Welcome to Emergency Medicine

Sudden, panicked shouting fills the halls. Patients — so many in uniform — appear out of nowhere. Multiple unannounced traumas peel away layer after layer of backup until no backup is left, and he finds himself alone, in charge of caring for a potentially critically injured police officer.

It’s July 7, 2016 — Blake Baker’s first-ever shift as an EM resident at Parkland Hospital. He’s the sole intern on duty when a troubled man ambushes Dallas law enforcement who are standing guard as citizens march to protest nationwide incidents of police brutality.

Armed with a handgun and an assault rifle, a sniper adds another mass shooting to America’s story, making gunshot wounds the focus of Dr. Baker’s inaugural shift as a physician.

Five officers would die during that shift; 9 more would be hospitalized, and a flood of bystanders would seek care. The night would dissolve into tragic chaos. But it started peacefully.

Like nearly every intern in every specialty, UT Southwestern EM resident Steven Blake Baker, MD, MPH, had arrived for his first shift equally excited and nervous. He drew the overnight straw, assigned to the trauma ED with upper-level residents and an attending. With 110 exam rooms in the ED and nearly 275,000 emergency visits per year, Parkland Hospital can test your mettle; it’s one reason UT Southwestern was Dr. Baker’s first choice for residency training. He’d prepared for this moment for what seemed his entire life. He found his station, reported to his attending, and checked in on a patient with kidney stones, diligently absorbing every detail.

So far, so good.

“With absolutely no warning, the whole place just erupted,” he said. “This was maybe 90 minutes into the shift. Nurses were shouting, the police were yelling, and we weren’t really sure what was going on. I remember rounding the corner with my attending and my senior resident and seeing a police officer in full uniform being carried through the doors by his fellow officers, with blood pouring out of his body, looking very pale and obviously already deceased.

“It’s so clear in my mind, that image,” Dr. Baker recalls nearly 2 years later, entering his final year of residency. “It has stayed with me to this day.”

Other pieces of that night are also burned into his memory:

  • Speaking with a Dallas police officer who arrived conscious and lucid. “He was right there with us, talking to us. He needed a chest tube. At that point we were so short of personnel, it was me and our senior trauma faculty — and the officer’s partner. I remember her with her bare hands, trying to help us save him. But his injury was essentially irreparable, and he passed away.”
  • Seeing more and more injured officers and bystanders arriving by car rather than ambulance, stretching resources ever further — and being proud of how every member of the Parkland team, from the attendings to the transport techs, responded as one.
  • Struggling to keep his first patient of the night (remember the kidney stones?) calm and in bed; coincidentally, she was a Dallas Police Department assistant chief who was determined to be with her stricken officers.
  • Looking up at 2 am when the Chair of Emergency Medicine arrived and pointed to him, saying, “You — come with me.” They opened Parkland’s urgent care clinic across the street from the main ED and began working through the backlog of “regular” patients. “It was our chairwoman, myself, and 2 Internal Medicine residents who happened to be nearby at the time. This was still my first day, and not only was I working alongside the chairwoman, which was intimidating in itself, but she had those 2 IM residents reporting to me. Meanwhile I’m just hoping I remember how to order things correctly.”
  • Getting into his car sometime after dawn, hearing grossly inaccurate news reports of the incident — then driving the rest of the way home in silence.

Barely 10 hours later, Dr. Baker was back on shift, along with the rest of his department. “We were right back at it, which wasn’t true for any other department,” he said. “Some people took months off to deal with that night. I think it just goes to show the emergency medicine mindset.”

History Repeats
That mindset has been uniquely ingrained in Dr. Baker. When he was almost 8 months old, Blake’s father, then an assistant principal at a suburban Dallas high school, was shot by the mother of a student he had sent home for shaving a banned symbol into his hair.

Steve Baker was saved by emergency physicians that day, and his family — including infant Blake — was protected by Dallas police during the ensuing months when a local gang targeted the school administrator because of the incident.

It shaped Blake Baker’s life. His passion for emergency medicine can be traced to that shooting, and his gratitude for law enforcement has never wavered.

“I believe things happen for a reason,” he said. “When I went to high school, there were still bullet fragments in the walls from where they missed killing my dad. My life could have been totally different had the doctors not worked so hard to save his life. It’s all the motivation I ever need. It’s why I ended up at Parkland as an emergency physician.”

A Lasting Lesson
After that first shift — on a night so remarkable that it led to a commendation from the Texas Legislature for the caregivers involved — Dr. Baker has spent time trying to put it in perspective. “The shock was intense,” he said. “You don’t really expect that on your first day — or at least I didn’t.”

Yet the unexpected is exactly what draws most EM residents to the specialty. It’s what nearly 2,300 interns en route to their own first shifts this July are both counting on and fearing.

Dr. Baker has one underlying message for those interns: “That’s the job — and we’re prepared for it, even if we feel vastly unequal to the task,” he said. “When things go bad — the very worst, in fact, for society or for individuals — you’re the person people are going to rely on. We are trained and capable of stepping up and handling it, whatever ‘it’ is. You’ll rise to the occasion.

“That’s what I learned from this whole experience,” he added. “You can’t always prepare for everything. You have to be resilient and roll with it as best you can, and remember to pick up the pieces later.

“But that’s the job we signed up to do, and we can do it.”

How Did You Survive the First Month of Residency?

While first shifts are milestones, the whole first month of residency can be challenging. Gain some perspective from those who have been there before you.

Rich Bounds, MD, FACEP, FAAEM
Program Director, University of Vermont

What did you expect your first month of residency to be like?
I expected my first month of residency to be incredibly challenging, and somewhat overwhelming. I had been told by a number of mentors that would be the case. I did a lot of reading and studying in the 3-4 months before July, and I used my elective time to do ICU sub-Is while many of my peers were having fun and doing more relaxing rotations. I think I was afraid... afraid of failure, or looking stupid, I don’t know. I just wanted to be as prepared as possible. I also liked critical care and dealing with sick patients, and I felt like if I was going to pay all this money for medical school, I was going to get my money’s worth!

What was it actually like?
My first month of residency was in the MICU on q4 call. I came in at 5 am for my first day and learned that it was my long call day. As bad luck would have it, I set the all-time record with 14 MICU admissions that night. I was destroyed. And I was still learning the new system so I finished my notes and post-call tasks at 4pm. Welcome to residency! (After that, they set up a “cap” for interns in the MICU.) Fortunately, although a few of them tried, none of my patients died that night. I had a great senior resident who was not only smart, but also very supportive, and a great communicator. The rest of the month was just as hard, with little rest or time outside the hospital, lots of end-of-life discussions, and patient deaths — but also lots of procedures and learning. Although I had considered critical care fellowship after residency, that month changed my mind. It was just too much — the long hours, the emotions, the sad cases — and I realized I wanted to focus on EM.

How did you cope?
That month, I just had to focus on the task in front of me, and “stay in the present.” (It actually helps you to focus when a patient’s life is at stake.) Also, I was honest about asking for help anytime I needed it or felt overwhelmed. I asked lots of questions, and I think my peers and supervisors trusted me and gave me autonomy because they realized that if I didn’t know something, I would immediately ask for help. I wasn’t afraid to admit my weaknesses, and I think that this insight and honesty was critical to getting through that first month.

Best advice for the new interns?
You have to study hard and try your best to be prepared as you get ready for July. It is no longer a test score at stake. It is the life and health of your patient. These are people in your community or city, someone’s family member, and they are depending on you, as their physician, to provide them with great care. They depend on you to make the right clinical decisions and to communicate with them as fellow human beings. Do not take this responsibility lightly. And don’t try to look smart. If you don’t know, ask. If you are not comfortable, get help. This will establish your integrity, and your supervisors, nurses, and peers will grow to trust you. They will see that you are comfortable in your own skin, and insightful about your skills (or lack thereof) as a new physician. This will set you up for success throughout your residency and the rest of your career.

Elena DiMecili, MD
PGY2, NYULMC/Bellevue Hospital Center

What did you expect your first month of residency to be like?
Who doesn’t get nervous when you start to think about July 1st? I know I was! I expected the first month to be fun, challenging, and a lot of hard work but I was excited to be spending the month in the ED with my intern class.

What was it actually like?
It was a blast! July is a special month because not only are there new interns but across the hospital each resident is stepping into a new role. You’re seeing new faces each day but it’s amazing how quickly you start to feel at home.

How did you cope?
I leaned on (and continue to lean on) my intern class. Being an intern is a shared experience and talking through your difficult days with people both inside and outside of your work environment can really help get you through your ED shifts and off-service rotations.

If you knew then what you know now, what would you do differently?
I would trust the process. You are training to become the best emergency medicine physician you can be and it takes time. Intern year is especially challenging because you’re not only learning medicine but an entire hospital system. Try to focus on the medicine and the rest will fall into place.

Best advice for the new interns?
The first few times you introduce yourself as Dr. [insert name here] might surprise you. Always remember how hard you’ve worked to get to this point, and recognize that everyone has been in your shoes. Don’t forget to take breaks both on and off shift, and make time to do the things you enjoy.

Sean Ochsenbein, MD
PGY2, Wake Forest University

What did you expect your first month of residency to be like?
Fun. Hard work. Hitting walls and overcoming them. Starting a new chapter in life. Growing as a doctor. Finding a new family in a new city.

What was it actually like?
All the above and more! It has been amazing and I credit that to my program! We have been in school for a long time and the first month of residency is like being a horse in the Kentucky Derby and finally being let out of the gates.

How did you cope?
I loved intern year — we are finally getting to do what we love! Just try and be the nicest and hardest working person in the room; if you do this, intern year will be great! Work out! Run, lift weights, swim, hike as much as you can. Don’t fall victim to the intern 15lb. Trust me, you will have more energy and feel better if you work out and eat healthy.

If you knew then what you know now, what would you do differently?
I would have paid more attention to my ED upper levels regarding how they manage critical patients.

Best advice for the new interns?
Don’t act like you know everything — people know you don’t, so don’t act like it! Ask questions of everyone (attending, co-residents, nurses, techs, radiologists, etc.). The more questions you ask the better your first year will go. If you think, “Maybe I should do this for the patient, but I’m busy — it can wait” STOP and do it. Cutting corners as an intern to save time will bite you every single time — patients come first, NOT your off-service upper level resident. Have FUN! And make sure to make time for all the other activities you love in life.

Linelle F. Campbell, MD, MS
PGY2, Jacobi/Montefiore

What did you expect your first month of residency to be like?
I had heard some horror stories about the first month of residency, not specifically my program, but just in general. I thought I would be expected to know everything about every disease that could possibly walk through the door. I thought I would get pimped and hazed. I thought the nurses would ignore me. I thought after my first week my program director would send me an email saying they made a mistake and would need me to resign immediately.

What was it actually like?
It was the complete opposite. My senior residents were extremely helpful from my first shift. They gave me the rundown of how the department worked, showed me how to use the EMR, and gave many useful tips on how to be efficient. My attendings also made me feel very supported. When they realized I didn’t know where something was or who to ask or even how to put in an order they always took the time to show me. One thing I struggled with was learning how to write my notes effectively and with proper documentation. I didn’t realize how this can determine if you leave on time or stay late. I also had to learn how to prioritize tasks that needed to be done for my patients and how to and who to ask for help. One thing that was an adjustment was the level of exhaustion I felt. While on shift I felt I had a lot of energy and rarely felt tired, but as soon I came home I just jumped in bed and went straight to sleep. There were definitely some weeks where I felt all I was doing was working and sleeping and didn’t have time for much else.

How did you cope?
One way I coped with trying to become more efficient was watching how my seniors prioritized. I also asked them to show me how they prioritized things that needed to be done for their patients. As far as time management, I made sleep a priority when I was working back-to-back shifts. On my days off I made sure to meal prep. When I had consecutive days off I would use one day to meal prep, do laundry, clean, run errands, and then I would use the next day to do something fun like go to movies, hang with friends, do something outdoors.

If you knew then what you know now, what would you do differently?
I wouldn’t be so hard on myself. As people in medicine we inherently hold ourselves to very high standards which can cause us to get easily disappointed when we don’t meet those high expectations.

Best advice for the new interns?
Residency is hard, but remember many other have been through it before you and made it out. You have to wake up every day and be thankful for the opportunity you have been given. Work as hard as you can, be open to learning, be nice to everyone — nurses, clerks, housekeeping. If you don’t know how to do something, ask. Get your rest, take care of yourself- eat well, exercise, continue to do the things you like outside of medicine. Finally — invest in blackout curtains and a good mattress.

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