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Top 20 "Do Nots"

Discussion in 'Emergency Medicine' started by DrQuinn, Jun 5, 2008.

  1. DrQuinn

    DrQuinn My name is Neo Moderator Emeritus 10+ Year Member

    Dec 6, 2000
    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.


    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?

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  3. roja

    roja 7+ Year Member

    Oct 20, 2003
    NYC--->San Francisco
    1. Don't sign out a pelvic, lp or lac repair.

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

    docB Chronically painful Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 27, 2002
    Las Vegas, NV
    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.
  5. that dr. jack

    that dr. jack Captain Bringdown 7+ Year Member

    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.
  6. GeneralVeers

    GeneralVeers Globus Hystericus Physician 10+ Year Member

    Mar 19, 2005
    Las Vegas
    Do not cherry-pick and leave the vag bleeds, peds patients, and lacs to your fellow residents/attendings.
  7. spyderdoc

    spyderdoc Physician Moderator Emeritus Lifetime Donor Classifieds Approved 15+ Year Member

    Jul 30, 2002
    SF Bay Area
    Do not EVER let go of the guidewire
  8. GeneralVeers

    GeneralVeers Globus Hystericus Physician 10+ Year Member

    Mar 19, 2005
    Las Vegas
    Do not use the words "not busy", "slow", or "quiet" around any of the nurses unless you wear a helmet to work.
  9. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner Moderator Physician Faculty 10+ Year Member

    Aug 2, 2006
    Thiamine and folate before sugar in the drunk.
    When it comes to sick or not sick, always trust your gut.
  10. Dr. Will

    Dr. Will 10+ Year Member

    Feb 27, 2002
    Houston, TX

    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.
  11. dirtridndoc

    dirtridndoc DirtRidnDoc 2+ Year Member

    Jul 4, 2007
    Danville, PA
    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?"
    Last edited: Jun 5, 2008
  12. CueDoc

    CueDoc 5+ Year Member

    Nov 3, 2006
    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.
    Last edited: Jun 5, 2008
  13. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

    Nov 2, 2004
    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.
  14. igcgnerd

    igcgnerd Hawkeye 10+ Year Member

    Apr 3, 2006
    You're not dead until your warm and dead.
  15. emedpa

    emedpa GlobalDoc 10+ Year Member

    Aug 25, 2001
    Taking an Away team....
    I got this from a cme lecture:
    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
    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
    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 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
    48. it's only epididymitis
    49. assume all dysuria =cystitis
    50.assume 5-10 wbc's in urine=uti= reason for abd pain
  16. Seaglass

    Seaglass Quantum Member 10+ Year Member

    Jul 25, 2003
    Winston Salem, NC
    Do not piss off the nurses - you will pay dearly for it.

    Bears repeating. Actually it could be all 10 things.
    Last edited: Jun 6, 2008
  17. Arcan57

    Arcan57 Junior Member 10+ Year Member

    Nov 21, 2003
    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.
  18. igcgnerd

    igcgnerd Hawkeye 10+ Year Member

    Apr 3, 2006
    Nobody knows your patient better than you do.
  19. Old_Mil

    Old_Mil Senior Member 10+ Year Member

    Nov 19, 2004
    There are three things that can happen when you give someone Vicodin, and two of them are bad.
  20. 1stresident


    Jun 3, 2008
    "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.
  21. bartleby

    bartleby Senior Member 10+ Year Member

    Jan 17, 2005
    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".
  22. Dr. Will

    Dr. Will 10+ Year Member

    Feb 27, 2002
    Houston, TX
    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.
  23. crewmaster1

    crewmaster1 Nattitwo 10+ Year Member

    Jul 26, 2005
    The Great Northwest
    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).
    Last edited: Jun 8, 2008
  24. ccfccp

    ccfccp Stays crunchy in milk! 7+ Year Member

    Aug 12, 2007
    Tourist Mecca, USA
    Never give a beta blocker to a pt with cocaine on board.
  25. Flopotomist

    Flopotomist I love the Chicago USPS 7+ Year Member

    May 22, 2005
    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...)
    Last edited: Jun 8, 2008
  26. ccfccp

    ccfccp Stays crunchy in milk! 7+ Year Member

    Aug 12, 2007
    Tourist Mecca, USA
    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.
    Last edited: Jun 8, 2008
  27. 8744

    8744 Guest

    Dec 7, 2001
    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.
  28. gasolino

    gasolino 2+ Year Member

    Apr 17, 2008
    classic line but so true
  29. theCamel

    theCamel wessssside 5+ Year Member

    Sep 18, 2006
    do not give 'just a little IV lopressor' to the tachy patient with asthma LOL
  30. JkGrocerz

    JkGrocerz Member 5+ Year Member

    Nov 8, 2005
    and nowadays, we shouldnt be reflexively giving iv lopressor anymore in the ED for ACS...especially if they're tachy
  31. docB

    docB Chronically painful Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 27, 2002
    Las Vegas, NV
    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.
  32. subtle1epiphany

    subtle1epiphany Junior Faculty 10+ Year Member

    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

    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!
  33. AmoryBlaine

    AmoryBlaine the last tycoon 7+ Year Member

    May 1, 2006
    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.
  34. subtle1epiphany

    subtle1epiphany Junior Faculty 10+ Year Member

    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.
  35. Chronic Student

    Chronic Student So Fresh, So Clean 5+ Year Member

    Feb 7, 2006
    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.
  36. subtle1epiphany

    subtle1epiphany Junior Faculty 10+ Year Member

    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.
  37. BADMD

    BADMD Physician 10+ Year Member

    Dec 28, 2006
    Don't order a test, then ignore the result.
  38. fab4fan

    fab4fan TiredRetiredRN Classifieds Approved 10+ Year Member

    Jun 29, 2002
    Desolation Row

    Sorry, but when I worked in the ED, it never failed...
  39. NPR

    NPR 2+ Year Member

    Jun 14, 2008
    Don't close facial wounds with staples.
  40. Chronic Student

    Chronic Student So Fresh, So Clean 5+ Year Member

    Feb 7, 2006
    Don't trust the triage eval.

    How many times have you been burned by fast-track patients?
    moestown1016 likes this.
  41. dpmd

    dpmd Relaxing Physician 10+ Year Member

    Sep 14, 2006
    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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