CLERKSHIP DIRECTOR WELCOME
Welcome to your Emergency Medicine rotation at Advocate Christ Medical Center Department of Emergency Medicine. We hope that you will find your experience both exciting and informative. Emergency Medicine is a challenging field that utilizes every aspect of medicine. The rotation is structured for fourth year medical students who have completed the core rotations in Pediatrics, Psychiatry, Internal Medicine, Surgery and OB/GYN. The Department of Emergency Medicine at Advocate Christ Medical Center is one of the busiest Emergency Departments in Illinois. We expect your rotation with us to be challenging, but structured in a way to help you learn and grow.
Orientation is held on the first Tuesday of your rotation. We will meet in the Department of Emergency Medicine Office, at a time specified via email, usually around 9am. The orientation may be moved to the next day at the discretion of the Clerkship Director. The first day is orientation only and does not require patient contact, so you may dress casually. Orientation will take approximately 4 hours. Please feel free to email me with any questions at christemstudents@gmail.com.
Karis Tekwani, MD
Student Clerkship Director
Department of Emergency Medicine
Advocate Christ Medical Center
GOALS AND OBJECTIVES
The goals of the rotation:
To provide an environment in which a fourth year medical student may gain knowledge of emergency medicine.
To provide an environment in which students under supervision may learn and perform procedures.
To prepare students who are interested in pursuing careers in Emergency Medicine.
To emphasize clinical teaching at the bedside by close one-on-one supervision with a senior resident or a teaching attending.
To provide didactic teaching through a series of focused medical student teaching rounds, weekly didactics, simulation cases, case presentations, and procedure labs.
The goals for the student:
To demonstrate the ability to take focused history and physicals in the acute care setting.
To demonstrate the ability to formulate treatment plans and manage the acutely ill patient.
To demonstrate professionalism while working as part of a team in the acute care setting.
To demonstrate proficiencies in basic emergency medicine procedures in the procedure lab.
The opportunity to perform emergency medicine procedures under the direct supervision of Board certified EM physicians.
To demonstrate knowledge of Emergency Medicine.
To demonstrate basic interpretations of imaging, lab results, and other ancillary studies.
To give a case presentation discussing the presentation and management of an interesting case.
To participate in simulation codes cases.
BEFORE THE ROTATION STARTS
Before the start of your rotation, you should receive or do the following:
You will receive an email regarding pre-rotation details roughly 2 weeks before your elective starts. Should you not receive an email, please contact Lucia Ontiveros at 708-684-5405
Or, at your convenience any time before the rotation starts, you can email the following information to Lucia:
Your preferred name or what you would like to be called while here. Your schedule requests for days off. A picture of yourself for identification purposes. The number of Emergency Medicine rotations you have done prior to starting this rotation. Are you planning on applying to Emergency Medicine for residency? Are you looking for a letter of recommendation from this rotation?
SCHEDULING
Students rotate through all areas of our department over 14 clinical shifts. Shifts are 10 hours long, and comprised of:
10 Shifts focused in the main Emergency Department
2 Night shifts in the main Emergency Department
1 Peds ED shift
1 Teaching Rounds shift
MAP OF THE MAIN EMERGENCY DEPARTMENT
The emergency department is divided into sections to allow better resource utilization. Your month in the ED will consist of shifts in the various areas. The drawing below is an architectural diagram of the ED. The blue, red, brown and gold areas constitute the main ED where critical and general care patients are treated. The VZ is designated for lower acuity patients. Due to the size of the ED there is a geographic division of the main ED to allow for better physician coverage. Your main room shifts will be listed as (R) meaning Red Team, (B) meaning Blue Team, (BR) meaning Brown, (G) meaning Gold Team, (VZ) meaning Vertical Zone, and (Flt) meaning floating between all areas. All teams see both critical care (high acuity) and general care (lower acuity) patients in an alternating fashion throughout every shift. The float shift is designed to help out all sides. NOTE: coverage on night shift and early mornings changes, you will be made aware of this on your night shifts..
REQUIREMENTS FOR COMPLETION OF THE ELECTIVE AND GRADING
The requirements for completion of the Emergency Medicine career elective at Advocate Christ Medical Center include the following items:
Distribute your electronic evaluation to residents/attendings, one per shift
Procedure log
Conference attendance
Procedure lab and Teaching Rounds attendance
Case presentation
Final Exam
Grades will only be calculated and submitted once all of the student's requirements are completed and/or turned in at the end of the rotation.
You will be given a QR code and link to individual electronic evaluations. These evaluations are to be given by you to the supervising physician you worked with at the end of your shift (resident and/or attending). These are used to evaluate your performance during clinical shifts. Your rotation grade is based 60% on the results of these evaluations. It is critical for your grade that you distribute an evaluation at the end of each shift.
The Procedure Log is a list of the procedures you directly observed or performed during your rotation in the ED. Log all procedures you were involved in. This list will also need to be turned in on your last day. Final exam and case presentations are discussed later.
GRADES
The grading system for your rotation in Emergency Medicine is:
60% Clinical Performance, based on your yellow evaluation sheets and the Student Review
20% Final written exam
20% teaching rounds, procedure lab, simulation cases, case presentation, etc.
STUDENT CHARTING AND EPIC ELECTRONIC MEDICAL RECORDS
EPIC charting system used in the Emergency Department. Orientation to the charting system will occur during orientation. Medical Students are not allowed access to charting, but will be given access to the tracking board and any relevant ancillary testing and past history.
SEEING PATIENTS
When seeing patient as a rotating student, you will encounter many different teaching styles amongst the teaching attendings and senior residents. The teaching styles will also vary depending on the demands of the Emergency Department. On days where the demands on your supervising physicians are light, you will see more extensive teaching and education. On days where there is a high demand, you will see a more focused educational experience. The focus is to provide you the best educational experience while maintaining the safety of the patients and the flow of the department. Every shift you have offers slightly different challenges. We have done everything possible to afford you the best educational experience during your rotation. The recommended process to seeing new patients includes the following:
Review EPIC computer tracking system to locate patients who are waiting to be seen.
Discuss with your supervising physician if that patient is appropriate for you.
Perform a focused H+P. Most history and physicals can be performed within a 10 minute period.
Before presenting the case to your supervising physician, think through the following questions:
What do you think is wrong with this patient?
What are the key aspects of this case?
How did you come to that conclusion?
What else could be the cause of the patient's complaint?
What do you think is the most likely cause of the patient's complaint?
What diagnostic test are indicated in this case?
How should we proceed from here?
Why do you think the patient requires hospital admission?
What discharge instructions do we need to give this patient?
Discuss the patient's management and disposition with your supervising physician.
Follow up on diagnostic labs and imaging, check on your patients, and help update that patients prior to admission or discharge.
Keep a log of all of the procedures you perform.
CDEM
The Clerkship Directors of Emergency Medicine offers a great online resource for medical students. On this website, one can find information on how to work up common complaints such as chest pain, fever, altered mental status, etc.
PARAMEDIC RIDE ALONG
The paramedic ride along is an optional experience available to you during your elective. When considering a career in Emergency Medicine, it is imperative to understand the capabilities of pre-hospital care providers. The ride is an 8 hour shift with a local paramedic unit. This shift is designed to help the student understand basic terminology, observe on-scene EMS care, and understand the difficulties experienced while attempting to deliver pre-hospital care and transport. Your experience will help you understand some of the situations not easily communicated during pre-hospital care.
If you are interested in this experience, Lucia will provide you the contact information to schedule the paramedic ride along during your orientation. Due to the volume of EMT, paramedic, and medical students ride along you will be asked to provide three available dates that the EMS coordinator can work with to schedule your shift.
CASE PRESENTATION
Don't worry...
Your presentations are only done in front of the other medical students, the Clerkship Director, and any resident on the teaching elective. Each student will present one interesting case at the end of the rotation. The case presentation is a short educational presentation (Powerpoint preferred) for your fellow medical students who are rotating in the department. The typical presentation last <10 minutes. Having the presentation on a USB drive and emailed to yourself is recommended.
Typical presentations start with brief, yet pertinent, history and exam findings, followed by a presentation of the patient's disease. For example:
Case: 65 y/o male presents with severe abd pain that radiates to his back…. Then the remainder of the history and physical exam…. and then the ED course....Dx is ruptured aortic aneurysm.
Topic: Ruptured aortic aneurysm is a condition........
This is followed by a short discussion. Easy-peezy, lemon-squeezy.
FINAL EXAM
The final exam consists of 40 multiple-choice questions. The exam covers toxicology, pediatric, and adult emergency medicine. The online study guide covers the most important aspects of emergency medicine, which will help you focus your exam preparation. There is no time limit in taking the exam, which is usually given on the last Friday of the rotation.
Study Guide for the final exam: Topic and What to Focus On
Intussusception- Diagnostic testing options -how do you work it up?
Cholangitis- Know diagnostic and management options
Alcoholic pancreatitis- Know diagnostic and management options
Unstable angina- What meds are needed and in what order?
Acute MI- What meds are routinely given?
Aortic dissection- What are some predisposing risk factors?
Atrial fibrillation- What drugs are used for management of a.fib?
Ruptured aortic aneurysms- What is the most definitive therapy you can do? hint: not xrays.
Acute pulmonary edema- What drugs are needed in its management?
Pulmonary edema- Of the drugs for #9, which are not going to give you immediate effects?
Nonspecific abd discomfort- Limitations of different imaging modalities
Strep throat- Clinical criteria
Allergic rxn and anaphylaxis- What drugs options are there and when would you use them?
Headaches- What imaging modalities are there?
Seizures- What drugs are used and in what order?
Unstable etopic pregnancy- How would you manage them? and If you were only given enough blood for one test what would it be?
Testicular torsion- What are some clinical findings?
Febrile seizure- What are some criteria to make the diagnosis?
Appy vs ruptured appy- Who’s at risk?
Neonatal sepsis- What are the likely bacterial organisms responsible?
Neonatal sepsis- What antibiotics are given for different age groups? i.e. 0-3 weeks, 3-6 weeks, >6 weeks
Kawasaki's Dx- Know diagnosis and management options
Pediatric sepsis- Know clinical s/s suggestive of severe disease
MI- EKG findings of different types of regional MIs
Pulmonary embolisms- What are and are not risk factors?
Pulmonary embolisms- Clinical and diagnostic signs?
COPD exacerbations – How do you treat?
PERC rule – What criteria make it up?
Common antibiotics for UTI, CAP in pediatric, adult, and hospitalized patients
Acetaminophen OD- How to calculate levels? What’s the toxic dose?
Acetaminophen OD- When is it dangerous and how do you treat it?
ASA OD- Clinical s/s
Heroin withdrawal- Diagnosis and management options
ASA OD- Management options
Trauma patients- What is the initial management, basics
Subdural hematoma- Clinical signs
Epidural hematoma- Clinical signs
Scrotal pain- Other causes besides testicular torsion
Female UTI- Organisms that are responsible
Febrile seizures- Long term consequences
LETTERS OF RECOMMENDATION
The Department of Emergency Medicine does provide composite, departmental letters of recommendation for students that are interested. These letters follow the standard letter of recommendation formed by The Council of Emergency Medicine Residency Directors (CORD). The letter is written by the clerkship director, with input from all pertinent staff, the residency director and associate residency directors. Any student asking for a departmental letter will be required to provide a copy of their CV, personal statement, and board scores.
Departmental Letter of Recommendations will attempt to communicate to the reader a summary of the student's clerkship experience, with input from the entire faculty. We strongly recommend that you waive your right to review your letter of recommendation.
Characteristics of a quality Letter of Recommendation
Authentic
Honest
Explicit
Balanced
Confidential
Appropriately detailed and of appropriate length
Technically clear
The Departmental Letter of Recommendation will contain personal, specific information regarding your rotation, including rotation scores, evaluation comments, and personality comments. If you do not wish to have this specific rotational information disclosed, it is recommended you do not request a departmental letter or recommendation.
TIPS FOR SUCCESS
Be on time for shifts and conference.
Dress professionally - scrubs and a student white coat are acceptable.
Coordinate with your supervising physician at the beginning of your shift before picking up a new patient.
If you are comfortable seeing new patients on your own, please let them know. Appropriate confidence is a “gradeable” trait.
Keep an eye out for interesting cases. If you are not busy with a current patient, help out with codes and procedures, even if those patients are not in your section. We encourage you to observe with cases and/or procedures that interest you. Please okay this with your supervising physician before leaving your section.
Maintain awareness of diverse cultures, health beliefs, and social factors that may impact the patient's care.
Seek help immediately if you feel there is an emergency or unstable patient. Do not hesitate to interrupt your supervising physician if you need help. The staff is there to help you learn.
Don’t be afraid to be wrong! Committing to a diagnosis or plan, even if it is not the actual problem, gives your supervisors insight into your clinical thought process. This is why you are here - to learn from your cases.
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EXTRA INFORMATION
MOCK ORAL EXAM - Since mock oral exams are frequently done during Wednesday conference, the below info may help you better understand this important concept:
The oral boards evaluate:
1) your knowledge of emergency medicine
2) your facility with playing the oral board "game." You have at least 36 months to learn emergency medicine. The purpose of the "MOCK" oral boards is to improve your comfort and ability to play the "game."
Scoring
The exam is scored in eight areas:
Data acquisition
Problem solving
Patient management
Resource utilization
Health care provided (outcome)
Interpersonal relations
Comprehension pathology
Clinical competence (Overall)
The grading scale is: 1= Very Bad, 4=Fail, 5=Pass, 8=Perfect. In order to score a "5" and pass, you must complete all the critical actions for your case. Set expectations for residents are: EM-1's score a "4" on all cases with an occasional passing score. EM-2's are expected to pass ("5" or higher) 50% of the cases. EM-3's are expected to pass 6 or 7 cases. Graduates are expected to pass the real exam!
Rules of the Game
Like the real exam, you must be on time. If you are late, the clock will start without you. Even the best examinees will find it difficult to pass with a five minute handicap.
No talking or discussing the cases. It is only fair that all examinees be given a fresh chance to solve the cases. When your well-meaning friend tips you off to the "easy case of strep throat", chances are you will also miss the retropharyngeal abscess.
Bring only a pencil. Scratch paper will be provided and must be left in the examiner's room.
Learning to Play the Game: Problems
Problem #1 Unnatural
The main problem with the "game" is that all the visual/auditory/olfactory clues you process instantaneously in real life, are missing from the exam. A real life patient that is hemiparalyzed (CVA), has ketotic breath (DKA), or is hot to touch (sepsis) can be sized up in 30 seconds. For the oral boards, this information must be methodically and specifically discovered.
Problem #2 Time
You may run into time problems. This is more common on the triple cases.
Problem #3 "Routine" Care
"Routine" Care at your hospital is never done on the exam. You must specifically order:
undress the patient
oxygen
pulse ox
oxygen saturation readings
IV's/Saline lock
Cardiac Monitoring
rhythm strip
Problem #4 Panic
It is easy to lose your way, become side-tracked, or find yourself in a dead end and then panic. This is especially true in the triple cases. Stay calm. You can pass many cases without actually getting the specific diagnosis.
Problem #5 Multiple Roles for Examiner
The examiner plays several roles including examiner, paramedic, patient, relative, nurse and consultant. Sometimes this is not done well and is confusing.
TIPS
Have an organized approach. After taking a side trip or ending up in a dead end, go back to where you left off and start gathering data from Hx, P.E., and tests.
Conserve time by cutting down on note taking. Write some notes in helpful. If you take extensive notes you may run out of time to take care of the test patients.
A suggestive approach is as follows:
o At the very beginning of every case, before history is taken, get a mental picture of the patient. Ask "When I look at the patient, what do I see?" or "When I walk in the room, what do I see?" or "What is the general appearance of the patient?"
o Before any history is taken, obtain a complete set of vital signs. The temperature may be omitted (on purpose). Getting a body weight and a pulse ox can't hurt.
o Stabilize life threats (A-B-C-D-E)
o Get an organized and systematic history from patient, paramedics, and/or relatives (don't forget medications, allergies)
o Order monitoring (pulse ox, cardiac monitoring) and some tests (blood, urine, X-rays, CT's, ultrasounds, ABG's, EKG's)
o Perform an organized and systematic physical exam (this is very unnatural and requires the most disciplined and practice).
o Based on Numbers 1-6, get more history and tests as needed.
o Establish the patient's problems and diagnoses.
o Begin specific treatment.
o Continually reevaluate the patient. After every order (a test or therapy), always ask for follow-up results. For example, after a hypotensive patient is given a fluid bolus, ask for repeat vital signs. If you order a Pulse ox monitor, immediately ask for the Pulse ox reading. If you don't ask, the information may not be given to you.
o Listen to the examiner. His response may be a clue. If you ask for something and don't get it (a) you may be asking for it too soon and are supposed to manage the case on your own for a while, or (b) what you want is irrelevant. An examiner response such as "normal" or "negative" may indicate your question is about something that has little or no importance to the case. If the examiner asks you to "Be more specific" with a question, it might mean that the area in question has some importance to the case. If the patient gets worse, the examiner is probably telling you that something has been missed along the way. Stop, stay calm and think again.
o Talk kindly to the "patient", "family", and "consulting physicians". Speak as if you are actually talking to them. You can speak "medical" to a consultant/RN, but should say "collapsed lung", not "pneumothorax to the patient/family member. This is part of your "Interpersonal Relations" grade-and free points from my point of view.
o Think twice before discharging a patient home. In real life, if a patient has a sore throat, you would send him home. If a test patient has a sore throat, he should also be sent home and not admitted (Resource Utilization). However, make doubly sure you are not overlooking some potentially life threatening problem. Make sure "just a sore throat" is not a paralyzed vocal cord, epiglottitis, an abscess, or diphtheria!
Scoring Criteria
Your score of the candidates's performance will be based on two criteria:
Critical actions- Each case is accompanied by a list of critical actions. The candidate must execute these actions to pass the case encounter.
Scoring components- You will also be evaluated in the following eight areas:
Data Acquisition- Did the candidate collect the appropriate data from the history, physical exam and laboratory to correctly diagnose and manage the patient, without going overboard?
Problem Solving- Did the candidate approach the clinical situation in an organized manner, collecting data from the history, physical exam and laboratory to correctly diagnose and mange the patient?
Patient Management- Was timely and proper treatment given? Were appropriate referrals obtained?
Resource Utilization- Did the candidate order the appropriate tests necessary to mange the case, or did he just shotgun? Shot gunning is disapproved and penalized.
Health Care Provided (Outcome)- From the perspective of the patient, and with reference to current medical practice and standards, was the best possible outcome achieved?
Patient Relations- Did the candidate interact well with the patient and/or close family members, allaying their fears, and treating them in a supportive and empathetic manner?
Comprehension of Pathophysiology- Did the candidate understand the scientific basis for his actions or did he simply rely on memorized routine procedures usually followed in such cases?
Clinical Competence (Overall)- All things considered, how well did the candidate handle these types of conditions or problems?