Thursday, July 7, 2011
With the start of the interns, many blogs have been providing advice to help them on their way to a successful career. Some of the better examples are here and here.
But this is emergency medicine, and while the given advice still applies, I wanted to add a little more, just for our learners. When I began my residency, one of our attendings handed us a copy of "The Ten Commandments of Emergency Medicine." I still have my original copy and now and then I hand it out to my residents. As I dusted it off this year, I realized that the article was written in 1991! Are the commandments still relevant? Read on. . .
Secure the ABC's
We pride ourselves on being the masters of resuscitation. Mastering the patients' ABCs should be the priority the moment you walk in the room. Simply walking in and observing your patient can give you an amazing amount of information. Is the patient able to speak full sentences? Are they talking at all? Do they make sense? How is their color, work of breathing, pulse, etc? If you find a problem, fix it first.
The authors of the article expand the ABC's mnemonic a little ABCD2EFG2. While most of these are familiar to us, the addition FG2 is useful to remember:
Fetal Heart tones: a needed vital sign in pregnant patients
RhoGam: Consider getting the type and Rh in pregnant trauma patients
Guardrails: Confused and elderly people fall out of bed far too often. If you put them down or find them down, then take the 10 second and put them up!
Consider or give naloxone, glucose, and thiamine
Relevance: Glucose, high; others moderate
Any patient with altered mental status or a new neurologic deficit deserves a fingerstick glucose. Almost every one of us has forgotten this truism once. The embarrassment experienced by performing the stroke workup only to get the critical glucose level back from the lab is never forgotten
As for naloxone, consider it, but give it in smaller doses if you give it at all. Remember "Priumum non Nocere." After witnessing an addict in iatrogenic withdrawal once, I'm more likely to give 0.2 to 0.4 mg or simply intubate the patient and wait.
Thiamine is safe and potentially helpful. While we still give it to the patient with alcoholism, the population that seems to need it the most these days are the post-gastric bypass population.
Get a pregnancy test
Relevance: Very High
I remember a story about a seasoned senior EM attending being asked what the biggest development of his career was. The answer? The urine pregnancy test. Any female, age 10-55, deserves this quick test. You'll lose count of how often your workup will be changed by the results of this test.
Assume the worst
Relevance: Very High
Amal Mattu likes to quip, "When emergency physicians here hoofbeats, we think lions, and tigers, and bears." We aren't after the zebras. Whatever can kill the patient we rule out first. Only then do we move on less severe and more likely conditions. Check your attitude at the door. Don't get hung up on the 20/10 pain while the patient sits eating a bag of chips. Take them at their word, do your best exam, and give them the benefit of the doubt. You will be humbled time and time again by the seemingly stable patient who tries to die, sometimes successfully, in front of you.
Do not send unstable patients to radiology
This is one area that has changed in recent years. It no longer takes as long to get studies done, and sometimes that septic elderly patient will need a CT to find the phlegmon of infection. I would change the commandment to: Do not send unstable patients to radiology alone; you must go with them. If conditions exist which can be fixed first then do so: secure the airway, begin fixing volume problems, etc. If an alternative exists, such as bedside ultrasound, use it to your advantage, but don't fail to make the diagnosis simply to avoid taking the patient out of the department. Oh yeah, and when you take them, take the right equipment too.
Look for common red flags
I always get a little but of a laugh when reading this one. It talks about FOUR vital signs! With pulse ox and capnography and pain (really?) we have more vitals than we know what to do with! The point is simple: look at the vitals and explain them. Your history will gain you more than an entire battery of labs. Ask about comorbidities. Ask about risk factors; that patient with an IV drug addiction who has back pain and a low grade fever isn't looking to score narcotics. Remember the extremes of age. Pay particular attention to revisits. These patients are giving you a second or third chance to make the correct diagnosis. And remember, before anyone goes home, they must be able to eat and walk.
Trust no one, believe nothing (not even yourself)
Anything that any tells you, in person, or in writing, might be false. The "frequent flier" may be in the department often, but also might have real disease. Always start with a open mind, talk to the patient, examine the patient fully, and look at every image and study yourself. Remember, the cardiologist and radiologist aren't seeing the patient and can miss significant findings.
The same advice applies to your teachers, and to this post. Be skeptical but not cynical. Take the time to check the facts, read the literature yourself, and try both old and new techniques. Did you find an absence of evidence about a treatment? You may have just found your research project!
Learn from your mistakes
I've learned far more from my mistakes than my successes. We all make mistakes. The important part is to learn from them. Possibly even more important is learning OF them. Emergency medicine is particularly prone to an absence of feedback about our mistakes. Did you have an uncertain diagnosis? Look into the case and follow up on the patient after discharge. Learning about our errors is essential to improving our practice.
Since we all make them, try not to judge others by their mistakes. Learn from their errors, but look deeper as well. Were there any system issues, communication errors, etc, that may have contributed to the error? Can any of these be fixed to prevent the error from occurring again?
Do unto others as you would do to your family (and that includes coworkers)
You'll more often do the right thing when you follow this maxim. Respecting our patients, colleagues, and coworkers demonstrates the caring attitude expected of a good physician. And remember this if you decide to be rude: "The toes you step on today might be connected to the backside you need to kiss tomorrow."
When in doubt, always err on the side of the patient
We see the patients that society and even healthcare tend to forget: the homeless, the addicted, the psychiatric, etc. We need to be the ultimate patient advocate. We strive to relieve suffering. To do what is right for the patient, we need to consider the course of action that would minimize their suffering and keep the patient safe. This will unfortunately put us at odds with our administrators, and at times, our peers, but if we fail to take care of our patients, then no one else will either and we will have violated our sacred oath.
As you can see, despite being 20 years old, these "commandments" still have a significant amount of relevance today. For sure, they could be added too, but for the start of your career, paying attention to this short list will help you to save lives become a better emergency physician.