Six Tenets of Teaching:/
I will only convey information to you that meets one of these six criteria.
- Things you need to know to practice.
- Things you need to know for board-style exams.
- Things that other people do differently than I, but make perfect sense.
- My opinions: always prefaced by some disclaimer that this is my opinion.
- Things the literature solidly supports, rejects or is inconsistent on.
- Things you need to know to stay out of court or make for a defensible chart.
- Buyer beware: the admitting doctor should have an understanding that the patient you are admitting to his/her service may have a condition that they cannot treat. (Example: this patient I am admitting to the Medical ICU has a CT of the abdomen pending that may reveal surgical disease and require you to consult someone who owns a knife for definitive therapy!) Very similar to the dissatisfied feeling one gets at Christmas when you unknowingly open a really cool toy that you want to start playing with immediately, but soon realize it was mislabeled for someone you know, but doesn’t like you enough to let you play with it. The normal reaction is to develop strong feelings of angst towards the gift giver as well as the intended recipient and refer the matter to M&M.
- Full Disclosure: similar to Buyer Beware, but with more emphasis on hiding necessary diagnostics from the admitting/consulting team. These tests may be critical, but not yet obtained or already obtained (the LP or CVL) and purposefully admitted when report is called to the admitting team for fear of rejection. Example: I called Jenny to ask her to the prom, because if she saw the huge gynormous new zit on my nose and that we would be taking my bike as transportation then she would surely tell me that she needed to take care of some other things (like washing her hair) before she gave me an answer.
- Buyer Beware and Full Disclosure: are most often combined when addressing the projected course of the patient. If you tell Jenny that your zit will be completely gone by the big night and you have the keys to your dad’s new Porsche, but on prom night you show up with a nose like gin-blossoms and sporting a Schwinn, then sorry sport. Good news is that you’ll have plenty of time to prepare your M&M presentation on prom night. In other words, don’t lie to the admitting/team consultant. Let them know that the patient is circling the drain and you have been actively involved in their care, but they need more work.
- Right of First Refusal: Usually the consultant who sees the patient in your Emergency Room has the right to refuse admitting said patient. This is most applicable when the patient is best suited for two services, but you can only get one of the consultants to physically look at that patient in your ED. In that case the early bird doesn’t have to eat the worm. The situation is very similar to a silent auction: the consultant who remained silent gets to take home the mystery-box. That being said, do not put a consultant in a position to take a patient they cannot manage (ie: an active GI bleed with NSTEMI may be better served in an Medical ICU managed by an intensivist, as opposed to the Cardiac ICU managed by a Cardiologist).
- Listen for the notes of the song and tune out the white noise: Thank you Dr. Billy Mallon. The patient will often sing you a tune that is part of the song, but you have to dig deep or pick out the highlights to put something together that definitively sounds like a musical diagnosis. Example: the patient that has chest pain, fever, teeth itch, fibromyalgia, bipolar, headache, and a groin rash, but if you really pare it down they have had had stuttering ACS like chest pain for the past 3 hours. You could easily get bogged down in the symphony, but the notes are really coming from the solo trumpet screeching-out some staccato alto notes requesting to be admitted for their chest pain. Of course the patient needs a psych consult, but later they rule in for NSTEMI!
On the other hand, at the end of a long shift the notes the patient may sing out may sound like Led Zeppelin to you (which you want to hear, I hope you want to hear), but they are really lip synching Milli Vanilli. Example: “Oh, I understand that headache isn’t too bad now and even though you have had a aneurismal clipping previously you don’t need the LP because I really need to get home.”
- Get to work and do something: Again thank you Dr. Mallon. For the truly “sick patient” you need to get actively involved with your hands on the patient from the moment they hit your door. You need to work quickly or that patient may be better off having had their estate in order than you as their physician. We must be more like the surgeon than our other medical colleagues in this case. We live in a world that requires us as emergency physicians to make decisions based on limited data and to be confident in those decisions without always having the opportunity to get a complete history and physical exam. This requires the exceptional ED doctor to be aggressive, self-assured and theatrical. Like it or not, there is a little bit of theater put-on each time we take care of a critical patient. Even if your persona is usually more California surfer than D.C. politician, you cannot afford to sit at the head of the bed of a crashing patient and pontificate about your next move. Not everyone has this persona, but if you do not find it for those brief albeit important encounters, then the rest of your team consisting of your own emergency nurses, techs, as well as the consultants and definitely the trauma team will eat your lunch and then charge you for it. When the crashing patient arrives get to work and do something with confidence, incomplete data and exam findings or they will die, but their lawyers will not. Welcome to emergency medicine, Chachi!
- Red Pill and Blue Pill: A concept that was admittedly blatantly stolen from the movie The Matrix. You must determine if you are a conspiracy theorist or blindly following the herd. Although I prefer the tag “appropriately questioning” to “conspiracy theorist,” the alternative is to accept those things that do not make sense because it is easier and more comfortable than questioning the flawed concepts laid out for us by those with something to gain. Unfortunately, you have picked the wrong profession if you find it difficult to “appropriately question” consultants, faulty data and drug company advertisements that are dressed up as “the literature” - the same literature that is paraded in front of us via our mailboxes as truth and fact even though you know much of it cannot make sense the way they say it does, but it sure seems to increase sales. Or, the consultant who tells you to send the septic patient home because in their experience “these cases are best handled in an outpatient setting.” The Red Pill/Blue Pill concept asks you as the EM practitioner to be aware, and not be led.