Author: Judith E. Tintinalli, MD MS (Professor of EM / Chair Emeritus, Department of EM, University of North Carolina) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)
A style of working, teaching, and learning in Emergency Medicine takes time to develop. We don’t get much opportunity to see how our colleagues operate, except perhaps on change-over rounds, which are always pressed for time, and which don’t allow for discussions about why different attendings do things differently. I’ve always thought of myself as a middle-of-the roader in our group: middle in terms of times, patients/hr, decisions to admit versus discharge. But I’m pretty good at documentation, work generally on the careful and compassionate side, can work at the speed of light when necessary, and have learned from the past so hopefully current mistakes are few and far between.
So, step into my office and I’ll share with you some of my habits, behaviors, and opinions that I’ve developed over the years.
Working in an academic medical center has great rewards. Being surrounded by shadowers, medical students, and residents of all specialties keeps you on your toes. Medicine has moved from time-lapse to fast-forward, and residents who have recently completed inpatient rotations are terrific sources of changes in specialty practice patterns. But the growing number of learners you are responsible for on a shift can be intellectually overwhelming and certainly slows down the process of patient care. A different approach is needed for each level, so that one can loosen (but never eliminate) the level of supervision for the most senior learners.
I start my shifts explaining how to structure presentations. The goal is to get a good mental picture of the patient – ill-appearing, obese, amputee, in pain, blind or deaf, angry, demanding. Then a concise statement of the triage note and patient’s problem, but with a listing of key meds/conditions that will affect the ED workup. ‘This is a 65 year old patient with atrial fibrillation on Xarelto with 2 hrs of acute abdominal pain’. Key meds for me are antithrombotics, immunosuppressives, steroids, insulin. I’ll never forget a ‘routine’ intern presentation of a 65 year old woman who fell at home, and now had a femur fracture. When I went to evaluate her, I was aghast at not being told she had a heart transplant and had severe COPD requiring home oxygen. How many times have I been told confidently that vital signs were ‘rock stable’, only to find a pulse rate of 120 or a BP of 230/170.
So, focused and concise presentations help a busy attending prioritize which patients need to be seen as soon as possible. They also teach learners how to present to consultants.
Teaching in the ED
There’s a growing body of EM literature that focuses on clinical teaching in the busy ED. Each of us has to develop our own style. I like to ask for the main, and then major differential diagnoses, before the learner spews out the orders, so the learner can demonstrate why each order is needed. I keep trying to minimize laboratory orders, but one of our jobs is to let each learner order stuff, and with experience, to be able to gain confidence in clinical judgement and stop ordering unnecessary labs and imaging. That is a trial and error process. One good tool is to ask the resident ‘If this patient came into your office, would you send them to the ED to get these lab tests or imaging?’
One of the best teaching tools I use is to ask a question that I myself cannot answer. Like – ‘OK this person with prior DVT and PE is on Xarelto, and now we’re concerned about another PE. What’s the failure rate for Xarelto and does this patient have any risk factors for failure?’ Another tool is to come armed with a recent article you’ve read, ready to whip it out when needed. For example, our residents like to order stress tests out of the ED for patients with low probability chest pain, because we have a protocol, but ask them ‘why’, ‘how’, or ‘what does it cost the patient’ and you’re met with silence. So for a while I kept a copy of Long and Koyfman’s article ‘Current Controversies in the Evaluation of Low Risk Chest Pain (JEM Dec 2016)’ in my doctor bag, let them see the current data on the topic, and then give the opportunity to re-evaluate their decision. Another one I kept with me recently was the recent study on single-dose decadron 12 mg po for adults with mild-moderate asthma. As residents don’t read journals anymore, it gives them the opportunity to at least read a journal abstract.
Procedures and Consultations
In emergency medicine, we’ve structured our residency programs so the majority of learning and teaching is in tertiary care centers. Consider the disadvantages: where specialty consultants are available 24/7, it can be a lot easier to call ortho to reduce a hip, evaluate a fracture or tap a joint, to call GU to place a difficult Coude catheter, or to have neurology decide who gets tPA for possible stroke. The community EM practices that most of our residents will select after graduation will typically have a very limited menu of emergency consultants, and I’m not sure we are training them well for these environments. I always have residents think through their treatment plans before calling the consultant, as this is their future reality. I remember during the early days of EM training, moonlighting was really frowned upon. The philosophy was that the only time anybody cared about resident learning was during residency, so every minute should be spent reading, seeing patients, and learning. The medical environment has changed, and our senior residents get invaluable experience moonlighting that we cannot give them in a tertiary care environment.
Disposition and Follow-Up
This is where I think attendings and residents diverge. I explain that everyone, learner or attending, has his or her own inherent ability to tolerate uncertainty. If a resident strongly wants to admit a patient that I feel can be safely discharged, I challenge him or her to present the case to the admitting team. This gives a chance to practice skills needed in a community ED setting. Another area of divergence is how far to go to exclude specific diagnoses in the ED. In our current medical care system, where so many patients have no insurance, giving them a clean bill of health in the ED means a lot. So ultrasounds, MRIs, and CT scans, and sometimes consultations in the ED to provide a clear follow-up plan, are more and more part of routine management. Disposition requires a lot of stepped-thinking. Recently I took over a shift where a young Spanish-speaking woman came into the ED with a disc of a head CT identifying a brain tumor. Imaging had been done at an outside community hospital without neurosurgeons, and the patient was told to make an appointment with a neurosurgeon. Mystified, she came into the ED. Her discharge had already been written by the previous shift team, and the phone number of neurosurgery clinic was provided. We held the discharge and consulted neurosurgery. The CT was reviewed, an MRI was then done, decadron and Keppra were recommended by the neurosurgeon, and a clear follow-up was arranged in 3 days in neurosurgery clinic. These steps would be very difficult to manage as an outpatient, where waits for an MRI can be weeks; payment is required before testing; the clinic appointment team may or may not speak Spanish; and it can take weeks to get an appointment in an overburdened neurosurgery clinic. Another important principle I try to teach is ‘we cannot predict the future’. Residents will sometimes say, oh, why get this specialized imaging; why call the consultant, they won’t do anything; why try for admission – there’s an easy answer. I cannot predict the future – can you?
Why I love Emergency Medicine
A recent JAMA article reported that emergency medicine has the highest burn-out and fatigue rate of any other specialty. If that is so, why are medical students flocking to our residency programs? Not every shift is wonderful – some are exhausting, filled with contentious problems or patients. Most times I look forward to a shift, but sometimes it is hard to put one foot in front of the other as I walk to my desk. But I think all of us would rather be emergency physicians rather than anything else. We have the unique ability to help patients when they are most vulnerable. We have to establish rapport within minutes, not weeks or months. We work in a terrific team environment. We learn to be flexible, can calm down irritable consultants, and like to make fast decisions. We can work a lot of shifts or fewer shifts. We don’t carry our patient burdens home with us. Life is good.