“You are not here to treat patients; you are here to LEARN how to treat patients.”

The role of the medical student in the emergency room is to see and experience the presentation of acute medical conditions and to participate in the care and treatment of these patients. It is not the role of the medical student to “keep the patients moving.” Managing the acute evaluation of several patients simultaneously is a difficult skill to acquire and master. Students should “look in” on many more cases than they are primarily involved in. For example, take the opportunity to examine a multiple trauma patient even though you will not be managing them primarily.

The medical student should take several cases each day from presentation to disposition. The exact number depends upon the type of cases being seen and the department volume.  In general, it is preferable for a student to have fewer, thorough evaluations than many superficial ones.  While the house officers will take the cases in the order they are placed in the rack, students are allowed to sift through the charts and find an interesting/appropriate case. You MUST ASK the attending physician or resident if you can see that patient and review the information on the nurse’s triage assessment prior to interviewing the patients. After obtaining the history and examining the patient, present the patient to the resident/attending, along with your initial assessment and your plan for the initial evaluation of the patient. Don’t be surprised if you are questioned about your assessment and plan; we want to know your reasoning for ordering tests & x-rays.  You should follow your patient through entire ED course and check on their progress/status repeatedly during their ED stay.   Emergency Medicine relies heavily on people functioning as a team, so it is essential that you communicate clearly and often with your supervising physician regarding their expectations of you and your clinical findings on a patient.

It is permitted for students to write orders in the UMHS ED; however, all orders must be countersigned by a physician before a nurse or tech may act upon them.  SJMH uses a computerized entry system that is only available to residents and attendings.  It is extremely helpful if the student does take notes as to their findings on the H&P and other studies.  This assists the resident / attending in creating the formal documentation of the patient’s care.  Students are not required to document during their EM rotation; however, assistance with collecting data is considered a part of your responsibilities.

Aftercare instructions are a vital part of EM. Appropriate follow up is crucial. You should print all your discharge instructions in easily understood language and determine that the patient can read and understand them. Make certain, if you are making a follow-up clinical appointment, they understand what it is for. Also, determine if they have a personal physician. They may need to be followed by him/her. If the patient needs to be seen within a week or two, you must get approval from one of the service’s physicians (i.e. neurology consultant for an urgent neurology clinic visit to have the patient scheduled as an add-on. You should provide the approving physician’s name to our scheduling clerks and the patient so they can obtain the urgent appointment. Always ask the patient to call back to the ED if they have problems obtaining the appointment within the time frame you think they need to be seen.

It is appropriate for a student to participate in admitting a patient or obtaining a consult agreed upon with your supervising physician.  When you are going to admit a patient to a medical service, the patient is not admitted until the senior resident on the service on call or the fellow, in the case of the ICU services, is notified.

The patients appropriate for evaluation by the medical student are sometimes difficult to define. Clearly inappropriate patients for a student to see independently include multiple trauma, cardiac arrest, acute MI’s, and other conditions that require emergent intervention. However, you can and should participate in the resuscitation of these patients as a part of the medical team.

WHEN IN DOUBT, CONTACT THE ATTENDING PHYSICIAN

One of the hazards of the Emergency Department is that patients do not typically present clearly labeled as to their illness.  It is not uncommon to have a patient’s condition rapidly change.  If you are concerned about a patient, it is a mark of good clinical judgment to get rapid assistance from an experienced physician.

NURSE-TECH SHIFT

All students will complete a minimum of 1 nurse-tech shift during their EM rotation.  During this shift, the student will be matched with a team of ED nurses and techs.  The primary purpose of this shift is to gain procedural experience.  Common procedures during these shifts are

• IV starts
• Phlebotomy
• Splint application
• EKG tracings
• Foley catheter insertion
• Nasogastric tube insertion
• Arterial blood gases

Students may participate in any procedures performed by a nurse or tech; however, they may not administer medications.  As with most experiences, students who are enthusiastic and proactive about their education, obtain more experiences.  Students often find that the triage area provides many procedural experiences.

At the start of an assigned nurse-tech shift, the student will report to the ED charge nurse at the main desk for assignment to a team.  Students must complete the ED procedures lab which is held on the first Monday of the rotation prior to completing this shift. The triage area of the ED’s are often an excellent place to find procedures.  If all required procedures are completed, the student may leave the shift early.

GOLDEN RULES OF THE EMERGENCY DEPARTMENT

The most common mistake in the ED is failure to appreciate the severity of the patient's illness or injury; therefore, assume the worst disorder consistent with the signs and symptoms and attempt to disprove it.

1. ABC          IV—O2—Monitor
2. Consider NGT (narcan/glucose/thiamine) in all patients with AMS
3. Don't label a patient with a diagnosis until you have adequate data to defend it. Once a patient is so labeled, the thinking process slows dramatically.
4. Nurses often know more than you do. Ask their advice and pay attention to their concerns.
5. Pay careful attention to vital signs, especially respiratory rates.
6. No patient is allowed to leave the ED unless they can walk, except if chronically bed-ridden or in a wheel chair.
7. No patient leaves the ED until all lab results/X-rays are back.
8. No patient leaves the ED for X-rays, CT, or ICU admission without an appropriate attendant who can recognize a change in the patient's condition.
9. Consider an X-ray on all lacerations produced by glass.
10. Check distal neurologic function first prior to anesthetizing hand wounds.
11. Splint all orthopedic injuries (plaster, metal, Ace wrap, etc.)
12. All diabetics over age 35 with chest or abdominal pain need EKG's.
13. Always calculate anion gap when checking results of electrolytes.
14. Never believe the history in an overdose patient - order a blood and urine toxicology screen with attention to treatable drug overdoses/toxins.
15. Do rectal exams on all patients with abdominal pain, trauma, and suspected spinal cord injuries.
16. Do scrotal exams on all males with abdominal pain.
17. Order a serum pregnancy test on all women of childbearing age with abdominal pain, dizziness, or syncope.
18. Prior to ordering arterial blood gases, perform and document results of Allen's test.
19. Record your findings on all X-rays.
20. A normal CT scan does not rule out subarachnoid hemorrhage; perform an LP if you suspect this diagnosis.
21. All intoxicated patients with suspected head injuries need a brain CT scan, cervical spine X-rays and blood alcohol level.
22. Document visual acuity on all patients with ocular complaints or blurred vision.
23. All infants and children with injuries should have child abuse ruled out prior to discharge.
24. Order rectal temperatures on all young children with fever.
25. When writing prescriptions, check for allergies and contraindications first. Spell out quantity of narcotics prescribed. Never phone in a prescription on a patient you haven't seen. Warn patients of side effects ("Don't drive while taking Tylenol #3, etc.).
26. Check a bedside blood glucose on all patients with AMS and all sick children.

Trauma maxims:
-Undress all patients completely. Clothes can hide a significant injury. .
-Immobilize C-spine until it is cleared. "Cleared" means visualization of all 7 bones and
  C7/T1 interface; if any doubt, maintain immobilization and order cervical spine CT.
-Monitor input and output.
-Check CVP after insertion of central IV catheter.
-Check urethral meatus for blood prior to insertion of Foley catheter; measure urine
  output.
-Look for occult injuries on patient's back.
-Order chest and pelvis films, in addition to C-spine, on all multiple trauma patients.
-All trauma patients with hypotension in the field or in the ED need evaluation for occult
  bleeding, including imaging of chest and abdomen.
-All multiple trauma patients need O2 and cardiac monitoring.

Fractures you will miss:
-C7 - always count the vertebral bodies on the lateral view.
-Odontoid - check open-mouth view.
-Lunate & perilunate dislocations - check alignment of carpal bones.
-Carpal navicular - check for snuffbox tenderness; if in doubt, cast.
-Tibial plateau - order additional films as necessary.
-Acetabulum - order additional films as necessary.
-Radial head - check for presence of anterior fat pad.

THE OUTSTANDING MEDICAL STUDENT IN EMERGENCY MEDICINE
(Exerpt from Academic Emergency Medicine, April 2001, 8 (4): 402-403.)

• Outstanding medical students learn the approach to common emergency complaints (such as chest pain, shortness of breath, abdominal pain) and work to improve on deficiencies in their knowledge by reading and asking questions.
• Outstanding medical students are able to take an accurate history and perform a thorough physical exam. For example, they perform a rectal exam on the patient with chest pain, syncope, or gastrointestinal bleeding; they do a complete neurological exam on the patient with headache or weakness.
• Outstanding medical students are able to confidently present a directed history and physical exam with attention to pertinent positive and negative findings; they address abnormal vital signs. When presenting, they do not hop back and forth between history and physical exam. They have given thought to the differential diagnosis with attention to life-threatening causes and have come up with a reasonable diagnostic and treatment plan for their level of training. They are able to integrate pathophysiology from their basic sciences and core clerkship rotations.
• Outstanding medical students document comprehensively and legibly; they obtain a family/social history and a complete review of systems when appropriate.
• Outstanding medical students stay on top of their patients without having to be reminded. They know when lab results or x-rays are available. They recheck their patients frequently and update them on the progress of their evaluations. They care about their patients and are attentive to their needs (pain control, warm blankets, meals if appropriate).
• Outstanding medical students are professionally attired and respectful of others. They act in a professional manner with patients, their families, the ED staff (physicians, nurses, clerks, techs, and housekeeping), and consultants.
• Outstanding medical students are honest and trustworthy, never falsifying history or physical exam findings to give the impression of being thorough. They ask for help or direction  when needed; they never try to be a hero or heroine at the patient’s expense. They recognize the importance of team building and have skills in conflict resolution.
• Outstanding medical students show up on time for shifts and leave only when they have tied up all loose ends with their patients. They sign out their patients with a diagnostic and treatment plan in place.
• Outstanding medical students are interested in learning. They do the required reading and apply that knowledge in clinical practice. They read up on their patients. They attend all required conferences and learning sessions.
• Outstanding medical students are eager to see patients and are interested in being in the department. They do not read the newspaper or surf the web when patients are waiting to be seen. When the department is slow, they ask to be of assistance, find out about other interesting patients, or read up on their patients. They show enthusiasm for the specialty of EM.
• Most importantly, outstanding medical students understand that providing patient care is a privilege, not a right. They show the personal qualities desired by patients, families, and medical staff, including warmth, compassion, and gender and/or cultural sensitivity. They conduct themselves with integrity, maturity, humility, and honor.