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