Advice for off-service interns starting in the ED?

[Depakote]

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Hi all,

I'm about to start my PGY-1 year and I'll be rotating through the ED first.

I never rotated through there as a med student and I'll still be getting used to a lot of the aspects of acting as a physician. Tack on the fact that I could still draw a 4th of July shift as one of my first, we're looking at lots of potential fun. Given the unique nature of the ED, I was hoping for a little advice.

Suggestions, words of wisdom, things you wish you knew when you were in this spot, things you wish your interns knew when they started? I'll pretty much take anything that can make me feel a little more steady when I hit the ground.

Thanks,
Depakote

BTW. I did use the search function... no real success, but I'll happily read any threads you'd like to link.

 

[Tiger26]

Welcome--

Here's a few thoughts:

-If you aren't sure about something, ask

-be nice to the nurses

-if something doesn't seem right, it isn't

-be aggressive treating pain and nausea/vomiting

-order CT's early on the elderly with abdominal pain

-if the thought to intubate crosses your mind, chances are you should intubate

-try to find out what's changed lately for somebody to come to the ED

-find a few minutes to eat and go to the bathroom during your shift

-don't take more pt's on than you're comfortable with

 

[pratik7]

Check in on your patients frequently. See if the asthmatic is feeling better post nebs. Is the old dude with chest pain still chest pain free. Serial abd exams. retemp the kid with a fever. If they are not getting better, it may mean they are getting admitted when you thought they maybe going home otherwise.

 

[Arcan57]

If someone looks sick, then get your upper level. CP patients with ischemic changes on EKG need the cath lab, not a 40 minute H&P. Also, will agree with re-evaluation frequently, it's a different paradigm then the q12-24h rounds of the floor. Have as many patients as you can manage and still be able to tell me why they are still in the ED. Most off-service interns will either: 1)pick up everybody in sight and know nothing about what's going on with any of them (making their upper level either do all the management or let the patients languish) or 2) only have 1-2 patients at a time and watch the board fill up as they check facebook.

 

[docB]

Try to have in idea of what the disposition for your patient will be. Home or admit. For example most young nausea, vomiting, diarrhea will go home eventually and your goal in the ED is to make them feel better with fluids and antiemetics and rule out real pathology like appy and electrolyte imbalances. Most old chest pain will be admitted and you do the work up to determine the level of care (e.g. CPOU, MT, CCU).

 

[anonymousEM]

-try to determine for yourself "Sick" vs"Not Sick" within the first 10 minutes...SIck = get your upperlevel/attending immediately
-talk to your upper level before ordering any CTs
-Take your relevant H&P then have an assessment and plan...you are a doctor now so tell me as your attending what you're worried about and what you're going to do for the patient, starting with the stuff that's going to kill them
-you don't have to do a test for everything that's going to kill them but be able to tell me what pertinent +/-, physical exam signs are ruling out the stuff like dissection, cauda equina, etc.
-the nurses and techs are your colleagues, treat them as such--with respect
-keep thinking about what you need to do or need to know to be able to dispo a patient. And, tell the patient too. Tell them what to expect...even if that is "I'm going to talk to my attending and we'll be back with a plan" Don't let the admitting physician introducing herself be the first one to tell them you'd like them to stay overnight and don't let the d/c nurse be the first one to tell them they're going home!

 

[Pinner Doc]

You don't have to know everything, but come up with a differential diagnosis on your patients - challenge yourself to come up with at least 5 diagnoses that could fit the bill. Your differential should include "things most likely to kill my patient" and "things that this is most likely to be."

For example: RUQ pain?

* choledocholithiasis
* cholangitis
* cholecystitis
* peptic ulcer disease
* pancreatitis
* GERD
* acute coronary syndrome
* sometimes even PE

Pertinent tests would include CBC, CMP, lipase, EKG (possibly troponin), RUQ ultrasound, etc.

I know this might seem sort of obvious, but I listened to a freshly minted off-service intern try to staff a pt w an attending last night, and I think taking a step back and reviewing this approach would have been greatly helpful.

 

[Depakote]

Thanks all, I appreciate the input.

 

[AmoryBlaine]

Try to get an appreciation for why the ED exists. Think about what we're great at (resus), good at (risk stratification), and terrible at (managing or diagnosing chronic issues).

If you understand the strengths, weaknesses, and capabilities of emergency care you will be miles ahead of most of your colleagues.

Also try to get a handle on the urgent care stuff - splinting, suturing, etc. If you are ever working somewhere were there is a disaster and you can do this you will be invaluable in the casualty tent!

 

[PsyChris]

Medications, Medications, Medications. Know what they do, know how they work and know when to give them.

I've worked with a huge number of med students and this is where they lack the most experience.

Also, treat the patient not the monitor. It takes some time to develop that sixth sense of acuity, so don't worry if you have to use a lot of algorithms at first, it will come to you.

Be very nice to the nurses, if you offer to help them with something they will love you and become your best ally in the department.

 

[The White Coat Investor]

Realize the expectations for you are pretty low. July 1st? Off-service? Everything you do right is bonus. Try to see as many patients as you can. Understand how EPs manage the emergencies pertaining to your specialty so you understand the calls you get later. Try to see stuff that doesn't pertain to your specialty to round out your experience.

Realize that EM isn't about "what's most likely" but rather "what's the worst thing this could be?"

Enjoy the challenge of dealing with undiagnosed complaints. Many specialties do little of this. Heck, just try to admit someone to the medicine service without a definitive diagnosis these days.

 

[Apollyon]

Heck, just try to admit someone to the medicine service without a definitive diagnosis these days.

It's funny you mention this, as, elsewhere on SDN, recently, this was said about IM:

the guy that can diagnose and treat basically everything that comes in

Yeah, except surgical problems, ob/gyn, and kids.

 

[leorl]

The very fact that you're asking this question would put you in the top 10% of all off-service rotators I've ever worked with 🙂.

The main reason ED is a requirement for you guys is for you to see how management in the ED differs from the floors. Medicine and Surgery are very good at saying, "well why didn't x come from the ER and how come you guys can't do x?" Maybe now you'll know (and Remember!) why.

 

[xaelia]

Nothing frustrates an attending more than having an off-service wander out from a 30-minute H&P when they need immediate attention.

If you're going to make a mistake, make the mistake by asking "stupid questions" or bothering an upper level/attending rapidly if you have any inkling this might need more urgent evaluation.