Ep 10 - Intro to EM: Staying safe in your first job

Starting Your Career in Emergency Medicine: Key Insights from St. Emlyn’s

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 post 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.

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:

1. Oxygen: Determine if the patient needs oxygen or airway support.
2. Analgesia: Ensure adequate pain relief is provided.
3. Fluids: Assess if the patient would benefit from intravenous fluids.
4. 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!