Introduction

Clerkship Information

Summer 2012 Emergency Medicine ClerkshipDartmouth Medical School

Welcome to the Emergency Department at Dartmouth-Hitchcock Medical Center and your 2012
Emergency Medicine Rotation. We are glad that you have chosen to spend time with us, either
for an Elective or for a Sub-Internship. In either case, we hope that the next few weeks you spend
with us will be an exciting, high-yield clinical experience and that you will walk away from your
rotation having gained unparalleled bedside teaching, valuable procedure skills, and a better
understanding of the unique and exciting specialty of Emergency Medicine. Who knows, maybe
well even convince you to join the growing field of Emergency Medicine!
We are continuing with our expanded Emergency Medicine curriculum, which was completely
revised in 2011. Student feedback from this expanded curriculum has been overwhelmingly
positive and includes expanded student responsibilities, procedure labs, simulation, didactic
sessions, ultrasound exposure, and closer interaction with faculty and our Emergency Medicine
residents. The emphasis of the rotation, however, remains the clinical evaluation of the
undifferentiated patient in the Emergency Department.
NOTE: It is essential that you are familiar with the enclosed documents, particularly the section
on grading, as they will help you navigate the course more smoothly.
As we continue to make changes to the curriculum, we value your feedback. We want this
rotation to become the most valuable and popular elective experience within the Medical School.
We need your help to do this. Feel free to give us feedback over the course of your rotation.
There will also be an opportunity at the end of the rotation for you to give us concrete feedback.
If you have any questions or concerns over the course of your rotation, please contact the Course
Director at the email address below. If for some reason you are unable to reach the Director in a
timely manner (we have to sleep too!), please contact Brenda Ellis, senior clinical secretary.
Thanks for choosing to rotate with us. We look forward to having you on the team!

E. Paul DeKoning, MD, MS

Brenda Ellis

Clerkship Director

Senior Clinical Secretary

Elisha.p.dekoning@hitchcock.org

Brenda.ellis@hitchcock.org

Emergency Medicine ClerkshipDartmouth Medical School

Medical Student Guidelines
The following are required for successful completion of MEDI 416 (Sub-Internship in
Emergency Medicine) and MEDI 510 (Elective in Emergency Medicine):
1. Clinical Shifts in the Emergency Department: Each student will rotate through an equal
number of clinical shifts in the Emergency Department at Dartmouth-Hitchcock Medical
Center. Students rotating for four weeks on the Intensive Rotation (July-Oct) will be
assigned up to 15 nine-hour clinical shifts, to include days, evenings, overnights, and
weekends. If your rotation does not include weekly didactic days, a four-week rotator
will be expected to complete 18 nine-hour clinical shifts (nine shifts for 2 week rotators).
Your shift schedule will be assigned at the start of the rotation. Absences must be
reported to Brenda Ellis (650-7254) as well as the Attending on Shift (650-7001). The
Course Director must also be notified. Anticipated absences, e.g. interviews and medical
school functions, must be reported in advance and rescheduled. The only guarantee for
shift change is residency interviews. Absences due to illness will be rescheduled at the
discretion of the Course Director. Only 2 shift trades per student are allowed and must be
approved in advance by the Course Director. A sample Schedule Template is at the end
of this document. The final schedule is at the discretion of the Course Director.
2. Didactic Days (July-Oct): Student-focused didactic sessions are held each Wednesday
afternoon of the Intensive Rotation, from 12 noon until 4 pm. These sessions will be held
in the Emergency Medicine Small Conference Room (off the waiting room), unless
otherwise noted. These sessions involve lectures, simulation, procedure, labs, interaction
with EM Residents, and are taught by Attending Faculty in the Emergency Department.
Attendance is mandatory.
3. Patient/Procedure Cards: In order to ensure a well-rounded clinical experience, you will
be given a Patient/Procedure Card for you to keep track of the variety of patients you
encounter as well as any procedures you perform. This card contributes to 10% of your
final grade. It is required that you document completion of 80% of both the Patient
Topics and Procedures by having an Attending sign-off on your card. You may, of
course, complete more than one of each topic, but multiple cases under one topic do not
count toward missed topics needed to reach 80%. Topics not on the card may be added.
You must turn your card in to Brenda Ellis at the end of your rotation.
4. Notes and Orders: This is not a note-writing rotation, however you are required to write
notes on at least 2 patients per shift. These should be concise, chief-complaint-focused
notes that clearly communicate the course of the patient during their ED stay. Please see
the attached template for format. Students may pend orders in the patients chart that
must be co-signed by an attending before they can be acted on. You are expected to
function as the primary care provider for your patients. You are expected to closely
manage and follow the progress of all of your patients, including test results, patient
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condition, and disposition. You will be expected to call consults, admit the patient, and
review discharge planning. In short, the patients you see are yours.
5. Timing and Efficiency: The nature of Emergency Medicine requires multi-tasking. EM
physicians simultaneously manage multiple patients of varying acuity at all stages of their
clinical course. This is a difficult skill to learn. The nature of the ED evaluation is
problem-focused; time is a luxury we dont usually have. By the end of your rotation, you
should aim to manage multiple patients at a time (up to three) and be able to perform a
complete H&P in under 10 minutes. NOTE: students must staff each patient with an
Attending before picking up an additional patient.
6. Reading List: There will be required independent study in order to successfully complete
the final exam. The Core Curriculum can be found at http://www.cdemcurriculum.org.
You are required to complete all of The Approach to modules, Specific Diseases
modules, as these two sections are designed to complement each other. It is strongly
recommended that you complete the DIEM cases for practical application of the material
in a simulated patient encounter. Our core textbook is the Emergency Medicine Manual
by Ma, Cline, and Tintinalli. You may check out a copy from Brenda Ellis in the EM
office. A $50 deposit is required and will be refunded upon return of the book in good
condition.
7. Introduction to Ultrasound: The utilization of Ultrasound in the Emergency Department
has many unique applications. Students in the Intensive Rotation will receive a brief
introduction to Emergency Ultrasound with hands-on practice. Techniques include the
FAST exam, gallbladder scan, AAA, peripheral venous access, etc. This will take place
during one of your Wednesday didactic sessions.
8. Journal Club: Journal Club is typically held monthly and is an opportunity for you to
interact with the faculty in a social, relaxed setting. The purpose of Journal Club is to
discuss articles relevant to the practice of Emergency Medicine, i.e. does this study
influence what we do in the real world and, if so, how? We meet typically on a Tuesday
evening over dinner. These are fun and relaxed (really!) and you are encouraged to attend
as our guest (i.e. the food is on us). We will send you the articles once they are available.
9. EMS: Students interested in pre-hospital patient care may do a voluntary ride-along one
of our local EMS services. This is not a requirement. Ride-alongs are for one day (8a-4p)
and are observation only. If interested, contact Brenda Ellis in the EM office for details.
10. Grading: This is designed to be a challenging rotation and it is difficultbut not
impossibleto get Honors. The majority of students will obtain either a Pass or High
Pass. In order to achieve the grade of Honors, a student must clearly demonstrate a

knowledge base and clinical skill level above that expected for their level of training.
They routinely function at or above the level of a PGY1 intern. A grade of 88% or higher
on the final exam (see below) is necessary but not sufficient to achieve Honors, i.e. the
student must demonstrate proficiency in all areas, not just the final exam. A grade of 80%
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or higher is required, but not sufficient, to achieve High Pass. A grade of 70% or higher is
required, but not sufficient, in order to receive a passing grade.
11. Final Exam: All students are required to take a multiple choice final exam, based on bedside teaching, didactic sessions, and the online independent reading material. This will be
administered the last day of your rotation. It is multiple choice and will count toward
25% of your final grade. Practice exams are available at saemtests.org. Contact Dr.
DeKoning for access.

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Course Grading

Faculty evaluationsbased on the Core Competencies....45%

Patient Care: Care that is compassionate, appropriate, and effective.
Medical Knowledge: Basic fund of knowledge and its application to patient care.
Practice-based Learning and Improvement: Ongoing appraisal and assimilation of scientific
evidence and improvement in patient care.
Interpersonal and Communication Skills: Effective information exchange with patients, families,
faculty, and staff.
Professionalism: Commitment to carrying out professional responsibilities, adherence to ethical
principles, and sensitivity to a diverse patient population.
Systems-based Practice: Demonstration of an awareness of the larger context and system of
healthcare and the ability to effectively utilize system resources to provide care.

Final Exam25%
Professionalism.20%
Attendance at lectures
Timeliness for shifts
Motivated work ethic and attitude
Professional interactions with staff, nurses, residents, and attending

Patient/Procedure Card..10%
Total.100%

Grade Key
Honors: 90-100%
High Pass: 80-89%
Pass: 70-79%
Fail: <70%
Students interested in Emergency Medicine as a career choice should set up a time to meet with
Dr. Kevin Curtis, the DHMC Emergency Medicine Residency Program Director. Please contact
Brenda Ellis (603.650.7254 or Brenda.ellis@hitchcock.org) to schedule an appointment.

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Helpful Hints
1. Plan to arrive 5-10 minutes prior to the start of your scheduled shift and introduce
yourself to the Attending(s). The physician home base is the Cave or Physician
Workroom located in the center of the Emergency Department. Attendings typically use
the corner computers in the Cave. There should be a computer workstation available for
you to use for your entire shift. Shift length is 9 hours, with the last hour to be used for
tying up loose ends, completing documentation, discussion with family, etc. Do not see
new patients during this last hour. Student shifts typically run 7a-4p, 3p-12MN, 11p-8a.
Attending and resident shift lengths vary.
2. The Attending physicians are responsible for EVERY patient in the Emergency
Department. Every patient seen by either a student or resident must be staffed with an
Attending immediately after evaluation. It is required that you present each patient to an
Attending and together develop a plan of care before you evaluate another patient. If at
any time you notice an unstable patient or you are concerned about a patient in any way,
notify an Attending immediately.
3. The primary goal of Emergency Medicine is to exclude life-threatening situations.
Subsequently, patients are seen first in the order of acuity (how sick they are or their
potential to decompensate), then the amount of time they have been waiting. This is
based on their triage level (see chart below). In other words, a level 2 patient should be
seen prior to a level 3 patient. If there are multiple patients of the same acuity, the patient
to see first is the one who has been present the longest. Be advised, that triage is an
imperfect science: a level 4 patient might actually be sicker than a level 2. Medical
Students should not evaluate patients with a triage level 1 without direct Attending or
upper level resident supervision. You should check with an Attending prior to evaluating
a level 2 patient. If you have any questions on which patient to see next, just ask.

4. Once you are ready to see a patient, sign up for them and go to evaluate them. Do not
sign up if you are not yet ready to evaluate the patient. The key to Emergency Medicine
is a focused history and exam based on their reason for presenting to the Emergency
Department. That being said, however, the vast majority of patients require a thorough
history (10 systems) and exam (8 systems). Your goal should be to complete the H&P in
5-10 minutes.
5. Students may pend orders in eDH. It is recommended that you learn to do this as it will
give you good practice in determining the appropriate diagnostic students and treatment
options for your patient. They are not visible or actionable until signed by an Attending.
Consider this an opportunity for you to select items that you would order if you were the
patients physician (you are!). Your goal should be to have a good idea about the
patients disposition before you leave the patients room.
6. Do not order laboratory testing or imaging if it will not influence on acute treatment,
decision making, or is not needed for follow-up. The Emergency Department is not the
setting for the extensive workup of non-critical problems.
7. After completion of the H&P and your proposed orders, present the patient to any of the
Attendings on duty. Start with the chief complaint, HPI, ROS, PMH, Meds, Allergies,
Social Hx, Exam (dont forget the vital signs!), and finally pay special attention to the
assessment and plan section where you summarize your findings and your plan (i.e. your
proposed orders). For example, Miss Jones is a 58 yr old female with post-prandial RUQ

abdominal pain with a positive Murphys sign. My differential includes A, B, and C. My

plan would be to perform X, Y, and Z. If the results show _______, then I would plan to
_______. This plan should include the ultimate disposition of the patient (i.e. are they
going home?). You must staff your patient before going to see another patient. Please see
the section Differential Diagnoses for common Emergency Department complaints.
8. After you and the Attending develop a plan, inform the patient and the family of the plan
and the expected time to perform testing and determine a disposition. Over-estimate the
amount of time, as things usually take longer than expected.
9. As stated above, it is your responsibility to follow the patients progress during their ED
stay, including following-up on labs and imaging, pain management, repeat
examinations, etc. Your patients are yours. After the patients workup is complete, it is
time to disposition the patient. If they are being discharged, you will need to provide
clear discharge instructions, a follow-up plan, and a list of signs and symptoms that
should prompt the patient to return to the Emergency Department. If the patient requires
specialist consultation or admission, it is expected that the student will, with Attending
supervision, call the consultation or to request admission. Notify the Attending
immediately if you encounter problems or unprofessional behavior from a consultant.

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10. Every patient must be seen by an Attending Physician prior to discharge, admission, or
transfer. The Attending must be notified of all patients who desire to Leave Against
Medical Advice (AMA) or without being seen (LWBS).
11. Respect patient confidentiality at all times.

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Common Chief Complaints in the Emergency Department

A. Chest Pain: For patients with acute chest pain or shortness of breath, please show their
ECGs to the attending physician immediately. Virtually any patient with the complaint
of chest pain should have an ECG performed.
B. Abdominal Pain
a. Pelvic exam is mandatory in women with abdominal pain unless the pain is
clearly non-pelvic in origin.
b. Pregnancy tests are mandatory for lower abdominal pain or vaginal bleeding, even
in the face of a normal menstrual history or no chance that Im pregnant.
Stranger things have been known to happen
c. Abdominal pain in the elderly may represent catastrophic disease. Always
consider ischemic bowel and AAA in abdominal and/or back pain.
C. Severe Infection: Patients with suspected septic shock or meningitis should receive
antibiotics at the earliest possible moment. Blood cultures should be drawn first;
however, lumbar puncture should be performed after antibiotics are delivered if the LP
will significantly delay treatment.
D. Head Injury
a. Examine and document - loss of consciousness (LOC), associated symptoms,
pupils, Neurological exam, and cervical spine exam. If you are worried about a
cervical spine injury, place them in a collar and discuss with the Attending.
b. CT scan should be obtained for any patient with continuing alteration in mental
status, abnormal neurological exam, or history of (+) LOC or amnesia.
E. Laceration Care
a. Please document: Cleansing, anesthesia, distal neurovascular status, tendons,
range of motion, size/depth of wound, presence/absence of foreign bodies,
number and type of suture.
b. Watch out for foreign bodies! X-ray if suspicious. Ask the patient! Document
wound exploration.
c. In general, use Vicryl for deep suture, nylon or prolene for skin, Dermabond is
also available for use on very specific woundsask the Attending
d. Suture removal: Face 3-5 days Scalp 5-7 days Upper extremities/torso 7-14 days.
Lower extremities 10-14 days. If the wound margins are under tension, i.e., over a
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joint or in a web space - 14 days, and consider splinting. Worrisome wounds

should be checked in 2 -3 days.
F. Psychiatric Patients: All patients presenting to the ED with a psychiatric complaint, will
receive a medical screening exam by the ED physician first. This is not the time to
address their psychiatric issues in depth, which is the psych residents job. The vast
majority of psych complaints in the ED do not require medical testing prior to psych
evaluation. However, new onset of psychotic features in a patient without prior
psychiatric history requires a medical workup prior to psychiatric consultation.
a. A brief history of the current problem
b. History of past psychiatric disease
c. Presence of active medical problems
d. Current medications
e. History of drug/ETOH abuse
f. A mental status exam which must include: level of consciousness, orientation,
mood, suicidal ideation, homicidal ideation, presence of auditory or visual
hallucinations.
g. A brief physical
G. Stroke: If a patient has symptoms of a CVA and the last known time they were normal is
less than 3 hours, a stroke alert should be called. Discuss immediately with the Attending

Please keep in mind that some patients may utilize the ED for seemingly non-emergent
complaints. But what may seem like a simple issue to us may be an emergency to them. And if
they have no primary care physician, the ED may be their only option. Do your best to reserve
judgment

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Sample Emergency Medicine Medical Student History and Physical

Chief Complaint:
HPI:
ROS:
Gen:

Weight loss/gain: no
Fever/Chills: no
Neuro: Weakness: not focal
Psych: Depression/anxiety:
Eyes: Visual change: neg
HEENT:Trouble swallowing: neg
Endo: Diabetes: neg
CV:
Chest pain: neg
Palpitations: neg
Pulm: Shortness of breath: neg
Cough: neg
GI:
Change in stool: neg
Abdominal pain: neg
Nausea/Vomiting: neg
GU:
Urinary infection: neg
MSK: Joint pain: neg
Swelling: neg
Heme: Anemia: neg
Abnormal bleeding: neg
Skin: Rashes: neg
Wounds: neg

PMH:
Family Hx:
Social Hx:
Smoker:
ETOH:
Illicit Drug Use:

Medications:
Allergies:
EXAM
VS:
General:
HEENT:
Neck:
Pulm:
CV:
Abd:
GU:
MSK/Ext:
Skin:
Neuro:
Psych:

Assessment & Plan:

ED Course:
Final Diagnosis:
Disposition:
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Differential Diagnoses for common Emergency Department complaints

Abdominal Pain: AAA, Acute appendicitis, bowel obstruction, mesenteric ischemia,
cholecystitis, diverticulitis, nephrolithiasis, testicular torsion, PUD/gastritis, pancreatitis,
hepatitis, ovarian cyst. In premenopausal women add ectopic pregnancy, ovarian torsion, PID.
Altered Mental Status: hypoglycemia, hypoxia, seizure, syncope, toxicology/overdose, infection,
CVA, myocardial infarction, encephalitis/encephalopathy.
Back Pain: AAA, Cord/nerve Compression, Fracture, Retroperitoneal issue, Kidney stone,
Infection (epidural abscess, transverse myelitis, discitis), uncomplicated low back pain.
Chest Pain: ACS, aortic dissection, pneumothorax, PE, pneumonia, pericarditis/myocarditis,
esophageal rupture/mediastinitis.
Headache: Subarachnoid hemorrhage, subdural hematoma, epidural hematoma, meningitis,
glaucoma, migraine, tumor with shift, intracranial hypertension/pseudotumor cerebri, saggital
venous thrombosis.
Orthopedic injuries: Neurovascular compromise, the second injury (i.e. the one you missed on
primary survey).
Poisoning/Overdose: Acetaminophen, Carbon Monoxide, opioids, salicylates, tricyclic
antidepressants, toxic alcohols, anion gap acidosis, decontamination.
Shortness of Breath: Airway obstruction, heart failure, pneumonia, pulmonary embolus,
Asthma/COPD, myocardial infarction, symptomatic anemia, toxins.
Shock: Anaphylactic, obstructive, cardiogenic, hypovolemic (includes trauma), sepsis,
neurogenic.
Vaginal Bleeding/Pelvic pain: Ectopic, miscarriage, placenta abruptia, placenta previa, ovarian
torsion, pelvic infection.
Weak and dizzy: CVA, myocardial infarction, infection, metabolic, intracranial bleed,
peripheral/central vertigo, dysrrhythmia.
Wound Care: Neurovascular exam, dominance, irrigation, anesthesia, tetanus status, foreign
body evaluation.

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