Author: Brad Kinney MD, Emergency Medicine Physician. Edited by Katherine Biggs MD, Aimee Kinney. September 23, 2019.
THE CHALLENGE OF EM
Introduction. This guide details my experiences and my advice alone, it does not necessarily represent the DOD nor any of its components. My educational road was somewhat circuitous and unconventional. I completed a Transitional Internship in 2012-2013 at Naval Medical Center Portsmouth (NMCP) before the categorical Emergency Medicine (EM) internship existed. After internship, I trained and served as a Navy Dive Medical Officer (DMO) for three years before returning to EM residency in 2016. During my final year, I served as the Academic Chief of our residency program until graduation in June 2019. This advice is an accumulation of my thoughts and ideas about how to survive, but also how to thrive during EM residency. Much of this information is geared specifically toward my people – Navy EM Residents – but many of the general principles can be applied to civilian residency as well. Much of what is discussed below is theory or mindset, there are occasionally specific tips and recommendations, but for more detailed gouge, please seek out your local leadership. Residency can be daunting, hopefully this provides you with helpful information and quality resources. Also, random pictures from our unique residency experience are inserted throughout this guide. Enjoy!
Knowledge, Procedures, Logistics. The challenge and the practice of emergency medicine is unique in that you must master a massive breadth of knowledge that involves the most critical presentations of every specialty. You must also establish competence in a diversity of procedures, and you must learn to apply that knowledge and those procedures in your hospital system with incredible efficiency. The EM skillset spans from primary care to the hyperacute critically ill patient, from pediatrics to geriatrics, and every acuity and age between. In one moment you will resuscitate a cardiac arrest, and then you will intubate a crashing respiratory failure. Then you will walk into the next room and perform a simple laceration repair, then console a mother who miscarried in her first trimester, then reassure a parent that her child with a fever is very well appearing and likely has a virus that needs to run its course. These patients must all be cared for simultaneously after mentally triaging and rapidly prioritizing. In this world, task switching is key, the variety is intense, the intensity is varied, and efficiency is king. We are by convention generalists in all specialties, but we specialize in acute stabilization. Or, as an EM physician, per our class mantra, I am a “Jack of all trades, Master of resuscitation.”
Problem Solving. Despite constant training and countless patients, nearly every shift challenges the EM physician with new complexities never before encountered. This dynamic mandates that we be problem solvers. Whether the problem is medical, logistical, consultant related, or an equipment deficiency, the emergency physician must adapt readily and find solutions quickly.
Jack of all trades, Master of Resuscitation.NMCP EM Class 2019
Decision Making. While we may never intimately understand the inpatient and outpatient environments of our consultant colleagues, we must master that nebulous, gray emergent world in between where the crashing, undifferentiated patients require a calm mind and a steady hand. We regularly act decisively on limited and often ambiguous information, and when the smoke clears and clarity prevails, some criticize our actions. But when time is scarce, our world is dominated by gestalt, by pattern recognition, by thin slicing, by type one thinking – we are biased to act. For the truly sick and injured require immediate action, they require procedures, interventions, and resuscitation. Only after initial stabilization of the critically ill do we allow a more cerebral, type two thinking pattern. But this cerebral analysis, if entertained too early, paralyzes the physician, kills patients, and grinds the entire ER flow to a halt. We see the initial acute undifferentiated presentations of every disease, so we train to react instinctually to specific disease patterns, and to think “worst first.” Once killer diagnoses are excluded, then we can address lesser issues. But we MUST make decisions, and we must make them quickly. Someone once said, “MD” means “Make Decisions,” this can be no more true than in the Emergency Department.
Teamwork. Working together effectively and efficiently as a team is paramount in the ER. Knowing your team, their names, their capabilities, their roles, your role, the patient, the patients’ needs, your facility, your infrastructure, your consultants, your ancillary staff and how to best facilitate each individual to provide optimized care to each patient is vitally important. Each system takes a while to learn, and longer to master, but expediting this learning process is key due to our ultimate reliance on the efficiency of processes. Even studying your consultants’ personalities and their workup preferences improves work flow. Refining these efficiencies and integrating with your ER team and the hospital staff takes time, but learning to operate as a finely tuned team is highly rewarding both personally and professionally. You MUST be a team player as an ER physician. Often this means compromise, and it often means swallowing your own pride to accomplish what needs to be done. Some battles are not worth fighting, but some are. So choose wisely. Teamwork makes the dream work.
You MUST be a team player as an ER physician.
Military EM. Military EM is the pinnacle of the practice of emergency medicine. Not only must we excel at resuscition in civilian facilities, but we must also master bleeding edge combat trauma management. When deployed, we manage complex injuries and wounding mechanisms rarely encountered in the US – penetrating trauma from multiple high velocity rifle rounds, devastating burns and blast injuries from improvised explosive devices, horrific mass casualty incidents, and obscure conditions only encountered in third world countries and in extreme environments. And we frequently practice in austere and resource limited settings while occasionally exposed to personal injury. As military physicians, we must be decisive and adaptive. Our residency program will train and equip you for these challenges like no civilian residency is capable of doing. Throughout residency, you will have opportunities to pursue training in operational medicine, and you will participate in multiple military training exercises – Bushmaster, Operation Gunpowder, the Humanitarian Assistance and Disaster Relief Course, USNS Comfort deployments, Mountain Medicine, Dive Medicine, Tropical Medicine, and unit specific operational rotations. Some of these opportunities are only available if pursued, but your leadership will support you, so pursue aggressively. The yearly Military Unique themed block will focus on the nuances of military EM, drink this up and learn as much as you can. Someday, your fellow service members will trust your unique clinical acumen to protect them in that foreign, austere, and resource limited setting.