Written by Rebecca DePalma, PA-S2
Rotations can be intimidating at first, but they can also be fun, exhilarating, and a time of exponential growth. Many look forward to them after didactic, but some also are scared for what they may hold. Or perhaps a little bit of both. Clinicals will shape your knowledge in ways that are not possible within the classroom. Embrace this time as one that will put you out of your comfort zone to the point where it integrates into what you are comfortable with.
One of the more intimidating rotations tends to be emergency medicine due to the fast pace and unpredictability it can hold. Below are some tips that will help prepare you for an upcoming ER rotation!
ER Tips
- Find out what kind of emergency room you will be in. It could be urban or rural, a level 1 trauma center or a level 4 trauma center. That can give you an idea of what to expect in terms of the types of cases they take or how busy the ER will be. Oftentimes the more rural the ER, the more you are able to do. They are less likely to be larger teaching hospitals with lots of students. Research the site of your ER rotation and see if there is any helpful information you can find.
- You want to have a good pace to match the ED, but also you are a student, so still show that you are being thorough.
- Have your medical apps downloaded and ready to go. UpToDate in particular. Some ER specific apps include Quick EM (for reference) and Rapid Fire EM Student (for ER related questions).
- Keep a notepad and pen on you. For notes, things you learn, and also to keep track of your patients, as most students have to log their patients for their program.
- Pack Snacks. Depending on how busy the ER is, eating may only occur quickly in between patients. Pack options including energy-filled snacks. I would also bring some sort of caffeinated beverage just in case (Especially if you always offer to help and to do more).
- If you are assisting your preceptor with a procedure, they will often offer to let you try it next time. Say yes to every opportunity. If they don’t offer, feel free to ask if you can try the procedure next time.
Things to be aware of
Triage – in the ER, patients are triaged. This is done by the triage nurse upon entering the ER, and the patient’s triage ranking is usually notated somewhere in the EMR. The levels are as follow:
- Level 1 – resuscitation: this is seen immediately. Example- airway compromise, unresponsive.
- Level 2 – emergent: this is seen as quickly as possible, <15 minutes. Example- responds to voice/pain only.
- Level 3 – urgent: this is seen in <30 minutes. Example- Low O2sat, signs of dehydration.
- Level 4 – less urgent: this is seen in <60 minutes. Example- atypical behavior.
- Level 5 – non-urgent: this is seen in <120 minutes. Example- sore throat, cold-like symptoms.
Note 1 – the levels listed above are examples, your ED levels may vary. Each condition also depends on how the patient presents, if they are toxic-appearing, and what their vitals are. In addition, preceptors can triage patients slightly differently, so it can depend on your preceptor.
Note 2 – the timeframes listed are goals, but do not always occur in that timeframe. It also is dependent upon how full the ER is. For example, if there is no level 1 present, the level 2 would likely be seen immediately.
Fast track vs. higher acuity – Many ERs have a “fast-track” which sees lower acuity patients (such as triage levels 4 and 5 for example). Depending on your site, it is common to have students be in the fast track. This is not always the case and many sites do put students with higher acuity patients as well, but it is just something to be aware of.
Codes – there will likely be a couple codes while you are in the ER. Code blues are medical emergencies such as a cardiac arrest. These are run by an ER provider with things like ACLS protocols and BLS/CPR. Typically, you will be ACLS and CPR certified prior to your ER rotation (if you are not, you should ask your program about this). If certified and knowledgeable on CPR, it is definitely possible for students to participate in codes. I would just ask your preceptor at the beginning of the rotation if they are okay with you going over to a code once one is called, and if they are okay with you participating in CPR. If yes, then once the time comes, take initiative! Get over to where the location of the code is quickly, and when they are in need of someone to switch for CPR, speak up and volunteer. This takes some initiative and can seem a little scary at first, but is a good experience to garner in your ER rotation.
Varying schedules – this is very site/preceptor-dependent, but your schedule may be more normal, or it may be very irregular and include nights. Be prepared for this possibility while on your ER rotation. If you do have a schedule that includes nights or will mess up your typical sleeping pattern in some way, be sure to plan out how you will convert your sleeping schedule including when you will sleep. Despite this, you will likely still be tired. Have the snacks and caffeine ready for when needed. The ER is a very unique environment often with a different schedule and lifestyle. Just immerse yourself in the learning experience and make the most of it!
About the author: Rebecca DePalma
Rebecca is currently a PA student originally from Seattle, Washington in her second year of PA school, nearing the completion of her program. She is currently on clinical rotations and documents her experience as a PA student along with providing helpful tips.
She enjoys helping others anywhere along their pre-PA path and connecting with those already practicing. Follow her Instagram page @rebeccawestcoastpa to see her first-hand experiences as well as garner valuable resources and tips for those in medicine.
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