For many of us, working within the ER is often seen as the least
desirable modality of services. As residents, we may spend part of our training
because this is expected. For others, we only "work" there when we're
“on call" because, again, it is an expectation, perhaps because we are
working within a department or group practice that requires this.
Therefore, we often tend to try to get our encounters there over
with as soon as possible. Sometimes this is necessary because of the number of
consultations waiting when we begin our shift (I think my record for one night
was 9 consultations. Some of you may have had more. I don't envy you that). At
other times, which requires more judgment and tailoring of our interview and
intervention, it can be somewhat appropriate because we are only assessing
someone in a critical state, for risk. We often feel under pressure from the ER
staff to see our patients and dispose of them as quickly as possible. Thus, we
often do not in the circumstances go into the whole history and try to come up
with a full and extensive plan.
When I was resident, one of my co-trainees on one occasion made the
remark that when he was on call, he did not mind if patients came in quite
psychotic. That way, according to his line of thinking, you could not
necessarily expect much in terms of compliance or a history and they could be
dealt with quite quickly. However, even then, we need to realize that they
remember the experience even when they are at their most ill.
Again, when I was a resident, a patient with schizophrenia whom I
knew from an inpatient service as well as some outpatient contact by that
point, came to the ER when I happened to be on call. He was quite paranoid and
somewhat overtly intimidating. Since I already knew him, I was not that worried
and took the usual precautions in terms of seating and manner of encounter.
When I saw him sometime later, he commented positively on how I had
respectfully listened to him and treated him at the time, in spite of his presentation.
This is the important point I want to make here. Patients can
remember how you treat them, no matter how ill or seemingly out of touch with
reality. It is something we need to keep in mind.
Another aspect of dealing with people in the ER has to do with
giving them our full attention. This is what these patients need at this time
because, again, they are often at their most needy and lowest functioning. My
first preceptor on acute adult inpatients as a resident was also my first
preceptor for my psychotherapy training. His beginning instructions were to me
that I should take no notes when I saw my psychotherapy patient, but write
everything up that evening. This was something I was able to do as a resident,
but it might not be something that always works in "real life."
However, after doing that for the one or 2 psychotherapy patients I had that
year, it had become a habit. It was a great memory-training practice.
As those of you who have been students or residents with me know, I
do take notes when I do my initial assessments in my outpatient practice.
However, that is often because I do not get a chance to get them dictated or
typed up for several days. My memory is not that good, especially at my age.
However, right up until the time I quit being on call 3 years ago, which
included seeing patients in the ER as well is on the ward in consultation, I
continued to not take notes while I was with the patient. It is amazing how
much more one can take away from the session when one's full focus is on the
patient. I believe they also benefit much more when they see that you are
giving them your full attention, just listening and not focusing on your
notepad. It is a practice I would encourage all to look into, if you are not
already doing that.
As I mentioned, having reached the age at which being "on
call" is no longer required in our department, I chose to drop the
privilege. I had been "on call" in one form or another since the
mid-' 70's, including frequently getting up and going to the hospital in the
middle of the night when it could be -30°. I thought I had paid my dues.
However, I still somewhat miss the intensity of those encounters. To some
extent, I miss even more the teaching component that came with being able to
spend time with a trainee, focusing on the patient at hand, and sometimes
having time to talk about it afterwards, more so than in a busy office
schedule.
To all of you still working in the ER, you are performing a valuable
service. Do your best and enjoy it.
