Clinical Year: Emergency Medicine


Going into my Emergency Medicine rotation, I was a little apprehensive.  I mean, anything can walk through those doors right?  At this point about halfway through my clinical year, I wasn't really thinking of myself working in the ED.  

The hospital I was working at was a smaller one, where there are usually 2-3 physicians and 2-3 PAs or NPs on at any given time.  My preceptor was great!  He loved to teach, and if we had any downtime, he would try to fit in a quick lesson about one of the many essential topics in the ER.  Everyone at that hospital was so nice and helpful.  I was the only student there and if anything interesting came in, the nurses or physicians or PAs would always come and get me.  

Basically the way the ER works is that a patient comes and signs in and they are triaged.  Their name and chief complaint are displayed on the provider's computer, and then each MD or PA decides who they are going to pick up.  It's important to keep a good balance of straight forward cases (like a cut that needs sutured) with more complicated cases that will require labs or imaging.  Since I was there, my preceptor would usually pick up 2 cases at a time and I would go see one patient while he saw the other.  

I was definitely right in assuming that the ED is unpredictable.  There would be some days that we were sitting around with not much to do, and then other days that there were so many patients, they were being treated in the waiting room.  Literally, one of the PAs would go in the waiting room, and if there was something simple they would treat the patient there.   Since the shifts are usually 12 hours, there would often be busy times and slow times during the same shift.  I ended up staying late a few times, just because it had gotten so crazy by the time I was supposed to leave.  

Working in the ER is a really great opportunity to see a lot of different cases and also to practice a lot of skills.  It's not the time to be shy.  If they give you a chance to do something, and you feel comfortable, then go for it!  There are so many skills I got to practice or see during this rotation, that it was extremely valuable.  I'll list a few off just so you can get an idea:

  • Suturing a cut from a chainsaw - I did this all by myself!  My preceptor said he would come check on me, but I finished before he had the chance.  I had a little suturing practice from my surgery rotation, but those were cleaner cuts.  My patient was really nice, and I remember his son was there and they were watching a show about puppies on the Animal Planet, which didn't seem quite characteristic, but was funny.  
  • Lumbar puncture - I was able to see an LP on a 4 day old (which was really hard to watch), and practice on a pt with advanced diabetes who we suspected might have meningitis 
  • Start a central line - My preceptor helped lead me through this one because I had only ever done it on models, but he helped me to find the femoral artery and go through the process, so that was really cool.  That's not something they do a ton at the ER I was at, so I was glad I got to see it
  • Intraosseous IV - I performed this on a pt who was currently having CPR done, and both efforts were unsuccessful unfortunately.  You really want to make sure you go in at a 90 degree angle to have a successful intraosseous IV
  • Remove a fishing hook from a pt's neck - Definitely interesting.  I just used a pair of pliers that look like they came from my dad's toolbox.  The pt did great though! 
  • See CPR - I didn't actually participate because by the time the pt got to the ER, the respiratory team was bagging the pt and they had the LUCAS machine on that does chest compression.  Pretty crazy to watch.  
  • Staple a child's head - Not the most fun, but good practice for working on kids.  You just have to be fast and hold them as still as possible.  
  • Drain a cyst - This was good practice for my current job in derm.  I still hate draining cysts.  The smell is just too much. 
  • Set a broken radius- I don't do well with bones.  Like those videos with people breaking their arms and legs?  I just can't handle them.  So when an 8 year old has a broken arm and they asked me to set it, I said sure just like any good student would do.  And then I almost passed out.  Whoops.  The feeling and sound and the MD "recreating the injury" to then put it back into place after I failed, that just didn't work for me.  So I turned sheet white and started blacking out as I ran out of the room to find a place to sit down.  I got made fun of just a little bit for that one.  
  • Watch a dislocated hip be realigned - More bones.  This was after the arm, and once the MD was standing on the bed and pulling on the patient's leg, I just decided to look at the ground.  But I heard it go back into place! 
  • Pop a dislocated shoulder back into place - For some reason I handled this ok.  It wasn't that bad.  Basically you pull down on the patient's arm, and then rotate their arm backwards and up and it slides back into place.  

So by the end of my ER rotation, besides the bone stuff, I really felt like I would enjoy working in that field.  I really liked the hospital I was at, and it would be a wonderful place to work.  Of course, in the ED, you get some drug seekers and difficult patients, or patients who really should just be at prompt care, but what can you do?  All of that is really just a part of medicine, so we deal with it.  The one thing I didn't love about the ER was the long shifts.  I felt like I went to work, came home, ate, slept, and then did it again for 3-4 days in a row.  So it was pretty exhausting, but I think it would be something you get used to if you do it all the time.  

Other Resources:

  • Here is a blog post with an interview with an ER PA.  And another one as well.  
  • "Advice to New Interns" - or to new PA students on rotations.  
  • ALiEM (Academic Life in Emergency Medicine) - This is a site with great articles and videos about emergency medicine
  • Here is a blog post from a fellow student about her experience and tips for an ER rotation.