BEFORE YOU ENTER THE ROOM
Unless the patient is crashing or there is an extremely time-sensitive issue like stroke, life-threatening hemorrhage, or STEMI; you probably have a moment to gather your thoughts before you enter the room.
First, finish the orders on your current patient. Unless the patient is crashing, do not move on to a new patient. If you do not put orders in you are delaying that patient’s workup and time in the ER and directly decreasing the function of the ER. You are fooling yourself that you are moving faster.
CHART REVIEW and TRIAGE
TRIAGE
Look at the nurse triage note. Remember that the triage nurse does not have the same breadth of history-taking and focus you do, but most often the triage nurse is a veteran nurse who can quickly distinguish between the sick and not-so-sick patient. They aren’t perfect, but they are often pretty good. They also usually have a very limited time with the patient and may miss a key piece of history.
A word on nurse stories. DO NOT fall into the trap of listening to a burned-out nurse tell you that somebody is faking, being dramatic, is here all the time, just wants pain meds or whatever other minimization of their story. I have known the homeless psychotic patient who comes in with some crazy story every 2 days that has come in with a headache because he actually had a skull fracture and intracranial hemorrhage. The alcoholic with constant abdominal pain may actually have spontaneous bacterial peritonitis and not just his typical ascites. Perhaps the patient is belligerent because of hypoglycemia or meningoencephalopathy. Anxiety can cause crushing chest pain, but crushing chest pain from their huge MI can also cause anxiety. Every patient deserves your attention and care and do not believe them to be unreasonable until they have very much declared themselves to be unreasonable.
VITALS
Look at the vitals. Your approach to a patient with a heart rate of 140 and shortness of breath is much different from a heart rate of 80. Make sure that ALL of them are documented. I often put a note in the patients discharge or a comment on their chart if there is a vital sign missing. It is easy to miss on a patient that is low acuity and only in the department for a short time.
I carry a pulse oximeter in my pocket and know I can easily check a pulse and pulse ox with very little effort and document it. Here is the one I use, but there are many other oximeters on the market. https://amzn.to/3Drh3UI It’s also handy if they are tachycardic to be able to check quickly if they are truly tachycardic or it’s because they ran in the front door when it’s 98 degrees outside.
CHART SCRUB
If you have access to past medical records, scrub them quickly. After you have learned the intricacies of your charting system, you can often dig through and find high-yield information in less than 1 minute.
My favorite piece to find is any recent (within a few months) primary care or internal medicine note, especially if it was a well visit. This will have most of their chronic conditions, meds, changes, and specialist follow-ups listed in a concise format and gives you a very clear picture of your patient.
From there, if there are any visits in the last few weeks or a recent hospital discharge summary, this is another high-yield document that gives you plenty of chances to have an idea of a recent problem and their chronic problems that might help you know more about their current problem. If they were just discharged with a DVT and now they have a chief complaint of shortness of breath; you already have a top differential of pulmonary embolism.
MED LIST
If you don’t have any past notes to look at, the med list is the next best place to look:
Look for the anticoagulants, warfarin (Coumadin), apixaban (eliquis), rivaroxaban (xarelto). Patients on these meds are high risk.
Look for diabetes meds: Insulin, metformin or the common second line meds like sitagliptin, empagliflozin, semaglutide. Also high risk patients.
Always look for immunosuppressive drugs. They almost always end in “mab" and place your patient at a much higher risk for odd infections or conditions.
Other meds get much more in-depth, I’ll post an appendix of other items I look for at some point that definitely help me with common presentations and chart scrubs. Ultimately, if you see a med you don’t know or recognize, look it up. You will learn so much by being able to put a condition to each one of your patient's meds and you will have a good idea of your patient’s history before you ever set foot in the door.
PLANNING
From a flow standpoint, try to think if there are ways you can decrease your dwell time in a room or the number of visits to a room. An easy example is if they have an eye complaint: bring the tetracaine, fluorescein, slit lamp, woods lamp, and tonometer with you the first time. It’s not the end of the world if you have to come back into a room, but even being able to numb up the eye with tetracaine while you gather equipment can save you time and maximize your time with the patient. Medications can be returned if you don’t use them.
If the patient has an x-ray that was ordered in triage, it might be worth doing something else for 10 minutes until it’s read so you can walk in with their known fracture and tell them the whole plan in one stop. Just don’t tell them until you complete your normal assessment so you don’t get tunnel vision and miss the other fracture or the serious reason they fell in the first place.
Ultimately scrubbing and chart review can save you from some difficult situations and having to backtrack with your patient. Even unreasonable people will cope better with more concrete boundaries. If they just got a CT yesterday, do they really need another one? If they just got 120 oxycodone yesterday, don’t promise a script before reviewing the PMP.
SUMMARY
If you do all this you can often walk into a room with a pretty good idea of what you need to do and what is going on. You often know your chest pain patient has a heart score of 4 before they even tell you a story, you know the patient needs labs, you know they probably need a CT, or you know they just had a full workup yesterday and you need to make sure nothing was missed. This can make your questions and conversation with the patient much more effective and high yield and give you some background before you ever meet them.
What are some things you do before you enter the room that maximize your efficiency or time with your patient?