Emergency Medicine Clerkship Guide

PA students
Written By Anne
 
 
 

In this comprehensive guide, you’ll get tips to help you navigate your Emergency Medicine clerkship with ease. We'll cover everything from the typical schedule, clerkship responsibilities, what to bring, documentation of patient encounters, how to study effectively, and favorite resources in Emergency Medicin

 

Here we’ll cover:

  1. What is Emergency Medicine: Definition of the specialty, common conditions seen in Emergency Department and practice settings.

  2. Typical schedule: See an example of a typical daily and weekly schedule in Emergency Medicine

  3. Clerkship responsibilities in Emergency Medicine: How to get started in your orientation, what you’ll do in Emergency Medicine (expectations and responsibilities of clerks), opportunities for learning

  4. What to Bring: Dress code, essential medical equipment and optional items.

  5. Documenting Patient Encounters: Tips, and types of medical documentation in Emergency Medicine

  6. How to Study during your Emergency Medicine rotation: How to review materials, background reading before the rotation, setting aside time to study, and reading around cases.

  7. Favourite Resources in Emergency Medicine: Recommended Apps, Books and Online Resources

 

I. What is Emergency Medicine?

Definition of Emergency Medicine

Emergency Medicine is a medical specialty that focuses on the immediate and acute management of medical emergencies. It involves the diagnosis, treatment, and management of a wide range of medical conditions, including trauma, cardiovascular emergencies, respiratory distress, and infectious diseases. Emergency Medicine physicians work in hospital emergency departments, urgent care centers, and other acute care settings, providing critical care to patients who require immediate medical attention. The field of Emergency Medicine is fast-paced, high-stress, and requires strong clinical skills and the ability to make quick and accurate medical decisions.

Common Conditions in Emergency Medicine

  • Undifferentiated Complaints: Abdominal pain, chest pain, headache, shortness of breath, fever, syncope, altered mental status, pelvic pain and back pain.

  • Cardiac: Acute coronary syndrome, Arrhythmias, Heart failure, thoracic aortic dissection, and Hypertensive crisis

  • Ear, Nose Throat: Epistaxis, Pharyngitis,

  • Electrolyte Distubrances: Hyperkalemia, Hypokalemia, Hyponatremia, Hypercalcemia

  • Endocrine: Diabetic Ketoacidosis (DKA), Adrena .Crisis, Thyroid storm, Hypoglycemia, and Hyperglycemic hyperosmolar state (HHS)

  • Environmental: Hypothermia, Heat stroke, drowning, Hyperthermia, Burns, Frost Bite, and Smoke Inhalation

  • Infection: Sepsis, Urinary Tract Infection, Septic Arthritis, Osteomyelitis, and Cellulitis

  • Immune: Allergic reaction, Anaphylaxis, Angioedema, transplant rejection, Kawasaki syndrome, Rheumatic Fever, Serum Sickness

  • Respiratory: Asthma exacerbations, COPD exacerbations, Pneumonia, Pulmonary embolism, Pneumothorax

  • Neurological: CVA, TIA and Stroke, intracranial hemorrhage, seizure, traumatic brain injury, and meningitis

  • Psychiatry: agitated patient, suicidal patient

  • Gastrointestinal: Appendcitis, Biliary Disease, GI bleeding, pancreatitis, and bowel obstruction, mesenteric ischemia, perforated viscus

  • Toxicology: Drug Poisoning/overdose (e.g. Acetaminophen, Salicylates, opioids, calcium channel blockers), alcohol poisoning, Illicit drug toxicity (eg. cocaine, bath salts, amphetamine), environmental exposure (e.g. lead poisoning, botulism)

  • Trauma: Foreign Body Removal, Fractures, Joint dislocations, Head injuries, Burns and Lacerations

  • Genitourinary: Renal Colic, Pyelonephritis, Testicular Torsion, ectopic pregnancy, pelvic inflammatory disease (PID) or tubo-ovarian abscess (TOA), ovarian torsion

  • Vascular Emergencies: Ruptured Abdominal Aortic Aneurysm, Arterial Occlusion,

Description of Practice Settings

The ultimate goal of the ED is to provide rapid, effective medical care to patients with urgent or life-threatening conditions, and to ensure that they receive appropriate follow-up care to promote a successful recovery.

  • Triage: Upon arrival at the ED, patients are assessed by a triage nurse or physician to determine the severity of their condition. Triage is based on a standardized system that assigns patients to different priority levels based on the severity of their illness or injury.

  • Treatment areas: EDs are typically divided into different treatment areas, such as trauma bays, resuscitation rooms, and examination rooms. These areas are equipped with the necessary equipment and supplies to provide immediate medical care to patients with different types of conditions.

  • Diagnostic services: EDs are equipped with a range of diagnostic services, including laboratory tests, imaging studies, and electrocardiograms (ECGs). These services allow physicians to quickly diagnose and treat a wide range of medical conditions.

  • Specialty services: EDs may also have access to specialty services, such as neurology, cardiology, or orthopedics. These services are often available on an on-call basis to provide consultation or treatment to patients with complex medical conditions.

  • Discharge planning: After receiving medical care in the ED, patients may be discharged home or transferred to another hospital unit for further treatment. ED staff work closely with other healthcare professionals to ensure that patients receive appropriate follow-up care and have access to the necessary resources to manage their condition.

 

II. Typical Schedule in Emergency Medicine

Daily Schedule

A typical shift in Emergency Medicine can vary depending on the hospital and the specific shift. Shifts are around 8-12 hours long. Here is an example of what a typical shift might look like:

  • Shift handoff: The incoming emergency medicine practitioners (MDs, PAs, NPs) meets with the outgoing staff to review any critical or ongoing cases, patient status, and discuss any other pertinent information about the department.

  • Patient evaluations: Performs your patient assessments including physical examination, review patient history, order and interpret diagnostic tests, and formulate a treatment plan for each patient. They must also document all patient encounters in the medical record.

  • Consultations: You may consult with specialists or health care staff to get input on patient care plans or to make decisions about the appropriate course of action.

  • Procedures: During your shift you may perform a variety of procedures, such as suturing wounds, performing lumbar punctures, inserting central lines, and more.

  • Shift handoff: At the end of the shift, you will meet with the incoming staff to review any critical or ongoing cases and discuss any pertinent information about the department.

Weekly Schedule

During your week in the Emergency Department, you'll rotate through various shifts, including day, evening, and overnight shifts. Each shift may offer a unique experience and exposure to different types of patients and medical conditions.

This could include three to five, 8 to 12 hour shifts. Examples of possible 8 hour shifts include:

  • Morning: 8 am to 4 pm

  • Evening: 4 pm to midnight

  • Overnight: Midnight to 8 am (some sites may or may not require overnight/'graveyard’ shifts).

 

III. Clerkship responsibilities in Emergency Medicine

Getting started in EM

When you first start your Emergency Medicine clerkship rotation, you'll likely receive an orientation to the Emergency Department and an introduction to the staff. You’ll obtain your hospital-issued scrubs, ID badge and login setups for the Hospital EMR.

  • Orient yourself to the different areas of the Emergency Department: Patients are assigned acuity based on CTAS (Canadian Triage and Acuity Scale) scale. CTAS is a triage tool used in emergency medicine to prioritize patients based on the severity of their condition and ensure that those who require urgent or emergent care receive it in a timely manner. The CTAS system categorizes patients into one of five levels, with Level 1 being the most urgent and Level 5 being the least urgent. The categories are based on the patient's presenting complaint, vital signs, and potential for deterioration.

    • Level 1: Resuscitation - threats to life or limb requiring immediate aggressive intervention (cardiac arrest, airway obstruction, major trauma, shock)

    • Level 2 Emergent - a potential threat to life or limb, requiring rapid medical intervention (chest pain with signs of shock, severe respiratory distress, major burns, seizure)

    • Level 3: Urgent: potential to progress to a serious problem that would benefit from intervention (abdominal pain with fever, asthma exacerbation, suspected stroke with no neurological deficit, possible fracture with severe pain)

    • Level 4: Less Urgent: potential for deterioration, would benefit from intervention (mild to moderate asthma exacerbation, non-specific abdominal pain, cellulitis with no systemic symptoms, minor head injury with no LOC, simple lacerations)

    • Level 5: Non-urgent (chronic or stable conditions, mild allergic reactions, minor injuries or skin conditions).

  • At the beginning of each shift, be sure to introduce yourself to the attending/your preceptor. It's important to communicate your goals and expectations for your clerkship rotation (and what you hope to do or see during the shift!).

What you’ll get to do in EM

  • Read the Nursing/Triage Note: A triage note is a brief documentation made by a nurse or other trained personnel during the initial assessment of a patient who comes to the emergency department. It includes vital signs, chief complaint, brief history of present illness, any relevant past medical history, and a preliminary assessment of the patient's condition. The triage note helps to prioritize patients based on the severity of their condition, and it serves as a reference point for the healthcare team during the patient's visit to the emergency department. Use this as a starting point when you pick up the patient chart.

  • Patient assessments: history taking, physical examination. This will include developing an approach to common complaints that come through the ED including chest pain, abdominal pain, shortness of breath and other undifferentiated presentations (see above for list). You will also learn how to be concise and efficient.

  • Appropriately order and interpret tests and investigations according to your patient assessments, including chest xrays, abdominal x-rays, 12-lead ECGs, head CT scan (to rule out acute bleeds or space occupying lesion), labs (blood counts, liver function, basic metabolic profiles, cardiac enzymes, and ABGs), MSK x-rays (e.g. assess fractures).

  • Clinical Reasoning: Based on the information you have gathered from your patient assessment, risk factors, and tests, you will generate at least 2-3 differential diagnoses. This will help inform the treatment plan.

  • Formulation of a treatment plan: Being a clerk is more than just history taking, physical exams and looking at tests! In the n emergency medicine, the formulation of a treatment plan is often focused on stabilizing the patient's condition and managing acute symptoms, while also taking into account any underlying chronic conditions or potential complications. Treatment plans may include medications, procedures, lifestyle modifications, patient education and facilitating referrals for ongoing monitoring and follow-up.

  • Case Presentations: After you have seen and assessed the patient, you will be expected to give a case presentation to your ED preceptor where you summarize your findings in a succinct and organized way. The presentation usually includes relevant patient information, medical history, clinical examination findings, test results, and a summary of the patient's clinical course. The purpose of the presentation is to allow the preceptor to evaluate your clinical reasoning and decision-making skills, as well as to provide feedback on their performance. The presentation is typically followed by a discussion between you and the preceptor, where the preceptor may ask questions or provide additional information to help you improve your clinical skills.

  • Requesting Referrals: Calling different on-call services when ED patients require additional expertise or interventions beyond the scope of Emergency Medicine. Here are some examples of specialty consultations that may be requested in the emergency department:

    1. Cardiology: Emergency Medicine physicians may consult a cardiologist for patients with chest pain, heart rhythm abnormalities, or heart failure.

    2. Neurology: Neurology consultations may be requested for patients with stroke, seizures, or other neurological conditions.

    3. Surgery: Surgeons may be consulted for patients requiring urgent surgical interventions, such as for appendicitis, trauma, or bowel obstruction.

    4. Infectious Disease: Infectious disease specialists may be consulted for patients with severe infections, sepsis, or suspected infectious diseases, such as HIV or tuberculosis.

    5. Psychiatry: Emergency physicians may consult a psychiatrist for patients with acute psychiatric emergencies, such as suicidal ideation, psychosis, or severe depression.

    6. Pediatrics: Pediatric specialists may be consulted for children who require specialized care, such as for pediatric trauma, neonatal emergencies, or pediatric surgical emergencies.

  • Point-of-Care Ultrasound (POCUS): POCUS is use of a portable ultrasound machine for bedside ultrasound to obtain real-time images for diagnostic or procedural surfaces. Some Emergency departments and Emergency Medicine PAs/MDs/and NPs are trained in POCUS. POCUS can be used to evaluate a wide range of conditions, including trauma, cardiac arrest, abdominal pain, and respiratory distress. In Emergency Medicine, it is commonly used to assess for fluid in the lungs or around the heart, to evaluate the abdominal organs for signs of injury or disease, and to guide procedures such as central line placement or joint aspiration.

Procedures

Different types of procedures you may assist with or perform in the ED:

  • Airway Management

  • Arthrocentesis

  • Fracture immobilization with casting/splinting

  • Fracture reductions

  • Foreign body removal

  • Insert Nasogastric Tubes (NGTs)

  • Insert Peripheral IV Catheters

  • Lumbar puncture

  • Nasal packing

  • Placing a wound drain.

  • Reduction of joint dislocations

  • Slit Lamp Examinations

  • Suturing lacerations

  • Wound debridements

Opportunities for Learning in EM

Your Emergency Medicine clerkship rotation will provide you with numerous opportunities for learning. You'll have the opportunity to work with a diverse patient population and encounter a wide range of medical conditions. You'll also have the opportunity to participate in procedures, attend lectures and conferences, and work alongside other healthcare professionals.

 

IV. What to Bring

Dress code

It's important to dress appropriately for your Emergency Medicine clerkship rotation. You'll be working in a fast-paced, high-stress environment and may encounter situations that require you to get your hands dirty. It's recommended to wear comfortable, professional attire that is easy to move in, such as scrubs or business casual clothing.

Essential medical equipment

This may include a stethoscope, penlight, and pocket notebook. It's also recommended to bring a clipboard and pens for documentation purposes.

 

V. Documenting Patient Encounters

SOAP Note in ED

Your SOAP notes in the ED will be similar to what you’ve done for other rotations:

  • Subjective: The subjective section of the SOAP note includes the patient's chief complaint, symptoms, and relevant medical history. This section should include a brief summary of the patient's subjective experience of their symptoms, along with any relevant past medical history, medications, allergies, or other pertinent information.

  • Objective: The objective section includes the healthcare provider's physical exam findings, vital signs, and other objective data. This section should be as specific and detailed as possible and should include any relevant diagnostic tests, such as lab work or imaging studies.

  • Assessment: The assessment section includes the healthcare provider's diagnosis and impression of the patient's condition. This section should include a summary of the patient's clinical course and any changes in their condition since their previous encounter.

  • Plan: The plan section includes the healthcare provider's treatment plan and management strategy. This section should outline any medications, procedures, or other interventions that are planned, along with any follow-up or referral recommendations.

 

Example SOAP note in the Emergency Dept

S: 45-year-old male presents with chest pain that started 2 hours ago. Pain is described as a pressure-like sensation in the center of the chest, radiating to the left arm. He also reports shortness of breath and nausea. No known history of cardiac disease.

PMHx: Hypertension.
Meds: No medications.
Allergies: No known drug allergies.
SocHx: Single, no children. Carpenter (full duties). Smokes 1 pack per day x 15 years. EtOH 3 drinks per day. No recreational drug use.

O: Vital signs: BP 140/90, HR 110, RR 18, O2 saturation 98% on room air. Cardiovascular exam reveals a regular rhythm with no murmurs or gallops. Lungs are clear to auscultation. ECG shows ST segment elevation in leads II, III, and aVF.

A: Suspected acute myocardial infarction. Differential: Pulmonary Embolism, GERD or Peptic Ulcer Disease (PUD).

P: Administer aspirin and nitroglycerin sublingually. Order cardiac enzymes, CBC, CMP, coagulation studies, and a chest X-ray. Consult cardiology for urgent evaluation and potential transfer to the cath lab. Admit to telemetry unit for further management.

Jane Smith, PA-S2
Clinical Clerk, Emergency Department

In service of: Dr. Y

 

VII. How to Study during your Emergency Medicine rotation

During your Emergency Medicine clerkship rotation, you'll encounter a wide range of medical conditions and procedures. It's important to review relevant materials to help solidify your understanding and improve your clinical skills. This may include textbooks, online resources, and lecture notes.

Develop an approach to undifferentiated, common chief complaints

Make sure to focus some of your study on the approach to undifferentiated complaints. There are so many different presentations you can see in the Emerg department (treating fractures, frostbite, ruling out ectopic pregnancies, addressing asthma exacerbations), it is nearly impossible to learn about every single condition that presents to the ED.

However, patients often present to the Emergency Department with undifferentiated complaints:

  • Back Pain

  • Chest pain

  • Headache

  • Fever

  • Nausea/Vomiting

  • Abdominal Pain

  • Shortness of Breath

  • … and more

Reading around cases

Reading around cases is an effective way to reinforce your learning during your Emergency Medicine clerkship rotation. After encountering a patient with a particular medical condition, take the time to read about that condition in-depth. This will help you understand the underlying pathophysiology, diagnosis, and treatment options.

 

VIII. Favourite Resources in Emergency Medicine

Best Emergency Medicine Apps

  • MDCalc (free): Calculators to assess risk including NIHSS, PECARN, PERC, ad HEART score

  • WikiEM Mobile App (free): Approach to common conditions in one of the largest open access medical education apps.

  • UptoDate: If your school or institution has access, see if you can get this set up on your phone!

  • Firstline (Institution specific antimicrobial approach/Antibiotic Steward): An app which provides guidelines on which antibiotic to use against certain pathogens based on profile of your area. You can look up data and guidelines including biogram data by antibiotic, dosing (afdults and peds), and by pathogen. (e.g. Firstline is used by a few hospitals in Alberta Health Sciences, Manitoba, CHEO - Ottawa, SickKids - Toronto, Joseph Brant Hospital - Burlington and more).

Recommended EM Pocket Reference Books

Recommended Long-Form Textbooks:

Podcasts

  • Emergency Medicine Cases Podcast: Based in Toronto, Ontario, this free open access medical education resources provides High yield cases, journal club, rapid review videos and quizzes to help reinforce your learning. The process is as follows: Listen to the podcast → Read the show notes → Watch the Rapid Review Video → Test yourself on the CME Quiz!

  • EMCrit Podcast: A #FOAMed (free and open access medical education) resource that provides episodes once every two weeks on how to approach critically ill patients in the Emergency Department.

  • RebelEM Podcast: Summaries of conditions that present to the ED, that end with clinical take-home points.

Online Resources

PAs in the Emergency Dept

 

Final notes

Completing a clerkship rotation in Emergency Medicine is an exciting opportunity for medical students to gain valuable clinical skills and knowledge. Throughout your rotation, you'll encounter a diverse range of patients and conditions, and have the chance to work with skilled health care providers!

Anne

I am a Canadian trained and certified Physician Assistant working in Orthopaedic Surgery. I founded the Canadian PA blog as a way to raise awareness about the role and impact on the health care system.

http://canadianpa.ca
Previous

General Surgery Clerkship Guide
Next

Internal Medicine Clerkship Guide