Hi Maimo Family,
Today's POTD is dedicated to our lovely, kind, hardworking, powerful, competent, reliable, wicked smart interns.
It's December now, which means we are exactly one month away from the 18 of you making your biggest transition of residency thus far: becoming the anchor North Wall residents on the 7a-7p and 7p-7a shifts.
This means that, for at least part of these shifts, you will be the sole resident covering all of the patients on the North Wall. I know what you must be thinking: exciting! Exhilarating! Expletives! This is always a big change for the interns, and it’s Maimo tradition to send a list of recommendations on how to succeed on these shifts from anchor North Wall residents come and gone. As a senior resident of mine passed along to us, “being the anchor is more than learning and knowing the medicine. It’s identifying sick patients, working with your team, and having a birds-eye view of the department.” So without further ado, below are tips on how to conquer the anchor North Wall shift.
Try to see new patients within the first 20 minutes of their arrival. Assume these patients are on death’s door until proven otherwise.
If multiple patients arrive, do a few things quickly: put your name on them, check triage vitals, quickly eyeball them, and make sure initial orders are in to get the workup started. (Some example workups to throw in…Chest pain? EKG, CXR, trop. Fever? Labs, blood cx, urine, CXR. Old person with AMS? Labs, urine, CTH.) Once you have a moment, return back to the patient to get more of the story.
Review triage orders if they have been placed. Since most of North Side patients will get labs and imaging, it is easy to assume that all the orders were placed in triage. It’s best practice to review the orders placed and make sure it aligns with what you want after getting a more thorough history and physical from the patient. The triage doc is an insanely busy role and already helping us out by starting the workup, but it’s our responsibility to ensure it’s complete.
Nurses and PCTs will be your best friends. If it’s the first time interacting with someone, introduce yourself and try to remember their name. They are the difference makers in patients getting stabilized on the North Side, and also they are just amazing people. Get them in your corner, and be in theirs.
Dispo ASAP. The more patients you can cognitively offload by admitting or discharging, the better your brain will feel.
Call the consultant even more ASAP. Get in the practice of asking every patient you see on North Wall for their PMD, and, once you’re back to your computer, immediately put in the call to the PMD via the Contact Center. Usually the two questions you’ll be asking are 1) any clarifying history and 2) who you would admit to. Even if you don’t end up admitting the patient, get the information right off the bat to save you the hassle down the road. Same goes for consultants; get them on board early.
Attend the codes and traumas when you can. Not only is it good practice to be a part of these cases, but helping out your resus resident with the FAST, primary/secondary survey, and putting in trauma orders can be a huge help when the resus bay is packed. These shifts especially rely on teamwork. Which leads me to…
You may become the resus resident if things get bonkers with multiple sick patients in the resus bay! Don’t panic. Just start the initial stabilization: speak with patient/family/EMS for the story, ensure IV/O2/monitor, get orders in.
Learn the extra stuff. Putting patients on cardiac monitors, hanging fluids, drawing labs, setting up BIPAP; these seemingly non-physician tasks can often be the most emergent, and knowing how to do them yourself can be a huge stress relief and time saver.
Have a system of keeping track of your list of patients. I use a sheet of paper with name, age, one-word chief complaint, abnormal vitals in triage, then leave space right below that for any weird details about the patient that I pick up from the history (e.g. PMD name, phone number of family, date of recent surgery, etc.). Next to that I jot down the general to-dos for the patient (e.g. labs, urine, CT, MICU, call family, etc.). And finally across from the name I make two check marks: one check mark once I wrote the note, and one check mark once I dispo’ed the patient. I think we all have a variation of this that works for us, with some people scribbling entire histories and some people just writing down PMDs. Try to figure out the system that works best for you.
Run your list over, and over, and over, and over. And over. If you don’t know what to do, run your list. If you and your attending happen to both be on your computers at the same time, run your list. If you just got done running your list, eat then run your list. Identify what’s pending and keeping you from accomplishing tip #5.
Run the board, too. This is the leveling up part of anchor shifts. Not only is it important to know your own active patients, but it’s helpful to have a general idea of the North Wall patients admitted, discharged, or coming your way from ambulance triage. Sometimes ambulance triage patients can sneak onto North Wall without you knowing, though usually you will get inkling based on the triage note, the vitals, or the name of the nurse assigned to the patient (making tip #4 all the more important). Run the board by yourself to make sure everyone has a dispo, and if they don’t, you’re working on it. Having this bird's-eye view will really help you achieve self-actualization as an EM resident and future attending.
Document on the go. This will be very different from South Side documenting flow, during which you can usually sit down, finish multiple notes, and see new patients when the chart documentation is all wrapped up in a bow. On anchor North Wall shifts, your documenting is going to be interrupted annoyingly often, but, unlike the South Side, it’s usually for something that does actually need to be addressed immediately (e.g. new patient, unstable vitals, agitated patient ripping out his only IV access, etc.) You’ll have to be flexible, and this means you’ll want to use F7 liberally. Document in F7 what you can, go fight the fire, and then return to finish your documenting when things calm down. Also utilize the ED Diagnoses portion of F7 to keep track of any labs, vitals, or workup that comes back abnormal. Adding diagnoses in there will help you on hour 12 of your shift when you’re trying to remember what the heck is going on.
You are truly never alone. The resus resident, the attending, the team triage doc, the South Side team, the Peds team, the charge nurses, any of us via phone…do not hesitate to grab us if you need help. Whether you’re worried, scared, overwhelmed, or just wondering where the best place to cry for a second is, we’ve been there. We get it. And we are here for you for whatever you need.
It sounds scary, I know. I can remember nearly hyperventilating while walking into my first North Wall overnight shift. But deep breaths. Because here’s the thing: you can do this. I know it might be terrifying, I know it might be hard, and I can promise that you will walk out of some of these shifts feeling more stupider than when you walked in. But you can do this. You got this. And we’ve got you, we promise.
You have spent the last 5 months showing us just how incredibly intelligent, curious, and driven you are; meet this challenge with that same energy and you will be the kick ass doctors we already know you to be.
Happy leveling up!
Kelsey