Authors: Linda Katirji MD, PGY-3 at University of Kentucky EM and Adam Kellogg, MD, Associate Program Director at UMMS-Baystate on behalf of the CORD EM Student Advising Task Force (SATF)

Procedures are a large part of Emergency Medicine and becoming competent with them is necessary. One of the questions many medical students starting their Emergency Medicine rotations have is what procedures they should be able to perform on their EM rotations. Experience with procedures varies widely in different medical school curriculums, but in general your experience in the ED will provide you exposure to many procedures that you may not get to see on other rotations. This post will serve to summarize the different procedures medical students would benefit from being prepared for  and a few high quality resources for each.

Please note, for the New England Journal of Medicine videos listed below you will need a log in. Most universities will have an account that can be accessed through the library website.

Procedures you should know:

Students should not expect to be completely proficient, but should have familiarity with these techniques. They may get to perform these procedures with supervision.

• • Basic laceration repair
    • • Closing the Gap
    • AAFP – Essentials of Laceration Repair

• • Digital nerve block
    • Core EM  

• • Abscess incision and drainage
    • • NEJM Abscess I&D Video
    • CORE EM – Abscess I&D

• • Peripheral IV placement
    • • NEJM PIV Video
    • • CORE EM – Starting a PIV
    • • MediStudents – PIV placement
    • PIV placement

• • Foley catheter placement  
    • • Male
    • Female

• Nasogastric tube
  • • NEJM NG Tube
  • LIFTL NG Tube Insertion

Procedures you may get to do:

Students should understand the concept and be able to explain the technique, indications, and complications. At times they may get to assist with these, and other times may get to perform with supervision.

• • Lumbar puncture
    • • EM:RAP Lumbar Puncture Tutorial
    • NEJM LP Video

• • Joint dislocation reduction
    • • Shoulder – 10 Ways to Reduce a Dislocated Shoulder – Larry Mellick
    • • Hip – Larry Mellick -Traumatic Hip Dislocation
    • Ankle- Larry Mellick – Ankle Dislocation reduction

• • Paracentesis
    • • EM:RAP – Paracentesis 
    • NEJM Paracentesis

• • Arterial line placement
    • • NEJM Arterial line
    • Taming the Sru – Arterial Line Placement

• IO placement
  • • NEJM IO Video
  • EM:RAP EZ IO Placement

• Splinting
  • • EMRA Splinting Guide (PDF)
  • • NEJM Basic Splinting
  • • AliEM – SplintER

Procedures med students rarely do – but may get to try:

Due to the complexity and likely urgency of these procedures, much of the time students will only be observing these procedures. However, there may be situations when they do get to attempt these procedures with close supervision, so it is not too early to develop familiarity with them.

• • Endotracheal intubation
    • • 5 Minute Airway
    • EM Basic – Airway

• • Central line placement
    • • Introduction to the Central Line Kit – UMEM
    • • NEJM CVC
    • US Guided Femoral Line – Larry Mellick

• • Chest tube placement –
    • • EM:RAP Chest Tube Placement
    • University of Maryland Emergency Medicine – Tube Thoracostomy

• Thoracentesis
  • NEJM – Thoracentesis

Procedures you may see, but are unlikely to get to do…yet:

• • Resuscitative thoracotomy
    • • Resuscitative Thoracotomy – Larry Mellick
    • Thoracotomy – University of Maryland Emergency Medicine

• • Cricothyroidotomy
    • • Life in the Fast Lane – Surgical Cricothyoidotomy
    • University of Maryland Emergency Department – Cricothyroidotomy

• • Lateral canthotomy
    • • EM:RAP – How to do a Lateral Canthotomy
    • • Lateral Canthotomy – Larry Mellick
    • Lateral Canthotomy – UMEM

• • Transvenous pacing
    • Taming the Sru – Transvenous Pacing

• Pericardiocentesis
  • • EM Curious – Pericardiocentesis
  • ALiEM – US Guided Pericardiocentesis

Ultrasound resources

There is no doubt that ultrasound competency is a cornerstone of the practice of Emergency Medicine. Mastering ultrasound is imperative during residency, however exposure and training still varies widely between medical schools. Most EM programs will likely not expect you to be a master of the ultrasound, however having some previous exposure to the basic concepts and frequent studies performed in the ED will decrease the learning curve and earn the student more opportunities.

Basic Ultrasound – 5 Min Sono – Knobology

• A basic introduction to the buttons and settings on the ultrasound as well as the different probes and when you might use each one.

FAST  – 5 Min Sono – FAST, ALiEM Cards – FAST

• This is likely the most common ultrasound that rotating medical students might be asked to perform – if you pick one study to be proficient at for a rotation – choose this one!

Cardiac – 5 Min Sono – Cardiac Windows, Pericardial Effusion, Pericardial Tamponade, Cardiac Function, Right Heart Strain

ALiEM Cards – Focused Echo

• Cardiac  ultrasound may be one of the more difficult studies for medical students to master. However, in the ED cardiac ultrasound can quickly narrow down a differential diagnosis and guide / change therapy.

PIV placement – 5 Min Sono – Ultrasound Guided IV and Ultrasound Podcast – Ultrasound Guided IV.

• Peripheral IV placement is an easy way to really help out with patient care in the ED as a medical student. Using the ultrasound adds a new level of complexity to peripheral IV placement, but if you can master it, you will be able to place an IV in almost anyone.

Ultrasound assisted IJ placement – Ultrasound Podcast – Ultrasound Assisted IJ Placement.

• Standard of care is now IJ placement with ultrasound assistance. You may have an opportunity to place a central line on your rotation, and if you are comfortable with the ultrasound aspect before hand it will make the procedure much easier.

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If you know of other high quality procedural resources to get students and other trainees up to speed on EM procedures, please share those in the comments below.  (Updated 4/27/19)