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Excellence in emergency doctors 7. Analgesia and conscious sedation:

....................................................................................... Managing pain is a fundamental
part of our work. Although it

In search of excellence
becomes a heart sink problem
when faced with the frequent flyer
attendee who has intractable
G Hughes chronic pain that even the pain
clinic has given up on, for the rest,
................................................................................... speedy and appropriate analgesia is
critical. Whether we give it orally,

n Search Of Excellence, by Tom Peters Knowledge of basic ventilators and rectally, intranasally, parenterally
and Robert Waterman,1 published in ventilation modalities is a prere- or via a regional block, we should
1982, remains one of the biggest quisite too. offer the service with expertise and
selling and most widely read business timeliness. Conscious sedation for
3. Triage and major incident manage-
books ever. It was then, and still is, minor procedures, with a benzo-
ment: This is core business. As with
touted as a seminal text for those trying diazepine and an opiate or a
resuscitation, it is part of our
to improve systems and deliver quality neuroleptic, should have a safety
armamentarium. These are not
to the public, mainly in the context of record second to none.
easy skills to acquire. We can be
business. I was advised to read it on a proud of our abilities in this speci- 8. Communication: For many reasons,
senior registrar management course I alty, but we can always do it better. sadly one of them being medicole-
attended in 1989. It’s not a page-turning gal, our record keeping, be it
bodice-ripper. I didn’t finish it. I tried 4. Imaging: From time to time we will electronic or hard copy, needs to
hard. always need the skills of a radi- be faultless. We need to set an
I mention this because I came across it ologist to help us interpret films, example for everyone else. Our oral
the other day while perusing the shelves whatever the radiological modality. and written abilities to communi-
of the hospital library. Later that day I A skill we can be excellent at is the cate with each other in a depart-
discussed the book with a friend who use of diagnostic ultrasound in the ment, a hospital, our colleagues in
runs a successful business. He agreed that resuscitation room. Focused assess- the community and pre-hospital
it is still widely referenced in business and ment with sonography for trauma arenas and, last but not least, with
training seminars. He then asked me the scanning, searching for abdominal our patient and their carers should
killer question ‘‘what are you guys [emer- aortic aneurysms in the appropriate be exemplary.
gency doctors] excellent at?’’ He followed context and looking for a dilated 9. Acting rationally to the unexpected and
this up by asking ‘‘don’t you refer every- right ventricle (via an echocardio- unknown, thinking on our feet and
thing on to specialists?’’. I was well gram) in massive pulmonary embo- keeping calm in a crisis: What more is
behaved and refrained from pouring a lism can be core skills. Ultrasound there to say?
jug of water over him. also improves the safety of central
10. Empathy and compassion: Let’s show
So, what are we excellent at? By the cannulation via the internal jugular
to the patient and their carers that
nature of our work, we are generalists and route. It goes without saying that
we care. Among the hurly-burly of
are pretty good at many things, but what fracture recognition on plain film is
our work, we must remember that
are we excellent at? In an era that revels a key skill.
there is more to what we do than
in having ‘‘top-10’’ lists for virtually 5. Electrocardiograms: After measuring intellectual thought, professional
everything, here are 10 things we are or vital signs, the glucose level, and achievement and diagnostic preci-
should be excellent at. I’m sure there will carrying out urine analysis, record- sion. In an age driven by targets,
be disagreement with my selection. ing an electrocardiogram is one of instant gratification and material-
our most common investigations. ism, we need to recall why most of
1. Resuscitation: This is the ‘‘raison
d’etre’’ for our existence. If we In addition to recognising arrhyth- us entered this challengingly com-
don’t do this better than anyone mias, all degrees of heart block, pelling profession. Most of our
else, then we need to shut the shop and the various patterns seen in clientele come to us at a moment
and throw away the keys. (or mimicking) acute coronary of dire need. For those who die, the
Knowledge of protocols, ability to syndrome and oddities, such as J way we manage the early grief and
think 2–3 steps ahead in decision waves in hypothermia, we need to bereavement of their relatives and
making and excellent team leader- be good enough to pick up rare and friends is critical. Let’s maintain
ship should be par for the course. subtle abnormalities which can our humanity and compassion and
have a devastating outcome if protect their dignity.
2. Resuscitation procedures: Apart from
missed, such as long QT syndrome Emerg Med J 2006;23:822.
basics such as the correct way to
maintain an airway, cannulate, and tri-fascicular block. doi: 10.1136/emj.2006.041673
defibrillate and perform external 6. Wounds and soft tissue infections pro-
Correspondence to: Geoff Hughes, The
cardiac massage, we need to be blems: This is core business. In Emergency Department, Royal Adelaide
excellent at rapid sequence induc- addition to managing everyday pro- Hospital, North Terrace, Adelaide 5000,
tion and intubation, recognition blems with skill and precision, we Australia;
and management of the difficult need to promptly recognise occa-
Accepted 29 August 2006
airway, advanced cannulation (be sional conditions such as erythema
it central or peripheral, arterial or nodosum, necrotising fasciitis and Competing interests: None declared.
venous) and intercostal drain so forth. Our accuracy for appropri-
insertion. We need to perform to ate and timely referral to surgical REFERENCE
the same standard as our anaes- specialties for both wounds and 1 Peters T, Waterman R. In search of excellence.
thetic and intensivist colleagues. infections needs to be spot on. 1982.