Emergency medicine is a team sport. From physicians to nurses and respiratory therapists, every person on the shift has a role to play. When we work together, we get to help people navigate through their toughest moments (and occasionally, their worst decisions).
When we focus on team-based care, it benefits our patients as well as our professional relationships. To that end, this month we’re introducing a new format for ERcast: Clinical Perspectives:
▪️Weekly releases about the medicine and science that is moving our practice forward.And in the spirit of collaboration, this month's blog post is a conversation between new host Brett Murray, MD and ERcast contributor Matthew Hall, CRNP, who’ll talk about the importance of teamwork, and how quickly things can fall apart.
We win together.
Matt:
I was working a shift in the ED as an RN, taking care of a patient with a lower GI bleed waiting on admission to the floor. She had been stable throughout her stay, though she was less than happy about boarding in the ED overnight and her NPO status. A few hours later, a bed was posted, and I started the process of getting her upstairs.
She had gone for a few trips to the bathroom throughout the shift, and other than feeling slightly more fatigued, she remained stable. While I was on hold to give a report to the med-surg nurse upstairs, our ED tech came up to say to me, “Are you sure she’s ok to go to the floor? She seems really tired, and her heart rate is up a little.”
I was on the clock to get my patient upstairs within the administration's expected timeline, but I looked through her vital trends and finally saw what I had been missing. Her heart rate was slowly climbing, and her pressures had gotten a little soft. One CBC draw later, the patient was instead slated to go to step-down, with a now very specific timeline for her scope.
I was so task oriented that I missed it. I wasn’t paying attention to the bigger picture, and thanks to a watchful ED tech, our patient got the escalation of care she needed.
Brett:
As ED physicians, we’re all super familiar with the idea of “task switching.” There are many, many articles on the number of interruptions per hour that ED physicians are burdened with while on shift (I’ll save you the lit search — it's a lot). From returned phone calls to ECGs to patient needs, we are constantly asked to switch our focus from one issue to another.
Part of being a great ED clinician is the ability to “triage” these interruptions and decide whether to shift our focus. The one interruption that is always triaged to the top of my list is one form or another of a nurse, tech, etc coming to me and saying, “Hey, I need you to come look at this patient. I’m really worried about them.” For me, this is an automatic stop what I’m doing and follow them to the patient.
Now, I won’t pretend that I don’t have a mental hierarchy of which nurses are calling me to the bedside. When a nurse with 20 years in the Emergency Medicine department tells you something is wrong, your heart rate spikes—you know they don't get rattled easily. It feels different than when a newer grad, whose clinical intuition is still forming, comes to you with a concern.
But regardless of who is asking, the response is the same: I get up and go with them.
We’ve all followed that team member to the room and found a patient who was perhaps mistriaged, or got sicker while waiting, and needs something from us right that second. That's a perfect encapsulation of the team work that is so ingrained in the ED. We can’t have eyes on every patient at all times.
On the flip side, we’ve all walked into the room to see a perfectly happy and healthy patient who probably could have waited another hour (or maybe never even been seen…). It can be easy to get upset about what we see as an unwarranted interruption in our flow in these moments, but I always challenge myself to use it as an opportunity to ask the nurse what made them uncomfortable, and explain my reasoning for not being acutely worried in the situation. This kind of real-time feedback is how that new-grad becomes the grizzled ED nurse we all respect (and sometimes fear) so much.
We lose together.
Matt:
A couple of years ago, I was working as an NP in our triage area, trying to find anything that even somewhat resembled a fast-track patient to help decompress our waiting room. An EMS crew came to the desk with an obviously confused elderly man, loudly informing our triage staff that they were told to drop the patient off at triage by a nurse in the back of the ED.
The medic then began to tell us that the call was for knee pain and that the patient had a history of advanced dementia. When the triage nurse asked him whether the family who called was on the way, he explained that the patient was from a nursing home.
As we looked at the medic with a mixture of perplexity and confusion, he went on to tell us that the nurse in the back kept cutting him off and dismissing his attempts at a report, so when she said, “Just take him up front,” he gladly obliged.
A busy nurse with a big ego dismissed and disrespected a seasoned medic, who, in turn, let his own frustration and ego get the better of him. What resulted was someone's grandfather with advanced dementia almost getting placed in a waiting room, instead of a monitored area.
Afterwards, the nurse and the medic continued to blame each other for the incident, neither taking ownership of their own part. Ultimately, they both walked away feeling that the other was in the wrong.
Brett:
I’m going to go down a slightly different route than Matt, because we can still lose together even when everyone on the team is in agreement about something. And maybe everyone being in agreement can be the problem. I’m referring to biases towards patients when I say this.
I recently came into an early morning shift with a bunch of reds on the board and settled into digging out a bit. Almost immediately, a nurse came over to me and started telling me about the patient whom she had roomed a couple of hours ago, “he’s a drug addict, he said he wants fentanyl, he keeps hitting the call bell, etc.” A few murmurs of agreement arose from the other clinicians in the doc box, including myself. It turns out one of the overnight physicians had even gone to start a US IV on him, but not really started any treatment or picked him up.
I went to see the patient (I knew him relatively well; the first thing he said to me was “remember when you put that big IV in my neck last time?!”). Did he have an opiate addiction and live in his car? Yes. Was he actually a pretty nice guy, who in my experience, was never really rude or disruptive? Yes. Was he sick as ****? Yes.
Once the story all played out an hour later, he was intubated, double-lined, a-lined and on a helicopter to get his massive descending aortic rupture fixed at a tertiary hospital.
The moral for me here was that if the team hadn’t had preconceived notions and biases given his opiate addiction, his care potentially could have started sooner. Most of the time when a nurse lays eyes on an ill-appearing and diaphoretic patient, they will bring that to the physician's attention immediately… unless biases cloud judgement. It is all of our responsibilities (docs, APPs, nurses, techs) to make sure we’re looking at patients through our own lens, and not letting biases “snowball” and carry over from one team member to another — that's how we lose together.
We grow together.
Matt:
When my wife was pregnant with our daughter, she was diagnosed with a subchorionic hematoma. Things were progressing along until she developed some significant pain and bleeding one evening. Since we were in the first trimester and it was the weekend, the ED was our only option for evaluation.
Now, while things turned out fine for my wife, there were two very memorable parts of the visit, and it wasn’t the doctor or the nurse.
The registration clerk who was checking us into the ED could tell my wife was scared and nervous. She took a few moments with a kind smile and a calming voice to explain the process of registration and triage. She was kind and empathetic, and in that moment, was exactly what my wife needed to help anchor her to some semblance of familiarity.
The other person who impacted my wife the most during that visit was the ultrasound technician. While she was performing the exam, our fears were painfully loud in a room of total silence. When she found the only thing that would give us the peace we were praying for, she turned up the volume as loud as it would go. The sound of my daughter's heartbeat filled the room.
It was a moment of kindness from the person with the singular ability to give us what we needed most.
We all have an important role to play: helping each other and our patients.
Brett:
I’m a little hesitant to give this up publicly because I think it is one of my favorite pieces of advice to give residents. I’m sure others dispense this sage wisdom as well, but for the purposes of my teaching ego, I’m going to keep pretending it's a “Brett Original”.
The single best way to get feedback on how you are doing as an overall ED physician is to ask the nurses. This holds particularly true for how you function as the team leader during complex resuscitations and within the department as a whole.
Attendings are great at giving feedback on your clinical acumen and everyone’s favorite medical educationalism “fund of knowledge,” but I always found the feedback on how I ran the room and department during residency to be lackluster… until I started asking the nurses.
Broad strokes here — but attendings tend to sugarcoat things a little bit. Your favorite neighborhood ED nurse, who has worked with hundreds of doctors, will have zero issue telling you, “Here’swhat you really sucked at during that code as a team leader”.
Additionally, when an attending is supervising you during a resuscitation, they likely are paying more attention to how your intubation goes, which meds you gave, etc and less likely to the overall “vibe” in the room.
I fully credit the seasoned nurses I worked with in residency for making me into the resuscitationist and team leader I am today. Even now, as an attending in the community, I always debrief with the nurses after resuscitations, and the first question I ask is “How did I do and what can I do better next time?”
The community of chaos.
The ED is often a favorite rotation for students and learners, getting a chance to dip their toes into the whirlpool of chaos that is Emergency Medicine. And while it is an exciting and fun rotation, most people choose a more structured and predictable area of medicine.
For those of us who call the ED home, we know that community is what holds it all together. The work is hard, the hours suck, and the demands are never-ending. Our ability to lean on each other for support is the foundation of what keeps emergency medicine running.
Regardless of our role or title, we all have a job to do. And at its core, our job is to care for people during what may be one of the worst days of their lives. Many visits to the ED aren’t for true emergencies, but every patient encounter is an opportunity to do what we can to help another human being.
To that end, we at Hippo are excited to launch our new vision for ERcast: a space to learn and grow as ED clinicians, but also a way to celebrate our wins, learn from our mistakes, and progress as a community. We welcome any feedback you may have and would love to hear from you about what keeps you coming back to the ED!
You can reach out with any comments or questions at emvertical@hippoeducation.com.