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A focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

Curbside consults with specialists, different takes from ED docs the world over, procedures, product reviews and the down low nitty gritty of emergency medicine.

Each episode of Ercast covers a single issue and tries to tease out all the relevant elements that affect your practice without overstuffing your frontal cortex. It’s for physicians and anyone interested in a bare bones look at emergency care.

10 AXIOMS IN EMERGENCY MEDICINE

1. Service to the group is in the same sentence as clinical shifts.

When I started with my current group, I saw that everyone managed atrial fibrillation differently. I wasnʼt even sure of the best way to do it. Bang, service to the group. I became an expert on a fib and developed a clinical guideline. We also had no ED ultrasound. I considered ED ultrasound the standard of care, so there was another opportunity to contribute. The ultrasound project took 5 years. 5 years! But I loved every second of it. If you donʼt have passion for the project, its going to suck because it takes a lot of time.

Avoid the trap of just punching the clock and worrying about your paycheck. Service to the group leads to career longevity.

2. Proximity to a CAT scanner is not an indication to order a study.

3. You can only see one patient at a time.

You may be 5 patients behind with a packed waiting room, but the patient in front of you is your only patient. When you freak out about all the other patients you have, need to see, or are standing in the line that extends beyond the front door, you start spinning your wheels and the inefficiency monkey is on your back. Trust me on that, Iʼve gotten to know that monkey well over the years.

4. Be nice to the nurses.

Over and over I see residents sniping at the nurses and barking out decrees. That will get you nowhere. I learned this the hard way very early on. Not only can nurses help you, they can teach you. They are part of your Emergency Medicine Fellowship. Another name for that fellowship is your first year post residency.

5. Take an advanced airway course early on in your career.

This pays huge dividends. An advanced airway course brings home what youʼve learned in residency and teaches you how to be smart, not just dexterous, with a difficult airway.

6. You are always a student first.

About 4 or 5 years into your practice, an education lassitude sets in and it takes discipline to stay current. Many docs feel like their fund of knowledge peaks at the end of residency, but thereʼs no reason for that to be so.

7. Be gracious with your consultants.

It may feel like they are trying to screw you ten ways to Sunday by not wanting to admit a patient or not wanting to come in, but this wonʼt be the last conversation you have with them. State your case and hold your ground, but keep it congenial. In residency, youʼre used to wielding the sword of your expansive knowledge of the literature and telling residents and fellows in the other specialties how it really is. But once youʼre working in the community, itʼs not that way. Or at least not as much. As Stephen Covey says, first seek to understand then be understood.

8. Go to the monthly meeting.

Even though you may think these are optional, they are not.

9. The second chief complaint of your non critical patients is anxiety.

This is not meant in a cynical way, but why else would they be there if they weren’t anxious about their symptoms. So you are really treating at least 2 diagnoses: the stared chief complaint and the anxiety that accompanies it. If you’re sensitive to that, you’ll be a better doctor and your patients will know you’re taking them seriously.

10. The prime directive. Always advocate for the patient.

If you feel like you’re in a sticky situation or your care is being compromised, remember your primary mission. Don’t feel like you need to protect your consultant or try to finesse a disposition. Always ask yourself whatʼs best for the patient and youʼll end up doing the right thing.

10 AXIOMS IN EMERGENCY MEDICINE

Comments

  1. Marshall Frank says

    Hi -- I am trying to subscribe via email. I’m not sure if this is the correct place to enter my information but when I click on “subscrive via email” link I do not get directed to a place to enter my information. Thanks for a great blog/podcast.

  2. Jeff Pepin says

    Rob,
    I wanted to start off by telling you what a huge fan I am of your podcast. You’re truly doing a great service to our specialty.
    I’m writing to you about a series of comments you made in your last podcast, “Afib Unleashed…” In a few occasions you mentioned getting shocked if you were to touch a patient during cardioversion. A few years ago I read this article from Circulation on “Hands On Defibrillation”. Essentially the article discusses the fact that it is safe to touch a patient during defibrillation. So like any curious ER resident I had to try it. During my first code after reading the article I asked the charge nurse to defibrillate the patient while I was wearing my gloves and doing CPR. To my surprise I felt nothing but the contraction of my patients muscles and NO SHOCK. Since that first code nearly 2 years ago I’ve continued this practice and still have not felt a shock. I know that Amal Mattu has also discussed this before on his podcast as well. Anyway, the article is: http://circ.ahajournals.org/cgi/content/full/117/19/2510
    I’d be interested to hear what you think of this after you read the article.

    • says

      You are righter than right on that one! It is indeed supported by the literature and experience, but before the conversation, I never had the balls to do it. Now I have hands on chest whenever electricity is being given, including the towel trick during AF cardioversion that Randy talked about in the podcast. The first time I did it, I took off all metal as a crowd of ED staff gathered outside the room to watch my impeding electrocution. To be honest, I thought I was going to get welded, but much like you describe, was pleasantly surprised when all I felt was the muscle contraction. Granted, the first patient I did it on weighed 300#, so there was quite a kick!

    • says

      Hi Bill,

      Looked into setting up CME at the podcast launch but it is a huge undertaking that costs a surprisngly large fortune to initiate and maintain. So the short answer to your question…unfortulately not.

  3. says

    Dr. Orman,
    Just wanted to tell you that I’m a huge fan and avid listener. Really enjoyed peds elbow and syncope; like all your other casts, well done!

    I just started my own site called the PEM ED Podcast. (Pediatric Emergency Medicine for the general adult-trained ED provider) and wanted to know what you thought. http://www.pemed.org

    Keep them coming!

    Andy

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