The ER can be an intense place to practice medicine. There are high-stress situations and high-acuity patients, and fast-paced decisions are constantly made. Here are a few tidbits that I have learned over the years working in the ER.
1. Always remember to re-check abnormal vital signs. You have a young healthy patient who has been barfing his guts out all night. He looks dry and is tachycardic. So, you give him some nausea medications, throw in a line and give him some fluids. Surprise … the patient is all better! But did you document that the vitals improved? To not document their improvement could be detrimental. What if, after 2 liters, the patient now has a fever and is persistently tachycardic. You might change your management, and he may need some further testing to get to the bottom of the abnormal vital signs.
2. Speaking of vital signs, let’s talk about temperature. You have an elderly patient who comes in for being weak. Pretty common, right? Well, they don’t have a fever, so you get pretty comfortable in your workup and take it easy. Until their white count comes back at 18,000, and then, you ask the nurse to do a rectal temp, which comes back at 103. Suddenly, you are racing against the clock to look for sources of sepsis and start administering antibiotics. We rely too often on oral temps. If someone has dry mucous membranes, their temp is not going to be accurate. When in doubt, get a rectal temp.
3. We miss a lot of valuable information if we don’t greet the medics at the patient’s bedside. If you see an ambulance coming in, try to get the report directly from the medic. We can lose key portions of the history because we get the secondhand story from the nurse, who is also trying to settle the patient in. You will have a lot more holes to fill if you don’t get the story firsthand from the medics.
4. Trust the nurses. They have a lot of experience and can give you good insight on the acuity of a patient or any underlying diseases that might be at play.
5. Don’t do what you’ve always done. Sometimes, guidelines change, and you need to stay on top of those. Remember when giving a beta-blocker was the standard for acute coronary syndrome?
6. Document the hell out of domestic and sexual assault cases. I was called in as an expert witness once, and I was SO RELIEVED that I wrote down every detail of the history and physical. We see so many patients, and these cases will often go to court. It won’t be your collaborating physician who gets summoned; it will be you.
7. Distracting injuries (They are very distracting.) Whether it’s a trauma code or just a regular old open fracture, make sure you get your own system and do your exams and workup the same on every single patient, every single time.
8. Avoid burnout and take a break. One thing I see a lot with new providers is that they take on way too many shifts. The ER is exciting, and it makes good money. The more shifts the better, right? Wrong. You need to continue to develop other interests and have a good balance in order to be a good provider.
9. Protect yourself. If you are going to ‘I’ and ‘D’ an abscess, place a trach, intubate or look into the throat of a coughing patient, you need to have the right gear. You do not want to become a patient because you were stupid. Eye protection, gloves and face mask—at the minimum. Period.
10. Don’t let patients get under your skin. They are likely having one of the worst days of their lives. They may be nasty, but don’t take it personally and don’t give it any emotional energy.
What other tricks of the trade would you add to the list?
Read more from Rachael Jarman here.
Rachael Jarman, PA-C, works in the ER of a busy Minneapolis hospital and as a pre-PA admissions coach, and occasionally, as a guest lecturer for PA programs in Minnesota. She is a graduate of Philadelphia University’s PA program.