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Dear Dr. Unfeeling, There are two immutable facts of emergency medicine: we work as a team with our nursing staff and we, the emergency physicians, are the leaders of that team. Therefore, the short answer to your question is that you need to step into that role and act more like a leader. Easier said than done, right? Essentially, a leader needs to do three things: give directions, implement plans, and motivate people. And while this may seem to apply more to administrators who are tasked with “accomplishing a vision for the department,” it is equally relevant for clinical situations, particularly when you consider how critically ill patients are handled. If we’re only as strong as our weakest link, our failure – or potentially our malpractice – is tied to our teammates in the ED.

Good leadership starts with good communication. This is not only good common sense, it’s an edict from the Joint Commission, which set down a requirement that hospitals develop a culture of teamwork that fosters an exchange of information. In your case, it appears that there was very little communication and you did not share a plan of attack ahead of time. In short, leave the screaming tirades to the surgeons.

Keep your cool. Nurses, patients, and families want to see emergency physicians remain calm and in control. When my patient is rapidly circling the drain, I want to be like Russell Crowe’s character Maximus in the movie Gladiator, when his team of prisoners is being attacked by an overwhelming force. He calmly tells everyone that if they stick together and work together they will survive. Compare that to the movie hero who always loses their cool and snaps under pressure. Oh wait, Hollywood doesn’t make movies like that because nobody likes a whiney hero who can’t maintain control of a critical situation. Although, my nurses can attest that I don’t always act as cool and confident as Maximus, the expectation is that the doctor will react professionally and appropriately, in the patient’s best interest all of the time while also acting in the interest of the ED and the team.

Knowing Your Role
Regarding your specific scenario, I would remind you that nurses and ED techs usually know their job limitations better than we do. As doctors, we always feel a little invincible when it comes to stepping up to new procedures. I see this when I credential people for hospital privileges and notice that every box is checked off no matter what experience the provider has in performing the procedure. Docs and mid-level providers are always happy to step outside their comfort zone and do whatever the situation requires, often without consideration of the consequences. However, when you ask nurses to step outside their scope of practice, they have very serious concerns about the possibility of losing their job and potentially their license. Whether we should feel as invincible as we do is another question, but the fact is that there is considerably more oversight on nursing and the rest of our team than there is on us, and we should respect that. Where I continue to see controversy involves drug delivery and monitoring for conscious sedation patients and the induction phase of RSI. If you don’t know your state’s rules and regs for nurses for these categories, you should learn them. Until then, defer to your nurses’ understanding of their rules.

We have a tough job
We have a tough enough job without having arguments within our own department. Admittedly, there are times when seconds matter and the chance to communicate logic just can’t happen. However, those are certainly the exception. Just like the OR team has a “huddle” prior to the surgery to make sure everyone knows the case and their role, we should be putting our heads together in the ED for critically ill patients. However, before you can take that step, you’ll need to repair the damage that you’ve done. You have to take responsibility for your actions and serve as the recognizable captain of the ship. Regardless of who was right about the medication, you need to apologize for your actions to the nurse – you should never publicly humiliate a coworker. The damage to your professional reputation within your department from treating a nurse badly in public could take years to mend if you sit back and do nothing. You need to aggressively work to improve that relationship and publicly be very supportive of the nurses on your team.

Emergency physicians need to set the tone for the department by leading with confidence and calmness and supporting the concept that each person has an important role on the team. We should praise publicly and do so often. Thank people after every shift for the work they did. Even better, sing the praises of coworkers who did a great job. When you need to educate, counsel, and perhaps even criticize, do so privately. And if you are thinking of criticizing, try to use the opportunity to teach and educate, showing your staff that you’re working with them, rather than against them. Remember, we’re the top of the food chain, and with that comes responsibility.

Michael Silverman, MD, is chairman of emergency medicine at Harbor Hospital in Baltimore, MD and is on TEAMHealth’s Medical Advisory Board.
 

Comments   

# FACEPJon 2009-12-30 17:12
Good article and I liked your comparison of the role and demeanor of the Emergency Physician in a critical situation to Maximus' in the arena from the movie "Gladiator."
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# ED physicianFred B 2009-12-30 17:39
excellant discussion topic,
Would like more info on the situation, if truly "life or death" then the idea that a nurse under a doctors supervision would refuse to give an ordered medication..... not only kick her out of the room , but possibly the department.
Unless the ordered medication was wrong for the the given situation, the "scope of her practice" is irrelevant when the doctor is physically present in the room, responsible for the orders and meds.
she is trained to deliver medicines , she is trained to assist the procedure as verbally directed. what part of "scope" was exceeded here?
this sounds more like blatant refusal as presented , a situation not addressed in the article.
Certainly nurses should and do question meds they are unfamiliar with , but in a life and death situation with the doctor present? never. and not usually a good time for educating and instructing.
team huddle before an elective surgery is fine , during a life and death emergency is not a time for an emergency worker on any level to cry "scope" and the situation may not allow for "communication and shared plan of attack"
Imagine Maximus if the response to his question "anyone serve in the army" had been "not in the scope of my practice" shorter movie for sure.
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