Em erg en cy Medicine Clerk sh ip Prim er A Manual for Medical Students Em erg en cy Medicine Clerk sh ip Prim er A Manual for Medical Students The “Clerkship Directors in Emergency Medicine” (CDEM), formed in 2008, is the first “Academy” within the membership of the Society for Academic Emergency Medicine (SAEM). CDEM members are medical student educators who are committed to enhancing medical student education within our specialty. CDEM will provide an opportunity for emergency medicine clerkship directors and medical student educators to join forces, collaborate, and become a unified voice at the national level. CDEM thanks the Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry for its support of the editing and design of this primer. Prim er Medical Editor: Chrysa Cullather Design: Chrysa Cullather An electronic version of this primer in Adobe Acrobat (for reproduction) is available on the CDEM Web site Copyright ©2008 Clerkship Directors in Emergency Medicine All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including, without limitations, photocopying, recording, or by any information storage or retrieval system, without written permission from th e publish er. Clerkship Directors in Emergency Medicine 901 N. Washington Avenue Lansing, MI 48906-5137 Telephone: (517) 485-5484 Fax: (517) 485-0801 E-m ail: cd em @saem .org Web-site: www.saem.org/CDEM ii Foreword Preface he focus of Emergency Medicine Clerkship Primer: A Manual for Medical Students is to assist m ed ical stu d en ts th rou gh ou t th eir em er- Tgency m edicine clerkship. Alt h o u gh t h e t arget audience for this manual is primarily junior and senior medical students, we believe that emergency medicine interns and off-service residents will benefit from the majority of the topics reviewed. Our goal is to produce a high-quality, professional guide that highlights the uniqueness of our specialty. This guide should provide the reader with a detail-oriented approach to think- ing like an em ergency physician—essentially a “how to” m anual. The Prim er can be considered a supplement to the many high-quality emer- gency medicine texts currently available. However, different from these, the Prim er focu ses on asp ects of ou r sp ecialty th at are often overlooked or underrepresented in traditional textbooks. Before the development of this Prim er, a comprehensive manual such as this was not available to the masses of medical students across the country. Good luck on your emer- gency m edicine rotation. David A. Wald, DO Director of Undergraduate Medical Education Associate Professor of Emergency Medicine Department of Emergency Medicine Temple University School of Medicine Project Editor and Lead Author David A. Wald, DO Temple University School of Medicine Associate Editors and Contributing Authors Douglas S. Ander, MD Emory University School of Medicine Jo n at h an Fish er, MD Harvard Medical School Michelle Lin, MD University of California, San Francisco, School of Medicine San Francisco General Hospital and Trauma Center David E. Manthey, MD Wake Forest University School of Medicine Cont ribut ing Aut hors Michael S. Beeson, MD, MBA Northeastern Ohio Universities College of Medicine Michael DeAngelis, MD Temple University School of Medicine Nicole DeIorio, MD Oregon Health and Science University Gus M. Garmel, MD Stanford University School of Medicine Permanente Medical Group, Kaiser Santa Clara, CA Charles J. Gerardo, MD Duke University School of Medicine Ju lian n a Ju n g, MD Johns Hopkins School of Medicine Sorabh Khandelwal, MD Ohio State University College of Medicine Charles L. Maddow, MD University of Rochester School of Medicine and Dentistry Sco t t M u rray, M D University of Connecticut School of Medicine Robert Rogers, MD University of Maryland School of Medicine Em ily Sen ecal, MD Harvard Medical School Ed ward Stettn er, MD Emory University School of Medicine Lynda Daniel-Underwood, MD Loma Linda University School of Medicine Joshua Wallenstein, MD Emory University School of Medicine Lori Weichenthal , MD University of California, San Francisco, School of Medicine Collette Wyte, MD Wayne State University School of Medicine William Beaumont Hospital iv Contributors Fo r ew o r d y the time this Prim er arrives for your review, Emergency Med- icine will be celebrating its 40th anniversary as an organized Bspecialty realm of practice. Formal recognition by the rest of tradi- tional medicine came nearly two decades later, but for those who under- stood the vision when it first appeared, four decades of service is the right number. As you prepare for your clerkship, please recognize our chosen specialty has several gifts in store for you. First, its faculty and residents recognize the responsibility we have to train you to understand and operate in our realm. Undergraduate medical education is a serious pursuit for emer- gency physicians, and your clerkship director holds a position of esteem in the departm ent. We understand the potential im pact of early inter- vention as well as or better than any other practitioner. In education, a shared truth or corrected perception can last a lifetime, and this is what we plan to offer each of you who spend time with us. In addition, we offer a unique contribution to your medical education. We are not trying to sell our specialty to you or trying to “convert” you from your chosen direction toward ours. What we have to offer is a unique environment and an opportunity to practice fundamental skills to which you have had limited exposure thus far in medical school. The most im portant of these is acute care decisionm aking. That is a unique m o- ment, usually unanticipated, when a patient forces you to make a series of decisions surrounded by uncertainty but of great importance none- theless. Time is not your friend, and you quickly find there is nothing “cookbook” about having a well-organized and thoughtful plan of ap- proach in such a circumstance. You will not only exercise new regions of the brain, you will also get to use your hands when working with us. Technical skills and accompanying virtuosity are critical elements in the day-in, day-out practice of emergency medicine. Many of these skills— vascular access, airway management, lumbar puncture and suturing— are all a part of a reasonable skill set for a senior medical student. Commitment to learning these skills can be highly variable in medical school, and opportunities to practice them may be limited. However, in the emergency department, you should have the opportunity to put them to use every day, just as we do. Lastly, think of working in an environment where more than 115 mil- lion undifferentiated patients com e to see you or your equivalent over the course of each year. Patients’ illnesses and injuries are not always what they seem to be, and you will learn to respect that statement like never before. The approach to unraveling a voiced complaint on the part of a patient while thinking about all of the worst possibilities of potential origin is a very different way of thinking than most of your experiences to date. We believe that you will find this experience will serve you well, both with us and beyond. Our specialty interacts with every other specialty, often at the raw inter- face of the unplanned admission on a 24-hour, 7-day clock. We know that most of you completing this clerkship will not choose emergency medicine, although more and more students do each year. We are excit- ed for your future careers in primary care, surgery, pediatrics, medicine subspecialties, and others, but we know that we will see you again in one guise or another. Therefore, it is important to us that you are well treat- ed, remember what goes on here, and leave with some degree of under- standing and a modicum of respect and appreciation. Therefore, you should expect to be treated well but with discipline and high expecta- tions. One clear gesture in our effort to make your experience with us most rewarding is this Prim er. Read it com pletely early in your experience with us, reread it as you see a wide variety of patients, and use it to help order and integrate the other teachings we will send your way. We are proud of what we do and the safety net role we play in our nation’s health care system. We welcome you while you are with us and look forward to a long-term relationship, day and night, no m atter what specialty you m ay choose. Take care of yourselves and the people around you. Glenn C. Hamilton, MD Professor an d Ch air Department of Emergency Medicine Wright State University School of Medicine vi Foreword Contents Preface.................................................................................................... iii Contributors ............................................................................................ iv Forew ord ................................................................................................... v Chapter 1. Introduction to the Specialty of Emergency Medicine ......................................................................................... 1 Chapter 2. Introduction to the Emergency Medicine Clerkship ......................................................................................... 4 Chapter 3. Emergency Medicine Clerkship Goals and Objectives ....................................................................................... 7 Chapter 4. Unique Educational