Top 10 Ways to Rock EM Clerkship

While it may not be the case in other parts of the world, Emergency Medicine in Canada has become a highly sought-after specialty. Some have even added an E to include it in the list of attractive lifestyle or [E]-ROAD specialties ([emergency], radiology, opthalmology, anesthesia and dermatology).

The stats from our matching service indicated that last year 88 students ranked emergency medicine as their first choice while there were only 65 spots available. Closer to home, my residency program received a whopping 76 applications for our 2 positions this year.

With all of this competition, one of the questions I am asked most frequently by medical students planning to apply to EM is: what should I do to prepare? In partial response to this I always tell them that it’s important for them to rock their clerkship. How? Here are my Top 10 Ways.

1 – Find Mentors

I think this is probably the most important thing you can do for yourself as a medical student. Much has been written about the importance of mentorship in medicine, but you won’t get it until you’ve experienced it for yourself. The doctors that are willing to invest in you by taking you under their wing, teaching you, supporting you, and opening doors for you are the ones that are going to make the biggest difference in your success. They’ll make you a better doctor, prepare you to impress on electives, and write your best reference letters.

Of course, finding a mentor and developing this time of a relationship is sometimes easier said than done. If there was a physician that spurred your initial interest in emergency medicine, they might be one. Give them credit, ask for their advice, and see how it goes. If that doesn’t work, try to meet up with the doctors that win the med student teaching awards – they love to teach and are likely natural mentors. If even that doesn’t work, just keep hanging around the ED and enjoying yourself. If you’re right for this job, you’re bound to hit it off with someone soon.

2 – Read blogs

I know you’re busy and have lots of other stuff to read, but this one of if not the best way to know what is happening on the cutting edge of the specialty. Getting this “education on the side” will broaden your perspective, give you fodder for tons of intriguing and educated questions, and help you to get more out of your on-shift learning. Most of the bloggers are some of the best educators in the world so the content they put out is damn good.

The easiest way to follow blogs is to amalgamate them with an RSS reader like this:
-Get a google account and log in
-Go to the blog you want to add
-Find the orange “RSS Feed” logo
-Click on it and add it to google reader
-Go back to your google account and go to your google reader

Additional tips:

-iPad – download Flipboard and login with your google account.  It presents the blogs like a pretty magazine.
-iPhone – download FeeddlerRSS and login with your google account. It’s not as pretty as Flipboard but is more economical with the smaller screen.

There are so many great blogs it’s hard to recommend only a few, but some of the ones I started with were: – The content on is unbelievable. Explore, read, follow. Its weekly R&R in the Fast Lane feature will lead you to many other awesome blogs. – This is another one of the originals and also has tons of helpful content. Check out her PV cards and get them on your iphone/android/whatever – they’re super slick. – This one is the most popular ones written by a med student. She teaches me things regularly. – A sweet Irish dude puts out this one. His anatomy videos are something to behold.

3 – Listen to Podcasts

The same points I made for blogs apply to podcasts. This free education is generally better than the one you’re paying for.

The easiest way to start following these is:
-Get itunes
-Go to the website and find the itunes button
-Click on it and then click to subscribe to their blog
-You can sync these with your iphone/ipad just like music and, if you really want to get crazy, the iphone/ipad can play them at double speed.

Again, there are too many good ones to name. Some of the ones I’d recommend starting with are: – Scott Weingart is a legend. I have a total mancrush on him – Great reviews of the peds stuff – More review than cutting edge, but its great for background – This one has some in-depth content but seems to be very accessible to students/residents.

4 – Learn to present patients

This is a harder task than it first appears. Presenting a solid history and physical in a way that your attending can follow is super important. Getting good at it will help you to appear more competent and confident while making you more fun to work with.

How can you get good at it? Read about how to make a good presentation (start here and here), remember that the emerg presentation is slightly different than what you’d see/here working in other areas, eavesdrop when junior residents are presenting (the senior ones will be much too concise), ask for feedback on your presentations, and practice by running through the most complicated presentations that you’ve seen.

5 – Join Twitter

There’s a lot of Doctor conversation going on there. It’s emergency medicine’s “digital watercooler” (as per @M_Lin) or your “finger on the fem pulse of EM” (as per @ERMentor).  Add them, @sandnsurf, @EMCrit, and I (@boringem). @FOAMstarter is also a great resource for beginners with lots of good suggestions for who to follow.

6 – Get the ERRes App

It costs a few bucks, but it’s a super fast and EM-specific reference for things we need to look up very commonly in emerg such as the decision rules (Ottawa foot/ankle/knee, PERC, Wells, CT Head, Canadian C-Spine, NEXUS, PECARN, Strep, etc etc), common medications, ALCS/PALS algorithms and more. The time saved on shift is worth the $3!

7 – Read the cardinal presentation chapters in Rosen’s

The start of this emergency medicine textbook goes over some common presentations. Either buy it (you’ll need it down the line anyways!) or read it online for free. I believe Canadian med students have access through the CMA Clinical Resources website. It is quite a bit of content, so it might help to match the presentation with your rotation (ie – read abd pain on gen surg, chest pain on cardiology, vertigo on neuro, etc).

8 – Read 12-Lead ECG: The Art of Interpretation by Garcia and Holtz from cover to cover

I think it’s the best ECG book there is with tons of well-interpreted examples and it will take you from “I vaguely remember something about that” to confidently reading them better than some of the junior IM residents. ECG’s come around frequently in the ED and knowing them well as a med student is impressive.

9 – Join (the Global Medical Education Project)

This website was made by the Life in the Fast Lane People and, while its early in its development, I think it may be the next big thing in consolidating all of the online resources. It’s kind of like facebook for doctors + a repository of ECG’s/xrays/CT’s/etc + podcasts/videos. Sign up now, check it out, answer some of the free questions and watch as it grows.

10 – Make a learning goal each shift and let your staff know

It is so unbelievably awesome to have a student come on to shift and let me know what they want to learn about. Something as little as “I’d really like to work on my ECG interpretation skills” gives me something to work with. I will always want to teach you something, but I want it to be something that you are actually interested in. If you tell me what you want to learn about I guarantee that I will go out of my way to teach about it. So give me the opportunity! As a learner myself, I find it hard to force myself to do this, but it will make the teaching you get better and you’ll be that much smarter for your next shift.

There is a lot of room to expand on many of these Ways to Rock EM Clerkship so I will be discussing many of them in this section over the coming months.

For any resident/attending readers, what advice would you give to a med student that wants to rock their clerkship rotation? Any other references that I should add?

Thanks for reading!

ECG of the Week – 31st December – Interpretation

A bit of a departure from the normal to herald in the New Year.

This week we have a rhythm strip I found.
I don't have any information on the case, patient, or management.
So what you see is what you get !


Click to enlarge

Two lead rhythm strip, leads II & V2, assuming standard calibration.

Three distinct rhythms:
Rhythm 1

  • Ventricular Rate ~150-100 bpm
  • Regular Atrial activity ~300 bpm (Flutter waves)
  • Variable conduction block - 2:1 & 3:1
  • Intervals
    • No P waves
    • QRS - Normal (~ 100ms)
  • Segments
    • ST Depression lead II
    • ST Elevation V2
  • Additional
    • Abrupt termination without preceding slowing of rate, or increasing block

Rhythm 2
  • Asystole
  • Duration ~4.9 seconds

Rhythm 3

  • Sinus rhythm
  • Irregular due to rate change
    • ~70 bpm to ~80 bpm
  • Intervals:
    • PR - Normal (~160ms)
    • QRS - Normal (100ms)
    • QT - 400ms (QTc Bazette ~ 460 ms)
  • Segments:
    • ST Depression 1mm lead II
    • ST Elevation 3-4mm lead V2
  • Additional
    • P wave inversion V2

  • Atrial flutter with variable block
  • Period of aystolic pause
  • Followed by sinus rhythm at appropriate rate
  • ST Segment changes - ? ischaemic ? hypertrophy
I don't have any clinical information on this case, differentials for these finding could include:

  • Iatrogenic
    • Chemical cardioversion
    • Correction of underlying acid/base or electrolyte disturbance
  • Sinus Node Dysfunction
Waitng to hear some of the thoughts of the 'ECG of the Week' team on this one, I will update this post once all the team has had chance to have a look.
References / Further Reading 

  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

Mentorship Section

In a slight departure from the usual for me, I have decided to create a new section of my blog. While I am quite excited to continue blogging about all things Boring in EM, I am also quite passionate about mentorship. As the target audience for my blog is EM-inclined medical students and residents, I hope the occasional post on EM clerkship and residency will be well-received. I have no particular frequency planned for these posts – they’ll just go up when I have an something I am excited to write about. Stay tuned for my first post on how to rock EM clerkship later today!