Preventing Nightmares: A Guide for Medical Students and Residents

Nobody likes waking up in the middle of the night gasping for air. When you make a mistake in the emergency department, that’s exactly what happens. Nightmares.

They come in all sorts of shapes and colors:

• The sixty-year-old man diagnosed with a strained lower back muscle who comes back with a ruptured abdominal aortic aneurysm.
• The fifty-four-year-old Hispanic female with generalized malaise who goes into cardiac arrest from a missed myocardial infarction.
• The two-year-old with gastroenteritis who returns to the ER the next day with a ruptured appendix.

It’s no surprise many of us wake up in the middle of the night, look up at the darkness, and question our management from our previous clinical shift.

It’s been ten years since I graduated from Stony Brook Medical School. Since then, I’ve had the privilege to be involved in the medical care of over fifty-thousand patients. And yet, the cases that are engrained in my brain—the ones that still keep me awake at night—are the ones that went terribly wrong.

Remember this: We all make mistakes. We learn throughout our training that dealing with our medical errors is a three-step process:

Recognize your mistake → Learn from it → Move on

It’s the moving on that’s the most difficult for so many of us. When we’re presented with a bad outcome, our first instinct is to doubt our knowledge and skills. We want to go back in time and make things better. We want to figure out what went wrong (despite having gone over the case a thousand times and knowing the answer). We want to reach out to the patient and their family. We want to make amends.

And often we want to quit.

A few days ago I woke up in the middle of the night thinking about a patient I’d seen in residency with a bad outcome. The particulars of the case are irrelevant, but what is relevant is that in the midst of my incessant internal conversation— as the thunderous clouds of critical consciousness tormented my sleep— I had a moment of clarity. Although there is no way to guarantee we won’t make mistakes, there are key aspects of our hectic and stressful clinical shift that we must be cognizant of in order to minimize future medical errors. These may be self-evident to the seasoned physician, but it’s advice I wish I’d had during my medical school and residency training.

My guide for medical students and residents

1. Prioritize your priorities. The job of an emergency physician is hectic. You will get interrupted one to two hundred times an hour while being bombarded with countless responsibilities: sign the EKG, order the blood test, see the next patient, view the x-ray, notify family, speak to the pharmacist, place a central line, intubate, get an ABG, admit, discharge, transfer. Often you will feel your bladder full and your stomach empty but will forget which you need to empty and which you need to fill. It’s a war of chores, and you need to keep in mind that out of the hundreds of things on your to-do list, there are things that are EMERGENT (and must be done STAT), things that are URGENT (and should be done soon), and things that are NON-URGENT (and can be done at your convenience). Unless you’re working multiple codes (and I assure you, if you do this job long enough you will), there is no reason to stress. Label each task with one of these three designations and go from there. The myriad things you have to do will suddenly become more manageable. Also, don’t schedule anything right after a shift. Never assume you’ll finish your shift on time. If you do, you’re likely to rush and make mistakes. Delivering quality medical care should be your number one priority.
2. Be wary of the eighth hour. The longer you work, the more prone you are to making mistakes. That’s self-evident. But there’s something about that eighth hour that increases your risk of medical errors exponentially. You’re likely to make more mistakes in the last four hours of a twelve-hour shift than you are in the first eight hours. Although mental stamina can be enhanced through good sleeping habits, diet, exercise, and minimizing stress, be aware that the longer you work, the more prone you are to mistakes. This should help guide your decision-making. Knowing that you’re not as sharp at the end of your shift as you are at the beginning should prompt you to be more critical about your patient management.
3. The Dead Bounce-Back Test. In our field, documentation is key. We often hear that “if you didn’t document it, it didn’t happen.” Good documentation will keep the lawyers away. But how do you know when you’ve documented enough? And how can you determine if your documentation is adequate? A few years ago, I started asking myself a simple question prior to discharging a patient: If this person comes back to the emergency department dead (or with a major complication), can anyone fault me for my work-up? This totally revolutionized my documentation. I was more critical about what I wrote and more careful about the discharge instructions I gave my patients; I was more likely to scrutinize the laboratory and imaging studies, interpret and relate these findings, and establish a better rapport with my patients and their family members.
4. Never stop asking. There is no better compliment than to ask someone for advice. As a medical student or resident, I guarantee that the veteran physician assistants, nurses, and technicians working alongside you have a lot to teach you. Your attendings, although likely overwhelmed, are there to answer your questions. You’re only a student and resident for a brief time, so take advantage. Make sure you soak in the knowledge of those around you. Don’t ever feel ashamed for not knowing something. When you stop asking, you stop caring.
5. Lastly (and above all), be nice. It’s been shown that people who are kind to others are happier, healthier, and more productive. Therefore, be nice to everyone with whom you interact: patients, family members, nurses, technicians, security guards, housekeepers, colleagues. It’s your job to be courteous, professional, and agreeable. Life in the emergency department is difficult enough without having to be antagonistic. Even if a consulting physician gives you a hard time, keep your cool. You don’t know how overworked they are, or what their life is like outside the hospital. Keep in mind that miserable people have miserable lives.

Bad outcomes are inevitable in our field. These tips should hopefully help you avoid mistakes, enhance your clinical experience in the emergency department, assist in providing higher quality care for your patients, and allow you to sleep better at night (or whenever you get to sleep).

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