EM Mindset: Reading My Mind
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.
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.