Monday, March 25, 2013


Preparation is the key to success. As you embark on fourth year, this is a great time to do your research, and set yourself up for success by planning your EM clerkship rotations. Here are jumping off points to get you started:

You need one HOME, and one AWAY, between May and September.

For most HOME will be your medical schools academic EM rotation.
Rotate early and get FEEDBACK.

AWAY offers a myriad of options:

 Decide WHAT you want and WHERE you want it.

Location, Location, Location - want to relocate, or try someplace new?
Your away rotation is your chance to try someplace out.

There Is No Place Like Home
Your away rotation is your chance to try a new setting:
If home is urban, try suburban.
           If home is a "community" ED try an "academic", or "county" ED.

Think about your home program’s attributes and look for something different. These rotations will help you learn what you like and dislike. As you interview, you can discriminate what is important for you.

Mirror Mirror - Review a program’s curent and recent residents on their website - look for residents similar to you in interests, experience, and education.  

Like minds, attitudes and interests, tend to flock together. If no one seems like you, it may not be a good fit.

 Dream A Little Dream - Go where you hope to be. 
Your away month is the best interview you will give. 
Consider taking a chance.

 Game Time - On your rotation:  Be prepared.  Be proactive.  Be positive.  
Be willing to change and grow.
Take the feedback you get at home and sail on.

Now that you are thinking, go ahead and read through the full details on the rotation application process and preparation.

Wednesday, March 20, 2013

Who can I trust...

In my opinion, the greatest challenge facing a medical student who is interested in Emergency Medicine is where to get trustworthy advice on the applying process.

There are numerous sources of information and it is difficult to know what you can trust.

This may sound ridiculous coming from a blog, but the best stuff is probably not available on social media and the internet.

There is no replacement for finding an advisor at your school or affiliated hospital.  Someone you can sit down with, face-to-face, and discuss your situation.  They can give you advice specific to your particular circumstances in a way that a blog like this one cannot.

This is not to say that the web does not provide useful resources.  Just be careful to not trust any single resource.

If you are interested in Emergency Medicine, but do not have any local advisor you can turn to for some personal advice, SAEM (Society for Academic Emergency Medicine) may be able to help with their e-Advising program.  These are Academic Emergency Physicians throughout the United States, willing to provide guidance, particularly on their region.

Sunday, March 17, 2013

For the MS4: Create your own Capstone

Some medical schools will provide you with an end of fourth year experience to prepare you for internship.

But some do not.

Do not despair soon-to-be-doctor.  You can still prepare yourself for July 1st.

There are some common concerns newly-minted interns share:
  1. Procedural inadequacies
  2. Getting yelled at by consultants and admitting doctors
  3. Not being able to function in the ED

And there are some things you can do about them:

1.  Procedural inadequacies mostly fall into two categories.  The skills you are expected to have and the skills you are afraid you do not have.  In your remaining rotations, take the opportunity to draw blood, start peripheral IV's, and do ABG's.  These are skills you may be expected to possess.  Most residency programs do not expect you to be an expert at central lines, lumbar punctures, and intubations.  But they are very happy when you show up and know why you would do these, how they are supposed to be done, and are thus ready to learn them early in your training.

2.  Start practicing diagnosing your consultants.  Put yourself in the shoes of the people you will call.  Think about what they want to know and how they want to be approached.  An internist may want more detail and to discuss your differential and management so far.  A surgeon may only want to know what you would like removed from the patient.  Residents are going to want different information than attendings.  Everyone needs to be communicated with differently in the middle of the night than at 10 am.

3.  Emergency Medicine is hard.  You will not be expected to be proficient immediately.  Your residency is expecting you to show up, try hard, care about your patients, and to improve.  Start practicing now the things that will help you get better.   Think about how you approach patients.  Start thinking about serious causes before you go into the room.  Force yourself to present an assessment and your plan, regardless of the setting you are working in.  Make a habit of reading about your patients.

Finally, there is something you are going to have to accept.  You are going to make mistakes.  No amount of experiential preparation will change that.  You should still strive to minimize errors, but they will occur.  Everyone makes mistakes.  Even your clinical mentor, as brilliant, unflappable, and supremely competent as they may appear/pretend to be.  

Wednesday, March 13, 2013

Learning Ultrasound

Michele Schroeder is soon to be an Emergency Ultrasound Fellow.  These are her favorite resources for the new ultrasonographer.



EM Ultrasound ($4.99 in App Store)
      Good technique and anatomy review.
      Examples of pathology.

One Minute Ultrasound (free)
      Literally 1 min clips reviewing the techniques; good brush-up after you've already learned the exams.  
      Meant to be looked at right before going into the room to do the exam.


EM Ultrasound (with Matt & Mike)

- Michelle

Friday, March 8, 2013

EM Scramble Advice

Match day is almost upon us.  With your rank list submitted and your “top programs” notified, you may feel like there is nothing more you need to do between now and March 14th.  This is true for the vast majority of students applying into Emergency Medicine.  Unfortunately, on the monday before the match, some applicants will receive an email telling them that they are now part of the scramble (now called the SOAP).  As future Emergency Physicians you will create back-up plans as a matter of course.  This situation is no different.  

If you are of a paranoid disposition, just skip this paragraph and go to the part about what you can do now.  If you are still reading -  you must want to assess whether there is a realistic chance you are not going to match.  The best marker is how many interviews you went on and how many programs you ranked.  If you rank eight to ten programs, or more, the likelihood you are not going to match is very, very small.  Conversely, if you did interviews only at places you rotated, you are at significantly greater risk.  Also, reassuring is the feedback you received from programs.  They would not be telling you how much they liked you if you bombed the interview.  And if you interviewed well at one program, you were probably on your game most days.  The opposite should be worrisome: if no one reached out to you, you could have cause for concern.  

So now that I have you adequately worried - what can you do?  

You need a plan.  And your plan needs a back-up plan.  

First, now is the time to decide if all of this will truly be worth the effort in the end.  How bad do you want to be an Emergency Physician?  There was no scramble last year in all of EM, and very little the years before that.  Scrambling to an EM program for a July 1, 2013 position is not a viable plan.  You are going to have to do something else for at least a year while you reapply.  

Once you decide that you are willing to do something else for at least a year before starting your EM training, you need to decide what to do with that time.  The best thing you can do with that time is gain clinical experience.  There are other options but none will enhance your application.  Doing a year of research, a popular idea, will not help you gain the kind of clinical skills that will make you an asset to a Residency Program.  

Clinical experience is the most reliable way to bolster the inadequacies in your application.  Your reapplication needs to address these inadequacies and you are going to have to look better on paper than those applying for the first time. That missing ingredient(s) that gets you the interview could be many different things, and should be discussed with an individual adviser.  The most common are boards score, clinical grades, and letters.  You are stuck with your grades and scores (unless your step 2 did not make your application).  Where you have a real opportunity to improve your application is in your letters.  

The next six months should include the pursuit of better letters of recommendations as both a student and intern.  As a student you may be able to do another away EM rotation.  Preferably at a program that is realistic for your reapplication.  

In addition to maximizing the value you get from med student experiences you should choose what you are looking for in the scramble with the same goal of making you a more attractive EM candidate next year.  

The absolute best position you can get is one that allows you to rotate early in the ED as an intern, at a hospital with an EM Residency Program.  And you need to perform as good or better than the interns who did match there.  And you want to get a letter or two from their faculty, so that other programs get to see how good you are.  

What kind of position you take is the subject of much debate among program directors.  Here are a few of their best points, pro and con:

Transitional pre-lim. year - Diverse exposure that is very applicable to EM.  These are becoming less available and probably need to be found in the Match, not the Scramble.

Categorical IM or FP (guaranteed PG2 and 3 spots) - Offers a safe landing if you don’t match on the second try.  However, these are less rigorous and generally less impressive to EM Program Directors.  

Surgical prelim year - Rigorous and impressive to Program Directors.  However, you get treated like a surgical intern for a year and may have trouble getting an early ED rotation, depending on the program.  

For all of these, the early ED rotation as an intern, should be part of the negotiation and your decision process.  

There are many opinions on which is best but here is mine:  being at a hospital with an EM Residency trumps all other considerations.  After that, the more clinically challenging, the better.  This is your chance to get a leg up on the competition, and build  skills that will lead people to say, “I cannot believe that _______ did not match the first time.”

The Match is an imperfect system.  Every year, good candidates who will one day be great Emergency Physicians, do not match for a variety of reasons.  Not matching does not mean you are not good enough to be an Emergency Physician.  It just means you are going to have to work harder to get there.  

Sunday, March 3, 2013

Better than a stethoscope...

This is the first post by Michelle Schroeder, a senior resident and soon to be Emergency Ultrasound Fellow...

Okay…. So it’s July 1st and you are on your first shift of your all-important Emergency Medicine “audition” rotation.   The first patient you go to see is a 73 yo female is sent in from a nursing home for altered mental status. Unfortunately for you, she’s never been to your ED (so no help from the EMR), and the patient has baseline dementia and is altered beyond that (so no history from the patient); all you have to go on is the nursing home problem list, which includes heart failure and recurrent aspiration pneumonia.  Her blood pressure is 80/40 and her oxygen saturation is 85% on Room Air, now up to 95% on nasal cannula, and she has crackles in both lungs.

She is clearly sick and you are going to go get some help from your resident or attending, but you want to wow them with a plan of action.  So is this an exacerbation of her heart failure that needs diuresis? Or is this pneumonia and sepsis requiring aggressive fluid resuscitation? It’s a big difference and you don’t want to make her worse?

You tell your supervisor there is a sick patient in bed 13 and bring the ultrasound machine to the bedside.  You see that her ventricles are squeezing overtime and her IVC is collapsed - this isn’t heart failure. So you put septic shock #1 on your differential and begin aggressive fluid resuscitation, broad spectrum antibiotics, and you look like a superstar.
Alright, so it sounds like something out of an “ER” re-run, but this sort of diagnostic conundrum happens all the time in the ED.  Ultrasound can be your saving grace, especially for patients who are too sick to go for advanced imaging.
Not a believer yet?  What would you rather do for the hypotensive 20 yo female who syncopized and has lower abdominal pain? Bedside ultrasound showing a positive FAST and off to the OR she goes or trying to keep her stable while you argue with OB and wait for a formal ultrasound.  

How about the 65 yo dialysis patient with hypotension and tachycardia? Quick bedside ECHO shows a huge uremic pericardial effusion, easily a diagnosis that could have been delayed without ultrasound.  

And although the greatest benefit of ultrasound may be in critical care, it’s essential for non-critical care as well. Pregnant woman with ankle fracture? Ultrasound guided peripheral nerve block obviates the need for conscious sedation. Want to map out that carotid artery before you drain a peritonsillar abscess? Endocavitary probe to the rescue!

I could go on (and on), but suffice it to say, ultrasound is an indispensable extension of our physical exam, as necessary as a stethoscope (and way cooler) allowing direct visualization of anatomy at the bedside.

So get involved, start using ultrasound now, be as comfortable with the machine as you are with your cardiac exam; be as facile at scanning as you are at texting on your iPhone.  

It’s no longer the wave of the future, folks, it’s here, it’s now, and it’s awesome.

- Michelle Schroeder