Lucy Huang – HowMedWorks

Clinical rotations can be intimidating, especially when one of your first ones is emergency medicine (EM)! For me, a current second-year physician associate/assistant (PA) student at Long Island University, it felt like being thrown into the deep end of the pool. EM is fast-paced, unpredictable, and demanding; you either sink or swim. Even before PA school, I had a strong interest in EM. I worked as a medical assistant in urgent care and also shadowed PAs in the emergency department (ED), so I was genuinely excited to step into a new role in the ED as a PA student. However, I know some of my classmates were less enthusiastic, and maybe you can relate. This article was written by Lucy Huang, a current PA-S2 at Long Island University. Whether you’re someone with an emergency medical technician (EMT) or paramedic background who’s super excited or someone with no prior emergency medicine experience who’s pretty nervous, you’ve come to the right place. Here are my top eight tips to help survive (and thrive) during your EM rotation. How To Ace Your Emergency Medicine Rotation 1. Prepare Before You Even Step Foot in the ED Before starting my rotation, one of the biggest ways I set myself up for success was by reviewing how to take a proper history. One tool that helped immensely was the Perfect H&P Notebook. This guide outlines every component of the patient history, review of systems (ROS), physical exam, labs, and assessment/plan (A/P). Because it’s crucial to be able to quickly recognize emergencies, I reviewed red-flag symptoms and common differentials for each chief complaint. For example: Chest pain (CP): myocardial infarction (MI), aortic rupture, aortic dissection, pericarditis, congestive heart failure, costochondritis Shortness of breath (SOB): chronic obstructive pulmonary disease (COPD), asthma, pulmonary embolism, pneumonia Syncope: arrhythmias, orthostatic hypotension, anemia, transient ischemic attack (TIA), hypoglycemia Dizziness: benign paroxysmal positional vertigo (BPPV), arrhythmias, orthostatic hypotension, hypoglycemia Back pain: cauda equina, herniated disc, sciatica, kidney stones, pyelonephritis Abdominal pain: build differentials by region Biliary colic Cholecystitis Cholangiitis Hepatitis Esophagitis Gastritis Peptic ulcer disease (PUD)Pancreatitis Myocardial infarction (MI) Gastritis SplenomegalySplenic infarct Pyelonephritis Ureter stone Constipation Small bowel obstruction (SBO)Large bowel obstruction (LBO) Colitis Pancreatitis Early appendicitis Umbilical hernia Aortic aneurysmSBO/LBOColitis Pyelonephritis Ureter stoneConstipationSBO/LBOColitis Appendicitis Ectopic pregnancy Ovarian cyst/torsionHerniaPelvic inflammatory disease (PID)Urinary tract infection (UTI)Urinary retentionPIDTesticular torsionDiverticulitisEctopic pregnancyHerniaPIDOvarian cyst/torsion Pro tip: Make sure to review atypical MI presentations, such as epigastric pain and dizziness, which tend to be more common in women, patients with diabetes, and older adults. Want to really impress your preceptor? Make sure you ask these key questions for any trauma patient that comes through the door; this includes bicycle accidents, motor vehicle collisions, falls, assaults, etc.: How did this happen? Did you hit your head? Did you lose consciousness at any time? Any nausea or vomiting? Do you have any back pain? If you were on a bicycle, was it a mechanical or electric one? Were you wearing any protective equipment (e.g. helmet)? Do you have any numbness or tingling anywhere? Are you able to walk? (Make sure to check.) Are you on any blood thinners? If there’s any broken skin, when was your last tetanus shot? If there’s any upper extremity involvement, which is your dominant hand? Something to keep in mind is that you might walk into your ER rotation expecting nonstop traumas, heart attacks, and life-or-death situations, but the reality is that most of your patients will be there for non-emergent reasons. You'll see a lot of chronic back pain, muscle strains, minor lacerations, small burns, ankle sprains, simple falls, upper respiratory infections, and medication refills. Some patients use the ED as their primary care because they lack insurance or can't get a timely appointment elsewhere. While these cases might not have the adrenaline rush you anticipated, they're valuable learning opportunities. You'll get plenty of practice with physical exams, suturing, wound care, and patient communication. Plus, part of emergency medicine is learning to quickly identify what's truly urgent versus what can be managed outpatient, and that skill starts with seeing the full spectrum of cases that walk through the door. 2. Brush Up on Your Clinical Skills Before rotations, I also reviewed physical exam techniques for each system and then practiced performing focused exams based on the patient’s chief complaint. Additionally, I brushed up on injections, blood draws, and suturing, knowing that laceration repairs are common in the ED. Pro tip: Simple interrupted sutures are the most common ones used in the ED, so practice, practice, practice! Below is a great video (8:30) on how to do simple interrupted sutures if you'd like a quick refresher. http://youtube.com/watch?v=pGEJEUZFIEk 3. Get Ready for Nights The ER operates on rotating shifts, which includes days and nights. My first week consisted entirely of night shifts. I’m naturally a night owl, but I would never naturally stay awake until 7 or 8 AM. My best tip would be to adjust your sleep schedule two days in advance. Blackout curtains or an eye mask definitely came in extra handy. Nights in the ED are unpredictable—either everything happens, or nothing happens. I made sure to pack snacks, emergency caffeine, and a review book to read during slower hours. One unexpected challenge that I faced was patients falling asleep on me as I tried to obtain a history. A tip that I learned was to prop their bed up so that they’re sitting up while talking to me. It worked pretty well most of the time to keep them awake and engaged. Pro tip: There's an unspoken rule in the ED: never comment on how quiet or unbusy it is. Tempting fate by saying the shift is slow will somehow summon every emergency within a 10-mile radius. You've been warned! 4. Pack Smart In addition to your white coat, stethoscope, and notebook, packing plenty of pens is a must on your EM rotation. You won’t know how, but they’ll disappear fast. When the red EMS phone rings and everyone scrambles to jot down patient information, they’ll be extra grateful you have a pen ready for them. Also, know where supplies are stored from day one and the codes to supply closets. (Definitely ask one of the nurses if you don’t know!) Half the battle is finding what you need quickly. I once spent ten minutes hunting down Dermabond. When you have time, familiarize yourself with how patients are connected to monitors and oxygen. They’re simple systems, but you don’t want to be figuring them out at the bedside in front of patients. Finally, keep essentials like trauma shears, saline flushes, alcohol wipes, bacitracin, gauze, and medical tape in your pockets. They’re extremely helpful in a pinch, and your colleagues will appreciate you. Pro tip: Download the MDCalc app for quick access to clinical scoring tools (you can scroll to the bottom of the webpage for IOS and Android app download links). Some common ones that you’ll use include the SIRS, Sepsis, and Septic Shock Criteria (for sepsis), PERC (for PEs), Canadian CT Head Injury/Trauma Rule (for head injuries), and CURB-65 (for pneumonia). 5. Master the ER Presentation Presenting patients was one of my first hurdles. It’s something you will constantly do throughout rotations, so get comfortable with it. It was easy for me to lose my train of thought because I would be nervous, which is why I created the following template for presenting in the ED. Feel free to use it as well! The patient is a [age] [sex] with a history of [relevant PMH/SHx] presenting with [chief complaint] X [time]. OPQRST (onset, provocation/palliation, quality, radiation, severity, time) Family history, surgical history, social history, allergies, medications ROS highlights Physical exam findings Assessment (3-4 differentials) Plan (labs, imaging, medications, etc.) I used this written template for every patient. Some preceptors prefer to listen to the whole presentation before asking questions, while others interrupt throughout. Staying organized helps either way. Pro tip: If a patient took a medication to try and relieve their symptoms, be sure to note the quantity and time of their last dose, as well as if it worked. Another question that preceptors encourage you to ask patients is, “Has this happened before?” Remember that your presentations should be focused. The ED is a fast-paced environment that is optimized to take care of emergencies, so you want to make sure to keep your presentations succinct and relevant to the acute complaint. For instance, a patient’s eczema history might be good to skip if they’re coming in for severe abdominal pain. Finally, the part of presenting that students struggle with the most is the assessment and plan portion. After each presentation, expect your preceptor to ask, "What do you want to do?” Therefore, you should always come prepared with a plan! ED physicians love differential diagnoses, so have three to five ready and be able to explain why each is more or less likely. Pro tip: A common mistake students make on EM rotations is leaving out differentials they've already mentally ruled out. Don't do this. Your preceptor doesn't know your thought process, so walk them through each possibility and explain why you're excluding it, even if it seems obvious. Mastering your differentials and clearly articulating your reasoning will really set you apart. 6. Ask, Offer, and Get Involved This goes for pretty much every rotation, but it’s true: your rotation is what you make of it. If there’s something you want to do, ask! Your preceptors are busy taking care of patients on top of precepting you, which means they oftentimes won’t know you want to do procedures unless you ask. Every time I volunteered, they were so excited to have me try. The worst they can say is no. Even then, I would ask to assist or observe. This shows them that you’re interested and also makes it more likely for them to let you try something the next time an opportunity comes around. During codes, it’s easy to feel like if you tried to jump in, you would get in the way. However, this is one of the most important opportunities to learn. The first time, I just observed and helped the pharmacist prep medications. However, during the next code, I volunteered for chest compressions; I figured it was the best way to contribute and learn without interfering. If there’s downtime, I recommend helping nurses with practical tasks like starting IVs, venipuncture, Foley catheters, and fingersticks. It helped me stay busy and get more practice in. The nurses were also very happy to have the extra help. Pro tip: This goes for pretty much any rotation, but be nice to the nurses! Always introduce yourself, ask how you can help, and show genuine appreciation for their work. Nurses are the backbone of the healthcare system and can honestly make or break your rotation experience. They know the patients better than anyone and can teach you invaluable practical skills. Also, they absolutely will remember whether you were respectful and helpful or dismissive and entitled. A good relationship with the nursing staff will make your shifts smoother, more educational, and infinitely more pleasant. 7. Take Care of Yourself The ED schedule is tough. Shifts tend to be anywhere from 10 to 12 hours, and night shifts can feel isolating. I was the only one amongst all of my classmates to be on nights, and I felt like I was in my own world. Certain cases will also inevitably take a mental and/or emotional toll. Seeing traumatic injuries, delivering bad news to families, or losing a patient can weigh on you in ways you don't always expect. It was comforting to eat a nice meal at the end of my shifts and meet up with classmates during weekends to decompress. For more self-care tips, below is a great video (7:57) sharing how healthcare providers like yourself can use a positive mindset and clear personal boundaries to survive and thrive through draining rotations. https://www.youtube.com/watch?v=GwJiEvbTIAQ 8. Study Strategically for the End of Rotation (EOR) Exam Last but not least is studying for the EM EOR exam. Finding time to study on top of working long, exhausting shifts is a challenge in itself. On top of that, studying for the EM EOR exam felt daunting because of how broad its topics were. Here’s how I did it: Firstly, I created study charts based on the PA Education Association (PAEA) Emergency Medicine Blueprint and Topic List, updating them as I reviewed. Next,I used WikiEM, which was especially useful for concise, up-to-date information; the residents used it constantly. Finally, or practice questions, I used HippoEd, which is free with an American Academy of PAs (AAPA) Student Membership, as well as the Blueprint Qbank. These were both excellent resources that were representative of the types of questions that showed up on the EOR. With these resources, I was able to pass the EM EOR exam! Final Thoughts Your EM rotation will be challenging, but it will probably be one of the most fun. I will genuinely miss this rotation. Whether or not you are interested in emergency medicine, it is such a great environment to see everything in medicine. Again, rotations are what you make of them, so ask questions, stay curious, and don’t be afraid to get your hands dirty (quite literally). Mistakes will happen, but be kind to yourself because it’s part of the learning process. Lastly, remember to take care of yourself throughout the rotation.