Sunday, June 30, 2013

Advice to new EM interns

The 10 Commandments of EM  are now over 20 years old, but still a must read before intern year. Dr. Rob Cooney did a great review of the original article on Better in EM. The commandments:

1. Secure the ABC’s
2. Consider or give naloxone, glucose, and thiamine
3. Get a pregnancy test
4. Assume the worst
5. Do not send unstable patients to radiology
6. Look for common red flags
7. Trust no one, believe nothing (not even yourself)
8. Learn from your mistakes
9. Do unto others as you would do to your family (and that includes coworkers)
10. When in doubt, always err on the side of the patient

I wanted to add a few bits of advice that have helped me as a resident:

1. Treat Pain. 

While you're debating what labs and imaging are needed to diagnose your patient, it's really easy to forget to treat the symptoms that they came in for in the first place. Do your best to help them feel better.

2. Ask the patient what they think is wrong with them.

On my first week of intern year, an attending told me "Patients will often tell you what they think you want to hear to get them what they think they need. It's your job to figure out what's actually going on."

I've found it tremendously useful to actually ask people what they think the problem is and what their biggest fears are. It has completely changed my management in several cases. Most importantly, it helps me address their specific concerns. The patient complaining of shortness of breath that got discharged yesterday may not actually here with uncontrolled symptoms, he's worried that he has lung cancer and thinks he needs a CT. Addressing those concerns directly makes everyone's life easier.

3. For every test you order, ask yourself why. What are you looking for? How will this effect your management?

Everything you order will cost your patient and/or your hospital money. More importantly, no test is benign. CT's come with radiation exposure and incidentalomas. People generally hate getting stuck with needles. Borderline lab results make dispositions difficult, especially when they are actually irrelevant to the complaint. Don't subject your patient to a more expensive and risky workup unless it's actually going to help them. No one wants to be a VOMIT.

This is a cat. 

4. Learn to put in IVs.

We get really good at ultrasound guided peripheral IVs and central lines, but it's still important to master doing regular old IVs. As long as it's keeping your skills up and not preventing you from seeing enough patients, it's probably not scut work.

5. See the patients that scare you.

When you read a triage note and your first impulse is to avoid the patient, you should probably see them. Confront your fears and your weaknesses and you'll be a better doctor.

That said, if you're concerned about your personal safety, problem solve with your team. The ED can easily devolve into unpredictable chaos, so we all need to be vigilant about keeping our workplace safe.

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