Fostering a culture of appreciation in the ED

The deepest principle of human nature is the desire to be appreciated. Whether it is the CEO of an institute or the housekeeping staff, everyone seeks appreciation for the work that they do. Knowing that our efforts have been recognized and appreciated makes us feel valued. Conversely, without appreciation we can feel taken advantage of, leading to negative reactions. Research suggests that people who feel appreciated are more productive, have greater levels of job satisfaction. Other benefits include more fulfillment, more positive attitudes, decreased stress and burnout.

While teaching children, preceptors make encouraging comments frequently, to make children feel appreciated, reinforce the good behavior and expedite the learning process. Parents praise their children for every effort but this is not done with colleagues at our workplace. Why not? Adults are no different. Self-esteem in kids as well as in adults contains a large component of internalized appreciation. A pat on the back makes individuals feel good and content about themselves and pushes them to achieve more.

This is something that we need incorporate in Medicine (esp. Emergency Medicine). Getting appreciation from colleagues is a rare sight due to a multitude of reasons. But a few words of appreciation can make our day. Also, lack of appreciation is the number-one reason for burn-out and people changing jobs. 

Feeling appreciated is an extremely strong emotion that makes a tremendous difference to relationships. For instance, your rapport with the consulting physician matters a lot when you ask for a consult in the ED. Healthy relationships are in fact build on appreciation. A personalized recognition of someone’s efforts, in a meaningful way to that individual, can make them feel encouraged. It lifts the morale and is a motivation tool that inspires to take that extra effort striving for praise once again. 


Components of Effective Appreciation

• Expressive Action (What you do to express gratitude)
• Inner Attitude (How you felt by a person's actions)

This needs to be done consciously at least in the beginning. People can easily make out the difference between a truly "heartfelt thank you" and an "insincere thank you".


Ways of showing appreciation

1. Saying Thank You - Using words like Please, Sorry and Thank You is important to be courteous towards individuals. But, get rid of the NAKED Thank You. Whenever you express gratitude, tell people about the resulting benefit they created for you and make it more meaningful. Make an extra effort to complete this statement. Don’t just say “THANK YOU”, instead, add the emotion about how you felt and how their act changed things for you. For instance, when you request a colleague to relieve you from work an hour before. Rather than saying an insincere Thank you, consider this

It is very kind of you for being so considerate and showing up early even after working last night. I truly appreciate that. This is going to make things very easy for me today. 

If an attending/ consultant teaches you about a topic following a hectic shift, he just gave you a few minutes of his lifetime. Be thankful to him for doing that.

2. Gifts - The price of the gift is not important here, it is all about the THOUGHT. Everyone likes to enjoy good food. So it is one good way of doing this. You know how it feels, when someone shows up with a box of doughnuts in the midst of a HANGRY (Hungry + Angry) shift! 

3. Publicly acknowledge people for what their work - This makes people feel recognized and also shows others what to aspire to. For instance, if a resident performs a difficult airway, taking 30 seconds and praising him during the next didactic session is going to  make him feel worthy and boost up his confidence. 

This works on the principal of mutuality i.e. the exchanging of actions.  In regard to commendation, that person would be pushed to do more for the former person and aspire for more.

4. Make your appreciation personal - Be specific as it makes people feel being heard, lifted up and understood. Rather than making cliche statements, be clear and candid. Tell them how they impacted your life, what you admire about them. It tells them that you actually spent some time thinking about them.

5. Appreciate yourself - If you have difficulty in praising others then I recommend you to start doing it with yourself first. Perform at least one good deed every day to make you feel appreciated and think what could you do better tomorrow.

6. See what others are doing RIGHT - Rather than focusing on the negative in a person, look at the positive habits. Start acknowledging people regardless of the outcome of the task but recognize the efforts that have put in. 


7. Make “I” statements - It is about how they made you feel, it is not about the other person. So focus on "I" statements. Rather than saying "YOU are awesome", say "I always enjoyed working with you as you constantly checked on my work making me feel secure". Just saying YOU ARE AWESOME is pretty non-specific and meaningless. Using "YOU" statements might make people feel being judged, which is another reason to avoid it.

Further Reading:
Attitude of Gratitude – Showing Some Love in the ED

Author:

              

     Lakshay Chanana

     @EMDidactic

                                                        

 

Breaking bad news in the ED: Who is going to bell the cat?

As Emergency Physicians, declaring unexpected bad news is a part and parcel of our job. On one of the most stressful shifts that I have had so far, I remember declaring 3 people dead over a span of 8-10 hours. This can be an extremely challenging task which if not done appropriately can have long standing consequences, not only on the family members of the deceased but also on the physician who breaks the news. Unfortunately, not much attention is paid on how to address this issue in many fields of medicine and only a few specialties receive the right kind of training of doing do such as Emergency Medicine, Critical Care, Palliative Medicine and Oncology. Moreover, even in various life support courses, this particular skill is seldom taught. 

Declaring a sudden unexpected death in Emergency Department is quite different from what happens in the Oncology/Palliative Care wards or even in the ICU. In case of a sudden death in the ED, families have a tough time in absorbing the news whereas settings like ICU/Oncology/Palliation wards often provide enough time for the family to adapt the situation. 

Here is a framework on how can we do this in the ED:

1. Setting the scene

To begin with, we need to set the stage right, ensuring privacy and giving respect to the family members. Introduce yourself, confirm their identity/relationships and most importantly know the name of the deceased. You have 1-2 minutes to set this right, connect with them, making them feel important and creating a rapport. To accomplish these, look professional, demonstrate empathy, watch you body language, voice tone and expressions. Also turn your phones on silent modes. 

I am sorry to meet you in these circumstances. This is going to be a tough conversation for us. 

I would also recommend to involve a social worker/nurse right, a chaplain and a medical student or resident with you. They can take control of the situation and provide continued support if you need to leave the room urgently for some reason and for a med student, this is the best opportunity to learn this skill.

This is not like a 1980-90s Bollywood flick, where typically a doctor exits from the operation theatre, shakes his head and says "I am sorry, he is no more" and then walks away. Declaring death is one of the hardest jobs that emergency physicians do and this can be very exhausting if done without apt training.

I believe that the most senior physician present in the ED should take the responsibility of doing this task. The gives a sense of reassurance to the family. A med student or a fresh trainee should never do this alone unless he has been appropriately trained. 

2. Breaking the News - Crux of the matter

After a quick introduction, avoid beating around the bush and building unnecessary tension. Come to the point fast and be succinct. You might consider them asking their view point and understanding of the circumstances so far, but avoid asking too many details. Try and deliver the news 2-3 minutes into the encounter. And remember, once you say the work "Death" or "Dead", just stay quiet and let them break the silence. Don't be afraid of silence and allow time for people to imbibe the event. If they break down, give them time and offer tissues or water. 

The less you say, the better it is. As physicians, we tend to mention minute details such as:

During resuscitation, we did chest compressions, administered adrenaline and delivered 300J shock but could not bring him back. It seems like he suffered from a refractory cardiac arrhythmia. 

Using medical jargon along with providing these minute details might sound a bit defensive and it is best to avoid doing this. It only adds to the confusion. Keep the conversation simple, clear and to the point. If the family witnessed the resuscitation, then they would already know the kind of efforts that you made, which helps them in understanding things better. 

3. Continuation of support

At the first place, try to give them uninterrupted time but if there is an emergency and you need to leave, excuse yourself and let the nurse and the social work over take over. 

I am going to excuse myself for a while. We have Sister XYZ and our social worker (XYZ) here to help you out further. I will be available in a few minutes to answer any questions that you might have. 

Social Workers play a vital role here in terms of helping the family understand about the next steps such as documentation, issuing of a death certificate and preparation of funeral.  They can also provide assistance if the relatives want to call and speak to someone.

As a physician, you need to visit them again to ask if they have any questions or concerns or if they would like to see the deceased person or perform some religious rituals. And if they want to see or touch the the dead body, take a few minutes to make the body look presentable and warn them for any disfigurement that they might see.  

Follow the local organ donation policies, involve the organ donation co-ordinator for this. I personally think you need not speak about organ donation with the family in a case of sudden unexpected death. This is best left to the organ transplant co-ordinator. 

But if your institute has a stringent policy that states emergency docs need to initiate this discussion, then start with something like this:

I am sorry for asking this Mr. XYZ, but have you ever had any discussions about organ donation ?

OR

Does  (Name of the deceased)  has an organ donation card?

In addition, you also need to mention the need to perform an autopsy if it is a medico-legal case. The brunt of doing this falls on the emergency physicians. The family (regardless of the cause of death) is never in favour of a post-mortem examination. If you think autopsy is required, be assertive on that and consider saying something like this:

Since this is an medically unexplained death/Road Traffic Accident. I am bound to fill a medico-legal form which is then passed on to the police department. Unfortunately, I don't have a say in this and things are going to move as per the law of the land.

Many hospitals also give follow up calls to the families to ask about their well-being 2-3 weeks after the event. 

Breaking a bad news might be an everyday thing for you, but for a family, this is possibly the most stressful day in the lives or probably a life changing event. Therefore, we need to keep everything aside and give them uninterrupted attention for a few minutes. They are going to remember what you say for the rest of their lives, so be sensitive and considerate. 

References:

1. https://www.acep.org/content.aspx?id=26468
2. https://edcentral.net/2013/12/21/im-sorry-we-did-everything-we-could-breaking-bad-news-in-the-ed/
3. http://theoncologist.alphamedpress.org/content/5/4/302.long

The shunned nursing note

Quality documentation is a integral part of our job. The care that we provide is always judged by the kind of documentation that we do. 

If a thing is not documented, it is not done. 

At the same time, there is something very unusual here, a big disconnect between the physicians and the nurses. I have always witnessed nurses checking out and reading a physician's note but a physician reading a nursing chart is a rare sight. Most of you would agree that physicians do not pay much attention to the nursing notes unless they are in the soup. And if you ask me why do physicians do this, I would say that this can be a multitude of reasons for doing that like a physician's ego, lack of trust, lack of a rapport or they just don't care about what nurses document. 

Everything goes smooth until and unless there is a mishap and a lawsuit. And in the court of law the documentation done by the physicians as well as the nurses is frequently scrutinised to review the case and understand the timelines. Things can really go out of the track  because of a mismatch between our notes. So, the importance of nursing notes cannot be underestimated. 

As compared to a doctor's documentation, nursing documentation is much more comprehensive in terms of the vital signs monitoring, communication and ongoing patient care. In my opinion, a nursing note is far more detailed, legible and honest. Next time, have a glance through their note and you will be surprised to find that how thorough they can get. You will find every minute aspect of patient care documented like assessment, what the patient exactly said, monitoring, counselling, teaching, medications, verbal and written orders, compliance, evaluation , plan and communication about all this with the physician. You might also find your name documented in their note! 

So, don't you think we should pay a bit more attention towards all their hard work? If not for all the patients, at least for those who are getting discharged from the ED  and for the ones who are critically ill.

When evaluating a patient in the ED, we need to remember that the documentation actually starts from the field followed by triage notes, nursing assessment and then the physician notes. Our responsibility then is to do our own history and physical rather than duplicating the same notes again. It is also crucial to be aware of the timelines and make sure that there are no discrepancies between the physician's and the nursing note. If there is a discrepancy, then mention that in your chart with reference to the nursing note to make sure the message is conveyed clearly. 

A typical nursing note: (it can get much more detailed)

14/03/2015  0900hrs Patient received on Bed No. 4. He is alert and oriented to time, place and person. Complaining of headache. No H/O Allergies. VS: PR 98/min  BP 110/74  RR 14/min SpO2 99% RA, Afebrile. Inj.  Acetaminophen 1gm IV given over 30 minutes through left ante cubital vein. Monitored continuously for medication effects and adverse effects. No other concerns verbalised at this point. Informed to the resident physician (Dr. XYZ) on shift. 

14/03/2015 1130hrs Patient now complains of severe pulsating type of headache and nausea. Says "This is the worst possible headache he has experienced so far". Looks distressed. VS: PR 108/min BP 150/88 RR 17/min SpO2 98% RA Temp -100F. Informed to the on duty physician (Dr. XYZ) STAT. Inj. Ondansetron 8mg IV and Inj. Fentanyl 50mcg IV administered. Patient seen by the physician and is scheduled to undergo a Non-Contrast Head CT scan. To be shifted to CT room on call.

The key point that I want to highlight here is that doctors and nurses need to start communicating well with each other. For physicians, it is good to have a sense and understanding about nursing documentation. 

Take Home:

• As physicians, make a habit of going through the notes of other healthcare providers (nurses/ paramedics) prior to discharging a patient and be on the same page with them.
• Good communication will improve patient care and prevent litigation.
• Documentation is not just for our self defence but also to foster patient care. 

For further reading:

http://thenursepath.com/2013/10/09/documentation-vs-communication/

https://crnns.ca/wp-content/uploads/2015/02/DocumentationGuidelines.pdf

Patients, Physicians and Google - What are we up to?

In this era of technology, all of us have dealt with patients who first "google" their symptoms, try and figure out what is possibly happening with them, reach a self diagnosis and try some remedies to see if their symptoms get better. And if things don't settle down, then they visit a physician. From whatever I have observed so far, most physicians tend to get upset with these patients (some physicians call them semi-literate patients or an e-patient) but only a handful of them actually try and talk to them, dig deep and understand their concerns, do shared decision making and reach a treatment plan that is acceptable to both, the physician as well as the patient. 
It is not uncommon to come across this demanding subgroup of patients in the ED but in the outpatient setting where there are no time constraints, every other patient is an e-patient. Let us understand why do patients do this:

Why ask google when physicians are available? 

In a physician - patient relationship, historically the physicians have dominated the conversation (ideally it should be the other way around) and patients have always been submissive. But things are changing and many find it hard to accept when a patient questions on a diagnosis or treatment plan. Also in modern day scenario, I think the key issue that we are dealing with is lack of trust on physicians . If we look back at the last decade, the way media and television has projected physicians, things have really gone away too far and it has changed a lot. Now, patients do not see physicians as someone they can readily rely on, so they want some baseline information to start with. And when they visit a doctor, their chief concern is that they do not want to be mislead with unwanted investigations and sometimes unnecessary medications. What remains the best way to get unbiased help is the always available "GOOGLE". 

And this may not be the only reason for googling symptoms, people have also become more aware and they want to know what is happening with them and much more about the medications, side effects. Fortunately (for some physicians), this wave of technology has spread only to the metropolitans and a majority of patients in India are still clingy and depend completely on doctors to make decisions for them.

How do physicians react when they deal with an e-patient?

All of us would agree on this that doctors have big egos and as physicians do get offended thinking that they are confusing our medical degree with google or we might think that 

How can he come with a self-diagnosis? 

Then why the hell did I go to medical school?

Due to this passive aggression, poor rapport and cold relationship these patients get shunted among various specialists (which is bad medicine) consuming time and wasting resources.

We as health care providers, need to understand that medicine is much more than just making the correct diagnosis and treatment. Empathising and emotional support to a patient often can do wonders to patient's compliance and symptom relief. Social media, technology and google cannot give them the healing touch, but you can. It just needs some patience and a few extra minutes.

What can we possibly do about e-patients?

Short answer: Shed your ego and do shared decision making

If a patient is enlisting his/her symptoms and also what they read about it on internet, be upfront and ask them what do they think is happening with them and be willing to listen to their self-diagnosis (which might be the correct diagnosis!). Listen to them carefully without the prejudice that they are wrong. Ask them where did they read about it and what do you think about what they have read. Also give them some more reliable resources to refer to a t then end of your consultation.

Most of them don't want to offend you and neither they are testing your knowledge but they are just concerned about their health and want to participate in understanding their illness, more importantly they want to have a feeling of security and reassurance that they are not being mislead. Unfortunately this is what we have come down to. Our job is still to help them out, take a few minutes and do shared decision making. These e-patients are only going to increase in future, so rather than creating being insecure and making a hue and cry about this, we need to accept this and be amazed if they are not googling their symptoms!

Googling symptoms is absolutely normal.

And guess what do physicians do when they want information on something?

Google

What if you have no idea about what they are talking about?

If you have no clue about a treatment that they are referring to, before you tell them that it makes no sense. Check on that and don't be surprised if they tell you something about medicine that you don't already know. (Something like non-surgical treatment for appendicitis). Medicine is making advancements everyday and it is hard to stay up to date. So hold on, tell them that you have not heard of something like this but you will find out more on this and revert back. Many times, patients with chronic diseases know more about their disease and treatment than an emergency physician!

I think sooner or later we are going to have a computer that can give a reliable list of differentials. We already have systems in place that alert us about various drug reactions, doses etc. then why not a list of possible differentials. But again, medicine is not about only the diagnosis and treatment. A physician has much more to offer..

Bottom Line:

• Shed your egos and just listen to them.
• Look at e-patients as a possible help. Most of them are just concerned and want to make sure they are on the right track. 
• Set the right rapport and build that trust to drive things smooth. 

Improving patient satisfaction

Emergency Departments represent the face of a hospital and it is based on the kind of care delivered in the ED, patients judge the institute overall. So it becomes extremely important for us, as emergency physicians to focus on this "customer care" part of our practise. I often equate a busy ED with a busy restaurant, where if someone treats you well, you always tend to remember that particular service provider. The only difference is that in a restaurant, you are less likely to get sued if your customer is unhappy! They might just swear at you and move to another one. On the other hand if they leave satisfied, they are more likely to use the same service again.

Most patients do not understand about the practical details of the processes and the treatments they go through in the hospitals. And for them an up to date evidence based care is not essentially equal to satisfactory care or a satisfactory experience. They don't care about sepsis goals or whether you are sticking to the guidelines or not. Here are a few things that we can do to improve patient experience in the ED:

1. See them as quickly as possible

Nobody likes to wait and that is human nature. Everyone wants to be attended ASAP. So one way to do this is physician assisted triage that demands extra staffing OR set up a fast track unit where minor ailments are handled quickly without interrupting the flow. The key is keeping the fast track close to the normally functioning ED, otherwise patients may perceive this as lack of attention on the physician's part. 

2. The way you Communicate and your body language matters: Once again, undoubtedly the most important component. Click here to read more on communication. 

3. If you made them wait, Apologise - Patients can get really annoyed if they are made to wait for too long. If this happens for whatever reason, just apologise without giving any sort of explanations because the one who is waiting does not really care. 

Physician: I am sorry to keep you waiting for so long, there was a really sick patient in the ED

Patient: Okay doctor, so you want us to land up in that critical state and only then you will attend me.

Engage them with something (brochures, television) while they are waiting and keep them posted about what is happening. Don't leave anyone unattended for more than 10-15 minutes. Make sure someone talks to them and resets their clock (it can be a physician, nurse, intern or a med student). This make a huge difference between the actual and perceived waiting times. Also remember that even minimal delay can seem long to an anxious patient, while longer delays may be well tolerated by patients at ease with events and confident that they are being looked after seriously. 

Everyone who speaks with the patient—including nurses, physicians, lab technicians, and radiologists—must inform the patient about what will happen next and roughly how long it will be until it happens. This information once again resets the patient’s clock. 

4. See things from their perspective: All subsequent caregivers must describe what they are going to do and what it will feel like. Giving them more information is key to reducing stress. 

Telling them how they will feel before inserting the IV can itself reduce the pain.

When a Gastroenterologist scopes a patients, he always keeps talking and explaining the patient about how he/she is going to feel with each and every step. 

5. Learn how to empathise: The physician's interaction with the patient is a major part of the ED experience. Few words of empathy can do wonders to your interaction.

I am sorry to hear that

That must be really hard to cope up with

Now you are at the right place, we will take care of that

6. Stop being judgemental: Most of us fall for this and start judging patients based on the acuity/ chronicity of their complaint and tend to get casual with the diagnosis. I think it takes a lot of time and courage to decide when to go to the ED because of the environment in which we work. Self treatment is always the rule and when nothing works or things get really out of control, only then we go to the ED.

If they land up early, we say "All right, it is just a day of fever. Did you try some paracetamol?" 

and 

When they come too late we ask "Why did not you come sooner?"

7. Tell them how the ED functions 

EM is still evolving in India and don't be surprised if patients are not familiar with your work process. Be upfront about the systems, if required take a minute to explain them triage and let them know we don't attend people on first come first serve basis, but the sickest is dealt with first.

8. Maintain Privacy

Patients gets to decide who is going to stay with him/her. We need to make sure that we maintain  privacy while asking personal bits of history and doing the examination. If you draw the curtains before starting the interview, it makes them feel safe and secure. Do not set your own arbitrary rules for them.

9. Educate everyone on how they can contribute

It is not only the physicians who should work towards improving the patient satisfaction, but everyone involved in the patient care. Educate each of one of them, right from the housekeeping staff to your nurses, interns, medical students. Working towards patient satisfaction is not optional, but this should be mandatory.  

10. Follow up phone call (My favourite)

This might sound a bit too much, but you will absolutely nail it if you can do this. Regardless of whatever happened during the ED visit (good or bad), if you can follow up your patients with a phone call then I guarantee you that all of them will turn back to you next time. This really goes a long way in terms of branding your ED and also building relationships.

For patients "care" of course includes not only the treatment but also the manner and social/emotional context in which treatment is given. Lower patient satisfaction means lower-quality care, regardless of the technical appropriateness of treatment and regardless of how well you do on the core measures. 

It is not how much you do, but how you do it

These were a few things that we can all try and do and make our patients feel better and more satisfied. Always make high patient satisfaction a rule and whey they are satisfied, you will be automatically satisfied.

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