ER Checklist — v1.0

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.

– – – – – – – – – – – – – – – –

※ 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.

– – – – – – – – – – – – – – – –

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.

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