Something New
Coming into this Emergency Medicine rotation, I felt that I had a pretty solid understanding of how to present patients to preceptors and attendings, but I quickly realized that an ED presentation requires a somewhat different approach. In other rotations, presentations often allow for a more complete review of the patient’s background, chronic conditions, and long-term management. In the ED, however, the presentation has to be more focused, efficient, and organized around acuity. I learned that it is important to quickly communicate why the patient came in today, what dangerous diagnoses need to be ruled out, what pertinent positives and negatives are present, and what the next immediate steps should be. This helped me understand that ED presentations are not just shorter versions of full H&Ps, but rather a different style of clinical communication centered on risk stratification, stabilization, and disposition.
I was also exposed to the level of skill it takes to care for patients who may be presenting on one of the worst days of their lives. Many patients came in scared, frustrated, in pain, or unsure of what was happening to them. I learned how important it is for a clinician to provide reassurance in a calm and confident manner while still being honest about the plan. I also had many opportunities to provide patient education, including counseling patients on following up with their primary care provider for suspicious imaging findings, explaining wound care instructions, reviewing return precautions, and discussing supportive care for viral illnesses. These moments showed me that Emergency Medicine is not only about acute stabilization, but also about helping patients understand what was found, what still needs follow-up, and when they should return for care.
Another new experience for me was spending a shift in the acute ED, where I was exposed to several higher-acuity cases, including an unconscious patient with DKA, a large pneumothorax, an alcohol-induced seizure, severe opioid withdrawal, and pneumonia complicated by CHF. This shift gave me a better appreciation for the level of expertise required to manage complex emergency patients. I saw how quickly clinicians must be able to recall high-yield differentials for altered mental status, sudden shortness of breath, seizure-like activity, and hemodynamic instability. I also saw how important procedural skills are in the ED, including point-of-care ultrasound, bedside echo, ultrasound-guided IV placement, and airway management. Several attendings and PAs provided me with helpful websites and resources on the management of these conditions, and I plan to continue reviewing them in my spare time.
Skills, Challenges, and Action Plan
One of the main challenges I encountered during this rotation was learning how to adjust my history-taking and presentations to fit the ED environment. I had to become more intentional about asking focused questions and identifying the key details that would change management. For example, rather than collecting every detail in chronological order, I learned to first clarify the chief complaint, acuity, red flags, relevant risk factors, and what made the patient come in that day. This helped me become more efficient while still being thorough. I also learned that an ED assessment often needs to be framed around the most dangerous diagnoses first, even when the final diagnosis may be benign.
The patients I found particularly challenging were patients who were poor historians. In these situations, I learned that I had to guide the conversation more actively and make my questions more focused to avoid going off topic or spending time on details that were not clinically relevant. I became more comfortable redirecting the interview while still remaining respectful and patient-centered. These encounters taught me that when the history is unclear, it becomes even more important to rely on focused questioning, collateral information when available, chart review, physical exam findings, vital signs, and reassessment.
Another challenging patient population was patients who present to the ED on a regular basis. These patients taught me the importance of clarifying early in the interview why they came in today and whether their symptoms are better, worse, or similar compared to prior presentations. I learned that while it can be tempting to assume the visit is similar to previous encounters, it is important to maintain a high index of suspicion and avoid missing serious pathology. Each visit still needs to be evaluated on its own, especially if there is a change in symptoms, new abnormal vital signs, or a different clinical pattern.
Patients with substance use concerns were also challenging because their history and physical exam could be clouded by intoxication, withdrawal, or complications related to drug use. These patients reinforced the importance of being thorough and nonjudgmental. I also realized how important it is to understand the effects and complications of different substances, including alcohol withdrawal, opioid withdrawal, overdose, altered mental status, seizures, trauma risk, and cardiopulmonary complications. These encounters helped me appreciate that substance use can complicate the clinical picture, but it should not prevent a complete and respectful evaluation.
Going forward, I would like to get more exposure to higher-acuity patients and continue building my procedural confidence. My shift in the acute ED showed me how much there still is to learn about managing critically ill patients, and I would like to continue observing and participating in these types of cases when appropriate. In future rotations such as internal medicine and long-term care, I plan to continue watching for opportunities to observe procedures such as ultrasound-guided IV placement, airway management, point-of-care ultrasound, and bedside assessment of unstable patients. I also plan to continue reading the resources provided to me by ED attendings and PAs so that I can improve my understanding of how to approach conditions such as altered mental status, respiratory distress, DKA, seizures, withdrawal, pneumothorax, pneumonia, and heart failure exacerbations.
Memorable Experiences
One memorable case from this rotation involved a patient who presented after what he believed was an episode of seizure activity. He reported that after experiencing sudden and intense back pain, his wife observed him grimace with his eyes rolled back. He denied urinary incontinence, tongue biting, postictal confusion, and witnessed tonic-clonic movements. Since this was the emergency room, I knew it was important to maintain a broad differential and consider dangerous possibilities, but based on the history, I suspected that this episode may not have represented a true seizure.
When the attending later evaluated the patient, they agreed with my assessment, and this was a meaningful learning experience for me. It reinforced the importance of trusting my clinical reasoning while still remaining cautious and open-minded. Patients may describe their symptoms using terms like “seizure,” “stroke,” or “heart attack,” but they do not always have the medical training to distinguish between similar presentations. As clinicians, we have to take their concerns seriously while also using the history, exam, and clinical pattern to determine what is most likely. This case taught me how important it is to balance a high index of suspicion with the ability to recognize a likely benign presentation.
The knowledge I gained from this case will be applicable in many future rotations. This experience reminded me that the words patients use are important, but the clinician’s role is to translate those concerns into a medically appropriate differential. It also helped me appreciate the value of asking targeted questions about seizure-like activity, including loss of consciousness, tonic-clonic movements, postictal state, tongue biting, urinary incontinence, triggers, and preceding symptoms.
Overall Reflection and Perspective
During this 5-week rotation, I learned that I naturally have an enthusiastic and eager personality, which was recognized by multiple staff members. This was meaningful to me because I want to maintain that attitude throughout the rest of clinical year and throughout my future career. I enjoy learning from each patient encounter, asking questions, and trying to understand how experienced clinicians think through complex cases. This rotation reminded me that enthusiasm is valuable, but it also has to be paired with preparation, organization, and the ability to stay calm in a fast-paced environment.
My perspective on Emergency Medicine changed because I now better understand the collective mindset of ED staff. Before this rotation, I viewed Emergency Medicine as a field that involved diagnosing rare or dramatic conditions, similar to what is often portrayed on television. However, I now understand that much of Emergency Medicine is about ruling out life-threatening conditions, stabilizing patients, managing uncertainty, and making safe disposition decisions. It is not always about finding one rare diagnosis or fixing every problem during that visit. Instead, it is about identifying what cannot be missed, treating what needs immediate treatment, educating the patient, and arranging appropriate follow-up.
One thing I would want my preceptor and colleagues to notice about my work is that I like to be organized and prepared for each patient despite the fast pace of the ED. Before seeing a patient, I tried to review their chart, think through possible differentials, and identify the key questions I wanted to ask. I know I still have areas to improve, especially with concise ED presentations and higher-acuity decision-making, but I hope they noticed that I was engaged, receptive to feedback, and intentional about improving. This rotation helped me become more confident in my ability to think clinically under pressure, while also showing me the areas I want to continue strengthening as I move forward.
