Emergency Medicine was the rotation for which I had been really excited ever since my first one (Ambulatory Care) where I learned that I really love case variety and quick patient turnover, and this rotation did not disappoint.

There was a lot I enjoyed about it: the duality of its case variety and case repetition, the moments of chaos, needing to know enough about a lot, needing to differentiate between emergent and non-emergent and prioritizing who walks through the door, seeing all kinds of patients from different backgrounds, the teamwork between providers and nurses, the algorithmic nature of much of the work, the procedures that make patients feel better, and getting the occasional chance to emphasize and educate patients on the importance of primary and longitudinal care. I felt like the providers with whom I worked were very competent, and helpful to work with and like with most other rotations so far, I started to find my groove around the end of the 3rd week. By then, I had a rough set of history questions to ask for common complaints, a good understanding of what follow-up questions needed to be asked depending on the patient’s story, the ability to create a dynamic list in my mind of what should be included in my focused physical exam, and an idea of what labs and imaging were pertinent to order.

I also had a patient experience that really put my PA student journey thus far into perspective: a 52-year-old female with PMHx porphyria presented initially for abdominal pain when suddenly while waiting in triage, she lost sensation and motor function of her right side; we transferred her to a stretcher and the attending subsequently administered a focused neurological exam. However, the inconsistencies in her neurological presentation, her rapid and breathless speech, and her persistent complaints about the severity of her pain made me question if she was really having a CVA, and not an anxiety attack, secondary to abdominal pain. Ultimately when the patient refused fentanyl for pain, requested Dilaudid, stated she would “leave AMA” if she did not get Dilaudid, pulled out her IV, and began using her phone with both hands, the determination was made that she was presenting with drug-seeking behavior (DSB). This was my first time seeing DSB, and my awareness that something was “off” made me realize that I had developed enough clinical acumen to recognize what a typical presentation would look like (in this case, a CVA) and recognize how it would not. 

I still feel I struggle with getting a differential, particularly when well-appearing patients presented with vague complaints and normal physical exams, but this is something I hope comes with more personal exposure.