The Rules for the ER
Greetings to all new ER interns. Your residency program signed you up for a free monthly magazine you lucky dogs. Now that you are committed to ER I figured I should bestow some grandfatherly advice which I learned from reading House of God. If you have never read House of God by Samuel Shem, go read it right now. You’re back? That was quick. Well done.
In House of God the Fat Man outlines the rules to his naïve and eager protégé, who quickly learns the wisdom of knowing when to do nothing and when to act (in that order).
In the complex and constantly changing environment of the ER, you must have a method to maintain your sanity. Personally I have done this by storing all of my feces in an enormous bin. You laugh, but some day a bus full of resistant C. diff patients will come in. Where would you be then? I’ll be ready, shoveling dose after dose of Dr. Brandt’s Steamy Colon Magic through NG tubes. You, however, need some tips.
Thus, with my apologies to Dr. Bergman (Shem), I give you the Five Rules for the ER.
Rule #1: Panic later.
Have you ever seen single digits on a pulse ox? How about someone rushed in through the front door after being shot? How about an apneic neonate? This is the time to act, not the time to flip out.
We have all had sphincter tightening cases. Some shifts I swear I could crack walnuts with my anus. However, the second you let that demon of distress and panic take over, you have lost the game. Even when the colostomy bag splatters against the fan, never let it show.
Why is it so important to stay calm? Think of famous meltdowns, who do you want to be? At the end of Christmas Vacation, Chevy Chase rants to his boss. In Ferris Beuler’s Day Off Cameron crashes his father’s Ferrari and crashes it through the garage. Sometimes I feel like Adam Sandler and I want to scream at my patients “Get in your home! Are you to good for your home!”
You need to be Jules from Pulp Fiction telling Honey Bunny to be like Fonzie, and what is Fonzie like? Cool. You want to be the hero at the end who keeps walking away with his shades on despite the giant explosions. You do not need to look back at the explosions, you can panic later.
Rule #2: When in doubt, you might want to look at your patient.
Every ER physician has had crazy-busy shifts where someone just does not seem to improve. During these shift sometimes labs and orders get thrown in with a cursory exam (or sometimes a flyby the room on your only trip to the bathroom in 6 hours). Despite a slew of negative lab work the nurse still says the patient looks worse. Still want to discharge her?
When you eventually get around to re-evaluating the patient, you realize that she has a decubitus ulcer which resembles a dachshund covered in ten pounds of seaweed. Her temperature is now 103, her heart-rate is 157, and her color has a distinctly Yoda-esque quality.
“Looking? Found the source you have, hmm!”
Rule #3: The enemy of good is better.
The patient with the sprained ankle had a pressure of 220/110. Now she has a pressure of 178/110 and is feeling fine. Good, send her home. You don’t need to make that better. Put that clonidine back in the pyxis. She does not need a pressure of 85/22.
This is not permission to be lazy. If a pressure is tanking, put in the central line and get moving. But in that patient you have worked up for his hyperglycemia, keep your wits about you. He came in with a glucose of 454. You gave him fluids and checked for DKA and everything is negative. His glucose is now 302. Great. He has close follow up? Wonderful. Check old records and you find out that is the lowest his glucose has been in two months. Great. He is good. You can put that dose of insulin next to the clonidine in the pyxis.
Rule #4: Leave your garbage outside.
The importance of positivity cannot be understated. Leave whining at the door and come in spewing positivity like a variceal bleed of joy. If you are feeling especially Eeyore today, throw on a smile and fake Tigger to the best of your ability.
No patient you see today started their day planning to do so (unless their looking for drugs (that doesn’t ever happen (every single (shh, it’s an article, we’re dreaming here) shift) except days ending in “day”) that rhyme with pellaudid). She was not planning on having severe lower abdominal pain today. She did not wake up thinking “oh boy I hope I can sit in a crappy gown, in pain, and have a stranger look at my crotch (you hope).”
No matter how bad your shift is going your patients day is usually going worse.
I love whining about my job. I love to pontificate with glorious embellishment about various interactions. Get a group of ER docs together and they will start trading war stories in under four minutes, it happens every time. Do that at home and be uplifting at work.
Rule #5: Let it go.
This rule might be counter-intuitive to the newbies out there.
This does not mean to ignore abuse or people in agony. No. This is the advice to stop helping people when help isn’t needed.
You know that drunk patient who keeps wandering the halls in his whitie-tighties with both legs through the same hole? He looks you straight in the eyes and says “F&$# you!” The nurse is calmly guiding him back to his room. Do not get rattled.
I had a guy come in after going over his handlebars. He had a few broken ribs and a pneumothorax. His main frustration was that his racing season had abruptly ended. His comment to me? “You have way to much gel in your hair, dude.”
Let it go. He had a bad day, and I know my hair looked fantastic.
An elderly drunken patient yelled at me continuously while spitting at staff. He had broken his leg due to excessive gravity but demanded to leave. He needed physical and chemical restraints for his (and our) safety. Here is where it became tricky.
While awaiting pharmaceutical dampening of his insanity, his son arrived and began screaming at everyone. He (son) then demanded his father’s discharge. Psychotic father remained agitated since the medication had just been given.
After convincing the son that we actually were trying to help, he acquiesced and everything turned out great. Everything except the frustration and anger of being yelled at non-stop by two people for doing the right thing.
Let it go.
Do the right thing, and then let it go.
Then ask them if they would like to try a sample of Dr. Brandt’s Steamy Colon Magic.