What this paper adds
Introduction
Background
Ramifications for training
Method
Study design
Study setting and population
Study protocol
Question 1:
Think back to a recent busy emergency department situation that was challenging for you—one in which you were asked to make difficult clinical decisions about how to proceed next with your overall management of the emergency department. Please share that experience with me |
Prompt 1: Tell me about what was concerning or challenging to you. a. What was your gut telling you? b. What did you notice about the scenario that made it stand out? |
Prompt 2: Tell me how you proceeded with emergency department management that day? a. What are the big picture issues that you take into consideration? b. What cues did you use to help fine-tune your approach? |
Prompt 3: How did you evaluate the outcomes of the plan that you chose? |
Prompt 4: As you think back what do you notice differently now? What stands out to you? |
Prompt 5: What, if any, equipment do you use to help you plan your actions in the emergency department? |
Question 2:
When you are working with other doctors that are less experienced than you such as residents, how do you incorporate them into your management strategies? |
Ethics
Data management and analysis
Results
Demographics
Attending emergency physician teachers | Residents | |
---|---|---|
Average age (years) | 38.7 ± 5.4 | 29.0 ± 2.4 |
Average years in practice | 12.0 ± 4.7 | 1.5 ± 0.5 |
% time spent at an academic centre | 96.0 ± 12.6% | 99.5 ± 1.6% |
Definition of challenging: ‘busyness’
… [I]t was a busy night and there was a patient who came in with like (sic.) a decreased [level of consciousness] secondary to like (sic.) a hypoglycaemia and the question was whether or not to give the usual like (sic.) [50% Dextrose solution]. [H]owever this was a patient who had, like, a genetic condition which put them in, like, a very small weight, very small structure so it was like a forced decision and there was a lot of pressure from nursing… it was challenging and I debriefed with my staff and she was, like, I understand why in the moment.
I was trying to balance a relatively busy department and make sure that people were seen and that disposition happened and that people were moving through. … It began to get busy once you had seen a few people and had to then keep track of their labs and their x‑rays and what was coming back … and making sure all of the consultants were phoning you back and actually seeing the patients who you had sent to them. So that was definitely very busy and I was task saturated.
…I was working in a busy community emergency department in which there were 8 to 10 people waiting to be seen in the acute side …. and most of those patients were undifferentiated chest pain, abdominal pain or dyspnoea in the elderly. None of them were thought to be acutely over sick requiring acute resuscitation. [Three Emergency Medical Service crews subsequently] arrived within probably 6 to 7 minutes with one [vital signs absent] patient, a patient in rapid atrial fibrillation and a boarded and collared patient with moderate velocity [multiple vehicle collision]. The challenge was: 1) prioritizing the management of the patients; and, 2) managing flow in the emergency department…
[A] recent situation that was challenging for me …was … a very busy department, one other attending staff was there finishing charts, then it was myself, multiple handovers, lots of bed no admits (sic.) and we had a paediatric arrest come in. So the paediatric arrest was managed with the assist of the second doc that took a lot of resources and a lot of staff kind of emotion which definitely affected the flow of the department and it was a challenge in that it was something that was hard to pull back on training for necessarily.
I had some multiple septic patients who presented around the same time. I was the only staff physician at the time. I did have learners with me. So the way I dealt with it was I quickly eyeballed all of them, decided who was the sickest of them, and started assessing that patient, while at the same time ordering lab work and investigations and even broad-spectrum antibiotics [on the other patients]… The second sickest patient I sent my resident to see, and as we were the only people there the third and fourth patients could not be assessed however I had already eyeballed them and ordered investigations and the nurses were comfortable with that plan and they knew where to come and find me if any of the less sick patients became sicker. In that way we managed to assess, start resuscitation and manage all of them.
Factors that contribute to a ‘busy emergency department’
Barriers to teaching prioritization and emergency department management skills
There are times where if I’m working with PGY5 that I treat them like another staff person with some degree of supervision. And so in that circumstance, we might strategize about finding locales to work out of. But the vast majority of residents are not able to cope with a strategy like that and so they continue to see one patient at a time.
[F]or example if there is a critical patient, I think that there is a tendency of junior learners to stay at the bedside forever and ever and ever with that patient… you have to remember that once you have stabilized the patient …you don’t have to remain at the bedside, that you need to get back and think about what else is going on in the department.
… Sometimes it becomes a bit of a discussion point. So if we hear a patch about a patient that’s coming in, I will ask them, ‘Okay, there is a patient coming in. At the moment we have no resusc[itation] capability. We have no beds available. What would your strategy be to help open a bed?’
I will try and send them to see things that will have both educational value or may be interesting or may be relevant in terms of a procedure that a junior learner is looking to do. So, I will look at the tracker, figure out who it is I think has the most educational benefit… and I will send them to go and see those patients while I will go and see the patients who have less educational merit.