Welcome to the world of emergency medicine! At St. Emlyn’s, we understand the challenges and excitement that come with starting your career in this fast-paced field. Whether you’re a new doctor stepping into the emergency department (ED) for the first time or a medical student gearing up for your rotation, we’ve got you covered. This podcast delves into the nuances of emergency medicine, sharing valuable insights from seasoned professionals, Iain Beardsell and Simon Carley, to help you navigate your journey effectively.
Listening Time – 14:44
Understanding the Unique Nature of Emergency Medicine
Emergency medicine is distinct from other medical disciplines. Unlike the traditional approach taught in medical school, which involves extensive histories and comprehensive examinations, emergency medicine requires quick, focused thinking and decisive action. The goal is to identify and address life-threatening conditions promptly.
Time-Pressured Environment
In the ED, time is of the essence. Patients arrive needing immediate care, and as an emergency physician, you won’t have the luxury of lengthy deliberations. Your patients want answers quickly, and this urgency shapes the way you practice. You’ll learn to focus on the presenting problem and drill down into the most critical aspects of their condition.
Different Thinking Model
The thinking model in emergency medicine is primarily hyperthetico-deductive reasoning. This means you’ll form hypotheses based on initial information and then test these hypotheses through targeted questions and examinations. For instance, if a 55-year-old man presents with central crushing chest pain radiating down his left arm, your first thought should be an acute myocardial infarction (AMI).
Prioritizing Life-Threatening Conditions
One of the fundamental differences in emergency medicine is the approach to diagnosing and treating conditions. Instead of trying to confirm what a patient has, you’ll focus on ruling out what they don’t have, especially the most life-threatening possibilities. For example, with chest pain, you’ll consider AMI, pulmonary embolism (PE), and aortic dissection as top priorities.
The 10% Rule
Interestingly, about 10% of patients presenting with symptoms like chest pain or headache have significant pathology. Your job is to identify this 10% while efficiently managing the remaining 90%. This approach ensures that you don’t miss critical diagnoses while not overburdening yourself with unnecessary details.
Practical Steps for Your First Shift
As you prepare for your first shift in the ED, here are some practical steps and philosophies to keep in mind:
Resuscitation First
Your primary goal is to identify if a patient needs resuscitation. Are they critically unwell? Do they require urgent interventions to save their life? This is your top priority.
Pain Management
After ensuring resuscitation, your next focus should be pain management. A pain-free emergency department is a goal to strive for. Administer analgesia as needed to ensure patient comfort, even before completing a full history or examination.
Rule Out Life-Threatening Conditions
When a patient presents with a complaint, think about the worst-case scenarios related to their symptoms and aim to rule these out. For example, with chest pain, consider whether the patient might have an AMI, PE, or aortic dissection.
Focused History and Examination
Conduct a focused history and examination to gather information pertinent to the presenting complaint. Avoid getting bogged down with irrelevant past medical history unless it directly impacts the current situation.
Implementing the Four Big Hitters
Simon and Iain emphasize the importance of considering four key interventions for every patient:
- Oxygen: Determine if the patient needs oxygen or airway support.
- Analgesia: Ensure adequate pain relief is provided.
- Fluids: Assess if the patient would benefit from intravenous fluids.
- Antibiotics: Consider if antibiotics are necessary for their condition.
Learning and Growing in the ED
The ED is a dynamic learning environment. Here’s how you can maximize your growth and effectiveness:
Ask Questions
Don’t hesitate to ask questions. No question is too silly. Engaging with senior colleagues and seeking their advice will enhance your learning and patient care skills.
Continuous Learning
Emergency medicine is a field where continuous learning is crucial. Keep up with the latest practices, guidelines, and innovations. Attend workshops, conferences, and training sessions to stay updated.
Collaborative Approach
Remember that emergency medicine is a team effort. Collaborate with nurses, paramedics, and other healthcare professionals. Effective communication and teamwork are essential for providing the best patient care.
Reflect and Improve
After each shift, take time to reflect on your experiences. Identify what went well and areas for improvement. This self-assessment will help you grow as a clinician and enhance your skills over time.
The Importance of Confidence and Competence
Confidence in your abilities is vital, but it must be balanced with competence. Strive to be competent in your practice, and your confidence will naturally follow. Be aware of the balance between these two aspects to avoid the pitfalls of overconfidence.
Unconscious Incompetence
One of the dangers in any medical field is unconscious incompetence—being unaware of what you don’t know. Stay humble, keep learning, and seek feedback from peers and seniors to continuously improve your competence.
Embracing the ED Culture
The culture in the ED is unique. It’s a place where decisive actions and quick thinking are valued. Embrace this culture and the opportunities it presents for hands-on learning and making a real difference in patients’ lives.
A Little Less Conversation, A Little More Action
In the ED, the Elvis philosophy—“a little less conversation, a little more action”—applies. Focus on doing what’s necessary for the patient rather than getting caught up in lengthy discussions. This action-oriented approach is crucial for effective emergency care.
Conclusion: Your Journey Ahead
Starting your career in emergency medicine is both exciting and challenging. At St. Emlyn’s, we believe in providing you with the tools, knowledge, and support you need to succeed. Remember the key principles: prioritize life-threatening conditions, focus on critical interventions, continuously learn and ask questions, and embrace the dynamic culture of the ED.
We love our jobs and hope that you, too, will find the same passion and fulfillment in your career. Good luck, enjoy the journey, and know that we’ll be with you every step of the way through this podcast and our wider St. Emlyn’s community.
Welcome to the world of emergency medicine. Let’s make a difference together!
Podcast Transcription
Welcome to the St. Emlyn’s podcast, I’m Iain Beardsell,
and I’m Simon Carley. And this podcast begins a series, especially aimed at doctors who are just starting their careers in emergency medicine, or coming up to their first post working in an emergency department, and also hopefully useful for medical students who are rotating through the ED. So Simon, I thought we should just give a little bit of background as to why we want to do this. We’ve both been interested in this aspect of education for some years. We’ve even both produced separately different online resources. So we’ll be linking to these via this new podcast.
Mine was something called C-MEP, which I did a few years ago, and we made some videos in Southampton, specifically aimed at induction. Now these are a tiny weenie bit dated now, not least the haircuts, but we’ll be including those in our show notes. You’ve been doing something similar, haven’t you, with St. Emlyn’s and via your virtual hospital? We’ve got the virtual hospital based on a middle platform, and we’ve been running introductory courses to emergency medicine now for about six or seven years. People seem to enjoy it, and it gives people an introduction into how thinking and practice in emergency medicine is really rather different to what they may have experienced when they’ve been on the wards. So these are some of the things that we’re going to try and cover over this and subsequent podcasts. We just want to give a bit of background in how emergency doctors think.
Now Simon and I are just two of many thousands of emergency consultants throughout the UK, and what we’re going to give you is a fairly personal view of how we think. Don’t forget that your consultants when you work in a department and you’ll register us may think slightly differently to us, and that’s great because we need people to be different and to think differently. If you happen to come across this podcast and you’re an experienced emergency physician already, hopefully we may still give you some ideas to take home and take back to your departments where you can use in your teaching and training methods. So Simon, maybe we should start off by just having a little chat about why emergency medicine is different because it’s not the same as medical school, is it? It’s not the same as doing a long history examination, taking an hour to do a long case. We work differently, don’t we? Well, we are different, aren’t we? We have a number of pressures on us, which make us practice in slightly different ways. So we are time focused, so we don’t have lots and lots of time to see patients, to see them today, to go and have a look at them tomorrow, to do some tests and come back and have another thing. We are time pressured because our patients want answers fairly quickly, and so that changes the way that we think. And we’re also very focused on what the patient has come with. We’re not necessarily, well, maybe some days we should be, but most of the time we’re not particularly holistic practitioners. We tend to focus on what people have come with on the day at that time, and that changes the way that we think. And I find that junior doctors do struggle with the idea of I asked them to ignore a lot of the past medical history, unless it’s relevant to the presenting complaint. So if the patient comes in with chest pain, as many patients do, I’m not that interested in whether they had an appendicectomy when they were 12, or other things that don’t necessarily relate directly to their chest pain. I want us to focus down, and that’s time, I guess, that makes us think like that, but also just a way of drilling down into how we can best help. So when it comes to our history and examination, we’re quite a lot more focused, perhaps, than that medical long case would have taught you at medical school, or even in your foundation year, when you’re doing what we used to call the House Officer work, up on the wards. Is that a fair way to describe what we’re wanting to do?
There’s a kind of model of thinking that people get taught at medical school, which is that you take an entire history, and then you do an entire examination, and then you think about what the differential diagnoses may be. Now there are rarely occasions when that’s the right approach, but one of the little tasks I give people when the first arrive is, you know, stop me when you have an idea what wrong with this patient is a 55 year old man in recess who’s got central crushing chest pain, going down his left arm, and he is, and if nobody’s already thought about AMI, by the time I’ve finished that sentence, they really do need to go back to med school. So we have a different way of thinking. We have patients who come to us with ideas, they come out with statements, they come out with physical signs, we may see something on the ambulance sheet or the triage car, which is going to make us think about potential diagnoses, and we’ll move ourselves either towards that diagnosis or away from it, dependent upon the questions we take, and answer, depend on the examinations that we do, but they’ll be focused to answer specific questions, and that’s a model of a model of learning, a model of taking histories, which is called hyperthetico-deductive reasoning if you want the posh name, and it’s what we do all the time. And I think Simon is part of that. The thing that we do is we work backwards. We take what could be the most life-threatening problem associated with the presenting complaint, and we aim to rule it out, which I do think is a different way of thinking. So if a patient presents to me with chest pain, I’m thinking about the five life-threatening causes that I have in my head that I want to know that patient doesn’t have, rather than trying to rule in what they might have, or trying to persuade myself what they have, and I think that makes us very different.
And that’s slightly related to the population of patients we see, because we do, I think, see people with more severe illness, perhaps, than present to their general practitioner, but it’s also the way in which we think, where our aim is not to lose, it’s to make sure we don’t miss the life-threatening stuff. So, for example, with chest pain, we’re trying to rule out the idea, has the patient had a mycarloid infarction? Could this be a PE? Is it aortic dissection? And asking focus questions around that? That ruling out way of thinking, I think, is very different.
It’s surprising, actually, if you look at the data, a lot of the conditions that we see, so things like chest pain, things like headache, they seem to hover around the 10% of patients who you see present with that symptom, have significant pathology. So, we’re kind of 10% doctors a lot of the time. We’re looking for those 10% of patients who’ve got significant disease, which of course means that 90% of them probably don’t, but we’re looking for those 10%. How do we get rid of those 90%? You haven’t got anything exciting, and spot the 10% who we may not even then be able to give a definitive diagnosis to, but we have more attention for, and we’ve got to send them on to further investigation.
And you just struck on something there that I think I do quite often, which is I’ll often talk to a patient and say, I know what you haven’t got, but I don’t necessarily know what it is that’s causing your problem. And again, I think we have to encourage our junior doctors to be comfortable with that. We don’t always know the answer. We’re just aiming to tell the patient what they haven’t got. And I’ll be open with the patient and tell them that. So, you’ve come in with chest pain. I’ve done a history examination, some selective testing, and we’ll talk about that. And I know that this, now, to the best of my knowledge is not a heart attack. This is not a clot on your lung. This is not your major blood vessels shredding down. It’s lining. And they’ll then say, so, doctor, what is wrong with me? And I’ll say, well, I have to be honest with you. I don’t actually know, but I just know it’s nothing dangerous. And I think as a junior doctor, that can be an uncomfortable way to think. That requirement that we have talked to as a medical school, that we come to a definitive diagnosis that either this is definitely something, or it’s definitely not, is often a fallacy. And a degree of honesty with our patients is fine. So, even if we can’t completely rule something out, we can have that sensible conversation with patients and say, it’s unlikely that this is terribly serious, but, you know, if you have any problems, then you can always come back and see us. And the door is always open in A&E.
Always. So, you’re about to start your first shift in the emergency department. And hopefully, you’re going to think about this when you see your first patient. You want to think, what are the worst things this could be, and then rule them out. And ask focused questions. And they may be closed questions. We can’t have the luxury always of asking all these open questions that we were taught about at medical school, focusing down on the things that we want to rule out. Now, while we’re doing that, we’re going to be working in parallel thinking about treatments. And so, I mean, I always talked to our doctors and say, well, there’s three real aims that I have for a patient coming to the emergency department. The first thing I want to decide is, do you need resuscitation? Are you critically unwell? And do I have to make urgent interventions to save your life? That is job number one. And my second question is, do you have any pain? And if they have pain, I will intervene and get them pain killers. Before probably taking even much of a history or doing examination, we should aim to have a pain free emergency department. So, those are my first two questions. And it’s only after I’ve sorted those questions out, I then talked to think to myself, what do I need to do next? Do you need to stay in hospital? Do I need to give you any further treatment? But it’s about doing things. Emergency medicine is doing specialty rather than often a thinking specialty, I believe. And that’s reflected when you go back and look at the C-MAP video, one of the things I talk about there is the Elvis philosophy, which is a little less conversation and a little more action. And I think that really does apply. So, if you’re the sort of doctor who enjoys doing things, emergency medicine is for you. There are my ways of approaching things. What’s the thing you do next, Simon, or you ask your doctors to do next?
I’m not sure, I do next, but I definitely agree with what you’ve just said. And what’s key to that is you don’t need a diagnosis and you don’t need a definitive answer to either treat pain or resuscitate patients. And I’m sure you’ve had conversations with specialist colleagues who come to the emergency department and they go, “What happened to this patient?” And you go, “I don’t know.” And you say, “How long have they been on well for?” And you go, “I don’t know.” And you say, “What medicines are they on?” And you go, “I don’t know.” But I am treating the patient, I am resuscitating the patient. There are a hell of a lot better than when they came through the door 20 minutes ago and they’d be very grateful if you could take into the intensity of the patient. Those kind of conversations, that’s very, very different. So we’ve got to deal with patients before we have a definitive diagnosis on basis of probability, on the basis of what we see in front of us.
So resuscitation, pain relief, absolutely. It always disappoints me when people say, “Well, I’ve not given them any analgesia because we haven’t come to a definitive diagnosis.” Or the surgeons haven’t come down and put a hand on the abdomen yet. It’s just not necessary. Our patients really want pain relief when they come through the door. And I try and make things, I am a simple soul, originally from the north of England, which you’ll understand, Simon is a place where simplicity is very much admired. I try and make things even more simple than that for the junior doctors and for myself. So I see a patient, “Do you need resuscitation? Do you need pain relief?” And I talked to our doctor all the time about the four things I asked them to think about. So does the patient need oxygen? That’s part of that resuscitation question. Now that can also mean to they need an airway to get oxygen into them. Do they need analgesia? And please, please, if you’re listening to this podcast, analgesia is one of the most important things we can do. We can’t help patients in many different ways with some of the problems they have, but the thing we can do is take their pain away. So oxygen and analgesia have a thing about fluids because a lot of patients will benefit from IV fluids. And then the fourth thing is antibiotics. So I ask our doctors to think every time after they’ve seen a patient before they come out of the curtain, does the patient need oxygen? Do they need analgesia? Do they need fluids and do they need antibiotics? Because actually most of the conditions we see will be improved by at least two, maybe three of those different things. And I just want to make it more straightforward for myself. Do you think in the same way?
I do. And I think if you go for those four big hitters then you’ll cover most of the time critical interventions or certainly be looking at the kind of patients in whom you really need to be careful. If anybody needs one of those four interventions they do probably if you’re a junior doctor need you to go and find somebody more senior in the department and come and have a chat.
So we’ve got the way of thinking. We’re going to work backwards. We’re going to try and rule things out. Think of the life threatening conditions related to that presenting complaint. And we’re going to go through these in future podcasts. So we’ll take you through the life threats for chest pain or shortness of breath. We want you to think about doing things. Always think what difference have I made to the patient? Could they have just sat at home, apart from if they’d stuck a fork in the leg to simulate having a blood test taken? Blood testing of course isn’t a treatment. It doesn’t make people feel better. So always think to yourself, how have I made this patient feel better? And then look for senior doctor. I’m sure Simon you’d encourage all of your juniors to ask questions all the time when they start in the ED. And beyond it doesn’t matter whether you’re an experienced doctor. I still ask my colleagues questions. But no question is too stupid. Take a history, do an examination, give some of those treatments if they’re necessary and just have a chat with somebody and they’ll help you get to where you need to be.
I agree. The only stupid question I know of is I don’t think I should ask anybody about this patient. Do you think that’s right? That is a silly question. Most emergency consultants I believe in the ones I’ve met just want you to talk to them. And actually the doctors we worry about the most are the ones who don’t talk to us. So you can never talk too much. You really can’t. And we just want to help you. There’s a phrase which I often say in the emergency department of the colleagues will come up and say I’m so much more confident in dealing with these patients. And I go that’s fantastic. Are you any more competent? And there is this sort of balance between confidence and competence which is can be a little bit scary. And the ones who really do worry me who have high levels of confidence which is not matched by their level of competence. And there’s a word for that isn’t the unconscious incompetence or something like that. We’re really dangerous. Yeah, we don’t want you to be those people. We really don’t. Just ask questions. No question is too silly. Just make sure that you get a handle on what’s wrong with that patient. Take their pain away and just ask for a bit of advice. Sometimes it’s really straightforward. And to be honest most of our patients can be quite straightforward in what you need to do next. But just discussing the straightforward cases helps you think about how you’re going to manage the more complex cases. Simon is something else you’d like to add?
Not really. Just enjoy it. Ask loads of questions and make sure that you see the full breadth of patients. There’ll be patients when you start an ED you’ll think oh I’m quite confident about this group. But make sure you get around the department. You see everything from minor injuries, major illness, minor illness and get into the resuscroom as well. See everything.
And I think we’ll say this throughout but I think Simon and I we both love our jobs and we love what we do. And hopefully you’ll feel a bit of that infectious enthusiasm from your departments. And you’ll start to love your job too. It’s frightening and scary when you start but there’s people there to hold your hand and take you through it as you develop. And we’ll be there too as part of this an emulence podcast. Good luck, enjoy it.
And we’ll be with you every step of the way.
Where to listen
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