Each ER shift is 8 hours, typically you will spend 4 hours on ‘Major’ side - monitored beds with patients with more serious complaints, followed by 4 hours on the ‘Minor treatment’ side - MSK injuries, lacerations, less serious complaints. There will also be some RAZ shifts (Rapid Assessment Zone,- adjacent to the ED, 1-9pm) interspersed in your schedule. The yellow daily assessment sheets are required at the end of each shift and preceptors are usually expecting to complete them.
You will see patients according to how they are triaged (Canadian Triage Acuity Score - CTAS):
CTAS 1: require resus., seen in <5min
CTAS 2: <15min
CTAS 3: <30min
CTAS 4: <60min
CTAS 5: <120min
Charts are colour coded based on acuity. It’s good to be familiar with this system, however your preceptor will typically choose which patients you’ll see.
This will change from shift to shift. Generally, you want to show up 5-10 minutes before the start of your shift- there is no need to call your preceptor ahead of time. You will find out who you are working with by checking the whiteboard at the front of the ER between the trauma bays and finding the attending’s name with the same start time as you-this is who you will work with for the shift. Some preceptors like to hand select you your patients, while others will tell you to pick charts at will. Every preceptor has their own style, so learn to be flexible and clarify expectations with each new preceptor.
Use this rotation to practice using differentials, FIFE (seriously, a quick FIFE can sometimes save you a ton of time), and getting hands on skills (suturing, codes, traumas, etc.).
Seeing patients: You’ll typically see patients on your own. Some will already have a bed, while others can be found in the chairs/ stretchers in the hallway or the waiting room. If you need a room for an assessment, ask the nurse responsible for that part of the department before moving patients.
Codes: ER Docs are responsible for responding to codes throughout the hospital. If a code is called, check with your preceptor to see if you will be accompanying them. Get as much hands on as you can! Pay attention to how everyone communicates, think about the big picture, and review ACLS algorithms. Preceptors are generally pretty happy for you to attend codes, even if they aren't going, as they can be good learning opportunities.
Traumas: There is an ER Doc responsible for trauma team lead. If a trauma comes in, you’ll often have heads up, so check in with them as well as your preceptor to see if they can get you involved. To get prepared, PPE (gloves, masks, gowns) can be found on the shelves opposite the entrance to the Trauma Bays. Pay attention to communication, division of labour, and actions of trauma team members.
Have Fun!
None, but you will have overnight shifts!
Ask to get involved in any traumas and codes.
Carry snacks and a few pens.
Practice ECGs and XR interpretations if you have some down time.
Some attending like tests to be ordered for patients before seeing them, eg. ECG for essentially all chest pain patients.
Write all over the chart to save space: eg. if more past medical history or allergies come up during your interview, record them in the already existing spaces.
Ultrasound EVERYONE, this is a great opportunity to practice.
Apps: WikiEM, Bugs and Drugs, PalmEM, MD on Call, Diagnosaurus, ECG stampede, Resuscitation
Check out EM Cases and Life in the Fast Lane websites.
Stay organized: Get a clipboard and some paper. Use it to keep track of your patients (chart ID stickers), your DDx’s, and your pending investigations.
Get a patient chart: Check in with your attending at first. On the chart, check chief complaint, vitals, any other notes. Write the time you saw the patient in the space provided on the chart.
Lay eyes on the patient: decide “sick vs stable-for-now”. Note: sick patients may need early intervention.
Write out your differential diagnosis (DDx): Use an app, Uptodate, your own approach, etc. A useful approach to any emergency DDx is Critical vs Non-critical. To help free up your cognitive real-estate while taking a history, it may be helpful to have the DDx in front of you.
Evaluate the patient: Introduce yourself, get patient to restate chief complaint (great opportunity to use FIFE), take a CC-focused history, refer to your DDx to support your interview. Finish the other items in your history. Perform a focused physical exam based on the items left on your DDx.
STOP and think about your likely Dx, your DDx, and COMMIT to a Plan (disposition, investigations, treatment)
Present to your attending: Please see separate heading below.
Keep track of your investigations: Write them on your clipboard and check often.
Keep every patient’s disposition in mind: ie. where are they going (eg. home vs. home with follow-up vs. admit vs. transfer).
Summary statement: State demographics, risk factors (look them up) for your suspected Dx, Chief Complaint)
HPI: OPQRST, OLDCARTS, etc.
Pertinent Positives and Negatives on history: State 3-4 associated findings on history (symptoms or risk factors) that support your suspected diagnoses and then state others that refute other items on your DDx, especially the critical diagnoses. Preceptors appreciate when you show them you asked about the critical ones.
Vitals: state abnormal values then comment that the remainder are in normal range.
Pertinent findings on physical exam: Signs that support your suspected diagnoses and absence of physical findings to refute the other items on your DDx. Again, preceptors often like it when you've examined a patient for critical diagnoses.
State your DDx: Numbered list with reasons why and why not.
Suggest Work-up: Labs, imaging based on DDx. Ask yourself if there are any critical diagnoses you need to rule out with testing before you would be comfortable sending them home.
Suggest Treatment: Medications, Disposition (home, home with testing and follow-up, admit), Consultation.