Student’s guide to the emergency department

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Chapter 48 Student’s guide to the emergency department

Sascha Fulde, Tiffany Fulde

The emergency department can be the highlight of a student’s day or the place where you feel most out of place, or both at the same time. Hopefully this chapter will outline some practical tips for getting the most out of this wonderful resource.

ADVANTAGES OF THE EMERGENCY DEPARTMENT

As the place where almost all of the patients enter the hospital, emergency department is a short case heaven. In addition, you can see patients before they’ve been overrun by a thousand other students and doctors. Just think, by the time a patient gets up to a ward, they’ve most likely had the same questions asked and been poked in the sore spot by the emergency department intern, registrar, intern on the admitting team and the registrar, plus at least one nurse. They’ve had a stressful time, feel unwell and, ultimately, probably just want to be left alone, whereas in emergency department they haven’t been examined that many times. They’re prepared to be undressed, poked and prodded because they recognise that that is what happens when they come to an emergency department. A student can often be useful either confirming examination findings, sometimes finding something someone missed, either on history or examination, or just alleviating some of the patient’s worry by spending some time with them while they’re waiting for results of investigations. Even if you’re only doing an examination, it makes the patient feel that something is happening and that they’re being taken care of. The patient is also in the mindset where they really want to talk about their story and those niggly details of symptoms as it’s pretty much all they can think about. Thus the emergency department is a fantastic resource for a medical student.

When the patient presents to emergency department they’re much more likely to present in a way that is useful to a student. Firstly, as no one knows what is wrong with them, you actually get a chance to test your clinical and diagnostic skills. Secondly, they present in the same way that short and long cases are often presented in exams. The complaints are also often at a level which you will be expected to know. For example, you are much more likely to see a patient with chest pain rather than a phaeochromocytoma.

Learn to handle emergencies

As a student my biggest fear was that I would actually kill someone! My second biggest fear was failing exams. And the third was, how do I actually save someone’s life? I’m not just talking about the big trauma cases but also the smaller practical procedures. This is one of the greatest things emergency department can teach you. By spending time there and talking to the doctors, you learn how to actually prioritise management and the basic couple of things that you need to do right now before you stop and work out the clinical management guidelines. You can also learn how to actually do them.

Find patients for tutorials, case histories and presentations

Although the hospital is full of patients, it can often be hard to find patients that fit the requirements of the task you’re trying to do—for instance, finding an interesting surgical case to present in a surgical tutorial or even for a bedside tutorial. As staff in the emergency department have seen all the patients that have entered the hospital, they are wonderful at knowing what patients are around and worth chasing up.

Fits well with problem-based learning (PBL) courses

At the beginning of a PBL course it can often be difficult to approach medicine on the wards as you have only learnt information on certain specific disorders or systems. This can make it overwhelming to approach a general medical or surgical term. However, in emergency department the patients present in the same way as a case in a scenario, and this allows you to approach things you haven’t seen before.

One of the strengths of PBL, which is that you focus on individual areas, can sometimes be slightly frustrating. By only focusing on one clinical vignette, you can sometimes feel like you don’t know much about broader medicine. By hanging around the emergency department even for only a short period of time, you can very quickly start to counteract that and learn a lot across a broad range of areas.

Provides a place to integrate a lot of knowledge

Whatever level you’re at in your training, emergency department provides a great place to pull both your clinical skills and esoteric knowledge together and practise what you’ve been learning. It’s always easier to remember something when you’ve seen a patient with it and seen how they were managed.

Get a wide range of clinical material

With increasing specialisation of medicine and increasing numbers of students, often you only get to experience a limited number of different terms. For instance, you may never have had the opportunity to do a cardiology term. Emergency department is the place where you can compensate for this deficit. All the acute cardiology patients will come through the emergency department so you can see how they are managed.

See mild patients that get discharged

Emergency department also has a range of severity of patients so you get to see the simple sprains, cuts and bruises before they are discharged.

See great signs before they are treated

Often you trail around the hospital trying to find a patient to practise your examination signs on, only to find that, while many people are unwell, they’ve already been treated, e.g. Mrs X had shifting dullness but we tapped it last night.

In emergency department you can see these signs often when they are at their peak before the arrhythmia is treated or blood pressure lowered.

Avoiding being barred

As a student you’re always going to be refused by patients. Even though you know it’s not personal, this is often demoralising. In contrast, it’s always exciting to go and visit a patient you saw when they first presented in emergency department and have them recognise you and happily let you repeat your exam to see their improvement.

Emergency department also provides an excellent opportunity to learn about the unspoken professional etiquette between different doctors. At some stage all doctors, whether interns or the most senior consultants, come and interact in emergency department. This allows you to learn a lot about the finer negotiations, for instance, of getting staff up late at night.

Use it as a light at the end of the tunnel

Little encounters that you can have in emergency department allow you to pretend to be a real doctor even if only for a few seconds—not just a nurse or cannulating technician doing a cannula or blood pressure but a real doctor. This not only reminds you what you’re working for but why you’re working so hard. It really allows you to put all the hard decisions you’re making into perspective. It can be even more important to remind yourself that there is a light at the end of the tunnel. This can be really motivating, either because being a doctor is exciting or because it makes you realise you’re not quite knowledgeable enough yet.

HOW DO YOU GET THE MOST OUT OF IT?

So how do you access this gem?

First you must get access either by your swipe card or the keypad access code. This is crucial. Emergency department staff are usually very happy to have you there but it’s much easier if you just appear at the doctor’s desk. If you have to constantly ask to come and go you’re probably much less likely to regularly be there.

Go to emergency department regularly. If you become a familiar face to staff they very quickly go out of their way to help you meet your learning goals or just to be friendly. A good tip is to leave the hospital via emergency department. This forces you to see if there are any interesting patients when you know you’ve got nowhere better to be. Even if you only see one patient a day, you’ll start to become part of the hospital team.

Emergency department can get very busy. When this happens people often get stressed. If you are around, do not automatically skulk back to the student room or ask if you can intubate the patient! Ideally find a way to be involved while getting in as few people’s way as possible. This can be standing at an outer edge as resuscitation is going on or going and seeing one of the low category triage patients by yourself to start with.

Attach yourself to a registrar

As emergency department is usually very busy you can also get a lot out of it by attaching yourself to a consultant or registrar and becoming their assistant. By doing the little tasks like chasing results you can really help them out. This often engenders a lot of good will, which means that you get good teaching on the way and opportunities to do practical procedures if you’re interested.

Follow your patients up

When you see a patient in emergency department make sure you take the opportunity to follow them to the next step in their treatment. For instance, watch their surgery or check on them in the medical ward in a few days time. Most teams are more than happy for you to be included in care when you explain you saw the patient in emergency department. Thus, you get to see many aspects of medicine and surgery.

Don’t come in hoards

Although it’s often less confronting to come in a group or with a partner, it’ll be easier to get accepted by staff and patients if you come by yourself. It’s also better to come alone as this is how you’re ultimately going to be in exams and it really allows you to realise your strengths and weaknesses and work on them.

Ask the nurses FIRST

Before doing anything, first ask a nurse. This is very important. Even if you have a doctor’s permission and the nurse is busy, wait until they are finished and then ask their permission. Nurses often end up coordinating care, so they know whether they’ve had time to give the pain relief that the doctor has prescribed so that the patient can handle talking to you.

Find the things that are useful to you as a student but that no one else cares about

There are many things that happen in a hospital that are commonplace, barely thought about activities but that can be really useful to a student. For instance, most people who come into emergency department get an ECG and some blood tests. If you regularly look up the results and try to interpret them, whether you know the patient’s history or not, you can become very good at interpreting results. This is easy to do and doesn’t need any doctor’s or nurse’s help—you simply look them up and then check how the doctor interpreted them.

Another useful skill you can learn is to practise writing up notes. After seeing a patient if you sit and practise putting the salient points down on paper you can then compare your notes with the registrar’s and see how good you were at getting all the points and putting them down in a clear format.

Ask about teaching

Most emergency departments have compulsory teaching sessions for interns or registrars. They are often more than happy for a few students to attend. These sessions are usually filled with teaching on diseases that are of interest to you and will often make it into exams. So just ask some of the registrars and interns who organises the tutorials, if and when they’re on and if you can attend.

Practise procedures—always take a bluey

Emergency department is a really good place to practise the basic procedures that you’re expected to be able to do as an intern. There is always someone who needs a cannula or catheter and people are usually happy to oversee you doing one. One important thing is to always check that you have all the equipment you need before you start a procedure. When you’re doing anything you’re a bit unfamiliar with, always take a bluey (a plastic protective sheet) so you don’t make a mess of the sheets. This alienates the patient and makes the nurses cross. Also always take a set of cotton balls and tape just in case something goes wrong—you can patch almost anything up.

If you have the chance, practise procedures on models. Many emergency departments have simulation centres or plastic models to practise procedures on. These can be fantastic for your first couple of times or if it’s been a while since you’ve done one.

Have a slightly thick skin

Unfortunately, at some point as a student you’re likely to get in trouble for something. While it’s important to be considerate and do your best to avoid it, at some point you will get on someone’s bad side. When this happens, just apologise and try to make it right. Then don’t let it get to you. It happens to everyone.

Find a friendly face and take advantage of them!

In every department there are a few really incredibly nice people. When you find them, make friends and then ask them about all those niggly things you need help with. They understand how hard it can be to be a student and they’re more than happy to help, but you need to ask them. The worst they can say is ‘no’.

Take more responsibility

When you’re in more senior years, take more responsibility. You can use time in emergency department as a pre-intern term. Go in at nights and help out. You can see some of the most interesting, diverse patients after dark. Plus, people appreciate your dedication and usually try to help you get the most out of it. You can even clerk patients from beginning to investigations and then take the write-up, just needing a signature, to your supervising doctor. This will help you and hopefully save them a little time even if they then go back and repeat it.

SUMMARY

Ultimately, make sure you enjoy both being a medical student and your life outside of medicine. Don’t let the stress of medicine or all the advice above distract you from enjoying your time as a student. We hope that you learn a lot from this book and that this chapter has helped to inspire you to head into emergency department.

EDITOR’S COMMENT

It is our responsibility, privilege and delight to help and supervise our future colleagues, especially senior students who quickly and enthusiastically take up a workload. A very good system is to ‘buddy’ them with a doctor—even nights and weekend shifts—they love it. Also remember you will be asked questions and that demonstration and teaching really improves and keeps your practice up to date. The emergency department is often the most desired term, as students sense the joy and terror of being the first to deal with unknown, unexpected and potentially very ill patients—all this among a great gang of healthcare professionals.

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