Emergency Medicine is one of the required rotations for PA students during the clinical year. We’re going to talk about some helpful things to brush up in addition to some expectations for your EMed rotation.

ACLS & ABCs

I’ll start this off pretty simple. Ensure that unstable patients have an airway, are breathing, and have adequate circulation. If these three needs are not met, your patient is in a lot of trouble. I would strongly suggest a review of the ACLS protocols because this is going to be what is followed for your unstable patients.

You should know what to do when a patient is complaining of vague chest pain or chest-related symptoms.

As codes and serious events come up, your preceptor may let you wander off and assist there. Getting to do CPR as a PA student is not unheard of either.

ECGs

You should get comfortable reading ECGs (or EKGs if you want to call them that). Find a systematic method that works for you and know it like the back of your hand. Read the ECG for yourself and don’t cheat by reading the top of the strip. Often times the strip is wrong and when being asked to read it you’ll inevitably be called out. If you need a refresher this Strong Medicine video works well to shake off the cobwebs.

Also if you haven’t found him already, MedCram has a few on ECGs that you may find helpful. Practice is what is going to really help it stick in your brain, so take a day to really sit down and methodically go through several ECGs.

Wound Closure

If you have a perfectionist personality you may enjoy suturing. This is one area where you want to make sure you’re comfortable before moving onto patients. First, you’ll want to review suture material choice and gauge. As a general rule, I’ve heard is 6-0 on the face, 5-0 on the hand, and 4-0 pretty much everywhere else. Like many rules, there will be exceptions so it may be best to ask your preceptor’s input. For superficial wound closure I found success with nylon but again I would speak with your ER Attendings / Advance Practitioners and find their preferences and choices.

Now onto suture technique. You will likely be doing simple interrupted, but it’s also wise to be versed in simple running and subcuticular as well. Ask around the ER to see if there is any opened or expired suture material that you can use as practice. Many have found success using items such as bananas for practice but I found success using simulation skin. There are also many helpful videos scattered around YouTube so I suggest you give them a watch.

Also don’t forget wound irrigation, tetanus status, and antibiotic coverage for dirty wounds.

I am simply covering superficial wound closure here. You may encounter multiple layer closure which is covered wonderfully in the General Surgery Survival Guide (to be released).

Alternatively, you may find that providers may choose staples instead of sutures. Typically you’ll find with deep scalp lacerations, staples are utilized more commonly than sutures. Staples are faster to apply and typically less painful for the patient. That being said, they may take two providers to apply and require more than just scissors to remove. If you get the opportunity to utilize a stapler during your rotation I encourage you to take advantage.

Sprains, Fractures, & Splinting

This is bread-and-butter emergency medicine. I’m sure many people reading this article have visited the ER due to some sort of rolling an ankle, tripping over something, or landing awkwardly.

When a patient like this comes in, you’ll want to get all the details you can about the incident. Upon getting this information you can begin your physical exam noting any tenderness and range of motion. A good rule of thumb is to always check one joint above and below because injuries can occur simultaneously. Another important test is checking neurovascular status. A quick review of the Ottawa ankle rules and Canadian C-Spine Rule can also help guide your proposed next step with your patients. Finally, don’t forget those specific circumstances such as snuffbox tenderness.

Most patients whether an acute fracture appreciated or not on imaging will receive a splint before discharge. Knowing how to use your specific splinting material is key to ensuring the stability of the injured area and patient comfort. Sharp edges and excessive wrap pressure are no-no’s when it comes to applying a splint. If you are unsure if your splint is too tight asking your preceptor is the best bet. Spend some time reviewing splint type for specific injuries in your patients, if you are shaky on this.

Neck / Back Pain

One of the most common complaints in the emergency department is neck or back pain. Understand what requires serious intervention (such as Caudia Equina or IV drug users with a possible epidural abscess) and which conditions can be followed up with primary care. These patients tend to present after motor vehicle accidents, sports injuries, falls, or minor collisions.

But back pain could also come from a patient suffering from a really bad kidney stone or even a patient with a AAA or heart attack.

Know the common medications we provide for non-specific back pain such as NSAIDs or muscle relaxants and when the back pain you’re dealing with could be something else.

Radiology

It is beneficial to review certain areas of imagining interpretation before starting your time in the emergency medicine. The systematic approach to reading chest X-rays is definitely a worthwhile investment in time. You’ll notice that many providers use these approaches because it ensures that nothing is missed on imaging. The link provided may be more in-depth than you’ve previously learned but It’s better to go in more prepared than less prepared.

Other areas to review include foot and ankle imaging, hand and upper extremity fractures, blowout facial fractures. Remember you’re probably only going to be responsible for the obvious or pathognomonic findings, so don’t stress out if the radiologist appreciates things that you missed.

Both Hip fractures and dislocations, as well as skull fractures and intracranial bleeds, are covered in depth in the Trauma Survival Guide.

Conclusion

Overall E Med can be difficult to prepare for but with a review of your program’s lectures and this quick summary, you should be up to par with what they expect from day one. It can be a very fast-paced rotation, but with these tips above, you should be prepared.

Patrick McDevitt

Patrick McDevitt

Physician Assistant

Pat is a currently practicing PA in Pennsylvania. He holds his MMSc in Physician Assistant studies from Salus University as well as a B.S. in Exercise Science from West Chester University. His clinical interests include trauma, critical care, and interventional radiology.

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