“The worst thing about busy shifts is that I never learn anything.”
– anonymous resident

A junior resident and I were contemplating the many difficulties of residency, especially when working at a busy urban ED where patients are plenty, but teaching during shifts may be harder to come by. We discussed the importance of coming up with at least one learning point or clinical question during each shift, and making a point of following through and reading up on it after.  (That shift we both learned about fat emboli s/p extremity fracture.)

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Why do most of us dread patients who complain of dizziness in the ED? Because it is so vague, and the differential is so broad from elusive posterior cerebellar strokes to ear wax clogging up our ear canals. And this is one of those diagnoses where the differential really depends upon performing a thorough physical examination. 

Think really hard, when is the last time you focused upon getting a complete and accurate physical examination? In medical school, there are courses dedicated to the art. I always laugh when I think of my neurology attending who just loved to bang on different parts of the body with his reflex hammer to elicit cool reflexes.

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“So there’s a patient, and umm…  they are in the hallway, they came to the ED today for breathing problems, I mean dyspnea.  They also don’t speak any English.  So, uh the respiratory rate is normal, and they had a blood clot, er… I mean PE, in the past, but not on coumadin anymore.  Shoot, I forgot to tell you my exam…they had pitting edema for 3 months.  By the way, the labs came back on that other anemic patient in the other hallway, and they are really anemic…” – Anonymous medical student

Sounds familiar? Imagine working in a hectic ED while listening to this chaotic presentation. 

What’s the secret to presenting patients?

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