In reflecting on my wonderfully addicting four-week stint in the NYU/Bellevue Emergency department, I began to wonder what advice I would have given myself before showing up to work that first day, knowing what I know now. What would I be more mindful of? What mistakes would I avoid repeating? This is how I came up with a list of 4 lessons I learned and the mistakes I made. I share these anecdotes with the hope that medical students may learn from my experiences, and that residents may be reminded of the awkward and brand new experiences medical students run into in the ED.

Lesson 1. Pay attention to the little things.

As a medical student, we often feel completely lost and inadequate, but we have one thing that the doctors don’t have—TIME! TAKE YOUR TIME.  Pay attention to the little things that the busy residents and nurses might miss.  Example: A Russian man who spoke no English was being worked up for ACS. He motions at me to come over to his bedside. He is grimacing and clutching his right chest. I rush over to him, worrying that he might be having a heart attack or maybe his aorta dissected (what do I know?). Should I bother a resident to come take a look? He says, “Here, here” while pointing to his chest. My mind is racing, and then I realize he’s pointing to the electrode pulling on his chest hair, obviously causing his pain. I remove the electrode, place it on a nearby area, and he smiles. Maybe I wasn’t prepared to intubate him if necessary, but I had the time to care for the little things that can have a huge impact on patient care.

Lesson 2. Do not accept anything less than respect, even from patients.

The doctor-patient relationship is a special one, but it should go both ways. One night, I was asked to triage a rail-thin, middle aged drunk man who presented with, well, drunkenness. I ask him what brings him in to the ED tonight, to which he responds, “Baby, I’m a rock star. I party hard. I party so hard and I gotta get outta here so I can party.” I repeat my question, slightly differently, to which he says “You gotta party with me… you don’t know what I can do to you,” his hand heading south. I awkwardly smile, leave, and go talk to a female resident that I feel comfortable with, asking what the heck I should do in a scenario like that. I was angry, shocked, and would have slapped him if it wasn’t unprofessional.  The advice I received was simple and direct: “You need to say, ‘Sir, that is extremely inappropriate behavior. We expect you to treat us with the same respect that we give to you.’” It might take some time to practice direct confrontation with inappropriate patients, but it’s important to be confident that you deserve the same respect in the hospital that you deserve in any other social situation.

Lesson 3. Be Bold & Break Bad Habits

A charming middle-aged man, wearing a tight black Ed Hardy tank top and fitted designer jeans, presents with a possible fractured rib. While interviewing him, two things became obvious. First: he was a crystal meth addict and was using meth, molly and K2 the night he broke his rib. Second: despite his drug use, he found time to spend hours in the gym each day—he had the body of a physical trainer. I spent some time with him, asking about his life, his family… and his drug use. He knew he had a problem and asked me about rehab options. Rehab beds at Bellevue are first-come-first-serve and the demand far outweighs the supply. So, I took another approach, although it felt slightly uncomfortable and risky. I asked him if he cared about his appearance (I and everyone else already knew the answer). He responded, “Of course, I have to look good, all of my friends look good.”  I then take out my iPhone and pull up a photo of before and after snap shots of crystal meth users. I show him the pocked skin, the rotten teeth, the hair loss, and the sunken faces of chronic crystal meth users. His jaw drops and he stares intently at these faces, grabs my phone, and starts swiping through the photos. “This can happen? Are you f***ing kidding me?” Realistically this may not be the last time he used, but I know he now had some motivation to stop using.

Lesson 4. Trust your instincts, but somehow keep an open mind.

I was asked to see a 22-year-old disheveled man in a dirty white tee shirt and khakis. I ask him why he’s here, and he tells his story. He was at a bar, stepped outside for some air, and got beaten up and hurt his knee. A few minutes later, his story changes—he was walking to a bar and got pushed by a crowd and hit his knee on the curb when he fell. Although his story kept changing, the things that remained the same were A) his knee hurt B) he reeked of alcohol, slurred his words, but only admitted to drinking one glass of wine C) he would intermittently insist nothing was wrong and he wanted to leave, and D) my patience was waning as it was 3:30 in the morning. I did my physical exam and concluded that his right knee was fine with no obvious deformity, normal range of motion, normal palpation, etc.  Diagnosis: he was just drunk and annoying. He was even annoying me during the exam—he raised his left leg to the sky on straight leg raise, but pretended to not be able to raise his right leg. “Come on… I know you’re stronger than that, I saw you walk in here, just raise it up! You can do it!” He was being such a wuss. An hour later, the x-ray comes back and his patella is in five pieces, and his knee is the size of a softball.  I had been totally wrong. I apologized to the man, felt terrible, and told my resident what I had done. The feedback I received was the following: Trust your gut, but try not pass absolute judgment.  There were 10-20 other intoxicated patients in beds that night, but I judged my patient too quickly. No two patients are the same, and no matter if its 3 am and you don’t believe the story, dig deep and keep your mind open. And, when you slip, be humble enough to apologize, learn from your mistakes, and hopefully share them with someone who can learn from them as well.

Although I learned these four lessons in the Emergency Department, I think they are universally applicable in any setting, be it at the hospital or at home. Taking your time to be considerate of others, asking for respect, being creative in problem solving, and having an open mind— it doesn’t require an MD to practice these lessons—all it really requires is having a brain and a heart. And, importantly, it requires some opportunities to make mistakes of your own so that you can learn from them, and hopefully teach these lessons to someone else.

Edited by: Hilary Fairbrother, MD