10 Tips for EM Sub-I's

Top 10 Tips for Emergency Medicine Sub-I's by Dr. Jonathan Warren (PGY-1 at Harbor-UCLA)

Links mentioned:

#1: EM Presentations

#3: https://ddxof.com/

#10: NuMose, ECG Stampede, LITFL

Accessible Text Version

1. Get Familiar with the 3-minute EM presentation: Having the ability to quickly and concisely present your patient’s history with pertinent information and order the presentation based on the chief complaint is one of the most important skills that you can have as a sub-I. Things move quickly in the emergency department and attendings are often busy with multiple tasks and getting interrupted. Being familiar with narrowing down your HPI to 3-5 minutes is the goal and worth practicing prior to the start of your rotation. For a great resource, see this link. Don’t forget that you still need to collect the whole history, it is just important to delineate what of that is crucial to the presentation.

2. Develop Rapport: History and physical examination are exceptionally important in the emergency department. You’re commonly treating and implementing plans before laboratory tests return and thus, everything that guides your initial management comes from the patient. Having your patient trust you will make them feel comfortable to reveal vital information. This also extends beyond patients. Developing rapport with the nurses and other ED staff is just as important and so that care is coordinated, and they often know additional information that you may have otherwise missed.

3. Have a Differential Diagnosis: Emergency medicine has a handful of primary chief complaints that comprise the majority of patient complaints. Developing a critical differential of diagnoses (ie- chest pain, headache, shortness of breath, etc.) that you do not want to miss for each one is important to direct your questioning and rule in/out life-threatening etiologies. Sites like ddxof.com may be a good place to start.

4. Develop Your ED Workflow: You want to be efficient and be able to see patients quickly but continue to be thorough and avoid lapses in care (be that waiting time or missed information). It helps to have a workflow that you use each time you see a patient. Sign up for a patient, go lay eyes on them if anything is concerning in history or vital signs (i.e – if the patient is being seen for shortness of breath, ensure they are not in respiratory failure and you have time to acquire more information). If you have time, read up on the history (if available) and any labs that have already resulted. Always read the nurse triage note. Prioritize sick patients, then discharges, then new patients and reassessments. Also, “run your list” to make sure each patient’s care is moving forward and not slowed as a result of your own actions.

5. Sick or Not Sick - Admit, Surgery, or Discharge: This is a skill that emergency physicians strive to develop over the course of their career, but it doesn’t hurt to start focusing on it and mastering the craft. The answers will guide management and eventual disposition. Try while you’re on a rotation to get a sense after the patient encounter an idea for if the patient is sick or not and where you think the ultimate disposition will be. This will also help your overall plan when presenting later.

6. Get Help: We are still learning medicine, but patients do not know this, and you may be assigned to a very sick patient. If something is making you worried, ask an attending to lay eyes on the patient: “Dr. XXX, I haven’t finished my H&P, but I would prefer if you lay eyes on the patient. They’re a xx yo M/F coming in for X and (insert reason you are concerned). I did this a couple times on my rotation and not only did it help me get a better idea for myself of “sick or not sick”, but also the attendings seemed to appreciate it as well.

7. Be Active. Be Engaged. Learn: You’re doing what you’ve been hoping to do for (at least) three years! You’ll be on long shifts and working overnights, but always be excited to be there and pass the “3 am test”. Keep those spirits up, offer to do any and all procedures, ask about ultrasounds, and help out in traumas (bring shears). Finally, remember you’re here to learn just as much as you are to show your skills. Be inquisitive, ask questions, learn as much as you possibly can.

8. Reassess Your Patients: The emergency department is dynamic and fluid. Patients may improve or worsen with time and interventions. Always reassess your patient after any intervention (labs result, after giving fluids/medication) or if things are not getting done. It is always helpful if running the list with an attending that you have a sense of what is happening in your patients care, what the next step will be, and how they are doing. Similarly, always review the possible diagnoses and plans with the patient. They want to be aware of what is happening just as much as your colleagues.

9. Optimize Your Note Writing: Note writing in the emergency department is slightly different from other rotations. The history and physical is important, but a well-documented and thought out medical decision making (MDM) is essential. This is where you will discuss your differential, and which diagnoses you are concerned for and which you are not. You’ll discuss why you’ve ordered tests, or why you have not given medications. It should also include your reassessments, additional interventions, and ultimate disposition as well.

10. Get Comfortable with EKGs: NuMose has a great guide to approaching EKGs in an ED-centric manner that is exceptionally useful. You can work on your pattern recognition with EKG Stampede. Finally, LITFL has great an in depth library for EKG learning tips and resources.

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