General Tips 

1.  Despite popular belief, you don’t need a daily CXR for every ICU patient, every intubated patient or every patient with pneumonia/ rib fractures.

2.  Don't get daily labs or daily imaging "just because". Get studies that will change your management. 

3. For stable patients, you don’t need to check a CBC immediately after every transfusion.

4.  You don’t need a PaO2 to wean FiO2. PaO2 is an infinitesimally small contribution to arterial O2 concentration. The equation is often simplified by removing it all together! CaO2= (Hgb x SaO2 x 1.38) + (PaO2 x 0.03) ≈ (Hgb x SaO2 x 1.38)

5.  Avoid adjusting multiple meds at one time when addressing a symptom (for example, adding a new medication and increasing the dose of another medication). Too many changes at the same time will make it difficult to know what medication change was responsible if there is a clinical change.

6.  Most patients don’t need a CXR after chest tube removal. If the pt has PTX that requires a chest tube, they will tell you (meaning they will be symptomatic). If you check a CXR on everyone, you will find small PTXs that don't need treatment.

7.  Not everything that hurts/ bleeds is a hemorrhoid. Exam is required to identify the etiology. If you treat a fissure with hemorrhoid meds (witch hazel, suppositories) they won't get better. Plus, witch hazel will burn and suppositories will be incredibly painful.

8.  Patients often get better despite us, not because of us. Many things we believe to be optimal treatment now will be considered heresy in the future.

9.  Sometimes not doing something is the best thing to do. Sometimes not operating is the compassionate thing for the patient. A patient doesn’t have to die with an incision on their abdomen.

Working with your team

1.  Trust the nurse when they say they’re concerned. Better to have a phone call for a patient who is ultimately fine vs not getting a call when the patient isn’t fine. If you respond to nurses by telling them it’s fine and not to worry, they will learn not to call you. If you respond to nurses with hostility, they won’t go out of their way to make your life easier.

2.  Don’t call your mid level resident/ chief/ fellow/ attending without any more information than you were initially given.

3.  When requesting a consult or calling your chief/ fellow/ attending about a new consult/ admit, give the bottom line upfront. This is especially true when you are waking someone up or need them to do something quickly (ie get dressed and drive in).

Tips for the OR

1.  While closing fascia, if you maintain counter-traction on the fascia with your pickup as you pass the needle through the fascia, you can release the needle while it’s still in the fascia and reload the needle farther back to push it the remainder of the way through the fascia. Then you can reload the needle and be ready for your next bite without having to touch the needle (decrease risk of needle sticks).

2.  Ask for instruments and sutures several steps ahead so you minimize pauses.

3.  Always ask for cell saver for a bleeding patient heading to the OR. You don’t want to be delayed waiting for it to be set up before you make your incision.

Tips in the Trauma Bay

1. Don’t use GCS 8 as an automatic trigger for intubation.

2.  If you intubate before addressing hypovolemia or relieving obstructive physiology, there is a high risk of cardiovascular collapse and asystole.