Dragon Slayer
ACADEMIC AFFAIRS COMMITTEE
Mary Claire O’Brien, MD FAAEM
A
resident confided to me that he is on a remediation plan.
“They say I am thinking too much,” he said. “I’m supposed to keep moving. Decide as soon as possible whether to admit or discharge. Push the consults! Be quicker about dispositions! Get the patients out of the ER! One way or the other, don’t think too much!” This resident is a contemplative sort of guy. Telling him “not to think” is like telling him not to breathe. “Hmm,” I said. “That’s not right. That makes you a glorified traffic cop.” The resident shook his head. “I don’t know,” he wavered. “It feels that way.” “Listen,” I said. “I don’t walk into a patient’s room trying to decide right away whether or not they need to be admitted.
We Dragon Slayers have four weapons in the epic battle that is emergency medicine.”
I’m a dragon slayer, not a traffic cop. A Dragon Slayer.” We Dragon Slayers have four weapons in the epic battle that is emergency medicine. Weapon One: Discernment. I can tell, fast: is the patient sick or not sick? First I decide if the patient is really sick. I’d better slay that dragon before it eats the patient! I resuscitate. I can decide which dragon it is later. It is enough that I can tell it’s a dragon. Weapon Two: Investigation. Ok, once the patient is stabilized, is the dragon known or not known? Do I recognize this pattern of illness? What exactly is going on? If they are not sick, I take a breath. I think! I think hard. What information do I need to figure this out, where is that information, and how do I get it? Weapon Three: Skepticism. Are there any risk factors that would interfere with my ability to tell number one or number two? Extremes of age, immune suppression, mental illness, cognitive decline, substance use? Is it possible the patient or their family is lying, or withholding information? O’Brien’s Rule #2 of emergency medicine is “Watch your back.” Question everything. Weapon Four: Integration. I am superb at putting it all together, in a hurry. So it’s not that I don’t think, it’s that I think fast. And I don’t mind re-thinking it all, when more information comes in that supportive or contradictory. This is a one-on-one duel, friend, me, and the dragons, over and over, each patient, all day, every day. Be a Dragon Slayer.
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COMMON SENSE MARCH/APRIL 2023