Archive | May, 2015

10 Mistakes Not to Make in the ER

26 May

ambulance

The ER can be an intense place to practice medicine.  There are high-stress situations, 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 recheck 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?  This is sloppy and 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, lets 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 work up and take it easy.  Until their white count comes back at 18000 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 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/sexual assault cases.  I was called in as an expert witness 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 supervising physician that gets summoned, it will be you.

7.  Distracting injuries- They are very distracting.   Whether its a trauma code or just a regular old open fracture make sure you get your own system and do you exams and work up 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 personal and don’t give it any emotional energy.

What other tricks of the trade would you add to the list?

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Missing My Dad on Mother’s Day

11 May
mothersdayflower

“You Gnomes How Much I Love You”

My world filled with homemade cards and paper cups filled with dirt seedlings on Sunday.  My girls were happy to give me their sweet gifts on Mother’s Day, but it was short lived because I had to work a shift in the ER.  I had an unwelcome feeling creep into my gut on the way to work.  An unsettling darkness settled over my head and I soon recognized that grief was creeping nearby. This was the first Mother’s Day without my dad.  He passed away last June and my family is still wading through the muck of loss and trying to figure out life without him.

I couldn’t quite place why Mother’s Day was triggering such sadness for me.  After a while I realized it was because my dad was such a good partner to my mom.  He cared for her, cherished her, and appreciated her.  He was incredibly affectionate towards her I remember him often looking at her and saying things like “Isn’t your Mom pretty?”I felt sad that my dad wasn’t here to cherish her.  Her kids could do their best to make her feel appreciated and loved, but a big component of Mother’s Day is your partner celebrating with you.

My dad also taught me a valuable lesson growing up about how I should be treated.  I was able to watch a man love and care for his wife.  He was respectful and my parents truly were a team.  When I chose my own husband, I had something to model our marriage after.  I, too, chose someone that would love, respect and cherish me.  What unspeakable gratitude I have for my parents and the healthy marriage I witnessed growing up.

My dad wasn’t perfect.  Some of his purchases for my mom on Mother’s Day were absolutely cringe-able.  There were outfits that were quickly returned, jewelry with questionable metals, but the sentiment was always genuine.  I’m sure my mom had moments of feeling unappreciated, like we all do at times.  But I know she never questioned whether or not she was loved.

Its interesting what pieces of my dad that I miss, and when they show up.  I didn’t predict that grief would hit so strongly on a day that was supposed to be about celebrating ME and the other women in my life.  That I would grieve the loss of my mom’s husband, separate from grieving my dad.  It always catches me off guard and I never recognize grief right away.  Its like this nebulous emotion that seems to come out sideways.  But I acknowledge it and feel it, and try to move on because I think it would completely break me if I let it.

After working my shift on Mother’s Day I went home.  I snuck into my kids’ room at one in the morning and woke them up.  I know, bad mommy.  We hugged and kissed and I know they appreciate and love me.  Then I went and cuddled with my husband and felt thankful for him.  The loss of my dad still hurts and it grips me by my throat sometimes.  But the love of my family is a balm that soothes and makes death sting a little less.

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