Medical Education, Wellness

How To Get Back Into the ED Groove

It happens to all of us: you've enjoyed a restorative vacation or you’re finishing an ultrasound rotation or even coming back after your wedding... and now you must return to the emergency department.

The last time you were here, you felt confident. You ran the department like a boss, but now you feel rusty. Things are not running as smoothly. Sound familiar?

These tips can help you get back into the swing of things. 

Before Shift

  • Visualize: Use return travel time or even the drive into work to your advantage. Imagine yourself running a code or critical resuscitation. Picture the room, the patient, the staff. Start from the beginning when EMS arrives. Go through all the steps. What medications are you requesting? What are you doing if the patient is in ventricular fibrillation, or you are concerned for an aortic dissection? It is helpful if you can hear the voice you would use to call things out. This builds your confidence. Daydream about the simpler cases as well. For example: You pick up a 43-year-old male patient with a chief complaint of chest pain. Come up with a list of differentials you are concerned about in the ED, then imagine the questions you would be asking the patient, the tests you would order, and the treatments you would initiate.
  • Reflect: Recall your past few shifts in the ED. What cases stood out? Why? Were there any “great saves” by you or your teammates? Were there any “textbook” cases? Was there a procedure that went right, start to finish? Recalling the cases that invigorated you can hopefully lessen any negative feelings for returning back to work after time away. 
  • Refresh: Reading or listening to any of the numerous EM-related blogs and podcasts the night before or right before heading to your shift can help shift your brain back into the EM mindset. While listening or reading, imagine yourself caring for a patient with that problem, or imagine yourself performing that procedure, step by step.
  • Create a to-do list: Create a list of things you tend to forget on shift, and refer to that list every time you go back to the ED after a break. The list can include anything from updating Tdap on patients with lacerations to providing crutches for an ankle sprain or even more dynamic items, such as the most recent changes in the admission process. 
  • Confidence: If you are the type of person who needs to look into the mirror to tell yourself “I am strong, confident, and smart,” do it! You are! You have been through so much training. You know what you are doing. Confidence is built through preparedness. If you review familiar concepts and ideas, you will start to regain your confidence.

On Shift

  • Brainstorm: When you pick up a patient, before seeing them, generate a list of differentials you would be concerned about in the ED. For example, a 52-year-old male with chest pain would bring to mind MI, PE, aortic dissection, pneumothorax, etc. Identifying your concerns will help you tailor your questions appropriately and you’ll be less likely to gloss over, say, the PERC criteria.
  • Flow: When returning to the department after a break, a common challenge involves managing patient flow. You may realize you are being slower than normal to disposition patients.
    • Be more cautious: Spend extra time reviewing labs and imaging before dispositioning your patient to make sure you are not missing anything. You do not want to forget the pregnancy test on the 32-year-old female being admitted for a non-intractable headache.
    • Start slow: Patient care is more important than trying to move the department. If you need to spend some extra time in a patient’s room to avoid missing a pulmonary embolism, it is worth it.
  • Confidence: This bears repeating, because it is so central to how we feel about ourselves and our abilities. Your confidence can feel crushed when your peers or attendings notice you are not on your A-game. Throughout your shift, visualize a time when you were running a code proficiently or having a positive discussion with a patient. Think of why you felt that way and try to work toward achieving that feeling again.
  • Relax: After shift, give yourself some grace. Acknowledge that you did your best and there is always another chance tomorrow. Find time to unwind with co-residents (who are likely feeling much the same way). 

As you advance in training, many of these techniques will become second nature. You may find it gets easier every time you transition back. Believe in yourself; you do know what you are doing!

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