Top 20 "Do Nots"

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DrQuinn

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So I'm trying to compile a list of 20 things never to do in the ED (humor and jokes aside but unless they're good....). So I can pass this off to our interns and residents. Something quick, one liner, but true.

Like:

Stone Heart - Don't do it. Don't give calcium to a person on digoxin (true or not, its a good one liner to remember).

Anyone have any others?

Q

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1. Don't sign out a pelvic, lp or lac repair.



(hard to come up with absolutes but I haven't had coffee yet...)
 
Don't send a non-intubated patient with no gag to CT.

Don't withold pain medication to "preverve the surgical exam."

Don't withold oxygen from a hypoxic patient out of fear of the chronic COPD respiratory depression phenomena.
 
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Don't send a non-intubated patient with no gag to CT.

Don't withold pain medication to "preverve the surgical exam."

Don't withold oxygen from a hypoxic patient out of fear of the chronic COPD respiratory depression phenomena.

i saw an ortho resident attempt this on a sexual assault victim with multiple pelvic fractures. she had been at another hospital without pain meds for 3 days. despite being a med student on an audition rotation, i let him know it was not cool at all and got the attending involved.

kinda glad i didn't match there cuz this guy was a major tool and always seemed to be the one on-call.
 
Thiamine and folate before sugar in the drunk.
When it comes to sick or not sick, always trust your gut.
 
1. Don't sign out a pelvic, lp or lac repair.



(hard to come up with absolutes but I haven't had coffee yet...)


I don't necessarily agree with this. The way our program/shifts are structured, procedures are signed out. My class, and I know the classes above us, all agreed to sign out procedures if we needed too (and it doesn't happen often) unless it would be considered part of your PE or an extension of your PE (ultrasounds). I think this is very dependent on how things are structured during residency. Now there is one caveat...I wouldn't do this in an actual job setting as an attending.
 
Not that anyone in an Emergency Med residency would even think of doing this but ....

Please don't call Family Med, IM or then Hospitalist to admit a patient to the ICU who just rolled into the door in cardiac arrest. :eek:

I swear this has happened to me while working as an FM resident in a community hospital ED staffed mostly by FM board certs. I looked at the doc and said "do you want me to admit them to heaven or the ICU?"
 
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1. If someone has ischemic changes in inferior leads get a right sided ekg (or if you suspect a RCA infarct). DO NOT give them nitroglycerin for chest pain.

2. DO NOT treat sinus tachycardia with a beta-blocker. Look for the underlying cause. (or Do not treat the number, treat the patient)

3. If you don't know what to do, don't do anything.

4. Just because neurosurgeons touch the brain doesn't make them smarter than you.
 
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Do not piss of the nurses - you will pay dearly for it.

Do not ingore red flags.

Do not break your own rules.

Do not start insulin on DKA patients before you see a potassium.

Do not give vitamin K to someone with a mechanical heart valve until you've thought really hard about it.

Do not lie when your attending asks you if you checked something - instead say, "That's #1 on my list of things to do."

Do not criticize other doctors in front of patients - it makes you look at least as bad as them.

Do not ever say about an altered patient, "He's just drunk" without examining the head, pupils, chest, abdomen, and having gotten an impressive EtOH back.

Do not forget to check the dexi. Really, it should be a reflex. ABCDexi...heck - Dexi, ABC.
 
You're not dead until your warm and dead.
 
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I got this from a cme lecture:
general
1. keep pts waiting
2.don't sit down
3.write see your dr if not better on all charts
4.use medical language with pts
5.don't write down details of h+p
6.never call family/friends of pts for more hx
7.assume everyone is drunk
8.don't read rn notes on chart
9. don't ask pts what they want
10.don't call the f/u doctor
eyes
11. give anesthetic eye drops to take home
12.use ophtho steroids without f/u with ophtho
13.don't check visual acuity
14.remove fb's without magnification
15.never look under lids
16.assume all kids with red eyes have conjunctivitis
17.refer to ophtho in 1-2 weeks for acute eye probs
18.neutralize acids with bases in the eye and vis versa
febrile kids:
19.use lots of cough syrup
20.keep the air as dry as possible
21.don't lsten to mom
22. don't record general impression or mental status
23.don't record hydration or skin signs
24.have vomiting kids seen in 4 days if not better
25. don't assume child abuse
26.give phone advice frequently
27.use alcohol baths
28.don't watch kids eat/drink after tx for n/v before going home
ortho:
29. use circular plaster on acute injuries
30.use long immobilization times without f/u
31. don't comment on joint above + below injury
32.keep hands dependent in splints
33.use heat early instead of ice
34.don't chart motor/sensory findings
35.give 2 weeks of pain meds without f/u
36/37/38.don't splint all wrists/knees/thumbs with acute injuries
39.assume all neg xrays mean no fx
40. assume no fx= no problem
head injuries:
41. assume it's the alcohol
42.don't hyperventilate head injuries with aloc
43.don't re=examine pts with long stays in the dept
44.do frequent skull films
45.give lots of fluid boluses
46.don't give instructions to the family at d/c
47.wait to call neurosurgery for as long as possible
urology:
48. it's only epididymitis
49. assume all dysuria =cystitis
50.assume 5-10 wbc's in urine=uti= reason for abd pain
__________________
 
Do not piss off the nurses - you will pay dearly for it.

Bears repeating. Actually it could be all 10 things.
 
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Don't let your ego get in the way of doing the right thing for the patient.
Don't let your consultant get away with doing something that you know is wrong to the patient.
 
Nobody knows your patient better than you do.
 
There are three things that can happen when you give someone Vicodin, and two of them are bad.
 
"Do not cherry-pick and leave the vag bleeds, peds patients, and lacs to your fellow residents/attendings."


I never understood this one though because I actually like the vaginal bleeds. I love to do pelvics. It's another cool procedure in my book. I mean it takes skill, just like a central or a lac repair or something.
 
there is one caveat...I wouldn't do this in an actual job setting as an attending.

If you know you shouldn't do something in an "actual job" why would you do it in residency? Unless you have a plane to catch and are straightforward about asking the person taking over for you to something, the last thing that a person coming on shift diving into a couple of new patients needs is to spend an hour doing cleanup on your signed out patient.

From the patient's perspective, it is difficult enough to trust someone you've spent maybe 15 minutes with to let them do something as invasive as a pelvic or an LP on you (or your loved one). It doesn't get any easier when someone walks into the room essentially saying "I don't know you, but I've heard some stuff about you, and now I'm here to do x to you".
 
If you know you shouldn't do something in an "actual job" why would you do it in residency? Unless you have a plane to catch and are straightforward about asking the person taking over for you to something, the last thing that a person coming on shift diving into a couple of new patients needs is to spend an hour doing cleanup on your signed out patient.

From the patient's perspective, it is difficult enough to trust someone you've spent maybe 15 minutes with to let them do something as invasive as a pelvic or an LP on you (or your loved one). It doesn't get any easier when someone walks into the room essentially saying "I don't know you, but I've heard some stuff about you, and now I'm here to do x to you".

It's the culture in our program...that's all there is to it. Our class has decided that this is the way we want to do things. No one is "cleaning anyone's mess up", we're helping each other out get out on time. That's what we have decided to do. They aren't going to be there any longer by helping a classmate out. Besides...sometimes you get called away on a flight towards the end of your shift and there is a ton of stuff left to do...again we call it helping each other out. It doesn't happen on a daily basis, but it happens.
 
In response to bartleby with regards to Cinci and Dr. Will:

We have decided to sign out procedures to the other residents at shift trade. But a pelvic or rectal is not a "procedure" it is part of the physical exam and can't be signed out. As far as doing procedures on people you have never met, it is just the way our program works. The second year residents do all procedures in the trauma bays, so on a daily basis we walk up to someone we have never met and do an CV line, A line, tube, lp, etc. We have a little phone and when the R3 in the trauma bay calls we come do the procedure. So signing out procedures to be done to the oncoming resident likely makes no difference because neither of us "know" the patient. This helps us get out on time because we do a ton of procedures and fly as R2s and manage an 8 bed pod. Obviously we don't sign out airways because those can't just wait!

I think it also depends on how you present yourself to the patient and family (first off many patient's getting these procedures are so sick they don't care at the time) and you don't just walk up and say "I don't know you, but I've heard some stuff about you, and now I'm here to do x to you." You say, hi I'm Dr. X, the procedure physician here at UC. I understand you need x because of X. My understanding is you have already discussed and been consented for x. Briefly, this is what that procedure is, this is how it is done, do you have any questions? Believe me it works very well. Many people like it because they feel like you are the "procedure doc" that does all of these procedures so you are experienced (which is true and not a false impression because we are doing a ton of procedures) and they feel like you are completely dedicated to them and their procedure at that moment, rather than the busy R3 that they see running all over the resus bays and dept (again you can shatter this belief if you get a flight, but that is the way it goes).
 
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Never give a beta blocker to a pt with cocaine on board.
 
Never give a beta blocker to a pt with cocaine on board.

There was just a bunch of articles about this in a recent Annals of EM - it might be an urban legend despite how much physiologic sense it makes. Don't have the articles in front of me though...

(I am such a dork for reading this as a med student...)
 
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Aacckk!! I'm obsolete already! I'll have to look for those.

Edit: Here's the article if anyone's interested:
Cocaine, myocardial infarction, and beta-blockers: time to rethink the equation?


Ann Emerg Med. 2008 Feb;51(2):130-4. Epub 2007 Oct 15.
 
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As for not signing out patients, at my program, we used to not sign out things and as a result our 12-hour shifts started to routinely stretch out to 13 or 13-and-a-half hour sifts with occasional 14s.

This was ridiculous, the only defense being to become a slacker on the last couple of hours of your shift to avoid arriving at the end with three or four really complicated patients who you can't disposition until labs or studies come back.

Most of us now accept signouts from our classmates with no questions asked.

Oh, and I still like doing procedures like lines and LPs so I don't mind getting them.
 
"DO NOT, i repeat DO NOT PISS OFF YOUR NURSES!!!"
classic line but so true
 
do not give 'just a little IV lopressor' to the tachy patient with asthma LOL
 
do not give 'just a little IV lopressor' to the tachy patient with asthma LOL

and nowadays, we shouldnt be reflexively giving iv lopressor anymore in the ED for ACS...especially if they're tachy
 
and nowadays, we shouldnt be reflexively giving iv lopressor anymore in the ED for ACS...especially if they're tachy
Unfortunately we have been saddled with the CORE measures obligations by our hospitals so where I am the EP is responsible for initiating B blockers. We usually give 25 of PO Lopressor. It would be better left for the internists or cards but when you've got to meet CORE measures it's always easiest to bully the contract docs.
 
Aacckk!! I'm obsolete already! I'll have to look for those.

Edit: Here's the article if anyone's interested:
Cocaine, myocardial infarction, and beta-blockers: time to rethink the equation?


Ann Emerg Med. 2008 Feb;51(2):130-4. Epub 2007 Oct 15.

Good article!
A JACC/AHA consensus statement followed on its heels:

James McCord, Hani Jneid, et al
Circulation 2008;117;1897-1907
DOI: 10.1161/CIRCULATIONAHA.107.188950
http://circ.ahajournals.org/cgi/reprint/117/14/1897

The primary author mentioned that although carvedilol has not been studied in this population, it may be show itself as an option, even in acute cases. It's thought that it has a more balanced profile versus labetalol, with more a1 blockade. Interesting stuff...!:D
And Flopotomist, if you're a dork, then I'll join you in the corner with the "dunce" cap!:thumbup:

Back from the tangent, I'm enjoying the thread! Keep it going!
 
There was just a bunch of articles about this in a recent Annals of EM - it might be an urban legend despite how much physiologic sense it makes. Don't have the articles in front of me though...

(I am such a dork for reading this as a med student...)

Hardly my friend. The real dorks are the ones who think that memorizing "Blueprints Medicine" or "Step Up to the Wards" is going to give them all the knowledge they need to know.
 
Hardly my friend. The real dorks are the ones who think that memorizing "Blueprints Medicine" or "Step Up to the Wards" is going to give them all the knowledge they need to know.

I completely agree with the above!
Journals are fantastic and I will admit that I'm rather "addicted" to reading articles. It's always exciting to find out new things and review articles with concise overviews of the pathology, diagnosis, and treatment are a "treat" to read. :laugh:
There's a large component of mental masturbation, but trust me, you'll be a better doc for keeping up and being inquisitive, you can't go wrong there! I'm confident in saying that even as a MS 3-4.
 
I completely agree with the above!
Journals are fantastic and I will admit that I'm rather "addicted" to reading articles. It's always exciting to find out new things and review articles with concise overviews of the pathology, diagnosis, and treatment are a "treat" to read. :laugh:
There's a large component of mental masturbation, but trust me, you'll be a better doc for keeping up and being inquisitive, you can't go wrong there! I'm confident in saying that even as a MS 3-4.

Awww, look its an internist in the making. How cute!

Ya know I'm just giving you grief.

If you actually enjoy reading journals than more power to you. I'm glad we have people like you.
 
Awww, look its an internist in the making. How cute!

Ya know I'm just giving you grief.

If you actually enjoy reading journals than more power to you. I'm glad we have people like you.

It's true, it's true...:oops:
But what can you do other than go with it? Not like it's all journals or all articles...gotta be good and interesting, clinical too...basic science is generally too dry and less interesting to me.
 
Don't close facial wounds with staples.
 
Don't trust the triage eval.

How many times have you been burned by fast-track patients?
 
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Don't close facial wounds with staples.

I worked with a plastic surgeon who would argue that it didn't matter what you closed with as long as you take it out early enough. Not that I'm advocating staples, but they would give a better result taken out at day 3 or so than an fine suture left in for two weeks.
 
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