Emergentology
2018; Lippincott Williams & Wilkins; Volume: 40; Issue: 7 Linguagem: Inglês
10.1097/01.eem.0000542257.46206.ee
ISSN1552-3624
Autores Tópico(s)Disaster Response and Management
Resumoemergency medicine, experience: emergency medicine, experienceFigureI realized recently that I am 10 years into my career in emergency medicine, having started residency in 2008. I wonder what 2008 Graham would think of 2018 Graham? What's changed in emergency medicine and my practice, and what hasn't? Probably and most notably, my residency no longer exists. I trained at St. Luke's-Roosevelt Hospital Center, which was bought by Mount Sinai in 2013 in the never-ending New York City hospital merger war. Mount Sinai St. Luke's-Roosevelt still has an outstanding residency program. I'd better not lose my diploma. The other biggest change is an obvious one: I don't read academic papers nearly as much as I used to. In residency, especially as chief resident, I had a trove of research papers (currently 406 MB on my computer) that I could call up at any time, print out, or shove in someone's face. I thought I'd maintain my interest in reading and critically interpreting academic papers, but now that I'm out of school, I don't enjoy it nearly as much as I used to. This is not to say that I'm not learning, of course. It's just that much more of my learning comes from reading, writing, and debating on Twitter (free open access medical education: #FOAMed), hearing lectures at my medical center, and attending conferences. I still enjoy getting into the weeds of a methodology section when I care about a topic and mentoring medical students and teaching residents during shifts, but the means through which I'm exposed to new research and topics certainly has changed dramatically. My clinical care has, I hope, improved. I allow more nuance into my plans and decision-making, and occasionally break my old rules. (On rare occasions, I'll let a patient go home with a heart rate of 102!) I think I'm a better judge of sick and not sick, I'm more liberal with including patients' goals and wishes into my decisions, and I'm more conservative and put my foot down harder when I'm really concerned about them. Better Care, Worse Metrics I give out fewer controlled substances. I try to look at all my own imaging studies, which I tried to do in residency but never really had the time. Obviously, I see all my own plain films, but I find skimming MRIs and ultrasounds to be helpful as well. I've learned to blunt my fight-or-flight response when calling consultants (mostly because I'm incredibly fortunate to have kind, caring, helpful colleagues); I was taught in residency that you should expect every consult to be a fight and not allow your consultants to boss you around. Dig in your heels, and don't give in. Threaten EMTALA violations. Now that I have a pretty good grasp of medicine and all the things that can go wrong with the human body, I'm much more confident in saying when I need to get the patient to the OR and when a three-hour delay isn't going to change anything. Note to current residents: You have to consult the same people for the next 30 years; learn to pick your battles and work together. I now use propofol to sedate patients for procedures. I rarely break my own rules, but I've always found that falling back on my ABCs and my gut, and rechecking vital signs have never let me down. I diagnosed a massive GI bleed on a stroke alert patient from the field by being crazy enough to expose the patient and look for trauma on her back. I still order rectal temperatures a few times a week, and I've found an explanation for a patient's tachycardia and quickly changed his workup. Ironically, I think my care has improved, but I think medicine's metrics have only worsened over the past 10 years. Draconian “guidelines” are now applied more than ever to an always-expanding number of patients. I feel like I'm much better at nuance, but today I'm allowed much less leeway in my practice to apply it. As the attending physician at the bedside, I'm pretty good at knowing when a patient shouldn't automatically fall into the “aggressive, do all things” sepsis pathway. I'm also good at knowing when a patient who doesn't meet any sepsis criteria needs an aggressive-as-hell-I-need-three-more-nurses-in-here resuscitation for impending septic shock. Ten years in, I'm a little more wrinkled, a little balder, and a lot readier to handle anyone who comes through the door. Patients have stopped calling me Doogie. Hopefully, they started seeing my confidence instead of my youth.
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