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    A primer for residents : Do's and don'ts of emergency medicine

    MIRAGE
    MIRAGE
    Admin
    Admin


    Masculin Messages : 2277
    Date d'inscription : 16/08/2009
    Age : 37
    Localisation : Maghreb united
    Emploi : Medical student

    A  primer for residents : Do's and don'ts of emergency medicine Empty A primer for residents : Do's and don'ts of emergency medicine

    Message par MIRAGE Sam 25 Aoû 2012, 12:35

    Resident Issues




    Eric Letovsky, MD



    Chief, Department of Emergency Medicine,
    The Credit Valley Hospital, Mississauga, Ont.; Associate Professor,
    Department of Family and Community Medicine, University of Toronto,
    Toronto, Ont.


    CJEM 2003;5(2):130-132




    After 23 years of practising emergency medicine at both tertiary
    care and community hospitals, there are a few things I'd like to share
    with you. Many pearls have come from working alongside some superb
    emergency physicians -- watching them practise and interact with
    patients and allied health personnel in the emergency department (ED).

    I've learned important lessons from my mistakes, and from the
    mistakes of colleagues. Sitting in on dozens of morbidity and mortality
    rounds and being a medicolegal expert on numerous cases has afforded
    unique opportunities to see the most common and most serious mistakes we
    make. This list of do's and don'ts contains some of my favourite
    pearls. It is by no means comprehensive, and is not written in priority
    of importance. I hope it helps you to become better and safer emergency
    physicians.

    Lessons learned


    1. Don't ignore abnormal vital signs.


    The child who is tachypneic may have pneumonia,
    despite the absence of a cough. The patient who becomes hypotensive
    following a traumatic injury is probably not having just a vasovagal
    episode. Don't assume anything and don't ignore anything.

    2. Don't take shortcuts on the physical exam.


    It is impossible to pick up a small petechial rash in
    an infant with a fever unless you undress the child. If you don't take
    off the underwear of a young male with abdominal pain, you may miss the
    strangulated inguinal hernia or the testicular torsion. Many zoster
    eruptions have been missed simply because the skin was not examined
    under the shirt or dressing gown.

    3. Don't wait for consultants to give antibiotics to sick patients.


    Pneumonia and meningitis are serious diseases that
    kill. If you think a patient may have meningitis, give antibiotics first
    and do the lumbar puncture later. If you think an elderly person has
    pneumonia, give a big dose of an IV antibiotic as soon as possible; it
    doesn't really matter so much what antibiotic you give, just give
    something.

    4. Don't be the health care police.


    It is important to be somewhat familiar with the cost
    of tests that you order and be conscious about appropriate resource
    utilization. However, if you think a test is appropriate, order it.
    Don't let your imaging or laboratory colleagues dissuade you from
    ordering a test you need, just because it's going to inconvenience them.

    5. Don't use "pink ladies" to rule out myocardial infarction.


    The Canadian Medical Protective Association can give
    you a list of patients with missed myocardial infarction (MI) who were
    thought to have esophagitis or gastritis simply because they had burning
    esophageal pain that was relieved by a "pink lady" in the ED. Remember,
    if you give 10 patients with a confirmed MI some arsenic, 3 will feel
    better. Relying on a "pink lady" to rule out myocardial ischemia is
    dangerous practice, and if you do it, you will end up a medicolegal
    statistic.

    6. Don't be afraid to wake up a consultant.


    Certain things cannot wait until morning. Testicular
    torsion, ovarian torsion and any other kind of vascular catastrophe are
    all examples where you need to wake up your colleagues, even if they
    give you flack over the phone, with the usual "Can't it wait until
    morning?" Your quality of care should be just as good at night as it is
    during the day.

    7. Do pay special attention to the very young and very old.


    People at the extremes of ages are at high-risk for
    serious disease, don't manifest the same signs in serious diseases and
    must be assessed thoroughly and repeatedly. The newborn infant with a
    fever has meningitis until proven otherwise. The elderly patient with
    severe abdominal pain has either an ischemic gut or abdominal aneurysm
    until proven otherwise. The absence of fever or high white blood count
    in the elderly does not rule out urosepsis.

    8. Do pay special attention to the intoxicated patient.


    Both the history and the physical examination in an
    intoxicated patient are completely unreliable. Over-investigate these
    patients and remember that, to rule out subdural hematoma in an
    intoxicated patient, one CT scan is better than a room full of
    neurologists.

    9. Do get second opinions / consultations if you have concerns or doubts.


    If a patient is just not fitting a typical pattern,
    and if you can't get a sense of what's going on -- ask someone. You may
    be tired, not thinking of something or simply haven't considered a
    particular diagnosis. Don't let your pride get in the way of asking for
    an opinion from a colleague or a staff physician.

    10. Do treat pain early and aggressively.


    If there is anything that we should do well in the ED,
    it is to treat pain. This is where we show our empathy and our
    compassion. Don't forget to do the simple things that relieve pain, such
    as ice and splinting, and do give opioids intravenously rather than
    intramuscularly.

    11. Do communicate well with patients.


    More likely than not, your patients are going to
    remember very little of what you say. Tell them what you're going to do,
    why you're doing it, and how long the process will take. If they've
    been waiting a long time for test results, go back and tell them why
    things are taking so long. Patients just want to be kept informed about
    the causes of the delays.

    12. Do communicate well with families.


    Families can be a great source of information about
    the patient's behaviour, especially for patients presenting with
    headaches or neurological symptoms. The only clue that you're dealing
    with a brain tumour -- even when the neurological exam is completely
    normal -- may be a family member telling you that the patient is "not
    quite right" or that he's been a bit confused over the past few weeks .

    13. Do treat each other with respect and courtesy.


    I believe there is no more stressful nursing job than
    ED nursing, and that there is no more stressful medical work than
    emergency medicine. We need to treat our coworkers with respect and
    courtesy to help make our workplace as healthy as possible.

    14. Do compliment your coworkers.


    Everyone needs positive feedback. The nurse who
    triages a patient well, starts an IV quickly, or gives you a good update
    on an ill patient should be complimented on his or her skills.

    15. Do consider the worst possible disease for every complaint.


    The 50-year-old man with abrupt onset of a severe
    headache has a subarachnoid bleed -- not a migraine -- until proven
    otherwise. The 50-year-old with severe epigastric pain has an infarct
    until proven otherwise, and the 80-year-old with severe abdominal pain
    has an ischemic bowel until proven otherwise. Have a wide differential
    and make sure that your documentation reflects that you considered the
    most serious of your differential diagnoses.

    16. Do get trauma patients to trauma centres early.


    In trauma cases, don't bother ordering tests that will
    only be repeated at the trauma centre, or will unnecessarily delay the
    transfer. Talk to the trauma team leader as early as possible.

    17. Do give blood early in trauma patients.


    As a general rule, no one will fault you for giving
    blood too early, but plenty of people will fault you for giving blood
    too late. You need to recognize the subtle signs of shock, and don't be
    afraid to give either type-specific or O blood.

    18. Do keep patients in the ED if they can't drink or eat.


    Patients who have been assessed and observed for
    abdominal pain or vomiting should have a trial of fluids in the ED to
    see if they can keep fluids down. If they can't, don't send them home.

    19. Do order pregnancy tests for women with abdominal pain.


    You don't want to miss an ectopic pregnancy. Order a
    pregnancy test for all women of child-bearing age who are suffering from
    abdominal pain or have non-specific complaints of nausea, dizziness and
    syncope.

    20. Do regional nerve blocks for facial lacerations.


    If you want a good cosmetic outcome on the patient's
    face, you must avoid infiltrating lidocaine locally and distending the
    tissues, which can alter the cosmetic results. Learn to do supraorbital,
    infraorbital and mental nerve blocks.

    21. Do watch a patient walk, if they have any dizziness or CNS symptoms.


    Brain stem and cerebellar infarcts can be subtle.
    Always watch a patient walk during the final part of your neurological
    examination.

    22. Do make sure that patients understand your discharge instructions.


    State your instructions clearly and slowly and, at the
    end, ask your patients and their families, "Do you have any questions
    for me?" You don't want your patients going home feeling that they
    didn't have every opportunity to ask questions.

    23. Do ensure follow-up for every patient.


    Make sure that all the patients you see know what to do if their symptoms persist, return or get worse.

    Many of you will have your own list of pearls. If so, please pass
    them on to physicians more junior than yourselves, so that your
    knowledge and experience helps shape and mold future generations of
    great emergency physicians.













    Competing Interests:
    None declared.









    Correspondence to:
    Dr. Eric Letovsky, The Credit Valley Hospital, 2200 Eglinton Ave. W, Mississauga ON L5M 2N1; eletovsky@cvh.on.ca

      La date/heure actuelle est Jeu 28 Mar 2024, 21:34