient is in pain or nauseous, pause the interview and find your resident and tell them what medication you’d like to order so that your patient isn’t waiting longer than they need to. Patients will be happier to answer your questions too if they’re more comfortable. 
• Keep your presentation TIGHT. Follow the three minute guide. Your team wants efficiency and to see that you’re working up the can’t miss diagnoses. It felt like on other rotations, the subjective/history was 1/3 of the presentation, the objective data was 1/3 of the presentation, and the A&P was 1/3. An EM presentation is 1/3 H&P, 1/3 assessment and 1/3 plan. You can include more details in your note but you only need to share relevant data that makes acute pathology more likely or less likely – make a compelling case that you’ve thought of every life-threatening condition and have ruled it out.
• Some patients will have twelve unrelated concerns which can be hard to piece together. Ask them what they’re most concerned about to narrow it down to 1-2 items on the problem list. 
• I found it helpful to sketch out the A&P in my note before presenting the patient to my team. Give yourself a few moments to ground yourself in the key pieces of information that you need your team to know.
• One of my senior residents told me this: [for chest pain]: “A good sub I says get an EKG and a troponin. A great sub I says they want this many troponins this many hours apart and if they’re positive then here’s what they’d want to do.” Think 2-3 steps ahead of where you’re at. You want a CT scan? Great – what are you looking for? If it’s positive, are you consulting someone or giving them a treatment? If it’s negative, are they safe to go home? Talk through this thinking in the A&P.
• Sprinkle in a clinical decision making rule in your A&P every chance you get. Some are better than others which you'll find out quick (people have strong opinions on these lol)
• Always look at your own EKGs and imaging. Try to compare the radiology report to your x-ray or CT or ultrasound clips, do you see what they see? Call/stop by radiology’s office to ask if they can walk through a scan if you have some time!
• Reassessments are key! 
• Check on your patient after any new treatment (fluids, nebulizers, Zofran) to see what’s changed and communicate updates on the plan (+communicate the plan with their nurses too).
• Update your team when test results come back (and mention what you’d wanna do next with these results)
• Sometimes it gets really busy, traumas are coming in and you get tapped to help with procedures on other patients. It’s also okay if you can’t circle back to check on your stable patients waiting for a bed upstairs - lean on your nurses and trust that they’ll call you if your patient needs you (why it’s so important to introduce yourself to the nurses!) 
• Practice what you’re going to say to your consultant with your resident and then call them on your own. Every specialty speaks a different language. In my experience, surgery wants the least amount of information and they’ll ask you questions if you leave anything out. Neurology wants a thorough neurological exam. If you’re consulting medicine, have the doses ready of every medication that your patient has received.
• No one expects you to know everything. And it’s hard to be honest about what you missed, but I wasn’t really shamed for it and my residents/attendings seemed to appreciate “I didn’t check. but I will right after this.” 
• Don’t push yourself to see one more patient if you’re starting to wear thin. It’s better to work up a few patients really well than drop the ball on one because you overextended yourself. Every shift looks different, some shifts I took four patients from start to dispo and helped with a bunch of procedures; other shifts I got a lil overwhelmed with my two complicated ones.  
• Ultrasound every patient you can. Cardiac and FAST were the most common, but you can learn a lot from a gallbladder, kidney, or bladder ultrasound too. Totally fine if you don’t have any ultrasound experience when you start but you can really build up your skills during a month in the ED!
• Other procedures you’ll want to read up on are laceration repairs (practice your simple interrupted + horizontal/vertical mattress) and I&Ds. I didn’t do any paracenteses or lumbar punctures (lower patient volumes over the summer/we were restricted to non-covid patients) but I’ve heard those are common too. 
• Leave things the way you found them. Wipe off the gel after an ultrasound, throw away the packaging and dispose your sharps after a laceration repair, turn the patient’s TV back on when you leave. 
• Slow down every once in a while to soak it in. You’re caring for people at their worst, on a hard day that they might remember forever. You’re tending to folks who have fallen through the gaps in our society. You have a front row seat to what’s happening in the world, whether it’s a pandemic or protests or racism or homelessness. This is a gift. It might not feel like it all the time but there will be something you’ll love about the department, whether it’s bonding with a patient or vibing with your team or piecing together an undifferentiated puzzle or coming up with a creative solution, whatever it is for you – slow down and soak it in!
• Don't forget to have fun!! You're a student, enjoy your role when you aren't responsible for the flow of the department. Follow the interns/junior residents on interesting cases, help with procedures that come up, go the traumas (and roll in the ultrasound machine/help with the FAST if your resident is okay with that)
• Eat and hydrate and pee when you need to!! It is TOTALLY fine to take a lil break (I would let my senior know when I was stepping away but they were so mellow that I did not have to / would be about to apologize for taking a long 15 min lunch break when my resident was like "wow you ate fast")

After each shift:

• Be ready to give a nice clean signout. Watch how the residents do it and emulate their style. If you’re patient is all squared away, just a one-liner on them + discharge paperwork complete/admitted to medicine is fine.
• Don’t pick up patients an hour before signout. You want to hand them off to the new team as tucked away as possible. Sometimes that means staying a lil later to finish an admission or get the answer to a consult question but it's not helpful to the oncoming team if you have a half-started workup with no labs back. 
• Make sure you meet your resident and/or attending for feedback at the end. Give yourself a pat on the back for what you’ve done well. Push them to see what next steps for you look like.
• If your team expects you to write notes, it’s okay to stay after shift and work on those. If your notes are done before signout, you can review them with your resident during your feedback session. 
• If you’re applying into EM/trying to improve your evals, draft out an email to the resident/attending that summarizes the shift  - the patients you saw together, the procedures/consults/admissions you did, the feedback they gave you. Send it a few days after your shift to jog their memory + maximize the quality of your evaluation. 
• Don’t take things home with you. A lot can happen on a shift. There are things to be disappointed or upset about sure but your next shift is a new beginning. Don’t take it personally if someone was rude to you – I just assume that it’s never personal and that this person is trying their best but they were stressed. We have to make really hard decisions or witness really hard things. Find a way to process what happened in a way that’s safe and restorative. Journaling after each shift helped me most.
• Keep track MRNs of interesting cases to follow up on (in a secure place of course)
• Read up a little bit on each patient you saw on shift. That can look like listening to a podcast or skimming UpToDate, looking at similar scans or doing a practice case on a similar topic. Add your notes to a mobile notebook like Evernote so you can easily reference them in the future.
• Don’t get bogged down about evals! Some people are just gonna write you a lame evaluation no matter what. Sometimes you only get to interact with an attending a few times on a shift and they don’t really get to know you. I got some meh evals which feels shitty in the moment but trust that the whole picture will come together the way that it’s meant to. You will never know what SLOE bucket you’re getting put into. You have no control over that, and it’s maddening when it plays such an important role in residency applications, but shift your attention to all the things that you do have control over.
• Take it easy dude! You deserve a break. Be diligent about getting your sleep in. Exercise, eat well, see your friends, do the things that you love so that you come into your next shift feeling recharged.

I know that was A LOT! You don’t have to do all of this stuff all the time – I just wrote out everything I wish I had known before starting my emergency medicine sub-Is. I’m so excited for you to start one of the best rotations ever! Like my coach says, “Have the shift of your life!” : ) 

xoxo