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
Are you a new intern working in the ER? Well, here are some tips.
Thus, with my apologies to Dr. Bergman (Shem), I give you 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 freak out.
We have all had sphincter tightening cases, if not, keep hanging out in the ER and you will soon see some. However, the second you let that demon of distress and panic take over, you have lost the game. Even when the colostomy bag hits the fan, never let it show. Staying calm is imperative.
I will date myself here, but you need to act like Jules from “Pulp Fiction,” telling Honey Bunny to be like Fonzie. And what is Fonzie like? Cool. You may be a torrent of disorganized rage inside, but on the outside you must remain cool. Getting frazzled, yelling, or losing your cool helps no one and actively makes a tense situation worse.
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, check your patient.
Every emergency physician has had crazy-busy shifts where someone just does not seem to improve. During these shifts, sometimes labs and orders get thrown in without a thorough exam. Despite a slew of negative lab work the nurse says the patient looks worse. Still want to discharge her?
It is time to re-evaluate the patient. Does she have a decubitus ulcer the size of a dachshund hiding in the sacral area? Has her mental status changed? Has the patients vitals improved? RECHECK YOUR PATIENTS!
Rule 3: The enemy of good is better
The patient with the sprained ankle had a pressure of 196/110. Now she has a pressure of 158/105 and is feeling much better. Good, send her home. You don’t need to make that better. Put that clonidine back in the Pyxis. The last thing you want to see is a blood pressure of 85/22.
This is not permission to be lazy. If a blood pressure is tanking despite interventions, well, not it is time to 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. Now you want to get his glucose back to 100… Be careful.
Yes, we must make sure the patient has medications and assistance. Also, be sure he has close follow-up. Wonderful. Great. He is good. You can put that dose of insulin next to the clonidine in the Pyxis.
Rule 4: Leave your attitude 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 started their day planning to do be in the emergency department.
She wasn’t planning to have severe lower abdominal pain. She did not wake up thinking, “Oh, boy. I hope I can sit in a horrible gown, in pain, being examined by a stranger.” No matter how bad your shift is, your patient’s day is 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 with your buddies. At work, strive to be the most uplifting person in the ER.
Rule 5: Be kind without judgement
Years ago, I had a list of critiques about patients depending on the chief complaint. I would get frustrated about people coming to the ER with chronic pain exacerbations.
I no longer do this.
Why?
Well, chronic pain sucks. Drug addiction? Yeah, that sucks too. Alcoholism? Yup also sucks. These are all debilitating diseases that horribly affect millions of people who are all in various stages of treatment and rehabilitation.
And, guess what? They need help, not judgement. If they are seeing you, you have an opportunity to help. If someone comes into the ER unconscious who reverts after receiving Narcan you have an opportunity. You could judge this person and think they are a “junkie” in your head, or you could realize this is a human with an addiction and maybe, just maybe you now have an opportunity to heal.
The original rule is “do no harm.”
Don’t forget it.