WITH 20 MINUTES TO TALK ABOUT EMERGENCY MEDICINE RESIDENCY THERE ARE BOUND TO BE DETAILS YOU WANT TO KNOW THAT I MISS AND FOR THAT I APOLOGISE I WILL TRY AND DO IS HIGHLIGHT SOME OF THE IMPORTANT TRAITS OF AN EMEGENCY PHYSICIAN AND USE MY JOURNEY THROUGH RESIDENCY TO ILLUSTRATE THEM

BUT BEFORE I START I WANTED TO GIVE YOU A PERSPECTIVE THAT I THINK IS UNDER RECOGNISED IN OUR FIELD AND THAT IS JUST HOW NEW THE FIELD OF EMERGENCY MEDICINE IS THE EDWIN SMITH PAPYRUS IS AN ANCIET EGYPTIAN TEXTBOOK OF TRAUMA SURGERY ONE OF THE FIRST DOCUMENTATIONS OF SURGERY DATING BACK TO THE 16C BC AND IS ACTUALLY HELD HERE AT THE THE NEW YORK ACADEMY OF MEDICINE

HIPPOCRATES SOME 2 1/2 1000 YEARS AGO IS CREDITED BY MANY AS BEING THE FOREFATHER OF WESTERN MEDICINE. AND THIS RATHER DASHING ENGLISH GENTLEMAN TO THE RIGHT, EDWARD ANTHONY JENNER, PERHAPS MORE THAN ANY OTHER WAS THE FOREFATHER OF MODERN WESTERN MEDICINE HE WAS THE PIONEER OF THE SMALL POX VACCINE IN THE 18TH CENTURY. WHICH SAVED MORE LIVES THAN THE WORK OF ANY OTHER MAN AND HERALDED THE DISCOVERY OF ANTIBIOTICS AND THE ERA OF MODERN HOSPITALS I PUT THESE SLIDES IN TO GIVE YOU A SENSE OF WHERE EMERGENCY MEDICINE LIES IN THIS TIME LINE.

SO EMERGENCY MEDICINE CRASHED INTO THE THE PUBLIC CONSCIOUSNESS IN THE LATE 1960S PREVIOUSLY EDs WERE A VERITABLE MASH OF TRAINING INTERNISTS, SURGEONS AND PSYCHIATISTS PUBLIC AND MEDIA DISPLEASURE AT THE LIMITATIONS THIS CREATED CAME TO A HEAD AROUND THIS TIME PROMPTING A GROUP OF 5 PHYSICIANS TO DEVOTE ALL THEIR CLINICAL TIME TO WORKING IN THE EMERGENCY DEPARTMENT AT THE ALEXADRIA HOSPITAL IN VA THE CONCEPT OF EMERGENCY MEDICINE TRAINING WAS FORMALIZED IN 1969 WHEN BRUCE D JANICK BECAME THE FIRST EMERGENCY MEDICINE RESIDENT. SO IN MANY WAYS WE ARE WHAT THE MEDIA REFERS TO AS THE “GENERATION X” OF MEDICINE, THE BIZ MARKIES OF MEDICINE, IF YOU WILL.

I THINK THE NOTION THAT YOU ALONE CHOOSE YOURE SPECIALITY IS IN SOME RESPECTS FLAWED I WOULD ONLY USE THIS SLIDE TO EMPHASIZE THE IMPORTANCE OF…. KNOWING YOURSELF WELL ENOUGH TO KNOW WHAT MOTIVATES YOUR DECISIONS. BEING HONEST WITH YOURSELF ABOUT YOUR INFLUENCES. BEING ABLE TO ROMANTISIZE YOUR JOURNEY AND BEING INSPIRED BY LEADERS ARE BOTH IMPORTANT INTERACTIONS BUT ULTIMATELY YOU HAVE TO MAKE A DECISION ON YOUR CAREER KNOWING THAT WHEN ALL THAT IS GONE, IT WAS STILL FOR YOU

IM NOT GOING TO SPEND TOO MUCH TIME ON THIS, YOU CAN GET THIS FROM ANYONE, THE SHIFT WORK IS CONSTANT : DAYS AND NIGHTS. FOR SOME THIS IS A PRISON, FOR OTHERS THIS IS LIBERATION ENABLING THEM TO NAVIGATE THEIR OTHER INTERESTS OR RESPONSIBILITIES WITHIN A STRUCTURED WORK TIMETABLE BUT JUST TO GIVE YOU AN INSIGHT INTO MY EXPERIENCE….

FROM AN EDUCATIONAL STANDPOINT….. THE GOALOF RESIDENCY IS TO BECOME “ADULT LEARNERS”, MOTIVATED AND INFORMED LIFE-LONG LEARNERS WHO KNOW HOW TO OBTAIN AND CRITICALLY APPRAISE THE INFORMATION THEY NEED.

A ACADEMIC LIFE IN EMERGENCY MEDICINE IS WIDE OPEN, GIVEN THE RELATIVE INFANCY OF THE SPECIALITY I’VE LISTED SOME OF THE MORE OBVIOUS WAS TO CONTRIBUTE BUT THE MAIN THEME IN YOUR MIND SHOULD BE CREATING A NICHE OR TWO, FROM WHICH YOU CAN DEVELOP CAREER LONGEVITY AND SATISFACTION. FOR ME THIS HAS STARTED WITH BOTH WORK IN COMMUNITY OUTREACH AND RESEARCH ON VASOACTIVE AGENTS IN SHOCK STATES

WELL DESCRIBED IN DEFINING THE EMEGENCY PHYSICIAN IS THE PHRASE JACK OF ALL TRADES, MASTER OF NONE. I’VE ATTEMPTED TO COME UP WITH A SLIGHTLY BETTER DESCRIPTION… AND I MAY HAVE INVENTED A COUPLE OF WORDS TO DO THIS. FELLOW LEVEL KNOWLEDGE IN ALL SPECIALITIES IS NEVER QUITE ACHIEVABLE……. …….FOR ME IT WAS IMPORTANT TO ACCEPT AND EMBRACE THE VAST AMOUNT OF KNOWLEDGE THAT IS APPLICABLE TO THE PRACTICE OF EMEGENCY MEDICINE EARLY ON YOU CAN GET LOST IN THIS JUNGLE OF KNOWLEDGE TO BE ACQUIRED THIS IS INTERNSHIP YEAR…

BUT THE STRUCTURE COMES FROM UNDERSTANDING THE CRITICAL STEPS IN EMERGENT CARE OF THE CRITICALLY ILL THE STABLE ILL TO BE ADMITTED THE STABLE ILL TO BE DISCHARGED FROM THIS FRAME WORK YOU CAN BEGIN THE LONG JOURNEY OF DEVELOPING NUANCED MANAGEMENT ALGORITHMS IN MANY WAYS THE KNOWLEDGE BASE YOU LEAVE MEDICAL SCHOOL WITH INITIALLY SHRINKS, BUT ALSO DEEPENS. THE REST OF YOUR CAREER IS SPENT RE-BROADENING YOUR KNOWLEDGE IN THE CONTEXT OF EMERGENCY CARE.

THE DANGER TO THIS AND WHAT BECOMES APPARENT AS YOU ENTER PGY3 YEAR, AND WITH EVERY TOOL YOU PICK UP ALONG YOUR JOURNEY IN EMERGENCY MEDICINE IT WILL EXPOSE THE ABSENCE OF THE NEXT TOOL YOU NEED TO ACQUIRE, THIS IS IN MANY WAYS ESSENTIAL QUEST TO BECOME A THE MACHINE, YOU BEGIN TRYING TO FIT SQUARE PEGS INTO ROUND HOLES, APPLYING IMMATURE OR INCOMPLETELY FORMED ALGORITHMS TO PATIENTS COMPLAINTS FOR SAKE OF EFFICIENCY AND NEGLECT OF CONSIDERING THE UNKNOWN UNKNOWNS. THE OUTLIER DIAGNOSES ARE MOST COMMONLY MISSED BY THE PGY2. I DON’T KNOW, MAYBE THE ATTENDINGS HERE THINK PGY3S LIKE ME A DROPPING THE BALL THE MOST

KNOWLEDGE ACQUISITION, KNOWLEDGE UTILIZATION, TEAMWORK, DIRECTING TRAFFIC. PRIORITIES, PRIORITIES, PRIORITIES. AND IT SHOULDN’T BE LOST ON YOU ALL THAT TO GET ANY OF THIS DONE, ANY OF IT, YOU HAVE TO HAVE THE RESPECT AND TRUST OF THE NURSING AND ANCILLARY STAFF.

SO MY LAST THOUGHT TO SHARE IS THAT EMEGENCY MEDICINE TRAINING IS ONE OF THE LAST TRUE APPRENTICESHIPS. YOU WORK SIDE BY SIDE WITH SENIORS AND ATTENDINGS EVERY DAY THE IDEA BEING THAT WITH ENOUGH DIVERSTY OF EXPERIENCE YOU WILL PICK AND CHOOSE WHICH CLINICAL FITS YOU BEST TEAM WORK GOES WAY BEYOND GIVING A GOOD HANDOVER AT THE END OF A SHIFT. IN THE EMERGENCY DEPARTMENT THERE IS NOWHERE TO HIDE. ITS FULL SPEED ALL SHIFT. THIS CAN EXPOSE ALL YOUR DEFICITS AND WEAKNESS IN FRONT OF PATIENTS AND COLLEAGUES AND THIS VULNERABILITY LEAVES YOU LITTLE CHOICE BUT TO BOND A SUPPORT EACH OTHER THROUGH IT ALL. SO THIS IS A CAREER IN EMEGENCY, FROM ONE RESIDENTS PERSPECTIVE. THANKS YOU FOR LISTENING.

Life In Emergency Medicine: A Residents Perspective. Peter A D Steel MA, MBBS, MD PGY3 NewYork-Presbyterian Hospital

A Perspective in Time. The Youth of Emergency Medicine Edwin Smith Papyrus, 16 C BC Queen Nefertiti, 13 C BC

A Perspective in Time. The Youth of Emergency Medicine Hippocrates 460 BC Edward Anthony Jenner 18 C

A Perspective in Time. The Youth of Emergency Medicine Bruce D Janiak University of Cincinnati Medical School, 1969 The first emergency medicine resident in the USA Marcel Theo Hall, a.k.a Biz Markie Born in Brooklyn 1969 “I’m the first graduate of hiphop university-e-e”

An Introduction. Your Specialty Chooses You…. Students beware ! Myopic romanticism Students beware ! The Charismatic mentor

One Mans Prison is Another's Freedom. Shift Work for Life Focused & mature preparation for a trauma PGY1: 19 shifts, all 12s. (Med/Surg/Peds/MICU) PGY2: 19 shifts, all 12s. (Tox/OBGYN/SICU/PedsED/NICU/ANAES) PGY3: 18 shifts 8/10/12. (PICU) PGY4: 16 shifts 8s (few 12s).

From Pedagogical to Andragogical. Learning to be Adult Learners Resisting the “forced-fed” learning of medical school 4 hr/week Wednesday Conference PGY2: 2 lectures (evidence / procedure based) PGY3: 1 lecture (CPC) 1 case report/month. PGY4: 2 core content lectures 4 case reports a month +/- chief resident duties

Academics in EM. Contributing to Evidence Based Medicine Jitters before a national presentation at SAEM - Published case reports - Book chapters - Clinical research - Review articles 1 project obligation: beginning in PGY2 year.

A Life Long Intern. The Personality Predisposition The proverbial Jack Of All Trades ‘the dichotomy of healthy insecurity when approaching the undifferentiated complaint and the confidence to make emergent, definitive decisions with exactness’ - Striving for fellow-level knowledge - Not the mastery of a boutique service Distinguishing between ‘Unknowns’ - Embracing vulnerability

The 400 meter Intern Race. Aim to Finish an Unequal First. Quiet reflection on the intern retreat - Heterogeneous education - Questions = Tools Type A. Clinical Autonomy Type B. Pimp my Intern “Attitude is the oil to the wheels of internship”

Procedures, Algorithms & Efficiency. The PGY2: Volvo With Upgrades Training to be a intubating Machine Central lines, chest tubes, intubations, I&Ds…… ….cracking chests !!!! - The goal of The Machine - Square pegs, round holes Outliers beware, the PGY2 is here !

The Porsche with a Heart. The Day in the Life of a PGY3: Case 1. Smoke inhalation airway - Intubation. 40% full thickness burns - Resuscitation. Head, neck, abdominal and chest trauma - Advanced trauma algorithm. - Toxicology - Carbon monoxide. - 3 consultations +/- transfer. 34 y/o male BIBA w AMS & respiratory distress s/p jump from 2nd floor of burning building. Holding your nerve with a 3 year skill set

The Porsche with a Heart. The Day in the Life of a PGY3: Case 2. - what is her emotional intelligence ? - what are her priorities ? - how is she responding to me ? how can I get what I need to get done from a medical perspective ? adjusting speed, tone, touch, eye contact- the salesman with little room for error. preserving what little beauty comes of a vulnerable experience. 27 y/o Dominican female rape victim with prior history of PID and depression. Remembering compassion is in your skill set

The Porsche with a Heart. The Day in the Life of a PGY3: Case 3. - Who’s running this show here ? - How quickly can we get the patient to the cath lab ? - Who’s the cath fellow on today ? - What are the critical steps to get them there ? - What could go wrong here ? - What was the bottle neck last time ? The PGY3 begins to consider patient flow and factors outside of the isolated disease state. 75 y/o male diabetic with Inferior wall STEMI on EMS EKG. Making the right quick decisions with a 3 year skill set

The Porsche with a Heart. The Day in the Life of a PGY3: Case 4. The business end: cancer, fever, trauma, TB, IVDU, neuro deficit, referred pain, AAA, urinary. - Physical exam, do they need imaging. - Why are they here ? - Who are they ? - Am I being lied to ? - Am I projecting- am I wrong about this patient ? - How can I help ? The PGY3 begins to see the wood through the trees. 55 y/o woman with lower back pain for 4 years requesting opiates. Open discussion helps prevent clinical error

Maturing into The Teacher. The PGY4 Role of ED Management and Education The easy part is over…… Flow of department Education of Juniors Fine tuning of algorithms Recognizing your deficits and limitations Recognizing others deficits and limitations Priorities & compromise Learning from experience

Outside of the Department. Maximizing the Opportunities of EM Residency International Medicine

Outside of the Department. Maximizing the Opportunities of EM Residency Disaster Relief

Outside of the Department. Maximizing the Opportunities of EM Residency Wilderness Medicine

Outside of the Department. Maximizing the Opportunities of EM Residency Community Outreach

Outside of the Department. Maximizing the Opportunities of EM Residency Political Involvement

Recognizing the Rub. Conflict Resolution is an Essential Tool - Consulting services - Admitting services - The patient Fiscal / medico-legal / insurance vs. the mission statement of an emergency physician. The ED, a common endpoint of conflict

Recognizing the Rub. Honesty is the Best Policy - High pressure, high stakes - Little down time Short-term patient relationships Shift work Middle range money High pressure, high stakes environment

The Emergency Medicine Family. The Last True Apprenticeship Moustache November, 2008