CLERKSHIP DIRECTOR WELCOME

Welcome to your Emergency Medicine rotation at Advocate Christ Medical Center Department of Emergency Medicine. We hope that you will find your experience both exciting and informative. Emergency Medicine is a challenging field that utilizes every aspect of medicine. The rotation is structured for fourth year medical students who have had some exposure to the core rotations such as pediatrics, internal medicine, surgery and OB/Gyne. The Department of Emergency Medicine at Advocate Christ Hospital is one of the busiest trauma center in Illinois. We expect your rotation with us to be challenging but structured in a way to help you learn and grow.

Orientation is held on the first Monday of your rotation. We will meet in the Department of Emergency Medicine usually at a time specified via email, usually around 9am. If that Monday is a holiday, the orientation will be moved to the next day at the discretion of the Coordinator. The first day is orientation only and does not require patient contact, so you may dress casual. Orientation will take approximately 1-2 hours. Please email me with any questions.

Dennis Ryan, MD
Medical Student Coordinator
Department of Emergency Medicine
Advocate Christ Medical Center  
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GOALS AND OBJECTIVES

The goals of the rotation:

1. To provide an environment in which a fourth year medical student may gain knowledge of emergency medicine
2. To provide an environment in which students under supervision may learn and perform procedures.
3. To prepare students who are interested in pursuing careers in Emergency Medicine.
4. To emphasize clinical teaching at the bedside by close one-on-one supervision with a senior resident or a teaching attending.
5. To provide didactic teaching through a series of focused medical student lectures by residents, attending resident conferences, case presentations, mock oral examinations and procedure labs.

The goals for the student:

1. To demonstrate the ability to take focus history and physicals in the acute care setting
2. To demonstrate the ability to formulate treatment plans and manage the acutely ill patient.
3. To demonstrate professionalism while working as part of a team in the acute care setting.
4. To demonstrate proficiencies in basic emergency medicine procedures in the procedure lab.
5. The opportunity to perform emergency medicine procedures under the direct supervision of Board certified EM physicians.
6. To demonstrate knowledge of Emergency Medicine.
7. To demonstrate basic interpretations of imaging, lab results, and other ancillary studies
8. To give a case presentation discussing the presentation and management of an interesting case
9. To participate in simulation codes cases 

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SCHEDULING

Medical Student rotation schedules are designed as follows:

Note: The ED shifts are comprised of 3 night shifts, 2 attending-only shifts in Fast Track, and 1 Peds ED shift, with the remaining shifts focused in the main Emergency Department.  

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MAP OF EMERGENCY DEPARTMENT

The emergency department is divided into sections to allow better resource utilization. Your month in the ED will consist of shifts in the various areas. The drawing below is an architechtual diagram of the ED. The blue, red, and gold areas constitute the main ED where critical and general care patients are treated. Due to the size of the ED there is a geographic division of the main ED to allow for better physician coverage. Your main room shifts will be listed as (F) meaning front half, (M) meaning middle, (B) meaning back half, and (Flt) meaning floating between all areas. The front rooms include 1-3 and 21-25. The middle includes rooms 4-12. The back rooms include rooms 13-20. The float shift is designed to help out all sides. NOTE: coverage on night shift changes, you will be made aware of this on your night shifts.

Additional shifts will be assigned in the pediatric emergency department (PED), and the fast track (FT) based on availability of the senior residents and attending's schedules. 

A few terms you may see or hear while in the ED:

Code Yellow signifies a trauma patient has arrived (trauma team cares for these patients).
Code 60 signifies a patient has an acute MI and will probable go to the Cath Lab.
Code 44 signifies a patient that is in critical condition has just arrived and needs physician attention immediately.
Code 30 signifies a patient with an acute CVA has just arrived.

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IBEX ELECTRONIC MEDICAL RECORDS

iBEX is the computer charting system used in the Emergency Department. Orientation to the charting system will occur during orientation. Medical Students are required to complete two full charts per shift in the iBEX system.

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SEEING PATIENTS

When seeing patient as a rotating student, you will encounter many different teaching styles amongst the teaching attendings and senior residents. The teaching styles will also vary depending on the demands of the Emergency Department. On days where the demands on your supervising physicians are light, you will see more extensive teaching and education. On days where there is a high demand, you will see a more focused educational experience. The focus is to provide you the best educational experience while maintaining the safety of the patients and the flow of the department.

Every shift you have offers slightly different challenges. We have done everything possible to afford you the best educational experience during your rotation. The recommended process to seeing new patients includes the following:

• Review iBEX computer tracking system to locate patients who are waiting to be seen.
• Discuss with your supervising physician if that patient is appropriate for you.
• sign up for the patient in iBEX, either under your name or your supervising physician's name
• perform a focused H+P. Most history and physicals can be performed within a 20-30 minute period.
• Before presenting the case to your supervising physician, think through the following questions:
  • What do you think is wrong with this patient?
  • What are the key aspects of this case?
  • How did you come to that conclusion?
  • What else could be the cause of the patient's complaint?
  • What do you think is the most likely cause of the patient's complaint?
  • What diagnostic test are indicated in this case?
  • How should we proceed from here?
  • Why do you think the patient requires hospital admission?
  • What discharge instructions do we need to give this patient?
• Discuss the patient's management and disposition with your supervising physician.
• Follow up on diagnostic labs and imaging, check on your patients, and help update that patients prior to admission or discharge.
• Keep a log of all of the procedures you perform.

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TRAUMA SHIFT

Given that Advocate Christ Medical Center is one of the busiest Level 1 trauma centers in Illinois, we offer our rotating students experience managing traumatic injuries. You will have one shift during your clerkship dedicated to working with the trauma team.

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PARAMEDIC RIDE ALONG

The paramedic ride along is an optional experience available to you during your elective. When considering a career in Emergency Medicine, it is imperative to understand the capabilities of pre-hospital care providers. The ride is an 8 hour shift with a local paramedic unit. This shift is designed to help the student understand basic terminology, observe on-scene EMS care, and understand the difficulties experienced while attempting to deliver pre-hospital care and transport. Your experience will help you understand some of the situations not easily communicated during pre-hospital care.

We will provide you the contact information to schedule the paramedic ride along during your orientation. Due to the volume of EMT, paramedic, and medical students ride along you will be asked to provide three available dates that she can work with to schedule your shift.

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REQUIREMENTS

The requirements for completion of the Emergency Medicine rotation at Advocate Christ Medical Center include the following items:

• Yellow Daily Evaluation sheets
• Procedure logs
• SAEM Online quizzes
• CDEM Online simulation cases
• Conference participation
• Simulation experience
• Final Exam
• Case presentation

Note: Grades will only be submitted once student's requirements are completed and turned in at the end of the rotation.

Yellow Daily Evaluation sheets are given out to you at the start of your rotation by Ann. These yellow papers are to be given by you to the supervising physician you worked with at the end of your shift. These sheets are used to evaluate your performance during clinical shifts. Your rotation grade is based 60% on the results of these yellow sheets. It is critical for your grade that you distribute a form at the end of each shift.

The Procedure Log is a list of the procedures you directly observed or performed during your rotation in the ED. Log all procedures you were involved in. This list will also need to be turned in on your last day.

Final exam and case presentations are discussed later.

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SAEM ONLINE QUIZZES

SAEM supports an online quiz web site used for medical students rotating through an emergency medicine rotation. Although these quizzes are optional, we have found students that take many of these quizzes build a stronger knowledge base, show more confidence in their clinical performance and score higher on the final exam. It is strongly encouraged that you perform as many of these quizzes as possible before the end of your rotation. This site requires a username and password that will be emailed to you prior to the start of your rotation.
To access the quizzes, go to http://www.saemtests.org/

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CDEM ONLINE SIMULATION CASES

The Clerkship Directors of Emergency Medicine offers a great online resource for medical students. On this website, one can find information on how to work up common complaints such as chest pain, fever, altered mental status, etc. Additionally, one can find realistic online simulation cases (currently, there are three) that you are required to complete. Go to the link below to access the website and the online DIEM simulation cases:

http://www.cdemcurriculum.org/

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CASE PRESENTATION

Don't worry...

Your presentations are only done in front of the other medical students, the Clerkship Director, and any resident on the teaching elective. Each student will present one interesting case at the end of the rotation. The case presentation is a short presentation (often powerpoint) for the fellow medical students who are rotating in the department. The typical presentation last about 10-20 minutes. Having the presentation on USB drive or emailed to yourself is recommended.

Typical presentations start with a short case followed by a presentation of the pt's disease. For example:

Case: 65 y/o male presents with severe abd pain that radiates to his back. Then ROS and physical exam and then the ED course....Dx is ruptured aortic aneurysm.

Topic: Ruptured aortic aneurysm is a condition........

This is followed by a short discussion.

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FINAL EXAM

The final exam consists of 40 multiple choice questions. The exam covers toxicology, pediatric, and adult emergency medicine. The online study guide covers the most important aspects of emergency medicine, which will help you focus your exam preparation. There is no time limit in taking the exam which is usually given on the last Friday of the rotation.

Study Guide for the final exam.

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GRADES

The grading system for your rotation in Emergency Medicine is listed below. 60% of your grade is determined by your clinical performance in the ED. This is calculated by the yellow sheets you hand out to your supervising physician after each shift. The other 40% of your grade is determined by the below factors.

60%  Daily yellow evaluation sheets given to the supervising physican
20%  Final written exam
20%  SAEM online quizzes, teaching rounds, procedure lab, simulation cases, case presentation, etc.

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LETTERS OF RECOMMENDATION

The Department of Emergency Medicine does provide departmental letters of recommendation for students that are interested. These letters follow the standard letter of recommendation formed by The Council of Emergency Medicine Residency Directors (CORD). The letter is written by the student coordinator, with input from all pertinent staff, the residency director and associate residency directors. Any student asking for a departmental letter will be asked to provide their CV, personal statement, and board scores.

Departmental Letter of Recommendations will attempt to communicate to the reader a summary of the student's clerkship experience, with input from the entire faculty. You will have the option to waive your right to review your letter or recommendation.

In addition to the Departmental letter, students may also ask an individual faculty member for a letter of recommendation. Most faculty members will honestly tell a student if they are not able to author a strong letter, and will respectfully decline. This may be unfair for the specialty, because if students submit only favorable (their best) letters, their potential may be inaccurately elevated. However, it is common that applicants request letters from authors who regard them in the best light and will write the best letter possible. Therefore, with the exception of medical student directors, who have the responsibility of composing at least the clerkship summary for the dean's letter, this practice will remain.

Characteristics of a quality Letter of Recommendation

• Authentic
• Honest
• Explicit
• Balanced
• Confidential
• Appropriately detailed and of appropriate length
• Technically clear

NOTE: Any Departmental Letter of Recommendation will contain information regarding your rotation including rotation scores, evaluation comments, and grades. If you feel you do not wish your rotational information disclosed it is recommended you do not request a departmental letter or recommendation.

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EXTRA INFORMATION 

MOCK ORAL EXAM

*** The Mock Oral Exam is no longer administered; therefore, it is not part of your final grade. Since mock oral exams are frequently done during conference, the below info may help you better understand this important concept. *** 

The oral boards evaluate: 1) your knowledge of emergency medicine and 2) your facility with playing the oral board "game." You have at least 36 months to learn emergency medicine. The purpose of the "MOCK" oral boards is to improve your comfort and ability to play the "game."

Scoring

The exam is scored in eight areas:

1. Data acquisition
2. Problem solving
3. Patient management
4. Resource utilization
5. Health care provided (outcome)
6. Interpersonal relations
7. Comprehension pathology
8. Clinical competence (Overall)

The grading scale is: 1= Very Bad, 4=Fail, 5=Pass, 8=Perfect. In order to score a "5" and pass, you must complete all the critical actions for your case. Set expectations for residents are: EM-1's score a "4" on all cases with an occasional passing score. EM-2's are expected to pass ("5" or higher) 50% of the cases. EM-3's are expected to pass 6 or 7 cases. Graduates are expected to pass the real exam!

Rules of the Game

1. Like the real exam, you must be on time. If you are late, the clock will start without you. Even the best examinees will find it difficult to pass with a five minute handicap.
2. No talking or discussing the cases. It is only fair that all examinees be given a fresh chance to solve the cases. When your well meaning friend tips you off to the "easy case of strep throat", chances are you will also miss the retropharyngeal abscess.
3. Bring only a pencil. Scratch paper will be provided and must be left in the examiner's room.

Learning to Play the Game: Problems

• Problem #1 Unnatural
  • The main problem with the "game" is that all the visual/auditory/olfactory clues you process instantaneously in real life, are missing from the exam. A real life patient that is hemiparalyzed (CVA), has ketotic breath (DKA), or is hot to touch (sepsis) can be sized up in 30 seconds. For the oral boards, this information must be methodically and specifically discovered.
• Problem #2 Time
  • You may run into time problems. This is more common on the triple cases.
• Problem #3 "Routine" Care
  • "Routine" Care at your hospital is never done on the exam. You must specifically order:
    • undress the patient
    • oxygen
    • pulse ox
    • oxygen saturation readings
    • IV's/Saline lock
    • Cardiac Monitoring
    • rhythm strip
• Problem #4 Panic
  • It is easy to lose your way, become side-tracked, or find yourself in a dead end and then panic. This is especially true in the triple cases. Stay calm. You can pass many cases without actually getting the specific diagnosis.
• Problem #5 Multiple Roles for Examiner
  • The examiner plays several roles including examiner, paramedic, patient, relative, nurse and consultant. Sometimes this is not done well and is confusing.

TIPS

• Have an organized approach. After taking a side trip or ending up in a dead end, go back to where you left off and start gathering data from Hx, P.E., and tests.
• Conserve time by cutting down on note taking. Write some notes in helpful. If you take extensive notes you may run out of time to take care of the test patients.
• A suggestive approach is as follows:
  • At the very beginning of every case, before history is taken, get a mental picture of the patient. Ask "When I look at the patient, what do I see?" or "When I walk in the room, what do I see?" or "What is the general appearance of the patient?"
  • Before any history is taken, obtain a complete set of vital signs. The temperature may be omitted (on purpose). Getting a body weight and a pulse ox can't hurt.
  • Stabilize life threats (A-B-C-D-E)
  • Get an organized and systematic history from patient, paramedics, and/or relatives (don't forget medications, allergies)
  • Order monitoring (pulse ox, cardiac monitoring) and some tests (blood, urine, X-rays, CT's, ultrasounds, ABG's, EKG's)
  • Perform an organized and systematic physical exam (this is very unnatural and requires the most disciplined and practice).
  • Based on Numbers 1-6, get more history and tests as needed.
  • Establish the patient's problems and diagnoses.
  • Begin specific treatment.
  • Continually reevaluate the patient. After every order (a test or therapy), always ask for follow-up results. For example, after a hypotensive patient is given a fluid bolus, ask for repeat vital signs. If you order a Pulse ox monitor, immediately ask for the Pulse ox reading. If you don't ask, the information may not be given to you.
  • Listen to the examiner. His response may be a clue. If you ask for something and don't get it (a) you may be asking for it too soon and are supposed to manage the case on your own for a while, or (b) what you want is irrelevant. An examiner response such as "normal" or "negative" may indicate your question is about something that has little or no importance to the case. If the examiner asks you to "Be more specific" with a question, it might mean that the area in question has some importance to the case. If the patient gets worse, the examiner is probably telling you that something has been missed along the way. Stop, stay calm and think again.
  • Talk kindly to the "patient", "family", and "consulting physicians". Speak as if you are actually talking to them. You can speak "medical" to a consultant/RN, but should say "collapsed lung", not "pneumothorax to the patient/family member. This is part of your "Interpersonal Relations" grade-and free points from my point of view.
  • Think twice before discharging a patient home. In real life, if a patient has a sore throat, you would send him home. If a test patient has a sore throat, he should also be sent home and not admitted (Resource Utilization). However, make doubly sure you ar not overlooking some potentially life threatening problem. Make sure "just a sore throat" is not a paralyzed vocal cord, epiglottitis, an abscess, or diphtheria!

Scoring Criteria

Your score of the candidates's performance will be based on two criteria:

1. Critical actions- Each case is accompanied by a list of critical actions. The candidate must execute these actions to pass the case encounter.

2. Scoring components- You will also be evaluated in the following eight areas:

• Data Acquisition- Did the candidate collect the appropriate data from the history, physical exam and laboratory to correctly diagnose and manage the patient, without going overboard?
• Problem Solving- Did the candidate approach the clinical situation in an organized manner, collecting data from the history, physical exam and laboratory to correctly diagnose and mange the patient?
• Patient Management- Was timely and proper treatment given? Were appropriate referrals obtained?
• Resource Utilization- Did the candidate order the appropriate tests necessary to mange the case, or did he just shotgun? Shot gunning is disapproved and penalized.
• Health Care Provided (Outcome)- From the perspective of the patient, and with reference to current medical practice and standards, was the best possible outcome achieved?
• Patient Relations- Did the candidate interact well with the patient and/or close family members, allaying their fears, and treating them in a supportive and empathetic manner?
• Comprehension of Pathophysiology- Did the candidate understand the scientific basis for his actions or did he simply rely on memorized routine procedures usually followed in such cases?
• Clinical Competence (Overall)- All things considered, how well did the candidate handle these types of conditions or problems?

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TIPS FOR SUCCESS

• Be on time for shifts and conference
• Dress professionally (scrubs and a white coat are acceptable)
• Coordinate with your supervising physician before picking up a new patient
• Always look for interesting cases. If you are not too busy, help out with codes and procedures even if those patients are not in your section. We encourage you to observe with cases and/or procedures that interest you. Please ok this with your supervising physician before leaving your section
• Maintain awareness of diverse cultures, health beliefs, and social factors that may impact the patient's care.
• Seek help immediately if you feel there is an emergency or unstable patient. Do not hesitate to interrupt your supervising physician if you need help. The staff is there to help you learn

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Frequently Asked Questions

Who can take an elective in emergency medicine at Advocate Christ Medical Center?

Any medical student who has completed his/her core clerkships in Surgery, OB/Gyne, Pediatrics, Medicine and Psychiatry, and has passed USMLE or COMLEX Step 1 may rotate. Typically, rotations are open to students in their entire 4th year. The rotations are open to all Allopathic and Osteopathic students in accredited US medical schools. At this time, foreign medical students are not accepted. All applications are extensively reviewed for the appropriate prerequisites, and an email confirmation with rotation dates will then be sent to you.

When should I apply?

Applications become available in late February or early March for the following academic year, and you may apply any time after that. Elective spots go fast, especially for the July-through-January timeframe. Only 6 students are accepted per block. While we do not primarily operate on the "first come, first serve" basis, we do selectively populate our schedule, and the sooner you apply, the more likely you are to get your first choice. Please contact Ann Nestor at (708) 684-1277 if you have specific questions about availability.

What kind of patient's will I see and care for?

Students who rotate through the Department of Emergency Medicine are involved in the care of all patients. They are part of a team of physicians caring for all patients from ankle sprains to heart attacks.

Do I get to participate in resuscitations?

Yes. Again, rotating students are part of the physician team and fully participate in patient resuscitations. Supervised procedures and assisting in critical patient management are cornerstones of the EM rotation.

How do I apply for an elective?

Application downloads are available on the main homepage. Completed applications may be emailed, mailed, or faxed. If you have any questions or problems, please contact Ann Nestor, at (708) 684-1277.

What courses are required before my emergency medicine rotation?

The core clerkships are required before rotating in the emergency department. ACLS, PALS, or ATLS are not required, but definitely helpful. Due to the fast pace of the emergency department, students who have not had core rotations are not able to learn from all the available experiences, or get the most from the rotation.

Why should I rotate at Christ?

Quite simply, we offer one of the best elective experiences in the country. We have a very busy, high-acuity department, with a very diverse patient population. We have an excellent teaching staff, with nationally recognized attendings, and some of the most intelligent residents in the country. Our elective is organized, comprehensive, and with only six students per block, personally attentive. Combine this with hands-on teaching and simulation labs, lectures, and conferences, and you can consider yourself immersed in emergency medicine.