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Title Page INTERNATIONAL
EMERGENCY
MEDICINE
EDUCATION
PROJECT

iem-student.org

iEmergency Medicine for

Medical Students and Interns
1st Edition, Version 1, 2018

A Free Book For

Emergency
Medicine
Clerkship
Students

Editors
Arif Alper Cevik
Lit Sin Quek
Abdel Noureldin
Elif Dilek Cakal

i
 Copyright ©2018 International Emergency Medicine (iEM) Education Project
Copyright Resources shared by iEM Education Project through website, book content,
image and video archive are distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 International License,
which permits unrestricted use, distribution in any non-commercial medium.
You give appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were made.

Edited by
Arif Alper Cevik, Lit Sin Quek, Abdel Noureldin, and Elif Dilek Cakal

Cover design
Arif Alper Cevik

Book design and production

Arif Alper Cevik

Published by
iEM Education Project, iem-student.org

First electronic edition,

2018, Version 1

INTERNATIONAL
EMERGENCY
MEDICINE
EDUCATION
PROJECT

iem-student.org
ii
What is iEM? International Emergency Medicine (iEM) Education Project is an
international, non-profit project, endorsed by International Federation for
Emergency Medicine (IFEM) and supported by Emergency Medicine
professionals from all around the world. Currently, there are 146
contributors from 21 countries in the project. It aims to promote
Emergency Medicine and provide free, reusable educational content for
undergraduate medical trainees and educators.

The project focuses mainly on undergraduate curriculum, but learners from

all levels (medical students, interns, residents) and their educators may
benefit from it. It is targeted at all learners around the globe. However,
learners from areas with limited resources have a special place in mind.

The book "iEmergency Medicine for Medical Students and Interns" is a part
of the project content and service. It was created by 133 international
contributors. At the publication time, the book content provided in the iem-
student.org has been visited by more than 20,000 visitors from 150
countries.

The content is entirely free and available in various formats including

website, iBook, pdf, image, video, and audio. Clinical image and video
archives are accessible in Flickr and YouTube accounts. The audio chapters
and podcasts are available via SoundCloud. Please visit the”blog” for up-to-
date posts. The website is mobile-friendly to maximize accessibility. We
support free open access medical education (FOAMed). All materials are free
to use, download and share.

iEM education project is run by volunteers, and you can join us. Please visit
“how to contribute” page to share your Emergency Medicine experience and
message with future colleagues from all around the world.

Arif Alper Cevik, MD, FEMAT, FIFEM

Founder and Director, iEM Education Project

iii
Preface “if you want to go fast go alone,
if you want to go far go together”
African Proverb

Undergraduate Emergency Medicine Education (UEME) is an undervalued area in

the development of Emergency Medicine around the globe. If you read the articles
regarding Emergency Medicine clerkships or if you travel to different countries and
discuss their undergraduate education with local leaders, you can easily recognize
the gaps between countries.

Today, there are few countries in the world that have appropriately designed
UEME programs in their medical schools. The majority of the countries (even
some developed ones) have no guidelines, curricula, or enough educational
resources. In addition, there are limited resources (textbooks, websites) for
medical students/interns which covers their educational needs based on current
UEME recommendations.

This book is a product of an international collaboration of emergency physicians

and Emergency Medicine enthusiasts. It intends to show that we can produce a
free book and resource if we work collaboratively. It is a product of endless hours
of hard work of all Editors, authors, and contributors. We thank all of them for
trusting us in this journey.

This is just a start to build up better Emergency Medicine resources for medical
students and interns, especially for developing countries. It is a continuous
process, and there are a lot of areas that we need to improve in this book.
Therefore, we are looking forward to your feedback and collaboration.

We also believe that international UEME will reach the minimum required
standards in all countries based on the endless collaboration of emergency
medicine professionals.

iv
Terms of Use
Notification
Some images in this book may be disturbing. Some of
the topics may contain medical-related information
that is sexually explicit. If you find this information
offensive, you may not want to use the book. This
book includes medical content, particularly emergency
medicine related, for medical students and interns.
Some of the content in this book may contain elements
that are not suitable for some readers. Accordingly,
viewer discretion is advised.
The book content is not suitable for persons under 18
years of age. Persons under the age of eighteen (18)
should not access, use and browse the book.
This book aims to provide general Emergency Medicine information and dis-
cussion to medical students and interns.The content and discussions found
on this electronic book are not individualized medical advice and can not be
used for this purpose. If you think you need emergency care or any type of
medical care, please contact your doctor or call local/national emergency
number.
The iEM is a global project and may contain various opinions and
approaches. The information and opinions expressed in this book have no
relation to those of any academic, hospital, practice, institution, or worldview
with which the authors or editors are affiliated, and does not represent
institutional policies.
The content of this book has been prepared by international authors to
provide this content to medical students and interns. The content, informa-
tion, opinions, references, and links to other knowledge resources provided
by Editors and authors are only for medical students and interns’
educational purposes. This book is not intended or advised for public use.
The iEM project, its’ Editors, contributors and its’ team do not intend to
establish any physician-patient relationship through the contents of this
book, nor does it replace the services of a trained physician or health care
professional, or otherwise to be a substitute for professional medical advice,
diagnosis, or treatment. Again, this is an educational book for medical
students and interns, and it is not medical care platform. Therefore, you shall
not make any medical or health-related decision based in whole or in part on
anything contained in this book. If you need medical care or advice, you
should consult a licensed physician in your community healthcare office or
hospitals.
Although their main interest is emergency medicine, the content of the book
was prepared by international contributors from different backgrounds.
Medicine itself is changing very fast. Therefore, we can not guarantee
v
providing complete, correct, timely, current or up-to-date our best to get functioning these links, but they may stop
information in the book. Similar to any printed material, the con- functioning any other reason.
tent may become out-of-date and may be changed without
notice. The Editors and authors have no obligation to update any The iEM project Director, Editors, and authors are not responsible
content in the book. The Editors may update the content at any for the content of any linked or otherwise connected websites.
time without notice, based on their absolute discretion. The iEM The iEM project Director, Editors, and authors do not make any
project Director and Editors reserve the right to make alterations representations or guarantees regarding the privacy practices of,
or deletions to the content at any time without notice. or the content or accuracy of materials included in, any linked or
third party websites or resources. The inclusion of third-party
Opinions expressed in the book are not necessarily those of the links in the book does not constitute an endorsement, guarantee,
Editors, authors and iEM project team. These opinions cannot be or recommendation.
applied to an individual case or particular circumstance. The con-
tent should not be used or relied upon for any other purpose, The book content is not suitable for persons under 18 years of
including, but not limited to, use in or in connection with any legal age. Persons under the age of eighteen (18) should not access,
proceeding. Some images in this book may be disturbing. Some use and browse the book.
of the topics may contain medical-related information that is sexu-
Although the Editors and authors have made every effort to
ally explicit. If you find this information offensive, you may not
assure that the information in this book is correct at publication
want to use the book. This book includes medical content,
time, the Editors and authors do not assume and hereby disclaim
particularly emergency medicine related, for medical students and
any liability to any party for any loss, damage, or disruption
interns. Some of the content in this book may contain elements
caused by errors or omissions, whether such errors or omissions
that are not suitable for some readers. Accordingly, viewer
result from negligence, accident, or any other cause.
discretion is advised.
For more information regarding terms of use, please visit website.
This project aims to expand medical students interest in and
knowledge of Emergency Medicine. Therefore, iEM Editors and
team continuously search for valuable third party links. The book
may contain links to other (“third party”) websites, videos, etc.
These links are provided solely as a convenience and not as a
guarantee or recommendation by the Editors or authors for the
services, information, opinion or any other content on such third
party websites or as an indication of any affiliation, sponsorship
or endorsement of such third party resources. If you decide to
access a given link, you do so at your own risk. Your use of other
websites is subject to the terms of use for these sites. We tried

vi
Publishing Process There is continuous work for the iEM book process. We applied multiple
editing and reviewing steps. We continue this process for many chapters
with the feedback from our readers and contributors.

The Editors and authors have made every effort to assure that the
information in this book is correct and appropriate for medical students and
interns. The Editors and authors do not assume and hereby disclaim any
liability to any party for any loss, damage, or disruption caused by errors or
omissions, whether such errors or omissions result from negligence,
accident, or any other cause.

We used original images, illustrations, diagrams provided by the Editors and

authors as much as possible. However, there were chapters that we needed
to use some copyright free material, Creative Commons licensed images,
illustrations, and diagrams with attribution to the original owners. We are
continuously searching for better images, illustrations, and diagrams. If you
have copyright free clinical images, illustrations or diagrams, please share
them with us. We would like to use them with your credentials in the book,
online archive, and website.

vii
Acknowledgement We thank the institutions and organizations which helped this project to see
the light. The United Arab Emirates University, College of Medicine and
Health Sciences supported funding the expenses of iEM Education Project.
The International Federation for Emergency Medicine (IFEM) supported the
project since beginning and officially endorsed on October 2018.

We thank the Council of Residency Directors in Emergency Medicine

(CORDEM) and American College of Emergency Physicians, International
Emergency Medicine Section (ACEP-IEM) for their help finding contributors.

We thank our Editors, authors, and collaborators for their time and fantastic
work during the production of this book.

We also thank Emirates Society of Emergency Medicine (ESEM), Emergency

Medicine Association of Turkey (EMAT), Sociedad Mexicana de Medicina de
Emergencias (SMME) for their continuous support for the project. We like to
specifically acknowledge the support of a young group of Slovenian doctors
for their amazing contributions.

We would like to thank Prof.Dr. Fikri Abu-Zidan for his wise advise and
continuous encouragement during the hardship of delivering the book and
its content.

viii
Editors Editors
Arif Alper Cevik, UAE
Lit Sin Quek, Singapore
Abdel Noureldin, USA
Elif Dilek Cakal, Turkey

Section Editors
Toh Hong Chuen, Singapore
Veronica Tucci, USA
Silvio Aguilera, Argentina
Funda Karbek Akarca, Turkey
Rahul Goswami, Singapore
Mary J.O., USA
Ziad Kazzi, USA
Jesus Daniel Lopez Tapia, Spanish Section Editor, Mexico
Olinda Giselle G. Saenz, Spanish Section Editor, Mexico

Language Editor
Sarah Elizabeth Noureldin, USA

ix
Contributors Abdel Noureldin, USA
Abdulaziz Al Mulaik, KSA
Aldo E.M. Salinas, Mexico
Alja Pareznik, Slovenia
Ana Podlesnik, Slovenia
Ana Spehonja, Slovenia
Amila Punyadasa, Singapore
Arif Alper Cevik, UAE-Turkey
Arwa Alburaiki. UAE
Assad Suliman Shujaa, Qatar
Ashley Bean, USA
Aya Dodin, UAE
Ayse Ece Akceylan, Turkey
133 contributors Azizul Fadzi, Malaysia
Bader AlQahtani, UAE
Begum Oktem, Turkey
are from Bita Abbasi, Iran
Bret Nicks, USA
Brian Hohertz, USA
19 different Charlotte Derr, Canada
Chew Keng Sheng, Malaysia
countries. C. James Holliman, USA
Dan O’Brien, USA
Danny Cuevas, USA
David Hoffman, USA
David Wald, USA
David Wood, USA
Diana V. Yepes, USA
Dejvid Ahmetovic, Slovenia
Donna Venezia, USA
David F. Toro, USA
Ebru Unal Akoglu, Turkey
Eisa AlKaabi – UAE
Elif Dilek Cakal, Turkey
Elizabeth Bassett, USA
Emilie J. Calvello Hynes, USA
Eman Al Mulla, UAE
Falak Sayed, UAE
Fathiya Al Naqbi, UAE
Farhad Aziz, USA
Fatih Buyukcam, Turkey
Feriyde Caliskan Tur, Turkey
Funda Karbek Akarca, Turkey
Gregor Prosen, Slovenia
Gregory R. Snead, USA
Gul Pamucu Gunaydin, Turkey
Gurpreet Mudan, USA
Hamidreza Reihani, Iran
Harajeshwar Kohli, USA
Hind Al Dhaheri, UAE
Jabeen Fayyaz, Pakistan
Jan Zajc, Slovenia
x
Jesus Daniel Lopez Tapia, Mexico
Joe Lex, USA
Jorge Luis Garcia Macias, Mexico
Josepph Pinero, USA
Justin Brooten, USA
Kaja Cankar, Slovenia
Kamil Kayayurt, Turkey
Katja Zalman, Slovenia
Keith A Reymond, Austria
Kemal Gunaydin, Turkey
Khuloud Alqaran, UAE
Khalid Mohammed Ali, Singapore
Kuan Win Sen, Singapore
Lamiess Osman, UAE
Linda Katirji, USA
Lindsay Davis, USA
Lit Sin Quek, Singapore
Mahmoud Aljufaili, Oman
Mary J O, USA
Maryam AlBadwawi, UAE
Maryam Darwish, UAE
Marwan Galal, UAE
Matevz Privsek, Slovenia
Matija Ambooz, Slovenia
Matthew Lisankie, Canada
Matthew Smetana, USA
Mehmet Ali Aslaner, Turkey
Meltem Songur Kodik, Turkey
Michael Butterfield, USA
Michelle Chan, USA
Moira Carrol, USA
Muneer Al Marzouqi, UAE
Murat Cetin, Turkey
Mustafa Emin Canakci, Turkey
Nidal Moukaddam, USA
Nik A.S.N. Him, Malaysia
Nik Rahman, Malaysia
Nur-Ain Nadir, USA
Olinda Giselle Garza Saenz, Mexico
Ozge Can, Turkey
Ozlem Dikme Akinci, Turkey
Ozlem Koksal, Turkey
Pia Jerot, Slovenia
Puneet Sharma, UK
Qais Abuagla, UAE
Rabind Anthony Charles, Singapore
Ramin Tabatabai, USA
Rahul Goswami, Singapore
Rasha Buhumaid, UAE
Reza Akhavan, Iran
Rob Rogers, USA
Rok Petrovcic, Slovenia
Rouda Salem Alnuaimi, UAE
Ryan H. Holzhauer, USA
Sadiye Yolcu, Turkey
Sarah Attwa, UAE
Sara Nikolic, Slovenia
Selene Larrazolo Carrasco, Mexico
Sercan Yalcinli, Turkey
Serpil Yaylaci, Turkey
Shabana Walia, USA
Shaza Karrar, UAE
Shanaz Sajeed, USA
Shirley Ooi, Singapore
Stacey Chamberlain, USA
Sujata Kirtikant Sheth, Singapore
Suzanne Bentley, USA
Tanju Tasyurek, Turkey
Tiffany Abramson, USA
Timothy Snow, USA
Tjasa Banovic, Slovenia
Toh Hong Chuen, Singapore
Tomislav Jelic, Canada
Veronica Tucci, USA
Vigor Arva, Slovenia
Vijay Nagpal, USA
Walid Hammad, USA
Will Sanderson, USA
Yadira Rubio Azuara, Mexico
Yusuf Ali Altunci, Turkey
Ziad Kazzi, USA
xi
Content 1. The Facts of Emergency Medicine
Emergency Medicine: A Unique Specialty
Will Sanderson, Danny Cuevas, Rob Rogers
Choosing The Emergency Medicine As A Career
C. James Holliman
Thinking Like An Emergency Physician
Joe Lex

2. Emergency Medicine Clerkship: Things to Know

The Importance of The Emergency Medicine Clerkship
Linda Katirji, Farhad Aziz, Rob Rogers
Medical Professionalism: The Dimensions That All Medical Students Should
Know About
Amila Punyadasa
Communication and Interpersonal Interactions
Vijay Nagpal, Bret A. Nicks
Data Gathering
Chew Keng Sheng
Diagnostic Testing in Emergency Medicine
Yusuf Ali Altunci
Creating Your Action Plan
Chew Keng Sheng
Documentation
Muneer Al Marzouqi, Qais Abuagla
Discharge Communications
Justin Brooten, Bret Nicks

xii
3. General Approach to Emergency Patients Acute Heart Failure
Walid Hammad
The ABC Approach to Critically Ill Patient
Donna Venezia Aortic Dissection
Shanaz Sajeed
Abdominal Pain
Shaza Karrar Deep Venous Thrombosis
Elif Dilek Cakal
Altered Mental Status
Murat Cetin, Begum Oktem, Mustafa Emin Canakci Hypertensive Emergencies
Sadiye Yolcu
Cardiac Arrest
Abdel Noureldin, Falak Sayed Pulmonary Embolism
Elif Dilek Cakal
Chest Pain
Assad Suliman Shujaa
A Child With Fever
Jabeen Fayyaz
5. Selected Endocrine, Electrolyte
Gastrointestinal Bleeding Emergencies
Moira Carrol, Gurpreet Mudan, Suzanne Bentley Acid-Base Disturbance
Headache Lamiess Osman, Qais Abuagla
Matevz Privsek, Gregor Prosen Hyperglycaemia
Multiple Trauma Hong Chuen
Pia Jerot, Gregor Prosen Hypernatremia
Poisoning Vigor Arva, Gregor Prosen
Harajeshwar Kohli, Ziad Kazzi Hyponatremia
Respiratory Distress Vigor Arva, Gregor Prosen
Ebru Unal Akoglu Hypoglycaemia
Shock Rok Petrovcic
Maryam AlBadwawi Thyroid Storm
Shabana Walia
4. Selected Cardiovascular Emergencies
Abdominal Aortic Aneurysm
Lit Sin Quek
Acute Coronary Syndrome
Khalid Mohammed Ali, Shirley Ooi

xiii
6. Selected Environmental Emergencies 9. Selected Neurological Emergencies
Burns Approach to Patients With Stroke
Rahul Goswami Matevz Privsek, Gregor Prosen
Drowning Acute Ischemic Stroke
Ana Spehonja Fatih Buyukcam
Heat Illness Intracranial Hemorrhage
Abdulaziz Al Mulaik Nur-Ain Nadir, Matthew Smetana
Hyperthermia Seizure
Puneet Sharma Feriyde Caliskan Tur

10. Selected Pulmonary Emergencies

7. Selected Gastrointestinal Emergencies Asthma
Acute Appendicitis Ayse Ece Akceylan
Ozlem Dikme COPD - Chronic Obstructive Pulmonary Disease
Biliary Disease Ramin Tabatabai, David Hoffman, Tiffany Abramson
Dan O’Brien Pneumonia
Massive Gastrointestinal Bleeding Mary J O
Dan O’Brien Spontaneous Pneumothorax
Acute Mesenteric Ischemia Mahmoud Aljufaili
Rabind Anthony Charles
Perforated Viscus 11. Selected Psychiatric Emergencies
Ozlem Dikme Acute Psychosis
Elizabeth Bassett, Nidal Moukaddam, Veronica Tucci
Stabilization and Management of The Acutely Agitated or
8. Selected Genitourinary Emergencies Psychotic Patient
Michelle Chan, Nidal Moukaddam, Veronica Tucci
Ectopic Pregnancy
Dan O’Brien Medical Clearance-Suicidal Thought/Ideation
Veronica Tucci
Tubo-Ovarian Abscess
Matthew Lisankie, Charlotte Derr, Tomislav Jelic
Testicular Torsion
Sujata Kirtikant Sheth

xiv
12. Selected Orthopaedic Problems and 16. Selected Procedures
Injuries Automatic External Defibrillator (AED) Use
Back Pain Mehmet Ali Aslaner
Funda Karbek Akarca Arterial Blood Gas Sampling
Lower Extremity Injuries Matija Ambooz and Gregor Prosen
Ayse Ece Akceylan Arthrocentesis
Pelvic Injuries Tanju Tasyurek
Sercan Yalcinli Basics of Bleeding Control
Spine Injuries Ana Spehonja, Gregor Prosen
Ozge Can Cardiac Monitoring
Upper Extremity Injuries Stacey Chamberlain
Meltem Songur Kodik Gastric Lavage and Activated Charcoal Application
Elif Dilek Cakal
13. Selected Infectious Problems Intravenous Line Access
Epiglottitis Keith A Reymond
KuanWin Sen Intraosseous (IO) Line Access
Meningitis Keith A Reymond
Alja Pareznik Emergency Delivery
Sinusitis David F. Toro, Diana V. Yepes, Ryan H. Holzhauer
Katja Zalman, Gregor Prosen Pericardiocentesis
Sepsis David Wald, Lindsay Davis
Emilie J. Calvello Hynes Lumbar Puncture
Khuloud Alqaran
14. Selected Toxicologic Problems Nasogastric Tube Placement
Opioid Overdose Sara Nikolic, Gregor Prosen
Aldo E. B. Salinas, Jesus Daniel Lopez Tapia Procedural Sedation and Analgesia
Nik Rahman
15. Selected Eye Problems Rapid Sequence Intubation
Eye Trauma Qais Abuagla
Serpil Yaylaci, Kamil Kayayurt
Reduction of Common Dislocations and Fractures
Red Eye Dejvid Ahmetović, Gregor Prosen
David Wood
xv
Splinting and Casting 19. Selected Emergency Drugs
Joseph Pinero, Timothy Snow, Suzanne Bentley
Antidotes
Urinary Catheter Placement Hamidreza Reihani, Elham Pishbin
Gul Pamucu Gunaydin
Drugs for Pain Relief
Nik Ahmad Shaiffudin Nik Him, Azizul Fadzi
17. Selected Diagnostic Tests
Paralyzing Agents
Arterial and Venous Blood Gases Analyses
Qais Abuagla
Kemal Gunaydin
Cerebrospinal Fluid Analysis 20. Selected Clinical Rules, Scores,
Arwa Alburaiki, Rouda Salem Alnuaimi
Urine Analysis
Mnemonics
Jan Zajc Clinical Decision Rules
Stacey Chamberlain
Whole Blood Cell Count – CBC
Kaja Cankar Mnemonics
Ozlem Dikme
18. Selected Imaging Modalities Classifications and Scores
EFAST - Extended Focused Sonography for Trauma Sarah Attwa, Marwan Galal
Ashley Bean, Brian Hohertz, Gregory R. Snead
POCUS in Patients with Undifferentiated Hypotension
Rasha Buhumaid
BLUE Protocol
Toh Hong Chuen
How to Read C-Spine X-Rays
Dejvid Ahmetovic, Gregor Prosen
How to Read Chest X-Rays
Ozlem Koksal
How to Read Head CT
Reza Akhavan, Bita Abbasi
How to Read Pelvic X-ray
Sara Nikolic, Gregor Prosen

xvi
Chapter 1

The Facts of
Emergency
Medicine
Section 1
Emergency Medicine: A unique specialty
by Will Sanderson, Danny Cuevas, Rob Rogers
Audio is available here
Imagine walking into the hospital to start your day – ambulances are blaring, the
waiting room is clamoring, babies are crying. You stroll through this sea of
humanity and eventually arrive at your workstation. After setting your bag down,
you prepare the basic tools of your trade: a stethoscope, a fresh cup of coffee,
and a sharp mind. Taking a deep breath, you prepare for the routine of yet another
shift. But there is no “routine.” There is only the excitement and variety of what is
about to come through those sliding double doors. That flimsy piece of metal and
glass is the only barrier that separates you from the thousands of people with a
multitude of medical ailments, any one of which could bring them to your
doorstep. With a low hum and an almost silent whoosh, these doors part to reveal
your next patient. To them, it is probably the worst day of their life. For you, it’s
another Tuesday.
Who will be your next patient? Is it the 4-year-old boy with the asthma attack
gasping for that next breath? Will it be the 78-year-old widower who fell at home
while fixing himself a sandwich? Maybe it’s the 31-year-old female who just rear-
ended another vehicle at highway speed; oh, did they also mention she’s 28 weeks
pregnant? You look over and see new patients filling the critical examination rooms
and the trauma bay. No matter what walks through that door, you’ll be ready. You
sit down. You grab a chart. It’s time to get to work. Today is going to be another
routinely awesome day.
18
Why choose a career in emergency medicine? Before discussing
where the field is going, it’s important to know a little background
on where it has been. And if you’re reading this and considering a
career in EM, do yourself a favor – take the time to watch this
documentary from the Emergency Medicine Residents’
Association (EMRA). As you’ll see, the specialty of emergency
medicine has evolved drastically over the last several decades
and continues to be an increasingly popular choice among
graduating medical students. Only a few decades ago,
emergency departments around the country were staffed by
physicians with a variety of training backgrounds. The vast
majority of these physicians had little to no emergency medicine
training at all. General surgeons, family physicians, neurologists,
and even psychiatrists were among those that staffed emergency
departments around the country and throughout the world. But
since the establishment of the first emergency medicine residency
programs in the 1970’s and the subsequent establishment of the
American Board of Emergency Medicine in 1979, the specialty
has continued its rapid development in defining its place in the
house of medicine. Walk into anything other than the smallest of
EDs these days and you’re likely to encounter an emergency
medicine residency trained physician. A study published in 2008
demonstrated that in its relatively short history as a recognized
medical specialty, the number of physicians staffing departments
across the country who had received emergency medicine
training soared from 0% to 70%. Why the dramatic shift? To
understand the answer to this question, you need to take a
d e e p e r l o o k i n t o t h e practice and lifestyle of the modern
emergency medicine physician.
Why EM?
Emergency medicine is a fast paced, team oriented, dynamic
specialty that focuses on the rapid evaluation and treatment of a
diversified patient population consisting of both pediatric and
adult patients. As the initial provider for many of their patients, the
emergency medicine physician is charged with the rapid
assessment and data gathering needed to launch the initial
workup and management of a wide variety of complaints that
bring patients to the ED. Their work has an incredible influence in
the patients’ care as it generates the driving force for further
medical evaluation; whether the patient is admitted to the hospital
or discharged home, the emergency physician plays a huge role
in directing both short and long term care well after their stay in
the emergency department. Here’s a look inside the lives of
several emergency physicians from Rob Orman of ERcast.
Variety is the spice of the EM life. There is no set routine or
expected patient list for the day. In the short span of a shift, you
may diagnose strep pharyngitis, intubate an unresponsive patient
who overdosed on heroin, reveal a cancer diagnosis to a young
patient with flu-like symptoms, reduce a dislocated hip, place a
chest tube in a patient with a hemothorax, and resuscitate a
patient undergoing a cardiac arrest. Your next patient could be a
six-year-old or a 75-year-old, both with abdominal pain. In a
setting where some may see chaos, EM physicians find order. It’s
19
exciting. It’s energizing. This diversity is a uniquely challenging t h e s h i f t w o r k i n t h e emergency department affords a
aspect of the medicine practiced in the emergency department. level of flexibility not seen in other medical specialties. Emergency
physicians manage the hustle and bustle of their department for a
EM physicians pull from a knowledge base that spans all medical
set number of hours, after which a fresh physician team arrives to
specialties including pulmonology, cardiology, gastroenterology,
take over. After his shift, the previous doctor hands over the care
trauma surgery, nephrology, ophthalmology, psychiatry, and
of his patients to the oncoming team to continue with the
neurology. Jack of all trades? Sure. Master of none? Not even
diagnostic and therapeutic management of the patient. In this
close. The gap between the medical and surgical specialties is
regard, one can wrap up, sign out, and head home without
bridged within the practice of emergency medicine. The
bringing any of his work with him. The nature of shift work also
combination of a broad knowledge base with the need to develop
allows for trading of shifts amongst the physicians staffing the
a focused procedural skill set makes the EM physician a veritable
department. Want a week off in April to spend some time at the
Swiss Army Knife within the house of medicine. From
beach? As long as you plan in advance, you shouldn’t have any
endotracheal intubation, cricothyroidotomy, fracture reduction,
trouble getting there. With enough planning, it’s quite possible to
and central line placement to pericardiocentesis, thoracotomy,
be at nearly every important life/family event you choose.
chest tube placement, and lateral canthotomy, even the most
enthusiastic proceduralist will find his hands full working in the Within the field of emergency medicine, physicians are employed
ED. in several settings. These settings range from hospital-based
and freestanding emergency departments, urgent care facilities,
Variety is a word that not only defines the practice of emergency
observation medicine units, emergency medical response
medicine but also the lifestyle it affords. Are you a morning
services, and even telemedicine locations. Patient volumes, even
person who is up at the break of dawn and thinks best with a
at facilities in close proximity to one another, can vary greatly.
fresh mind after breakfast? Or are you a night owl who gets a
Some facilities are designated trauma centers while others are
burst of energy in the wee hours of the night when most others
not. There are facilities teamed up with a strong academic center
are sound asleep? Are you a weekend warrior who prefers to
to provide numerous subspecialty support and others are
keep your schedule open on those days? Or would you rather
resource-limited community hospitals. No matter what your
work during the day to finish in time to pick up your children after
preference, there are a variety of settings to fit your needs. But
they finish their day at school? Irrespective of your preference,
let’s get to the real question at hand: are emergency medicine

20
physicians satisfied with their career? This is really the crux of any
discussion regarding career choice. How devastating would it be
to realize after spending over a decade in college, medical
school, and residency that working in the emergency department
isn’t for you? Well, in 2015, emergency medicine physicians came
in 4th in overall career satisfaction compared to other medical
specialties. 60% of all emergency physicians surveyed were
satisfied with their income. Emergency physicians typically work
more intensely for fewer total hours compared with other
physicians and enjoy above-average compensation per hour.
Below, Dr. Kevin King of the University of Texas Health Science
Center San Antonio discusses the Pros and Cons of a Career in
Emergency Medicine: Pros and Cons of a Career in Emergency
Medicine. As you can see, the life of an emergency medicine
physician is not a perfect fit for everyone. EM physicians suffer
from relatively high rates of burnout. However, as the field evolves
and physician wellness becomes a priority for all physicians
within medicine, this will surely improve. If the characteristics
outlined above are consistent with the qualities you are looking
for in a specialty, emergency medicine may well be the perfect fit
for you.

References and Further Reading, click here.

21
Section 2
Choosing the Emergency Medicine As A Career
by C. James Holliman
A video is available here
Audio is available here
The specialty of Emergency Medicine (EM) is a great career choice for medical
students and interns. In August 2013, I celebrated my 30th year in full-time EM
clinical practice, and I remain very happy and satisfied with my career choice. I
have served as a career advisor to medical students and interns for over 30 years
now and am very interested in encouraging people to undertake EM as a career.
Why is EM a great career? The main summary reason is that it is challenging and
very personally rewarding. You can directly and quickly see the benefits and
positive results of your diagnosis and treatment of patients who have emergent
medical conditions. You have the satisfaction of knowing you have made a big
positive difference in patients’ lives and well-being. EM encompasses a very wide
variety of patients and medical and surgical problems. EM deals with patients of
both genders and all ages. The variety of cases seen by EM is probably greater
than that of any other specialty, and this aspect is part of what makes EM so
interesting and stimulating. The practice of EM encompasses a nice mix of
diagnostic medicine and of performing diagnostic and therapeutic procedures.
The EM practitioner sees patients with undifferentiated symptoms and so must
make the initial diagnosis of many conditions. EM interacts with all the other
medical specialties, and at most hospitals accounts for the majority of hospital
admissions.
22
Unique subjects routinely taught in EM include: cost-effective
ancillary test ordering, efficiency in patient flow, managing
multiple simultaneous patients, coordinating Prehospital and
Emergency Department (ED) care, focusing the approach to
medical problems, speed and efficiency of patient evaluations,
efficient use of ancillary personnel, efficient recording and
transmittal of clinical data, and injury and violence prevention. EM
is also a young, vibrant specialty with a lot of enthusiastic
practitioners, most of whom have extended interests and talents
outside of medical practice, and who serve as role models and
mentors.
EM also encompasses the supervision of and interactions with
prehospital care. EM receives patients brought to the hospital ED
by ambulance. EM is responsible for training the prehospital
personnel, and in some countries, EM practitioners may find
themselves directly staff ambulances, both ground and
aeromedical. EM also is the main specialty involved in the
planning for, and management of disasters and mass casualty
situations, both of which also require close interaction with
prehospital care.
EM has well-developed residency training programs for medical
school graduates in many countries. The length of these training
programs varies from country to country but generally is three to
five years. The EM residencies each have some clinical rotations
on other services or specialties (such as anesthesia, surgery,
intensive care, pediatrics, o b s t e t r i c s , i n t e r n a l m e d i c i n e ,
cardiology, trauma, etc.), and this direct exposure to other
multiple specialties makes EM residencies more interesting. Of
course, the majority of time in most EM residencies is spent in the
hospital ED. Most EM residencies also offer opportunities to
participate in prehospital care and EM research. One validation
of the strength of EM as a career is that in the U.S. each year it is
the first or second most popular choice for residency by medical
students, and the overall residency program “fill” rate in the
National Residency Matching Program is over 99%. For more
information on EM residencies from the perspective of EM
residents, check the website www.emra.org.
EM has also developed a number of sub-specialties which
enhance the career options in EM. Each sub-specialty offers
post-residency fellowship training programs of one to three years
duration. In the U.S.A., the following EM subspecialties are
officially recognized and have their own sub-specialty exam
certification: Pediatric EM, Toxicology, Critical Care, Sports
Medicine, Hyperbaric Medicine, Emergency Medical Services,
and Palliative Care. Additional EM sub-specialty fellowship
programs include International EM (or Global Health), Ultrasound,
Research, Education, Simulation Training, Aeromedical, Disaster,
Trauma, Administration, and Information Technology. Check the
website www.saem.org for the most up to date listing of EM
fellowship programs.
23
One of the greatest assets of EM as a career is the wide variety of national healthcare system, and there is extensive medical
post-residency career choices or options. These include literature support for the value and efficacy of EM.
practicing in a variety of hospital types: university, teaching,
Another nice EM career aspect is the opportunity after residency
community, government, military, etc. EM physicians can also
or fellowship to participate in one or more of the EM specialty
practice in “freestanding” ED’s (not directly connected to a
state, national, regional, or international organizations. Most
hospital) or in urgent care centers. If a person does not want to
countries have a national EM organization which carries out some
practice at just one hospital, there is the option to undertake
activities including annual educational conferences. The
“locum tenens” practice in which the person works clinical shifts
International Federation for EM (IFEM) has a large number of
at multiple different facilities. For those in the military or interested
committees, task forces, and special interest groups which are
in a military career, EM has been shown to be one of the most
carrying out a wide variety of projects which need more
needed specialties in the military. EM physicians can undertake
individuals to participate and contribute (check www.ifem.cc for
leadership positions in hospital administration, prehospital care,
more information on IFEM). Becoming involved with one or more
and in the government developing and directing health policy.
of the EM specialty organizations can provide one with career
Unique advantages of EM as a career include the almost satisfaction in helping improve and develop the specialty as well
unlimited opportunities in international EM development, control as obtaining leadership training and experience.
over and predictability of one’s work schedule, usually not having
So in summary, EM is a great career choice with a very wide
to be “on-call” when not directly on duty, and having “geographic
range of post-residency work options, a very safe job market for
flexibility” in the variety of places to practice. There are also a
the future, and the personal satisfaction of knowing one’s work
relatively small number of EM physicians in academic practice, so
directly and quickly helps patients, and that one’s work is a
it is often easy for physicians interested in an academic career to
critical component of the national healthcare system.
rapidly advance up the “academic ladder”.
References and Further Reading, click here.
Another positive aspect for EM is that in most countries it is
projected to be an undersupplied specialty for many years, and
so there will continue to be many open job opportunities in EM.
EM has also been shown to be a critical component of any

24
Section 3
Thinking Like an Emergency Physician
by Joe Lex
“Emergency Medicine is the most
interesting 15 minutes of every other
specialty.”
– Dan Sandberg, BEEM Conference, 2014
Audio is available here
Why are we different? How do we differentiate ourselves from other specialties of
medicine? We work in a different environment in different hours and with different
patients more than any other specialty. Our motto is “Anyone, anything, anytime.”
While other doctors dwell on the question, “What does this patient have? (i.e.,
“What’s the diagnosis?”), emergency physicians are constantly thinking “What
does this patient need? Now? In 5 minutes? In two hours?” Does this involve a
different way of thinking?
The concept of seeing undifferentiated patients with symptoms, not diagnoses, is
alien to many of our medical colleagues. Yet we do it on a daily basis, many times
during a shift. Every time I introduce myself to a patient, I never know which
direction things are going to head. But I feel like I should give the following
disclaimer. Hello stranger, I am Doctor Joe Lex. I will spend as much time as it
takes to determine whether you are trying to die on me and whether I should admit
you to the hospital so you can try to die on one of my colleagues. You and I have
never met before today. You must trust me with your life and secrets, and I must
trust that the answers you give me are honest. After today, we will probably never
see one another again. This may turn out to be one of the worst days of your life;
for me, it is another workday. I may forget you minutes after you leave the
department, but you will probably remember me for many months or years,
possibly even for the rest of your life. I will ask you many, many questions. I will do
25
the best I can to ask the right questions in the right order so that I
come to a correct decision. I want you to tell me the story, and for
me to understand that story, I may have to interrupt you to clarify
your answers. Each question I ask you is a conscious decision on
my part, but in an average 8 hour shift I will make somewhere
near 10,000 conscious and subconscious decisions – who to see
next, what question to ask next, how much physical examination
should I perform, is that really a murmur that I am hearing, what
lab study should I order, what imaging study should I look at now,
which consultant will give me the least pushback about caring for
you, is your nurse one to whom I can trust the mission of getting
your pain under control, and will I remember to give you that work
note when it is time for you to go home? So even if I screw up
just 0.1% of these decisions, I will make about ten mistakes
today. I hope for both of our sakes you have a plain, obvious
emergency with a high signal-to-noise ratio: gonorrhea, a
dislocated knee cap, chest pain with an obvious STEMI pattern
on EKG. I can recognize and treat those things without even
thinking. If, on the other hand, your problem has a lot of
background noise, I am more likely to be led down the wrong
path and come to the wrong conclusion. I am glad to report that
the human body is very resilient. We as humans have evolved
over millennia to survive, so even if I screw up, the odds are very,
very good that you will be fine.
Voltaire told us back in the 18th century that “The art of medicine
consists of amusing the patient while nature cures the disease.”
For the most part, this has not changed. And Lewis Thomas
wrote: “The great secret of doctors, learned by internists and
learned early in marriage by internists’ wives, but still hidden from
the public, is that most things get better by themselves. Most
things, in fact, are better by morning.” Remember, you don’t
come to me with a diagnosis: you come to me with symptoms.
You may have any one of more than 10,000 diseases or
conditions, and – truth be told – the odds of me getting the
absolute correct diagnosis are not good. You may have an
uncommon presentation of a common disease or a common
presentation of an uncommon problem. If you are early in your
disease process, I may miss such life-threatening conditions as
heart attack or sepsis. If you neglect to truthfully tell me your
sexual history or use of drugs and alcohol, I may not follow
through with appropriate questions and come to a totally
incorrect conclusion about what you need or what you have.
The path to dying, on the other hand, is rather direct – failure of
respirations, failure of the heart, failure of the brain, or failure of
metabolism.
You may be disappointed that you are not being seen by a
“specialist.” Many people feel that when they have their heart
attack, they should be cared for by a cardiologist. So they think
that the symptom of “chest pain” is their ticket to the heart
specialist. But what if their heart attack is not chest pain, but
nausea and breathlessness; and what if their chest pain is aortic
26
dissection? So you are being treated by a specialist – one who
can discern the life-threatening from the banal, and the cardiac
from the surgical. We are the specialty trained to think like this.
If you insist on asking “What do I have, Doctor Lex?” you may be
disappointed when I tell you “I don’t know, but it’s safe for you to
go home” without giving you a diagnosis – or without doing a
single test. I do know that if I give you a made-up diagnosis like
“gastritis” or “walking pneumonia,” you will think the problem is
solved, and other doctors will anchor on that diagnosis, and you
may never get the right answers.
Here’s some good news: we are probably both thinking of the
worst case scenario. You get a headache and wonder “Do I have
a brain tumor?” You get some stomach pain and worry “Is this
cancer?” The good news is that I am thinking exactly the same
thing. And if you do not hear me say the word “stroke” or
“cancer,” then you will think I am an idiot for not reading your
mind to determine that is what you are worried about. I
understand that, no matter how trivial your complaint, you have a
fear that something bad is happening.
While we are talking, I may be interrupted once or twice. See, I
get interrupted several times every hour – answering calls from
consultants, responding to the prehospital personnel, trying to
clarify an obscure order for a nurse, or I may get called away to
care for someone far sicker than you. I will try very hard to not let
these interruptions derail me from doing what is best for you
today.
I will use my knowledge and experience to come to the right
decisions for you. But I am biased, and knowledge of bias is not
enough to change my bias. For instance, I know the
pathophysiology of pulmonary embolism in excruciating detail,
but the literature suggests I may still miss this diagnosis at least
half the time it occurs.
And here’s the interesting thing: I will probably make these errors
whether I just quickly determine what I think you have by
recognition or use analytical reason. Emergency physicians are
notorious for thinking quickly and making early decisions based
on minimal information (Type 1 thinking). Cognitive psychologists
tell us that we can cut down on errors by using analytical
reasoning (Type 2 thinking). It turns out that both produce about
the same amount of error, and the key is probably to learn both
types of reasoning simultaneously.
After I see you, I will go to a computer and probably spend as
much time generating your chart as I did while seeing you. This is
essential for me to do so the hospital and I can get paid. The
more carefully I document what you say and what I did, then the
more money I can collect from your insurance carrier. The final
chart may be useless in helping other health care providers
understand what happened today unless I deviate from the clicks
and actually write what we talked about and explained my
27
thought process. In my eight hour shift today I will click about
4000 times.
What’s that? You say you don’t have insurance? Well, that’s okay
too. The US government and many other governments in the
world have mandated that I have to see you anyway without
asking you how you will pay. No, they haven’t guaranteed me any
money for doing this – in fact, I can be fined a hefty amount if I
don’t. A 2003 article estimated I give away more than $138,000
per year worth of free care related to this law.
But you have come to the right place. If you need a life-saving
procedure such as endotracheal intubation or decompression
needle thoracotomy, I’ll do it. If you need emergency delivery of
your baby or rapid control of your hemorrhage, I can do that too.
I can do your spinal tap, I can sew your laceration, I can reduce
your shoulder dislocation, and I can insert your Foley catheter. I
can float your temporary pacemaker, I can get that pesky foreign
body out of your eye or ear or rectum, I can stop your seizure,
and I can talk you through your bad trip.
Emergency medicine really annoys a lot of the other specialists.
We are there 24 hours a day, 7 days a week. And we really expect
our consultants to be there when we need them. Yes, we are fully
prepared to annoy a consultant if that is what you need.
I have seen thousands of patients, each unique, in my near-50
years of experience. But every time I think about writing a book
telling of my wondrous career, I quickly stop short and tell
myself “You will just be adding more blather to what is already out
there – what you have learned cannot easily be taught and will
not be easily learned by others. What you construe as wisdom,
others will see as platitudes.”
As an author, Norman Douglas once wrote: “What is all wisdom
save a collection of platitudes. Take fifty of our current proverbial
sayings– they are so trite, so threadbare. None the less they
embody the concentrated experience of the race, and the man
who orders his life according to their teachings cannot be far
wrong. Has any man ever attained to inner harmony by
pondering the experience of others? Not since the world began!
He must pass through fire.”
Have you ever heard of John Coltrane? He was an astonishing
musician who became one of the premiere creators of the 20th
century. He started as an imitator of older musicians but quickly
changed into his own man. He listened to and borrowed from
Miles Davis and Thelonious Monk, African music and Indian
music, Christianity and Hinduism and Buddhism. And from these
disparate parts he created something unique, unlike anything ever
heard before. Coltrane not only changed music, but he altered
people’s expectations of what music could be. In the same way,
emergency medicine has taken from surgery and pediatrics,
critical care and obstetrics, endocrinology and psychiatry, and we
28
Another random document with
no related content on Scribd:
PETER ALTENBERG (1859-1919)

MITÄ HÄN VOI TEHÄDÄ HÄNEN TÄHTENSÄ?

Sun tähtes mitä tehdä voin?!? Voin kävelyllä sinun viittaas

kantaa – voin kysyä, sä kuinka olet yösi nukkunut – –. Kun
sua vastustetaan, katseellani voin mä tietää antaa: »Sä olet
oikeassa, sinä vain!» Jos poissa oot, voin olla sairas sekä
alakuloinen – – – voin onnestani vavista, kun astut yli
kynnyksen – –. Voin teatterissa myös antaa kiikarini kätehesi
ja virkkaa kohteliaisuuden hänen tyttärestään isällesi.

Voin herkulliset mandariinit tuoda sulle.

Ja monet pikku palvelukset onnistuvat mulle.
Mut sydän sentään tyydy ei, se joka hetki kysyy noin:
»Sun tähtes mitä tehdä voin?!?»

PELKO
Mä pelkään vuokses, Anna – – –.
Mut miksi pelkään, tiedä en,
vain pelkääväni tiedän.
Mä pelkään!
Kuin äidin valtaa pelko aiheeton,
he kaikki vielä iloiset ja terveet on – – –!
Ja niinkuin laivurikin pelkää, pelkää, pelkää,
kun huolettomin silmin vielä tähyävät
muut pilvetöntä taivasta ja tyyntä merenselkää
ja varoittajan viisaudelle hymähtävät.
Mä pelkään, niinkuin pelkää hän,
ken näkee rannan hiekkakunnahalla lasten leikkivän
ja tietää: vuoksi nousee, nielaisee nyt juuri – pakoon!
Mä pelkään, niinkuin pelkää mies,
ken tietää: riipun hirsipuussa kello seitsemän.
Niin, niin mä pelkään vuokses sun – – –
vuoks itseni: sä oothan elämäni mun;
mut sinä omaa tietäs käyt, pois rinnaltain,
et pelkää ahdistavaa pelkoain,
sä syöksyt uuteen kohtaloon, käyt uutta elon-rataa – – –
vain kaste uusill’ aamuteilläs on
mun kuolinhikeni, mi jalkais juureen sataa!
CARL HAUPTMANN (1858-1921)

KALLIOÄÄNIÄ

(Originaalin pohjalla vapaasti muotoiltu.)

Yö, yö… Yöhön me vaivumme, syöksymme kohti

kallioseinää, kuoleman kuiluja, hornannieluja. Niinkuin heinää
jumalat niittävät sieluja. Murha – murha on elämä, turha, turha
on elämä. Äänet vyöryen soi läpi yksinäisyyden, äänet
huutavat: voi! Nyt kivi, kallio kylmä me olemme. Kiveen
hautasi meidät harmaa aika. Ah, hätähuutomme yöstä nousta
tohti, ahnaan ampui nuolensa kaipaus aamua kohti. Ammoin
jo lämmitti aurinko meitä, vuorilähteet nuolivat jyrkänteitä –
mutta me kalliot olemme kylmät ja kovat. Vapahda… vapahda
meidät!

Me nukumme… Me nukumme… Auringonsäteitten kutsuja

kuulemme, avaten kiviset huulemme kurkoitamme ne valoon.
Maata me olemme, maa, kova kivi on sukumme… Olemme
jälleen valossa nuoret, haparoimme ilmaan. Sen mitä kätkivät
graniittikuoret, kiviset nielut syvälle, syvälle unettomuuteen,
sen me nyt nostamme aamuun uuteen. Pimennostamme
nousevat nimeä vailla sielut. Mikä on kiveä ollut, pääsee
kivestä irti. Näkee taivasvalot, nostaen sielukasvot puhtaat ja
jalot.
MAX DAUTHENDEY (1867-1918)

SUN SILMÄS HILJAISET

Sun silmäs hiljaiset suo vuoteekseni.

Se paikka hiljaisin on maailmassa.

Sun katsees varjoon hyvä jäädä on.

Sun katsees hyvä on kuin vieno ilta.

Maan piiristä on pimeästä

vain yksi ainut askel taivaan porttiin.
Mun maani loppuu sinun silmissäsi.

SYVÄSS’ ASTUMME HIEKASSA

Syväss’ astumme hiekassa, merta päin,

ja nääntyvin askelin, käsikkäin.
Kera käy meren henget hirveät.
Joka hetki me olemme pienemmät.
 Lopuks pienen pieninä astutaan
meren pohjalla samaan simpukkaan;
siki-unessa kasvamme kirkkauteen
ihanast’ ihanampahan, helminä veen.

HARMAAT ENKELIT

Harmaat enkelit kulkevat ympärilläni, katsovat murheella

sinua, sieluni, seisovat hervottomin siivin tuhkakummun
ääressä, miettivät; ulkona ja sisällä on ilta, sieluni.
GUSTAV SCHÜLER (1868-1938)

ILTA

Oi tule, ilta tullut on.

Me sitä kaipasimme niin.
Tuoss’ on se nyt. Ja viitta yllä
se nojaa vanhaan poppeliin.

Nyt silmänsä se auki luo

ja katsoo, nyökkää, vallaton,
Yön silmät – sinun silmäs ovat,
ja huulet yön – sun huules on.
FRANZ EVERS (1871-1947)

NUORUUS

Oratuomen tuoksuvan alla – kai tunnette paikan sen? – nuor’

paimenpoikanen siellä luki aamusiunauksen. Vei lampaansa
laitumelle yli aurinkoisen maan; hänet nummella uuvutti helle,
hän uneksi uniaan.

Oratuomen tuoksuvan alla – kai tunnette paikan sen? –

nuor’ paimentyttönen siellä luki iltarukouksen. Tuli nummelta
tuulenhenki, hänen suuteli hamettaan. Ja kumpikin,
kumpainenki näki ensi uniaan.
CHRISTIAN MORGENSTERN (1871-
1914)

LINTU SYNKKÄMIELI

Yli maailman lentää musta lintu,

kovin’ surullinen sen laulu on…
Ken kuulee sen, hän ei muuta kuule,
ken kuulee sen, hältä päättyvät päivät,
ei katsoa saata hän enää aurinkoon.

Joka sydänyö, joka sydänyö

se nukkuu sormilla Kuoleman.
Tämä hiljaa silittää sitä, sanoo sille:
»Nyt lennä, lintuni, taas! Nyt lennä, lintuni, taas!»
Ja huiluäänin se lentää yli maan.

METSÄN YÖSSÄ
Metsän yössä kuljit polkuasi,
omaa jalkaas edes nähnyt et.
Pelon voitti tieto tunnossasi:
Ties johdattaa.

Tuhat tuskan ansaa matkallasi.

Mik’ on päätös viimein? Vapiset.
Pelon voittaa tieto tunnossasi:
Ties johdattaa.
RAINER MARIA RILKE (1875-1926)

SYKSY

Ja lehdet putoo, kaukaa jostakin, kuin taivaan puistikot ois

lakastuneet; nuo pienet kieltäjät, ne maahan hajoo.

Maan raskas pallo öissä kauas vajoo

pois tähtisikermästään etäisyyksihin.

Me kaikki vajoamme. Tämän käsi vajoo.

Ja katso: saman kaikessa mä nään.

Mut Eräs sentään pitää kaiken, mikä vajoo,

niin rajattoman lempeästi kädessään.
ALFRED MOMBERT (1872-1942)

PUUTARHASSA

Ei himoiten, mut täynnä rakkautta käyn luoksesi ja kysyn suita

hiljaa: Sä minut tahdotko? Näin kevään aikaan istun mielelläni
puutarhain kastehisten siimekseen, kun tuulenhenki tulvii
kukkasaran yli. Puutarhurin jos vanhan kohtaisin, mä puhun
mielelläni hänen kanssaan neljänneksen, niin, hänen
pensaistaan ja hänen maastaan. Ja lintu laulaa puussa. Me
puhelemme, mekin: mitä puhelevat ihmiset. Jos silloin otan
puusta lehden ja panen suureen kätehesi sen, niin sinä tunnet
sen: on sydämeni sinun.

PEHONEN

(Der himmlische Zecher, 52)

 Minä nojaan ikkunasta maailmanavaruuteen. Kirjava
perhonen liihoittelee maailman halki. Se tanssii lähemmäksi.
Se asettuu ikkunanlaudalle. Sen silmien lasissa, sen siipien
silkissä säilyy kaikkien kirjavien tähtien värivalo. Se lyö
siipiään: ja värit kipunoivat humaltuneen pääni yli – vihreä, ja
kaukaisimman tähden vieras puna – minun ylitseni sisään
ikkunasta.

MEREN POHJASSA LEPÄSIN

(Der himmlische Zecher, 67)

Meren pohjassa lepäsin unen-jäykkänä. Ylläni katto

kirkkaan, ohuen jään. Rannalla seisoivat korkeat kuuset.
Lumesta valkeat. Niiden kuvat valvoivat hiljaa ympärilläni
syvyydessä. Auringon näin ja tähdet kylminä, talvenvalkoisina
meren yllä.

***

Maailman halki liukui varjo. Astui luokseni alas mereen.

Suuren kotkan näin minä liitävän vahvojen siipien varassa
vapaana meren yllä.

***

Alemmaksi liiteli kotka nyt. Kuusissa helisi lumi, keinuivat

vihreät oksat, valkoiset pallot hypähtelivät maahan.
Salamoivat pisarat. Aaltoja vaelsi meressä, heräsi yksi, se
 puhui sisar-nukkujalle, vyöryi tämä; ja kolmas soi. Aivan
luonani syvyydessä, kangistuneen ruumiini, henkeni luona
tunsin mahtavan-lämpöisen rinnan, tunsin kotkan
lemmenkatseen meren yllä.

***

Kevät tuli. Nyt kimalsi meri.

Kulkivat kultaiset tuulet.
Kasvoi tummanpunainen kukka
ruumiistani.
Korkealle. Välkkyvän-vyöryvän veden läpi
Yleni vedestä esiin.
Katsoi kotkankatsetta kohti.

***

Alas ampui kotka. Meren pohjasta irti

tempasi kukan.
Tempasi irti minut, kaikista syvistä juurista irti –
hymyili – tempasi! – värjyi! –
Liiteli:
liiteli mahtavasti meren luota pois.

***

Haamun näin. Taivaalta poimi se tähtiä kirjavan kimpun.

Lentomme tunsi se – kääntyi: – Hän oli isäni. – Vinhuen
varisivat tähdet nyt hänen käsistään. Hän tavoitti minua –
ulvonnassa myrskyjen suurten! Hän tavoitti minut –
ukkospilvien välistä! Kotkani siipien ja kynsien välistä.
 ***

Avaruuksista nousivat jyrkästi mustat kukat. Katsoivat

kotkankatsetta kohti.

***

Kotkan näin minä kaukana liitävän. Synkkänä

myöhäissyksyn pilvenä riippuvan kuihtuvan maailman yllä.
Mustista kukista, murhe-kukista kaukaisista solisten virtasi
tähtiä. Hän joka ylhäällä kantoi minua, korkea loihtija,
isänrintaansa vasten painoi minut, punaisia hän suuteli
kukkiani, jotka nyt vienosti haihtuivat palavaan pilveen,
kiertäen häntä ja peittäen ihanat silmänsä hänen… Palava
pilvi!

KUUN TAHI AURINGON TÄHDEN

Kuun tahi auringon nähden runotyöhöni lähden – ani harvoin

paistaissa tähden. Minä pienemmät valot jätän teille, te
saksalaiset runoniekat jalot.
ELSE LASKER-SCHÜLER (1869-1945)

ME KAKSI

Tuo ilta kukkaistuoksuin kaipuun nurmikkoomme, ja vuorill’

loistaa kuura lailla timantin, ja taivahalta pilkistää pää enkelin,
ja me kaksi paratiisiss’ oomme.

Ja koko elo ihmeellinen kuuluu meille, tuo tähdin kuvitettu

kirja vailla rajaa, miss’ etäisyyksiin pilvipedot toisiansa ajaa, ja
pyörretuuli nostaa meidät kotkain teille!

Ja hyvä luoja näkee lapsuusuniaan taas paatatiisista ja

leikkitovereistaan… Ja ruusut katsoo meihin
oaspanssareistaan…

Puut viheriät peitti vielä synkän maan.

ALBERT EHRENSTEIN (1886-1950)

VAELTAJAN LAULU

Ystäväni ovat häilyviä niinkuin ruoko, heidän sydämensä

istuvat heidän huulillaan, puhtautta eivät he tunne; tanssia
tahtoisin heidän päänsä päällä.

Tyttö jota rakastan, sielujen sielu sinä, valittu,

valosyntyinen, koskaan et sinä katsonut minuun, sinun sylisi
ei ollut valmis, minun sydämeni paloi tuhkaan asti.

Minä tunnen koiran hampaat, Viima-päin-kasvoja-kadulla

minä asun, seula-katto on minun pääni päällä, home pitää
seinillä iloaan, niissä on hyviä koloja sateen varalta.

»Tapa itsesi!» sanoo veitseni minulle. Loka on makuusijani;

korkealla ylläni juhlavammissa vetävät vihamieheni kuu-
sateenkaarta.

EPÄTOIVO
Viikkokausiin en sano yhtään sanaa;
yksin elän ja kuihdun.
Taivaalla ei pala yhtään tähteä.
Tahtoisin kuolla.

Ahdistus himmentää silmäni,

kyyristyn johonkin loukkoon,
tahtoisin olla pieni kuin lukki,
mutta ei kukaan muserra minua.

En ole tehnyt pahaa yhdellekään,

autoin vähän hyvässä kaikkia.
Onni, ei minun pidä sinua näkemän.
Ei tahdota haudata minua elävältä.
FRANZ WERFEL (1890-1945)

PUHTAUDEN RUKOUS

Oi minun Isäni, taaskin on tullut yö, tuo vanha

ja aina sama,
läpi kaikkien meidän, ihme-sokeiden, ihmeiden
keskellä käyden.
Ja hetki on tullut ihmisten, syvästä
tunnustähdestä tiedotonten,
astua vetensä ääreen, kastaa päänsä ja likaiset
kätensä pestä.

Oi maan pyhä vesi, kaksinkerroin määrätty

juotavaksi ja puhdistamaan!
Oi minun Isäni, Jumala, oi pyhä Vesi
henkimaailman!
Enkö sinun vilpoisuuttasi kaivaten tietäisi,
että sinä virtaat ja loiskut,
enkö minä myös epäuskossani sinun
pulppuamistasi kuule?
 Alas painan pääni ja lampunpiirin kateuteen
sen vajota annan.
Kurkoitan käteni sinulle, niinkuin lapsi,
joka illalla kylpyä vartoo.
Nyt päivän valheesta itseni koota tahdon
ja tosi tänä hetkenä olla.
Ajan itseni karsinaani, kunis turhamielisyyteni
ulvonta vaikenee.

Vihamiestään vastaan, oi minun Isäni,

lauloi psalmistasi,
vihamiestäni vastaan, oi minun Isäni,
nyt minä psalmini laulan myös!
Vihamiehiä ei ole minulla, sillä ei vihaan
ihmisen rakkaus riitä.
Vihamies on minulla vahva, hän minua saartaa
ja kaikille porteilleni hän kolkuttaa.

Vihamies on minulla, oi minun Isäni, pöytäni

ääressä istuu hän, ylensyömän tuo;
kädet kuivettuneet ristissä paastoan itse,
ja ikkunan takana seisoo nälkäisten lauma.
Vihamies on minulla, hän ylenkylläisenä
savukettaan polttaa ja paisuu vatsaltaan;
yhä pienemmäksi minä itse käyn, minun täytyy
katsoa, kuinka hän sieluni aarteilla mässää.

Vihamies on minulla, oi minun Isäni; on sanat

parhaatkin lorujuttuja hälle ja itsepetosta.
Vihamies on minulla, silmänpalvelijaksi hän tekee
tuntoni, rakkauteni hän velttouteen tukahduttaa.