EM Mindset: Rob Orman – The Successful ED Mindset

mindsetWe at emDocs are proud to introduce our new series called “EM Mindset.” We hope our audience enjoys the pearls of wisdom that each of these seasoned EM vets have to offer on developing the “EM Mindset.”

In case you missed it, please check out the first post of this series by Bob Stuntz. Look out for “EM Mindset Mondays.” Enjoy!


Author: Rob Orman, MD (@emergencypdx) // Editor: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)


Humility that we don’t know everything and that we might not always be right. Arrogance can close the mind to new ideas, alternative diagnoses and a drive to learn. If we think we know everything, what’s the point in trying to improve?


There are few lulls in an emergency department shift. One rarely sits and often there’s not enough time to go to the bathroom, let alone eat. Even clerical tasks like documentation take tremendous focus. It’s not just the physicality of the job that’s draining, it’s the mental and psychological intensity. We become immune to much of it, but moments of reflection or relaxation are rare to nonexistent.


We deal with all levels of society. ALL. From the most destitute homeless polysubstance addled prostitute to world leaders (sometimes in the same day). What do they have in common? They are all human beings. Our training hardens us to the horrors of the job: abuse, death, neglect, violence. That can translate into a hardness toward humanity. It can be hard to find the good in a drunk that’s calling you a ‘bitch’ or a ‘fucking asshole’. We all have our limits of tolerance of what we will and won’t accept in the department, but even the most horrible of humanity still has some humanity left in them. I remember suturing the wounds of a serial rapist who had been injured from a high speed chase with police. Talking to him made me want to vomit. Even thinking about it today brings up negative emotion. But in moments like that, we are the physician and not the torturer or judge. Just do the job and be kind to everybody. Even if you have to send them to jail for poor behavior in your department, you can still be nice about it.

The Pressure Head

For me, this has always been one of the greatest stressors of the job. There are too many patients to see and even more waiting in the waiting room, maybe a few ambulances coming in as a bonus. I work in a small community hospital with single physician coverage for most of the day. When 8 people check into triage in a 10 minute span, there are 10 patients on the board, 6 to be seen, and there is an ambulance coming in with a sick trauma patient, that’s when my stress level rises. How to cope with that? I can only tell you what I’ve done over the years.

  1. Empower your nurses. A good ER nurse knows how to get a workup started for pretty much any chief complaint. When it’s busy, I have a quick meeting with my crew and say, “I am task saturated and need your help…”
  2. You can only see one patient at a time. Despite 6 patients to see, you can only talk to the one in front of you. Some docs ‘thin slice’ and do a 30 second encounter to get the workup started on each patient and come back for a more thorough H and P later. I’m not a huge fan of that unless it’s a multi-casualty scenario and I need to figure out who’s the sickest.
  3. Close the loop. I am always looking for points of closure on each workup. If I can complete a disposition and take my energy away from a patient or encounter, I can use the energy elsewhere. The more loops I can close, the better. The caveat or the danger is total commitment to closing the loop. If a workup is done and I’m giving the final explanation to a patient, they may ask about another symptom they’ve been having. “Oh, by the way, I’ve been having some chest pain.” “Sorry sir, only one complaint per visit, this was knee pain, your knee is fine and off you go.” It’s frustrating when you think you’re closing the loop but your patient opens a new one. Usually, we can avoid this in the initial visit by asking if there’s anything else the patient wants to talk about or anything we haven’t addressed that they’re concerned about.


This is my least favorite part of the job. Period. Whether it’s handwritten, dictation, or EMR, documentation is the albatross of emergency medicine. We learn to live with it and make it less onerous, but the amount of time put into making a chart is time we’re not in the arena of patient care. We can make it better with templates/macros/etc but, for me, not the best part of the job.

Lifelong Learner

No matter how advanced, special, high ranking, smart, educated, handsome, beautiful, or awesome you are, there is still more to learn. The best doctors are perennial students.

Fecal Matter and Vomit

A tolerance to stool and vomitus is essential to success as an emergency physician. If the idea of a patient with explosive diarrhea spreading fecal effluent around the exam room like a golf course sprinkler is revolting to you, you’re normal. If it’s no bother, welcome to the club.


We are purveyors of uncertainty. Most specialties are not this way. I was caring for a patient the other day who said, “I want you to work up this chest pain until you don’t find anything.” He understood the heart of emergency medicine.

You Set the Tone

If the physician is a whiny complainer, that will bring down the mood of the department. It may even reduce the quality of care. Even if you’re in a bad mood, suck it up and put on a leader’s demeanor. When was the last time Captain Picard was grouchy and didn’t want to see any more patients?

Be Smart

About five years into my practice (post residency), I felt like I was at a nadir in academic development. I was working in a huge community ED and had a decent fund of knowledge. The problem was, it was the same fund of knowledge I had at the end of residency training. This was a travesty.

We should deliver better care throughout the arc of our careers, not only because we are more experienced, but because we know more stuff. Keeping up is not just checking off the CME boxes, it’s a genuine interest in mastering a skill. Our skill is the cognitive process of evaluating undifferentiated complaints. There’s the resuscitation aspect, procedures and the like, but the vast majority of what we see are things like chest pain, abdominal pain, headaches, etc. Is this a life threat? Is there a decision instrument for this? Does this fall outside the parameters of that decision instrument? Has thinking changed on this complaint and what’s acceptable (or not)?

The post EM Mindset: Rob Orman – The Successful ED Mindset appeared first on emdocs.

Diagnose on Sight: Lip Swelling

angioedemaCase: A 24 year old male presents with right sided lip swelling that began several hours ago. This is the second time he has had this type of swelling. His mother has also had this before. He currently has no urticaria, dyspnea, wheezing, or stridor. What is the cause of this patient’s symptoms?



Diagnose on Sight Poll


Author information

Jeff Riddell, MD

Jeff Riddell, MD

ALiEM Assistant Editor

Diagnose on Sight series;

Chief Resident

UCSF-Fresno Emergency Medicine Residency

The post Diagnose on Sight: Lip Swelling appeared first on ALiEM.

April 2015 “Skeptical Edition” REBELCast

April 2015 "Skeptical Edition" REBELCastWelcome back to a special edition, or should I say “skeptical edition” of REBELCast. We have started to do something new by inviting guests onto the show to discuss papers in the literature they find interesting.  This month I had the pleasure of working with Ken Milne, an emergency room physician in Canada. Today, Ken and I are going to specifically discuss a new device that recently got FDA approval for CPR in Out of Hospital Cardiac Arrest (OHCA), and the question we are trying to answer is:

Is active Compression Decompression CPR with Augmentation of Negative Intrathoracic Pressure for Treatment of Out-of-Hospital Cardiac Arrest superior to standard CPR?

April 2015 “Skeptical Edition” REBELCast Podcast

Click here for Direct Download of Podcast

Who is our guest this month on REBELCast?

Ken MilneOur guest this month is Ken Milne, MD (Twitter: @thesgem) who has a fantastic podcast of his own called The Skeptics Guide to Emergency Medicine or The SGEM for short. The SGEM is a knowledge translation (KT) project started in 2012. The goal of the SGEM is to cut the KT window from over 10 years down to 1 year. The SGEM does this by using social media to provide the audience with high quality, clinically relevant, critically appraised, evidence based information, so you can provide EM patients with the best possible care. The SGEM consists of a weekly blog and 20min podcast. Each week Ken invites a guest skeptic to perform a critical appraisal on a recent article while trying to find the right balance between education and entertainment.

Marshal Mcluhan

Finally, the SGEM uses a validated and reliable tool from the McMaster University the home of evidence based medicine. The tool comes from the Best Evidence in Emergency Medicine (BEEM) group. It is used to probe the literature.


What clinical question will be covered in the April 2015 “Skeptic Edition” REBELCast?

  • Question: Is active Compression Decompression CPR with Augmentation of Negative Intrathoracic Pressure for Treatment of Out-of-Hospital Cardiac Arrest superior to standard CPR?


What specific article will we be covering?

  • Article: Aufderheide et al. Comparative Effectiveness of Standard CPR versus Active Compression Decompression CPR with Augmentation of Negative Intrathoracic Pressure for Treatment of Out-of-Hospital Cardiac Arrest: Results from a Randomized Prospective Study. Lancet. 2011 January 22; 377(9762): 301–311.  PMCID: PMC3057398


What is the clinical bottom line for the above clinical question:

  • Bottom Line: It is not clear if this device works in improving survival with good neurologic outcomes for patients with OHCA, but this study does not prove that it does.

March 2015 REBELCast Show Notes

The post April 2015 “Skeptical Edition” REBELCast appeared first on R.E.B.E.L. EM - Emergency Medicine Blog.