Most of the mistakes are not failures of incompetence. When things go wrong in the ER/ED it’s because we fail to do the basics well. This is a (incomplete) checklist, to help remind you not to take the basics for granted.

As always, you do your ABCDE, and make sure you don’t slip on the following steps.

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※ Do the basics well.  

• Lab. 
  – Check anomalies, pay extra attention to electrolytes (like potassium and sodium), blood count, Creatinine, and CPR/Leukocytes.
  – Then check change over time, normal values that have changed significantly over time can indicate something pathological.
  – A blood gas is almost always a good idea (for most cases a venous sample is sufficient). 
• ECG.
  – Check it systematically everytime, even absent chest pain.
  – Take serial-ECG:s when needed.
  – Make sure you can recognize Wellens, De Winter’s, and other non-schoolbook pathologies that might get missed.
  – Lewis leads are fun, but get a transesophageal electrocardiography when needed.
• Physiology. 
  – Pay attention to pulse, blood pressure, breathing, and current deviations and deviations over time (take serial NEWS to help you assess).
  – Cushing’s syndrome if head trauma?
  – Is their pulse at a false low (pacemaker? beta blockers?)?
  – Does the physiology and the clinical presentation add up?
• Trauma.
  – C-ABCDE (catastrophic bleeding).
  – If the CT-scan doesn’t find anything pathological, but clinical evaluation indicates it, get an MRI.
  – Call in help early when needed.
• Listen and observe.
  – What is the patient telling you?
  – What are they not saying?
  – Are you asking the right questions?
  – What do you observe?
  – Does it all add up?
• Read & write the medical journal.
  – At the ER: look for allergies (warnings?), addictions (to opiates?), medications (anticoagulants? beta-blockers? sedatives?), and previous medical history.
  – At the ED: same as above, but also for patients with long hospital duration, try to do a summary — take the time most don’t, build a concise and cogent picture of the patient.
  – If a senior colleague makes a decision you don’t agree with, make sure to document who took that decision thoroughly.

※ CRM — know your team and resources.   

• Location & stuff. 
  – Where is the defibrillator located?
  – How does the NIV work?
  – Etc.
• People. 
  – Who are you working with today?
  – Who is the most experienced among each personal category?
  – How can you get a hold of each other if/when needed?
• Externals. 
  – Important numbers you might need to dial quick, like to anesthesiologists, surgeons, cardiologists, and radiologists (always carry a cheatsheet).
  – Know the most common medications and doses you need to give when delay can be fatal, like the treatment for anaphylaxis, CPR, hyperkalemia, hyponatremia, severe gastrointestinal bleeding, and sepsis.

※ CRM — Communication. 

• Make time for a time-in, where the team present itself and different roles are outlined.
• If possible make time for a time-out when possible after each case or, at least, after each day, and evaluate in order to help improve the next case/day.

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That’s it. It’s not by any means a complete list. But it’s a good starting point. I will be adding, subtracting, and refining the list as I keep working in the ER and on this site.

It’s a work in progress.