skyfall Posted July 14, 2015 Share Posted July 14, 2015 I started my ER rotation recently. I did IM, FM, Geriatrics and Cardio before this, and have been getting use to getting super thorough histories, and thinking about a lot the underlying causes for symptoms. I've been told to be too "family". I need to filter out the "crap" and figure out emergent differentials, and quickly decide from a buffet of labs/imaging. Did anyone else have a hard time transitioning from FM/IM mindset to ER mindset? Any advice? Link to comment Share on other sites More sharing options...
jtmathew Posted July 14, 2015 Share Posted July 14, 2015 You will probably get much more qualified advice to your query but, in my limited experience working/shadowing, it seemed that physical exams/historys were tailored to the patient complaint. You wont be doing a rectal exam on a patient presenting with chest pain. Your h&p is succint and specific and should allow you to SPIT a differential. Ill leave this here and wait for some of the more experienced clinicians to discuss. Good luck and enjoy the ride. Link to comment Share on other sites More sharing options...
medic25 Posted July 14, 2015 Share Posted July 14, 2015 EMRA just released a video on how to present ED patients ( starring one of our residents!). This might help with focusing on the most important aspects of the patient from an EM perspective. Link to comment Share on other sites More sharing options...
fishbum Posted July 14, 2015 Share Posted July 14, 2015 That video is awesome...love the guy with the knife sticking out of his back. "I'll be right there...." Link to comment Share on other sites More sharing options...
epengell Posted July 15, 2015 Share Posted July 15, 2015 EM Basic (which I've found to be a very helpful Podcast in general) has a great episode on how to give a a good ED patient presentation. http://embasic.org/how-to-give-a-good-ed-patient-presentation/ Link to comment Share on other sites More sharing options...
greenmood Posted July 15, 2015 Share Posted July 15, 2015 I had a hard time with it. Long story short, my preceptor stopped letting me use a notebook while taking patient histories and I improved my synthesis skills immensely. If you write a lot while interviewing patients, try stopping cold turkey. Just talk to the patient. You might be surprised by how much faster your brain can process when it's not distracted by miscellaneous nonsense. Link to comment Share on other sites More sharing options...
SERENITY NOW Posted August 10, 2015 Share Posted August 10, 2015 you are absolutely right that you can't use the internal medicine comprehensive approach in emergency medicine. the outline of the EM approach that was taught to me really helped me conceptualize the proper way of thinking, and its like this: 1 - SICK OR NOT SICK? you gauge this based on looking at the patient/gestault, primary survey (ABCs), vitals, and a very brief hx 2 - if patient is sick... IMMEDIATE RESUSCITATION/STUDIES NEEDED? airway management? breathing treatment? IVF/blood? fingerstick glucose check? EKG/CXR? etc. for most of the patients you see as a student, you'll be blowing by these first two steps in a matter of seconds, but don't forget that they're there and be systematic about thinking about them. 3 - FOCUSED HX AND PE. (still always ask about pmh, meds, allergies, etc) CREATE DDX. 4 - from your ddx, ANTICIPATE the worst case --> what tx to have on hand? what orders to put in? 5 - PUT ORDERS IN, including workup studies + initial/symptomatic treatment. get good at managing pain, n/v, dehydration. 6 - with study results, decide on a WORKING DIAGNOSIS --> initiate SPECIFIC TX 7 - decide on DISPOSITION of patient. pay attention to follow up instructions, patient education, return precautions, etc. these things aren't often taught well in PA school and take some practice. more general tips to get most out of EM rotation: you should listen to every EM basic chief complaint podcast. seriously that is the best place to start for the ED workups. to practice, you should download the phone app "resuscitation". it is a really great case simulator for a very reasonable price... highly highly recommended. as you are listening to the podcasts and practicing sim cases, keep track of the "workup order sets" for a given chief complaint. much of the ED is order set driven. after you present your patient with chest pain and your preceptor asks what you'd like to order, you should be able to rattle off the laundry list of an order set. that being said, you should definitely know WHY each lab/imaging test is on the order set to begin with. study up and memorize the "cant miss" diagnoses for the main chief complaints. read up on the decision tools that help you rule these out... ie the PERC rule, etc. hope this helps! Link to comment Share on other sites More sharing options...
FfIghter23 Posted August 10, 2015 Share Posted August 10, 2015 All of the above advice is good. If you want to go above and beyond, download these ER notecards (free!) http://www.aliem.com/pv-cards/ and try to memorize most of them. They will help you with the patients that you are on the fence about because nothing in medicine is cut and dry/by the book. The most important thing is learning to develop a differential diagnosis and understanding the things that you can't miss. Link to comment Share on other sites More sharing options...
gbrothers98 Posted August 13, 2015 Share Posted August 13, 2015 http://emupdates.com/2010/09/15/screencast-how-to-think-like-an-emergency-physician/ GB PA-C Link to comment Share on other sites More sharing options...
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