EM Mindset: Alex Koyfman – A Career Worth Pursuing

Author: Alex Koyfman, MD (@EMHighAK – emDOCs.net Editor-in-Chief; EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) // Edited By: Manpreet Singh, MD (@MPrizzleER – Clinical Instructor & Ultrasound/Med-Ed Fellow / Harbor-UCLA Medical Center)

Special acknowledgements to: Alina Gorelik (my brilliant/beautiful wife); Justin Bright, MD (Henry Ford EM); Mike Winters, MD (UMaryland EM); Reuben Strayer, MD (Mount Sinai / NYU EM); Mike Runyon, MD (Carolinas EM); Compton Broders, MD (UTSW EM / EMC COO); Brit Long, MD (SAUSHEC EM); Manpreet ‘Manny’ Singh, MD (Harbor-UCLA EM)

Happy Holidays from all of us at emDOCs.net! Thank you to all of the amazing EM docs  that have contributed to our new EM Mindset series this past year. As we take a break from this series to accumulate more of your pearls, wisdom and life lessons through your journey in EM for our next chapter in this series, we at emDOCs leave you with this EM Mindset. Enjoy!

#1: Address the vital signs + triage/nursing notes

Every abnormal vital sign needs a reason – whether observed or charted. Don’t forget both sides of the spectrum – we freak out over fever, but forget that subtle hypothermia can indicate serious pathology too.  An unexplained tachycardia is a predictor of serious illness and adverse outcomes. Symptomatic bradycardia cases are some of the most exciting. Beware of tachypnea; it is the most sensitive vital sign for critical illness, especially in the elderly patient who may not display any other vital sign abnormality. Be wary of the documented respiratory rate of 16; all of our patients seem to be breathing at this rate at triage. Take a moment to watch the patient breathe and look for truncation of their sentences as a subtle sign of dyspnea. Vital signs don’t happen in a vacuum. Normotension in a patient who normally lives with a relative hypertension must be explained. Don’t flood every hypotensive patient with fluids, as you may make them worse; take a thorough history, do a focused physical, and connect the dots with the RUSH exam (go here for further discussion: http://www.emdocs.net/rush-protocol/). Why is your patient hypoxic? Is it the heart, lungs, central process, perfusion state, etc? Sign out is the most dangerous time for patient care in our ED – don’t forget to sign out abnormal vital signs, your thought process on each, and expectations for your colleague(s).

Read each triage and nursing note; acknowledge this in your patient evaluations. It isn’t necessary to chase every piece of information, but you must address the triage statement and tie it all together via documentation of your thought process. Complaints in the triage note that are not addressed, or nursing notes that don’t correlate with your notes, can sink both you and your patient.

#2: Invest in others

Emergency medicine was started out of necessity in the 1970s and has developed into the heart of medicine. Each generation of emergency physicians has moved the field forward.  Dedicate time and resources to your students and residents; one day they are destined to wow you. Teaching the next generation of physicians is the greatest contribution you can make to our field.

#3: Read and learn something new each day

We are the masters of many skills, and we leverage that skill in our patient’s favor; never stop learning. We are fortunate to be surrounded by many engaged colleagues in the era of social media. Leave your shift and elevate your care for the next patient. Run cases by your colleagues. If you work in an academic setting, contribute to and grow from conference.  If you don’t work in an academic setting, be proactive and deliberate in seeking out conferences. Read a new journal article or textbook chapter. Listen to a new podcast. Do this each and every day with focus to improve your care.

#4: Love your patients / believe them

Each patient holds the story to their disease process. These stories don’t always flow logically.  Sometimes, the patient is so eager to help you help them, that they offer information they think is helpful, but really just throws you off the path.  It’s your job to put everything into context.  The burning a patient is feeling in their chest is not from the chili dog they ate 6 days ago – it’s a heart attack.  Be a detective and dig for what made the patient present today specifically. When we forget to connect with our patients and believe in them, we make mistakes.

#5: Initial 5 items in your differential diagnosis

Train your mind to be the best it can be… the eye doesn’t see what the mind doesn’t know. The more you read, the more you know and will recognize. For each patient, put together a thoughtful DDx (5 possibilities is a good place to start). Even with patients who present with benign causes, consider life threats… this doesn’t mean that it has to be followed with labs/imaging. If you consistently think of life threats, you’ll pick them up when they present. We don’t tend to miss atypical illnesses presenting classically; we get burned on the classic illness presenting in an atypical way. You will not solve all cases; it’s prudent to enter some patients into a diagnostic uncertainty pathway. Keep asking: what else could this be?

#6: Mental simulation

Before a shift or to bounce back after an extended time off, run through cases that scare you a bit.  We all have them. After shifts, read up on one case you managed.  It reinforces what you learned when you can picture a patient.  During stressful times, we rise to the level of our training; nothing magical happens if you’re not prepared. Visualize yourself performing each step of infrequent procedures (cricothyrotomy, thoracotomy, etc) so that you will be prepared when the opportunity arises.

If you are interested in reading the rest of this and other EM Mindset pieces, please see “An Emergency Medicine Mindset,” a collection evaluating the thought process of emergency physicians. This book is available as ebook and print on Amazon.