I recently posted a question to the Twitterverse:
“Imagine that an Emergency Medicine intern asked you for advice before his/her FIRST SHIFT. What would be your FIRST ADVICE?”
I also raised the same question in Turkish. In a couple of days, I received nearly 100 answers from reputable names of Emergency Medicine working worldwide. I highly benefited from these advice, and I think that our site’s valuable readers can also benefit. I tried to select the most inspiring ones and divided them into main categories. Under each advice, you can find the name of the tweet owner and the link to the original tweet. Let’s start.
Imagine that a new Emergency Medicine resident asked you for advice before the FIRST SHIFT. What would be your FIRST ADVICE? (The answers will be used for a blog post- Pls RT to spread) @EBMgoneWILD @EM_Educator @EM_RESUS @emcrit @Damian_Roland @FOAMpodcast @ssuner @FOAMedinburgh
— İbrahim Sarbay (@ibrahimsarbay) July 3, 2020
Core
Enjoy being on the frontline by helping patients who are seeking your help in their most difficult time. This is a great privilege and responsibility that we should never forget.
Never forget what a privilege and responsibility it is that people don’t know you ask for your help on the WORST DAY OF THEIR LIFE.
In the Emergency Department, you may be worried about 'why am I here?' one day, but you may think that you are doing the best job in the world another day. Now you have a lifetime which every day and every patient is different. Love your profession EVERY WAY, glorify knowledge and skill, and always be at peace with your job.
Education
Never be afraid to say, "I don't know." It's why you're here to be taught. If you already knew everything, then you wouldn't need residency.
Trust yourself as if you know everything, try to learn as if you know nothing.
Want to get smart? Do 2 things: 1) Read up on at least 1 patient every shift. 2) Ask lots of questions to residents, attendings and consultants.
Feel free to ask me (or another senior) about anything (/everything). When I was at that stage I wish I’d asked more. I suspect some people think asking is a sign of ignorance or weakness. Actually, it helps us to be safe & to appreciate other perspectives.
This is the Emergency Room; this is the lion’s den; first, you have to protect yourself, and you will do this with your knowledge. So don't think ‘I'll practice, I'll fill my knowledge gap in 3-5 months', sit down, and read the textbook.
First compel yourself to read at specific points, and gradually you will find your appetite for reading. You are the one primarily responsible for your education!
Never feel shy to ask or say I don't know. It's your chance to make mistakes and learn, share the knowledge you have and don't keep it to yourself.
Of course, you cannot know everything, but you can start learning.
80% of “KNOWLEDGE” is "INTEREST"
Resilience
The Emergency Medicine career is a marathon, not just the first few years of residency. Don't waste your energy inordinately for things you can't fix. Invest in the future self.
When you dance with the bear you can't stop until the bear wants to stop.
Calm down. Every shift eventually ends.
Rest and eat, whenever you get the opportunity. The Emergency Room is like a HIIT, you need to slow down first to speed up.
If you are a parent, sleep when the child sleeps.
Empathy
Don’t judge patients or consultants without walking a mile in their shoes.
Think of every patient as your relative. Balance your professional authority with your kindness.
Communication is important. Tell the patient and one of his/her relatives what you already did and what you plan to do, and ask if there is anything they want to ask.
Peter Rosen once said, “Nobody woke up this AM decided to ruin your day.” Happiness is YOUR choice. Be happy, stay positive.
Remember, when you see a patient in the middle of the night who requests you to apply his/her prescribed topical cream on his/her back because –apparently- he/she can’t, that person is the joy of the night.
Follow up on your patients. This will reinforce your learning. Call patients at home to see how they’re doing. They will love it, and it reminds you of why you chose this profession.
Remember to acknowledge that you most likely are a stranger to your patient. It only takes a few minutes to reassure someone that you are there to help them through their ER experience as a team. We tend to forget this in the busy ER.
Values
Nobody expects you to know much (yet). But it is expected you to be 100% reliable. Never EVER EVER EVER lie. If you don’t know something or you don’t do something, be honest.
Your attitude to this advice will determine your path through our specialty. The blindingly following advice will bring as much peril as ignoring it all. Emergency Medicine requires you to consider impacts on patients, professionals & the populations - no one approach fits all.
Never EVER EVER EVER be arrogant. You will be wrong many times in your career. Learn humility NOW.
What I like most about emergency medicine is how it allows us new perspectives every day. In the pandemic, we are treating the same disease all the time, but each patient and their family brings a different story, and every time I feel more humble in the face of life, the disease, and the future. Being in a LIMC country can be so challenging, so painful to treat and suffer along with inequalities and lack of resources... But we have the opportunity to be our best, as I said yesterday to my residents: we don’t have the best hospital, but we can be our best and give the patient what they may not have in the best hospital: treatment with dignity and respect and love. For me, being able to show my patients that I care, and receiving their gratitude has been undoubtedly the only possible prevention of Burnout. So I would say: Our specialty is beautiful, the opportunity for growth is vast, but it takes humility and perseverance to complete this journey.
Never allow senior residents of other departments to treat you as if you are their junior.
Our fingers are not equal, and so are the attendings whose hands you train on are not the same nature. There is the gentle one who loves you and there are critics who believe that development comes only with criticism and a dose of pain. Your job is not to try to classify them but to do what is required of you and to benefit from everyone.
We want you to be the brain of a machine in which none of its cogs can work properly. Sometimes, even if you don't know how to swim, you will find yourself in the ocean surrounded by the waves, but most of the time, in the hardest moments, you will find a huge army with you. Welcome...
If you think a senior is wrong about something, give him evidence, but don’t be obstinate...
You may be untutored, but never be uninterested. Because knowledge definitely comes to those who have interest.
Appear weak when you are strong and strong when you are weak. Look weak when strong; look strong when weak. Also don't forget to look at vital signs 😉
Don’t be a d*ck.
Enjoy your junior days, qualify for your senior days.
Patient Records
(Carefully) Fill out the patient records. What will save you from everything are these records.
Spoken words fly away, written words remain. Record everything...
What is not written is deemed not done. First, protect yourself and then protect the patient. Choose a good role model.
Workup
No workup can replace a good physical examination.
Never order a test that you won’t check the results.
Know your tests! Know their rough sens/spec and when to trust them (and more importantly, when NOT to trust them)!! No test is 100%, and all are context-dependent!
Decision Making
Being efficient should never be at the expense of being thorough. You will eventually have to waste more time making things right.
If someone brings up a concern, go to the bedside.
Think simple, make a quick decision. Determine the senior you will take as a model.
Once you suspect about a diagnosis, be sure to rule it out.
Do not forget to consider emergencies and other diseases while focusing on frequent diseases of the period, such as COVID. The most important thing that the emergency doctor needs to do is to look at the case from a wide perspective from the very beginning.
Watch out for the last patient who came just before your shift ends.
In emergency medicine [and in life :)] the possibilities are 0% or 100% only in limited scenarios. You need to quickly learn managing probabilities, setting priorities, distinguishing acceptable and unacceptable risks. Also you need to learn reading the environment; because it usually gives many signs before the problem emerges.
Patient in the Resus is easy. Spotting the patient with a real emergency in minors is the tough one.
First rule of emergency response is to ensure your own safety!
When in doubt or worried about someone, talk to floor senior physicians EARLY.
I would say to try your best to remain open-minded and try to be aware of your biases and blindspots. This applies especially to patients with psychiatric illness and substance use disorders. If you're explaining X symptom on Y problem, always ask yourself, "Does this actually make sense?
The most frequently overlooked diagnosis in the emergency room is the second diagnosis! Do not limit your perspective to one diagnosis. Most frequently missed fracture in the emergency room? The second one! Remember that the patient may have a second fracture!
While assessing only isolated parts, don’t miss to assess the patient as a whole. Do not evaluate the patient on a single system, single organ basis. Emergency Medicine requires ‘holistic assessment’.
Discharging
No hospital bed belongs to you. If in doubt, do not discharge the patient.
Do not discharge the patient relying on what someone else is telling you without assessing by yourself!
Do not discharge the patient after midnight: You may be tired, you may overlook something, the patient and his relatives may not find a car or money to leave, or they may try to go to the town or another city but have an accident on the road, etc. Those all happened (Not my personal experience, but I have seen them), evidence based...
Before discharging the patient whose treatment is completed, make sure to think like that: ‘Is there any possibility that this patient will come back with a cardiac arrest before the shift ends?’ If you are hesitant, prolong the process.
The patient at the hospital is better than the patient at home’. Do not discharge if you are not sure.
Team Play
Emergency Medicine is teamwork. Get along well with your colleagues, your nurse, your intern, your staff and your secretary. Find yourself a role model, try to be a good example for others. And enjoy the Emergency Medicine.
You may learn a lot of thing from your nurse, act like a teammate.
That’s all for now. By the way, what would your advice be?