Top 10 Tips for New ED Docs
Author: Alastair Ireland
Most doctors about to start an ED post – especially their first – approach it with a degree of trepidation. They’ve heard from others about terrible rotas, the stress of working in a busy department and the desperately sick patients. But also the weird and wonderful cases that others have been involved in. They wonder if they will have the skills to manage.
The truth is that a job in the ED will be one of the most stimulating and exciting jobs that you will ever do and just about everyone who has gone before you – whether they thrived or just survived - looks back on the post with great memories and experiences that will stay with them and help them throughout their careers. You will be no different!
Yes, the ED can indeed be a dangerous place but there are people there who will support you, teach you, provide advice 24/7 and help to ensure that that this job will give you the confidence to manage a huge range of emergencies and for the first time, make real decisions on your own. We hope this short post will give you tips on how best to approach clinical encounters (once you’ve gone past ABCDE), show you some traps and pitfalls to avoid and give suggestions on how to make referrals and safely discharge patients. We will also explain how to approach asking for advice and managing difficult patients.
But first a starter for 10.....
So why is the ED dangerous?
The range of presentations to ED is limitless and you can’t possibly know how to manage all that you will see. Some say A&E stands for: Anything and Everything. Sure it’s a challenge, but for most doctors and nurses in ED that is exactly why they love the job. Nor do people ever present with textbook histories and examinations. Invariably the presentations are atypical and complicated by incomplete histories and co-morbidities, which can really test your problem solving skills.
Every person you see will be a stranger to you and you have to very rapidly establish a rapport and gain their trust just when they are feeling at their most anxious and vulnerable. They are often distressed – which of course can manifest itself in a variety of ways.
And everything is time-critical. Even if your patient’s presentation is not immediately life or limb threatening, you have to be ‘acting fast’, quickly getting to the nub of the issue but also thinking continuously of flows in the department. Major EDs have 200-300 presentations every day with 25-30% of these needing admission and if you can’t keep moving your patients towards decisions and appropriate treatment, queues will form. This is one of the hardest concepts to grasp but you need to be constantly mindful of the other patients waiting to come into cubicles who – even after initial triage assessment - could be sitting in a corridor or waiting room with an unrecognized MI, sub-dural, sepsis or stroke. Studies show that mortality rises when EDs are crowded and patients can’t access a cubicle for assessment. So there is a fine line to find in which your assessment is sufficiently thorough to make safe decisions but not taking too long and indirectly causing harm to others who are waiting. But it's not easy and it’ll probably take you to about the end of your rotation to get the hang of this!
Also – yes there’s more! – you usually need to manage several patients simultaneously, not get muddled up and crucially take real care that the right labels go on the right bottles and sharps go in the right place.
You’ll see patients who present with symptoms suggesting catastrophic illness who turn out to have nothing wrong and – more worrying – people who present with seemingly innocuous issues who are actually very unwell and you need to keep an open mind at all times.
Given all that is going on, you can see why the intensity of decision making in a busy ED is almost certainly greater than any other area of medicine and you are constantly reminded that (in the words of a certain TV series) ....
“You know nothing” and
“Winter is coming”!
So how will we keep you and your patients safe?
It probably helps to know that your seniors know that you “know nothing”. Indeed seniors get more worried by a junior new-start who seems to be making bold decisions than one who asks for advice. You are not expected to have this cracked on Day One. Admit this and set about being open to learning as much as you can and you will be fine. Here are Ten tips to keep you right:
1. Treat People not patients
No matter what, approach each new person you treat as just that … a person. Imagine how they are feeling or if how you would manage them if they were a friend or relative of yours. Always introduce yourself and if they’ve had a long wait just come straight out and sincerely apologise for the delay. An ideal introduction is to ask them how they are feeling now, followed by a broad opening starter - which works in just about every situation – such as “So what’s been happening?”
And then shut up! Just listen. Let them tell their story. Don’t interrupt. Once they’re finished you can then zero in on the key points and begin narrowing the options down. One of the commonest mistakes in history taking is not actually listening, jumping to conclusions and then firing a series of interrogatory questions – sometimes almost accusatory – which is guaranteed to start a rapid downhill spiral in the consultation and can lead to serious errors. If you let them know that they’re being listened to, they will begin to trust you – particularly if you appear sympathetic and 9 times out of ten the diagnosis (or the ‘problem’) will be clearly evident after a few minutes.
2. Think what else this could be
Once you have an idea what may be going on, you need to ask yourself two very important questions:
a) How sure (in percentage terms) am I of this diagnosis? and
b) what does the remaining percentage comprise – or ‘what else could this be?’
This is a really important ‘cognitive forcing strategy’ helping you to cover both the System 1 rapid intuitive thinking (described by Daniel Kahneman in his book ‘Thinking Fast and Slow’) to the slower and more analytical System 2 thinking. System 1 is usually right but not always and this System 2 switch is a very important check that you must make to avoid error. One of the commonest errors is ‘Anchoring’ to your original diagnosis – even as evidence gradually mounts up suggesting an alternative is much more likely. Whenever you receive an unexpected result, don’t dismiss it as an incidental anomaly without going back to square one, reviewing the history and rethinking the options. Here is a list of common cognitive errors – the main ones to note in addition to ‘anchoring’ are ‘confirmation bias’, the ‘ostrich effect’, ‘stereotyping’ and ‘overconfidence’
3. Listen to relatives
Always pay attention to what relatives are telling you – whether it is the parents of a child or the family of an older patient – as they really know the person and their insight and instincts are usually right. Always make sure that they are in the room, especially where elderly patients are concerned, as sometimes they are asked to wait in waiting areas while staff put people in gowns, do ECGs etc.
4. Let people know they can come back
The six words that strike terror into the hearts of ED doctors: “Remember that patient you sent home …?” Suddenly you feel an icy hand grip your chest as you try to remember what you said … and wrote. When discharging someone you have treated, always give a reasonable expectation of their likely course, explain how long symptoms may last and always highlight signs to watch for, prompting a return visit. And write it down. In fact, best to advise everyone to just come back if they’re worried. It is very unlikely that they will, but both you and your patient are protected by this advice if anything goes wrong or has been missed.
5. Geography is destiny
Triage usually determines the area of the ED in which the patient will be seen and assessed. Occasionally this can be wrong and the danger for us is that we have an understandable tendency to have a ‘mindset’ approach which varies depending on which area we are in. Everyone in Resus (almost without fail) has venous access, bloods, a venous lactate and ECG and CXR within minutes of arrival – whether they need it or not! In minors conversely, bloods are rarely drawn and ECGs are rarely obtained. Observations may not always be recorded. It is really important that you keep an open mind. One of our team recently saw a patient in minors with an oddly discoloured toe after apparently stubbing it – while most might have x-rayed it, she was concerned and moved the patient to Resus, where within 30 minutes they were intubated and ventilated and receiving treatment for meningo-coccal septicaemia!
6. Vital signs are vital
Always write down the Vital Signs – this is a useful way to ensure that you won’t miss an abnormality in a patient who seems otherwise well. Don’t send a patient home with abnormal vital signs until you have corrected them or found a reasonable explanation for them.
7. Ask for advice
Advice is ALWAYS available. Please don’t phone other specialties for advice unless your senior has suggested it. Many of the page-holders will be at a similar career stage to you and are unlikely to be able to answer a question that your registrar or consultant can’t answer. When we ask for external advice, we need a definitive answer from a senior person in that discipline – not a vague promise to pop down at some point and have a look or a suggestion that we organise a CT. When you do ask a senior for advice, do be careful not to be seen asking another the same question. New ED docs do tend to rotate around the seniors asking for advice, as they understandably don’t want to be seen to be asking too many questions – but don’t worry, we know this will happen and we’d rather you asked than dithered around not quite knowing what to do.
8. Hit your referral goals
There is a particular skill to making referrals (and summing up cases for advice from seniors) and the SBAR (Situation, Background, Assessment and Recommendation) format is good to keep in your head. Your first sentence should sum up the whole ‘situation’ and place the person you are speaking to into the correct mindset for your further information: “This is a 65 year old male, NEWS of 0 with cardiac sounding chest pain, normal ECG and troponin of 9 who I plan to admit for observation and a 3 hour troponin”. Right, now we know what you’re talking about. Now give some ‘background’ – just the positives and key exam and test findings. So my assessment is – this is normally a reiteration of the ‘situation’ and then your ‘recommendation’. Everyone is busy and (ED doctors in particular) have short attention spans so don’t waffle. Think of yourself as lining up to take a penalty: you know where the goals are … choose where you are going to aim the ball and put it there, precisely and firmly!
9. Mistakes are twice as likely with difficult people
You will encounter many situations where people can be difficult to assess – often due to intoxication or underlying mental health problems. It can be frustrating trying to establish the facts in these situations but one sure-fire way for the consultation to break down is if you become irritable yourself. Try as hard as you can to remain open, friendly and show that you are here to help. The vast majority of people respond to this and when they realise that you are on their side, usually quickly calm down and become much easier to assess. Taking an officious tone in these situations is totally counterproductive. No matter what their social situation or circumstances, people have a certain pride and respond very poorly to any perceived lack of respect. These are the very situations when you will miss important pathology. Just remember: adverse events are known to be twice as likely to occur in people with mental health problems. And if you can’t walk, you can’t go home. This applies in intoxicated people who quite often may require a short period of admission to ensure that they are safe on their feet before they leave – to prevent further injury and re-attendance!
10. Realistic Emergency Medicine
It’s okay for people (with capacity) to decline treatment or admission. All your plans should be made with people and it's important to remember that while there may be very compelling reasons for someone to follow your advice on treatment, that may not be the right thing for that person at that particular time for other reasons in their life that are more important to them. Rather than reaching for the “Irregular Discharge’ form, check their understanding of the situation, ask them what their concerns are and what they were hoping the outcome would be. Find out what matters to them. Then explore options and alternatives, ensure that they understand the true risks and also ensure that they know that they can return in the event of a problem. This is eloquently described by Dave Caesar from Edinburgh in this post and is part of the person-centred approach advocated by the Chief Medical Officer for Scotland in the recent publication “Realistic Medicine”(2). Remember back to Tip number 1: we treat People not Patients.
Finally, do remember that you are working in a highly public area and in many EDs people waiting in cubicles and corridors – with nothing else to do – can often hear every word you say. Discussions about interesting cases interspersed with laughter don’t create the best of impressions so try to keep the volume down as much as possible.
So there you have it – all you need to know on day one! Hopefully this will make you feel a little more confident. There’s lots more to learn and the other pages of this site are a great start in some of the essential knowledge you’ll need. Everyone who works in ED – no matter how experienced - learns new things every day. So final words: work hard, but be curious, care for your patients, learn from them and enjoy.
1. Thinking Fast and Slow. Daniel Kahneman. 2011. Published by Farrar Strauss and Giroux
2. Realistic medicine: http://www.gov.scot/Publications/2016/01/3745