Things that we all can do to manage a busy Emergency Department

Emergency Medicine is a relatively new speciality in India, though there are many one and two year programs that have been around since early 1990s. Medical Council of India recognised EM as an individual speciality only in 2009. Currently there are about 48 MD positions to cater a population of more than 1.25 billion i.e we are producing 48 Emergency Physicians annually on an average to serve the whole country! 

The number of seats are increasing gradually but not on par with our exponential population growth. One problem that we are going to come across certainly in near future is “Overcrowding” which is already a major issue in countries where EM got recognition in the last century. There are many factors that are going to contribute to the problem of ED overcrowding like very few existing Emergency Departments, those which exist are often misused and abused by the other specialities, increasing population etc. There is no doubt that overcrowding affects our performance, increases stress levels and decreases efficiency. Lets look at some ways that might help us in improving the flow through a busy ED:

1) Appropriate Risk Stratification

Risk stratification is something that we do everyday. This can save a lot of out time and can lead to a quick discharges. Many of the deadly diagnosis can be risk stratified only with a good “history and physical”, without requiring any labs. Everyone who walks in with a chest pain does not need a troponin and every abdominal pain does not need a sonogram. If a patient looks stable but needs an investigation that is not really going to change your management in the ED, DO NOT DO IT NOW but do that as an outpatient work up. Don’t make them occupy a bed in the ED unnecessarily. This might look like a trivial thing but it is not. I have witnessed physicians securing airways kneeling down and doing intubations on the floor because ED beds were occupied by young low risk patients waiting for their second sometimes third troponin or sometime by stable outpatients who came to the ED to get their routine blood transfusion! Stay away from this practice. Order those tests that will help you in disposing a patient either to a room/ICU/home. Use clinical decision rules to back up and justify what you are doing. Do not order c-ANCAs/p-ANCAs from the ED. ED is not the place to work up a PUO and vasculitis. 

Always ask yourself before sending a lab test, what are you going to do if the results turns out to be positive/negative?
Do not compromise the care for sicker ones by filling beds with the stable patients who are waiting for an inpatient bed allotment. Not fair..

2) Communicate well - Communicate well - Communicate well

No matter how busy you are, establish a rapport with every patients. You deal with human beings. Try to look at them as people rather than as "bed number 5 with mesenteric ischemia." Explain them what to expect, give them rough time lines, handouts to read about their illness. 

Something that I started doing quite late in my training is making multiple short visits to every patient. This give them a feeling of being looked after well and also strengthened your relationship that has many advantages in the long run like less likely to get sued in case there is a bad outcome or they might mention your name as a "star physician" in the feedback form. This visit can be as short short as 15 seconds where you just make sure that they are doing fine and ask them if they need anything. Also encourage your nurses to do this. You will soon realise that nothing gives more satisfaction than a genuine word of appreciation.

The analogy that I like to use here is (though it is not very precise), think of yourself as an experienced steward/attendant in a restaurant. Your job is to make sure that quality of food is maintained and it gets delivered on time. 

3) Keep the consultations/referrals smooth

Now I have covered this bit in the recent past. A couple of additional points that I would like to make here are:

• Involve your specialty colleagues early if you have a good sense of what is happening. For instance, don’t wait for the white cell count for appendicitis before you call a surgical consult. If you think it is appendicitis, get them to see the patient ASAP. White cell count is an overrated crappy lab. You cannot rule out appendicitis/sepsis with a normal white cell count. 
• When the ED is packed, speak to the attending/consultants directly because they are the ones who are going to make a decision. Do not linger around with a resident who has joined the service last week. Click here to read more on how to ask for a consult.

4) Stay in touch with everyone

EM is demanding and it can get tougher when you have 25 patients and you are the only registrar/consultant on the floor with four other residents. In my opinion, nurses can play a big role here whether its reassuring a patient, or mobilising patients to the ICU. Nurses are extremely under-utilised in India. At this point of time, Nurse Practitioners and Physician Assistants are almost non-existing in India, that puts all the responsibilities on physicians. Empower the nursing staff. Get rid of your ego as a physician and start work together with the nurses. Know their names and address them by using their name.

Nurses work with you, they don’t work under you.

5) Monitor the flow and plan things ahead

Make sure you know why each and every patient is there in the ED, who is waiting for the consultant, who is waiting for labs and who is waiting to get discharged. Now I do understand this is not always possible, so consider using your smartphone, a whiteboard or a computer to do this. I am a bit old-fashioned here, so I have always used a pen and a sheet of paper for this purpose and it works pretty well for me. Find out what suits you and make that a habit. Don't try to do everything but delegate tasks to the residents and follow up on them. 

Regarding procedures, when the ED is busy, do only those procedures in the ED that are required to be done right away and those that will make a difference. If there is no pressing indication for a central venous access, it is okay to give vasopressors through a peripheral IV for a few hours. CVC can be placed in the ICU. 

Always remember that ICUs can close their doors once they are fully occupied but it is hard for Emergency Departments to do that.

6) When you are on shift, you are on stage!

I learned this during The Teaching Course 2014 and this is how most of the medicine is learned. We learn by observing our mentors, we incorporate their qualities (good or bad) which are passed on to the next generation. A lot can judged about your mentor based on your behaviour. The way you speak, empathise, listen, express....everything. So it is like when you are on a shift, you are on the stage and residents are watching you, learning from your behaviour. Therefore, be at your best possible behaviour. 

Be ready to do even the seemingly easy tasks like starting a peripheral IV or starting a transfusion or passing a blanket/ a glass of water to the patient or passing a bed pan to a patient. Small efforts like this eventually get appreciated by nurses/housekeeping/patients and this would be useful in the long run. In addition, your residents will watch this and pick up these behaviours knowingly or unknowingly. 

7) Ask for help before care gets compromised

When things really go out of control, get into the “disaster” mode. Ask for dermatology in patient beds, speak to the medical superintendent and get them down in the ED. Do whatever you can to avoid any sort of compromises with the patient care. You can involve the patients, the stable ones who are occupying a bed, request them to occupy a chair. Many of them would be more than happy to do that. 

Things that actually matter the most to patients:

• Empathy/attitude (They don't judge you by the quality of medical care that you provide)
• Timeliness of care
• Technical competence of care providers
• Pain management
• Information dispensation 

Other things that you may try out:

• Physician at Triage: Expedites care and almost one third can be can be rapidly discharged
• Virtual wait rooms: Still in the conceptual stage. For non-urgent patient, paramedics contact the hospital to schedule a visit. The patient gets added to the ED queue without having to be there in person and could wait at home. As the scheduled time approaches, the patient comes to the ED.
• Have a dedicated transport staff
• Have a dedicated person to manage financial issues (major problem in India) and arranging in patient beds.
• Point of care testing

References:

1. Campbell SG, Sinclair DE. Strategies for managing a busy emergency department. CJEM. 2004 Jul;6(4):271-6

Understanding Diabetic Ketoacidosis

This episode talks about diabetic ketoacidosis.
Some key points on how insulin maintains normoglycemia before we end with a couple of clinical take home points.

Diabetic Ketoacidosis

Want to read more on DKA, then checkout:
http://rebelem.com/diabetic-ketoacidosis-dka-myths/
http://lifeinthefastlane.com/ebm-diabetic-ketoacidosis/
http://www.emdocs.net/myths-dka-management/

Is CE technique the best way to do BVM - May be not!!

We all are familiar with the CE technique that is used to deliver BMV. This is what we routinely learn during the ED/ Anesthesia/ critical care rotations and also at the life support courses. Is this the best way to deliver ventilation? May be not!

Another technique that can be used is the "The two thumbs down technique" or "The thumbs up technique" that has potential advantages over the standard CE technique.

You might get a weird look from those who are not familiar with this technique. Let people know what you are doing and why you are doing this OR just show them this video (by Rueben Strayer, emupdates).

                   

Take Home: BMV is always a 2 person procedure (regardless of technique used) - Skilled person holds the mask and anyone else can provide the breaths + Consider the 2 thumbs down technique for BMV instead of the CE clamp.

And Believe it or Not - Learning BMV is more important than mastering Laryngoscopy !!
DO check out this link (if you have not already) - emupdates

What Emergency Physicians Should Know About Informed Consent

Every patient with an intact mental capacity has the right to decide on treatment/procedures that he or she would like undergo. And as Emergency physicians, taking an "informed consent" is something that we do on everyday basis. This is another area where mishaps are likely in a chaotic ED. 

First take home point from this post would be to understand that "even if you perform a procedure that was necessary without any complications, you can still be held liable for not obtaining the consent." Therefore, it is vital to have a clear understanding about "informed consent" to avoid miscommunication and bad outcomes. 

So what does "informed consent" mean?
Informed consent is the process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment (informed refusal). It originates from the legal and ethical right the patient has to direct what happens to their body and from the ethical duty of the physician to involve the patient in her health care. Informed consent may not be applicable only to procedures, but also to other significant management decisions.

Patient should get a clear understanding about the facts and the possible consequences before giving the consent. A good way to do that is, questioning yourself  "if you have disclosed the information clearly enough?" or ask yourself “Have I provided the patient with an understanding of what her or she would want to know?”

With an informed consent, we invite the patients to participate in the process of "shared decision making." Once again, stay away from medical jargon while explaining something to the patients. 

Elements of a full informed consent?

• Nature of the decision/procedure 
• Reasonable alternatives to the proposed intervention (regardless of there costs)
• The relevant risks, benefits, and uncertainties related to each alternative 
• Assessment of patient understanding 
• Acceptance of the intervention by the patient

Concept of Battery

Battery is legally defined as the intentional infliction of offensive or harmful bodily contact, regardless of whether the person was trying to harm or help. For instance, if a surgeon consented a patient for an operation on the right ear and while the patient was under anesthesia, he discovered the left ear was worse and operated on that ear with a poor outcome. The patient will get the damages not based on malpractice, but on lack of obtaining informed consent.

To prove lack of informed consent, patient must prove that:

• Physician failed to disclose adequate information regarding benefits and risks of proposed treatment, as well as alternative treatment options
• Patient need not prove negligence in the performance of the treatment; liability arises solely from inadequate disclosure (Physician is liable even if treatment was medically appropriate and performed skilfully right to damages arises from unauthorized contact)

What is informed refusal?

Informed refusal is when a patient refuses a recommended treatment/ procedure based upon his understanding of facts and implications of not following the treatment.

Waivers to informed consent:

• If the patient does not have decision-making capacity. Find the proxy, or surrogate decision-maker
• Implied consent in emergency
• When the patient has waived consent
• When a competent patient designates a trusted loved-one to make treatment decisions for him or her

For simple procedures like auscultation, drawing blood, physical examination etc. consent can be skipped (implied consent). We generally do not explain patients about risks, benefits and alternatives for auscultation!

How much information is enough?

There are three ways to look at it:

• Reasonable physician standard: What would a typical physician say about this intervention? This standard allows the physician to determine what information is appropriate to disclose. This standard is generally considered inconsistent as the focus is on the physician rather than on what the patient needs to know. 
• Reasonable patient standard: What would the average patient need to know in order to be an informed participant in the decision? This standard focuses on considering what a typical patient would need to know in order to understand the decision at hand. 
• Subjective standard: What would this particular patient need to know and understand in order to make an informed decision? This standard is the most challenging to incorporate into practice, since it requires tailoring information to each patient.

As a physician, you must disclose all of the information that the patient needs to make a decision, but not so much that it frightens the patient from making a decision that would be of most benefit to him or her. This can sometimes be difficult and this is where you can employ some amount of discretion. I personally go with the "subjective standard" and individualise information as per the needs of each and every the patient. 

Consent Forms:
It is fine to have consent forms signed by the patients before the procedure/major treatment (tPA for stroke), making sure that they are aware of the process and understand it. In the ED, patients are distressed and sometimes they just want things to move quickly. This can be one reason for signing the consent form without going through it in detail. The way these forms are designed is scary. For a minute, if you read it through the patients eyes, it can give you goose bumps for sure. 

This is what a typical consent form says:

I confirm the following:

My physician has explained to me the nature, purpose, and possible consequences of the procedure(s) as well as the risks involved, and the possible complications and/ or alternative methods of treatment. I understand that the explanation I have received is not exhaustive because of unforeseen circumstances that may arise and I have been advised that a more detailed and complete explanation of the preceding matter will be given to me if I so desire. Upon reading the previous statement, I do not desire such further explanations. Furthermore, I acknowledge that I have received no guarantees or assurances as to the results that may be obtained from the performance of this operation or procedure.

When we purchase something (a mobile phone), we all enquire about the warranty/guarantee periods but when a patient submits their body to a physician to carry out a procedure/treatment for their own benefit, there are no assurances because every human body is unique and may respond differently to same treatment. 

These "consent forms" carry little value in the court of law. However they do acknowledge that a discussion took place between the physician and the patient but it is hard to find out what exact bits of the consent form were actually discussed.

  

Risk Management Strategies:

When obtaining an informed consent:

• Have a meaningful, unhurried conversation with patient. 
• Make the patient an active participant in the shared decision-making process.
• Provide supplementary information, such as brochures or videos.
• Disclose the most severe risks and the most common risks.
• Don't forget to mention about the alternatives.
• Obtain signed informed consent form.
• Avoid giving casual answers e.g This surgery is as risky as any other major surgery or I have done dozens of such surgeries. Be a little sensitive.
• Be professional.
• Avoid quoting exact numbers or percentages.
• Most important: Never ask a colleague or junior physician to obtain an informed consent on your behalf. This leads to confusion, chaos and miscommunication. Person doing the procedure (Yes, even the the senior physicians) must take the consent. It is important to make sure that the patient and family have the capacity, are clear on the facts and have their concerns addressed by an experienced physician before getting to YES,.

Informed consent requires disclosure, understanding, capacity and voluntariness. It is not just another signed document. Patients must have an intelligent understanding of their diagnosis, risks/benefits of proposed treatment and alternative options.

References:

1. Appelbaum PS. Assessment of patient’s competence to consent to treatment. New England Journal of Medicine. 2007; 357: 1834-1840. 
2. Moore, Gregory P., et al. "What Emergency Physicians Should Know About Informed Consent: Legal Scenarios, Cases, and Caveats." Academic Emergency Medicine 21.8 (2014): 922-927.

Explanation, Planning and Closing: ED Medical Interview (Part III)

This is the last part of medical interview. Again, this is when you need to display strong communication skills. As a beginner I often used to skip this step until I started looking  things from "the patient's perspective". In my opinion, this is the major difference in terms of how medicine is practised in developing countries, in contrast to the developed world. 

This is where I prefer to sit and talk to the patients at least for a few minutes. A busy ED cannot be an excuse for not doing this. Patients expect us to have a conversation with them at the end of the interview hoping to get an understanding and possible explanations of their problems. 

This could also be the most important piece of conversation if you are planning to send them home, good (written+verbal) discharge instructions can save you as well as your patient. 

EXPLANATION

Assess their current understanding

By now you should have some idea of where the symptoms are coming from. Assess the patients understanding and ask them what to they believe/ think about the origin of their symptoms (if you have not asked them already). If they come up with a medical diagnosis, ask them how much do they know about it. This is important to know before you explain them about an illness. Don't waste time explaining the very basics of diabetes mellitus to someone who googled it just prior to the visit!!

Diagnosis/ Differentials

In the ED, reaching a diagnosis is not always possible. Few patients understand this while other might not. Your job then becomes to tell them the possibilities and say that we are going to deal with the life threats first and other trivial problems can be dealt later. Now I have come across situations when patients didn't like this statement of only "ruling only the life threats". Don't loose your cool. Many of them may not be aware how systems work in the ED. Give them some time and avoid rushing through these issues because this often leads to patient dissatisfaction. Giving them a few extra seconds to digest the info here will go a long way. 

Learning how to reassure them comes with time. If you can't explain the occurrence of a particular symptom, be honest and accept that rather than trying to explain using medical jargon! 

Google/Youtube

It varies depending on where you practise, the kind of background from where your patients come from. Use resources to show images, pictures and short videos to help patients understand the pathology better. Give them resources from where they can read more about it and I promise they will tell you something new about their illness next time!

Timelines

Whenever you want them to wait for something, set a timeline. Say if you are sending labs, give them a timeline on turn around times. If CBC takes 1 hour to come, tell them its going to take 90 minutes. If you promise 60 minutes and get back after 90 minutes, patient is not gonna be happy. If CT is going to take 15 minutes, say 30 minutes. (Always under promise and over deliver). 

PLANNING AND CLOSING

Ask their opinion and do Shared Decision Making

Whenever there is an option to choose from, tell them the pros and cons and let them choose. Guide them, help them but avoid imposing your advice onto the patients. Unless you answer the "WHY" question for them, they are not going to stick to the advise. Tell them why something is important, benefits of following and possible harms of being non-compliant. 
Here in India, we frequently come across patients who are not comfortable making any sort of decisions by themselves and want the physician to weigh the pros and  and the cons, and make the best decision for them. It is fine as long as they are made aware of the all the possible options and alternatives. 

Discharge and Safety Netting 

Importance of spending the last few minutes with a patient cannot be emphasised enough. This is probably what they are going to remember out of the visit today. They are going to recall and use this info before they visit you next time for a similar ailment and also might pass on this to friends/family!!

Explain them what you thought initially about their symptoms, how you excluded things based on history/labs/probability and what you are finally left with. Some patients like this info to be short while others look for in depth details. 

It is okay not to reach a diagnosis at the end of an ED visit. Sometimes reaching a diagnosis takes days or weeks. What is expected from us is not to miss the life threats and acute pathologies. (Most patients appreciate and understand this)

Talking about Meds: How it works? How it is taken? What to expect while on medication? What to do/not to do when on meds? (With no medical jargon!)

Red flags - When to come back? Be explicit on this. 

We are here 24x7x365, please feel free to come back if you ever feel something is not right. Also provide with ED contact number in case..

Having a symptom specific discharge advice saves time - You can have printed advise sheets for common problems like mild head injury, diarrhoea, flu etc. Patients can read this then you can reinforce on this. 

Given them written + oral advice to cut down the confusion. They can read it as many times as they want. Don't fall into the trap on providing only oral instructions. ED attendances are often unexpected, chaotic, people are distressed. Don't overload them with info.

Further concerns and questions

This is the last question that you should be asking them before closing. It once again checks if we have missed anything or if they have something left unattended. This makes them feel reassured and cared for. 

Emergency Medicine is tough. People come to us when there is nobody else to help them out. They might not like us (and would like to see their family physician) 

As emergency healthcare providers, we are not their choice but their fate!

Reaching out to their expectations at this point is something we all should strive for and this is what makes EM special.

Gathering Info: ED Medical Interview (Part II)

This part forms the core of the interview. In the ED, this should take about 10-15 minutes typically.

1) Encourage patients to tell the story: Give them about a minute without any interruptions. Within a minute you will have a good idea about their chief complaint. If there are too many chief complaints then ask them what is bothering them the most and focus on that complaint. Often there are 2/3/4 chief complaints and then you need to prioritise them and set them in order. Of course we all come across patients who take us all over the map, do not lose your patience with them and very gently bring them back to the track. It is important to use words like we/us/together rather than I/me/you during the conversation.

What brings you here today?

How are you doing?

2) Use open ended questions first: It is recommended to start with an open ended question in the beggining and set them free to express symptoms and concerns. If they miss something important then use closed ended questions to clarify your doubts and best some specific info. As you actively listen to them, make neutral utterances and give them non-verbal cues to encourage them to tell more. If you ask a specific question, give them a few seconds to think. Avoid giving them a list of options to pick up one, unless they are unable to explain. If you come across a guy with shoulder pain for 6 years and now he is in the ED, it is important to ask about the triggers that made him come to the ED. 

Say: Tell me more about the chest pain (open-ended)

How long you have been having this pain (closed-ended)

Don't say: Is the pain burning, heavy, sharp? 

Avoid giving them a list of options.

3) Be attentive, sensitive, supportive

As they are telling you their story, listen attentively, facilitate the process if they have issues with something. Body language (speech, expressions, voice tone) and non-verbal cues play a major role here. Once again, if you are taking notes as you are talking to them, make frequent eye contact. Give them non-verbal cues, pick up their verbal and non-verbal cues. If you are not clear about something, paraphrase that and clarify. Acknowledge their agony. When talking about sensitive issues, once again ask for their permission.

Say: I can imagine how difficult it is.

So you are saying that the pain started around the umbilicus and then moved to the lower abdomen. Is that right?

4) No Jargon
Despite out best efforts to stay away from it, we still use jargon. It is best not to use medical jargon during the interview. The way you communicate can be gauged with the educational status/ occupation of individual patients. What I do is, I tell them beforehand that I will try my best to avoid using medical jargon, if there is anything they are free to interrupt and ask me.
Patients might think that they will sound stupid if they ask a question or if they ask us the exact meaning of a word (say Resuscitation). Therefore, it is recommended to avoid jargon as far as possible.

Say: I am going to ask you a few questions regarding the chest pain to find out exactly what is happening. I will try my best not to use any medical jargon, in case I do that unknowingly, please feel free and interrupt me. Is that okay?

5) Understand their perspective and don't be judgemental
Understand how patients look at an illness and what are their beliefs. Sometimes they tell us the diagnosis right away. Nevertheless it is important to always work with an open mindset, when you are doing the work up (because patients with meningitis can have SAH too!). Few key questions that can provide us invaluable info are:

• What are you concerned about? (highlights the chief complain again)
• What do you think is the reason for the knee pain? (Tells us about their beliefs or sometimes "the diagnosis")
• Is there anything else that you think I should know? (Often this question gives us the most important piece of history)

6) Summarise and check accuracy
When you are done with the history, present a brief summary to them to make sure that you got it right or if they want to add anything to it. Don't overdo this. Just a 15-30 seconds summary to check the accuracy of the history.

So, you have got this chest pain that has bothered you a couple of times during the last week. It comes on exertion and gets better when you rest. Do you want to add anything? 

Key points for gathering info:

• Start with open ended questions and then get specific with close ended questions
• Be attentive, sensitive and supportive 
• Ask for the triggers
• Avoid using medical jargon 
• Understand the patient's perspective and don't be judgemental 

William Osler: Listen to the patient, he is telling you the diagnosis

The first 60 seconds - ED medical interview (Part I)

As physicians, we encounter a variety of individuals everyday. Establishing relationships and building a rapport with people is something that we all should be expert at. These communication skills are undoubtedly crucial to gather the right information, ensure patient comfort and better patient care, but these skills represent one of the most overlooked aspects of medicine at least in this part of the world. 

Learning how to do a "medical interview" takes time. It is a process that is learned over years where we try to quickly develop a supporting relationship, gather information and offer information at the same time. 

We are going to cover this in three parts:

Part I: Initiating the session (First 60-seconds)
Part II: Gathering Information 
Part III: Explanation, Planning and the Closing the session

Initiating the Session (The first 60 seconds)

The first few minutes that we spend with the patients sets the foundation for the interview as well as for our relationship with them.  

1. Welcome 

• Appearance: Patients find cleanliness, conservative dress and name tag reassuring. Always have your ID displayed.
• Hand Hygiene (No excuse for this!)
• Greeting: Shaking hands is fine but be sensitive and look for the non-verbal cues because cross gender hand shakes are considered inappropriate in some cultures. At the same time, keep a watch on the non-verbal cues like facial expressions, posture, body language (throughout the interview). Remember that the patient is also observing you and reading your nonverbal cues. So be attentive, maintain a good eye contact, smile, be polite and respectful. Demonstrate your concern and make them feel important. 

If the family is around, be sure to acknowledge and greet each one of them, enquiring their names and relationship with the patient. (Maintain confidentiality when family is around). Ask the family respectfully, to leave before you start the interview unless the patient  wants them to stay.

2. Using the patient’s name

Some patients like to be addressed by their first name when they are greeted; but others prefer either their last name. So it is always better to be formal to start with (Use Mr./Mrs. or Ms. if you do not know a woman’s marital status) and address them using their last name in your initial greeting. After formally greeting the patient, ask how do they prefer to be addressed and use the preferred title/name the next time. It is easier to go from more formal to less formal terms of address than the reverse. If the patient's name sounds unusual to you, then ask them how to pronounce it.

"I am afraid of mispronouncing your name. Could you say it for me?" Then repeat their name.

3. Introduce your self and identify specific role

Use both your first and last names when introducing yourself. Avoid saying, “Hey Philip, I’m Dr. Chandy” or “Welcome Mr. Philip, I’m John.”  
After you introduce yourself, mention your official role, for example, "attending, resident or medical student”. Occasionally at the beginning but more often after some time, a relationship on first-name basis may develop.

"Mr. Philip.. Hello, I’m Dr. John Chandy. I’m the resident physician here who will be looking after you. How do you prefer to be called?"

4. Ensure patient readiness and privacy

Be courteous, make sure they are ready for it before you start the interview. Once ready, then you can ensure privacy by shutting the door, pulling a curtain (with their permission) around the hospital bed or respectfully excusing the family members. 

5. Remove Barriers to Communication
Make every possible effort to remove the barriers that hinder communication. When dealing with elderly, they should be able to see the your mouth in order to speech-read. If there is any question, ask the patient whether she or he can hear you well. Patients experience that you have spent more time with them if you sit, so do so whenever possible. Communication is optimal if you and the patient are at the same eye level. Attention to the nonverbal aspects of communication is important. 

If possible, Avoid taking notes when you are doing the history. At times, we do need to take the notes for comprehensive documentation. When doing this, do make some eye-contact and put down your pen intermittently.  

6. Ensure comfort and put the patient at ease 

These efforts are always worth the time  Determine if anything at the immediate time is interfering with the patient’s comfort. Questions like, “Are you comfortable?” or “Is the light bothering your eyes?” or “Can I raise the head of the bed for you?” are essential. Take their permission before you start the interview. Pay constant attention to patient’s comfort as you proceed. Show your care, compassion and concern. In short, treat them the way you would like to treated!!

Engaging in a little social conversation is another good way to put the patient at ease (if they are stable and have a minor illness). This breaks the ice and allows the patient to get more comfortable with you. 

If you are ever in any doubts, step into the patient's shoes and you will almost always come up with the right answer!!

Stay tuned for Part II: "Gathering information" that forms the core of the interaction.

References:

1. http://onlinelibrary.wiley.com/store/10.1046/j.1525-1497.12.s2.7.x/asset/j.1525-1497.12.s2.7.x.pdf;jsessionid=64F85FD04AEF5D03A8946EC4B3BC025D.f03t01?v=1&t=igywaxdv&s=ec03fdf5028bee52b6da44a9918f90683ceaa79f
2. Makoul,G.,A.Zick,andM.Green,An evidence-based perspective on greetings in medi- cal encounters. Arch. Intern. Med., 2007; 167(11): 1172–1176.
3. Frankel,R.M.andT.Stein,Getting the most out of the clinical encounter: the four habits model. J. Med. Pract. Manage., 2001; 16(4): 184–191.
4. Kahn, M.W., Etiquette-based medicine. N. Engl. J. Med., 2008; 358(19): 1988–1989. 
5. Mast, M.S., On the importance of nonverbal communication in the physician-patient interaction. Patient Education & Counseling., 2007; 67(3): 315–318.
6. Roter, D.L., et al., The expression of emotion through nonverbal behavior in medicalvisits. Mechanisms and outcomes. J. Gen. Intern. Med., 2006; 21(Suppl 1): S28–S34.
7. Gladwell,M.,Blink:The power of thinking withoutt hinking,1 the dition.2005, New York: Little, Brown and Company.
8. Frankel, R. and T. Stein, Getting the most out of the clinical encounter: the four habits model. Permanente Journal., 1999; 3(3): 79–92.

Towards a better EM Residency: Resident Welfare Programs

Residency (referred as post-graduation in India) can a stressful time for the residents, especially when it comes to much demanding acute care specialties like Acute Medicine, Emergency Medicine and Critical Care. It is a period of enormous personal as well as professional development, when trainees identify themselves with consultants and unknowingly introject many of their qualities and behaviours, making them a part of their own personality. 

As budding physicians residents learn a plenty of new skills, take responsibility for the sick patients and also understand how to communicate with distressed patients and families. They do come across hard situations that they have not dealt with before and if not taken care of at the right time, these issues can have a deeper impact on their working ability and lead to physician impairment and burnout. EM needs a special mention here  because Emergency docs work in the most unexpected and uncertain circumstances. Over years they learn how to converse with all the other services working in different parts of the hospital. They have no other option but to learn and speak the language the other co-specialities understand and then further gauge things as per individual preferences. 

And Emergency Medicine is one such speciality, where your work is almost always cross checked by a "specialist" or one of your colleagues and people judge you based on that without appreciating the kind of circumstances under which you worked. We all know that medicine is not always seen as blacks and whites. Opinions differ many times and there is always a potential for a conflict!

These issues might sound trivial alone but we need look at the bigger picture to really understand how all these minor sounding issues together, can affect the performance and mental health of residents. It is therefore essential to understand the the residents' perspective and look at what problems they are facing on day to day basis and only then we can figure out together on working towards "Resident Wellness" because only healthy (mentally and physically) residents can provide quality care to sick patients.

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Here are some key issues with Resident Wellness:

• Sleep Deprivation
• Long working hours
• Difficult Consultants
• Difficult work relationships (with nurses/colleagues) 
• Difficult Patients
• Peer Competition
• Exposure to infections/ patient mortality

Specific Issues with women:

• Discrimination (Patients often assume female physicians as nurses!)
• Lack of female role models
• Multiple Responsibilities (marriage, family, motherhood)

As a speciality, EM is still in the developmental stages in many parts of the world. Some trainees choose it out of interest and others because they did not match anywhere else! Trainees might also feel that they have nobody around to look up to because hospitals often employ is a single consultant for a 15-20 bedded ED.  

If greater attention is paid towards physicians and residents well-being, it can be associated with better patient care. There are some possible ways out through which we can try and fix these problems. 

Residency Programs should have:

• Annual Leave Policy
• Fixed Duty Hours
• Circadian Scheduling policy (Considering personal preferences)
• Wellness Workshops (for nursing as well as medical staff)
• Including wellness in the curriculum
• Teaching personal safety skills, communication and negotiation 
• Record all the didactic sessions (Night workers can watch them at their own ease)
• Department social events (interdepartmental as well as intra-departmental)

For the residency programs, it is frequently not possible to stick to all these measures due to various reasons, and residents also must take some onus to work towards their own wellness by having individual coping mechanisms like:

• Have a written set of goals for every trimester/semester
• Have a mentor
• Always try and think from the other person's perspective
• Have a fixed time for friends/family
• Exercise and eat well 
• Learn to communicate well: This can make or spoil your day!
• Prioritise and learn to say "no" to a few things

Dealing with other specific issues:

• Substance Abuse: Encourage self reporting, Speak to the program director
• Circadian Disruption: Learn the art of working in shifts
• Litigation: Improve documentation, Know the risk management strategies 
• Exposure to diseases: Always and Always use PPE
• Exposure to Mortality: Post death debriefing, Spend time with friends/family and understand that death is part of EM

Key Points:

• Acknowledge the fact that as an emergency health care providers, you are vulnerable.
• As residents, work with the residency program to create a healthy learning environment. 
• Appreciate the opportunities created by the residency programs and make the most out of it.

To keep the body in good health is a duty...otherwise we shall not be able to keep our mind strong and clear - Buddha

Further Reading:

• Schmitz GR, Clark M, Heron S, et al. Strategies for coping with stress in emergency medicine: Early education is vital. Journal of Emergencies, Trauma, and Shock. 2012;5(1):64-69. doi:10.4103/0974-2700.93117.
• Schwartz AJ, Black ER, Goldstein MG, et al. Levels and causes of stress among residents. J Med Educ. 1987; 62:744-753.
• Whitley TW, Gallery ME, Allison ED, et al. Factors associated with stress among emergency medicine residents, Ann Emerg Med. 1989; 18: 1157-1161.
• Houry D, Shockley L, Markovchick V. Wellness issues and the emergency medicine resident. Ann Emerg Med. 2000;35:394–7.