02: compassion and humility with Erik Anderson, MD
This episode is a conversation with Dr. Erik Anderson, a board-certified emergency physician and someone I’m lucky to call a friend. Erik is an attending physician of the Department of Emergency Medicine (EM) at the Alameda County Medical Center – Highland Hospital, in Oakland, California. Before that, he was the Chief of Emergency Medicine and Trauma Medical Director for the Northern Navajo Medical Center in Shiprock, NM, which is an awesome facility on the Navajo Nation with a deep mission and a dedicated staff. You can find Erik on Twitter with the handle @esoremanderson.
Many non-crucial details of emergency medical cases, like when a case happened or the age or gender of the patient, have been changed randomly to preserve patient confidentiality. As always with the Emergency Mind Podcast, the goal is not to provide medical advice or commentary on medical care, but to explore best practices and ways that we can all improve how we think during an emergency and apply knowledge under pressure. Additionally, the views expressed on the podcast are personal views and do not represent the views of the employers or organizations at which we work.
02:00—We don’t get into it at all during this episode, but Erik is also does an enormous amount of work in the fields of HIV and Hepatitis C screening out of the Emergency Department, as well as on the opioid epidemic and access to emergency care in rural environments. If you’re interested in learning more about this other side of his work, you can find his publications here, including two papers we worked on together.
03:50—For context, Northern Navajo Medical Center (NNMC) is about a 45-minute drive to the closest hospital with 24-hour trauma surgery care, and 1-2 hours by helicopter to the closest Level I trauma center. The medical and non-medical staff that work at NNMC are awesome, dedicated people, but there are some things, like a seriously injured trauma patient, that small hospitals like NNMC just do not have the resources to handle. In this situation, the emergency team would do their best to stabilize the patient and start treatment while arranging for transport resources to transfer the patient to a facility able to offer a higher level of care. If you’re interested in understanding more about the different levels of trauma care available at different facilities, the American Trauma Society has an explanation. Additionally, in large part due to our experiences working at NNMC, Erik and I worked with some great researchers at Stanford and the University of New Mexico to publish this paper looking at access to trauma care in New Mexico, which highlights the continued need for improved access to trauma care in rural areas and areas with higher populations of American Indians.
05:00—I misspoke here: Erik did not go to NNMC right after residency, but first did a year-long fellowship in Social Emergency Medicine and Population Health (the study of how social factors like hunger and homelessness are related to emergency health needs) at Stanford University
06:14—“What do we do in this situation in this hospital?” I think this is a really powerful and understated idea. No matter where we practice our art, we for sure need to look within and work on ourselves. However, humility and open mindedness about what is different within an unfamiliar system are often key responses to uncertain and important situations. How do we do things in this ER? This jiu jitsu gym, this neighborhood, this team? Everyone can be humble and learn. Empty your cup.
07:50—“I’ve always felt that the most important characteristic of an ER physician is humility.” That’s worth calling out and reading again. Not depth of knowledge, speed of action, or steadiness of hand, but humility. Ryan Holiday’s excellent book Ego is the Enemy digs deeply into this idea, and is definitely, definitely worth a read.
09:00—Fast tests and slow tests. Erik is describing here the differences between tests that are relatively fast to execute vs those that are slow or take more significant resources to execute. This is different but related to the ideas of thinking fast vs thinking slow (see this book by Daniel Kahneman which in late July / early August I am partway through and really enjoying). In this case we’re talking more about what we can accomplish quickly and less about what ideas we can quickly arrive at, but the concepts are definitely linked, especially at around 09:30 when Erik starts talking about the need to slow down his thinking and regroup after having completed the fast tests. A few definitions: ISTAT – a hand held, point of care lab test machine (here) which gives a few key lab metrics for a patient nearly immediately. POCUS – Point Of Care UltraSound – rapid and powerful ultrasound tests performed by the emergency physician in the exam room (the rush protocol for example).
16:38—The podcast I’m describing here is the EMCrit #230 on Resuscitation Communication. It’s available here, and it’s really worth a listen. There’s a lot of gems in there about things we can be doing better to communicate, organize our team, and execute under pressure. Since listening to this podcast, I’ve made a number of changes to my communication during resuscitation events, including notably the sterile cockpit idea during intubations.
19:26—It is, in fact, true. Erik is much nicer than I am.
22:35—The Buddhist monk Pema Chödrön talks a lot about the idea of Shenpa. This article is a great place to start and talks extensively both about the idea of how we learn to recognize when we are hooked and what we can start to do about it.
22:50—I meant molehill into a mountain, not the other way around clearly.
27:04—Hypoglycemia (critically low blood sugar) can manifest in a number of ways, ranging from mild confusion and lethargy to coma and even death. It can also mimic an acute stroke with global or focal neurological deficits. Its presentation is extremely varied and must always be kept in mind by emergency practitioners in the setting of a patient with altered or depressed mental status.
30:15—In “go back to the bedside,” Erik is describing the idea that when the next step seems unclear, the team should go back to their fundamental skillsets of doctoring: talk to and examine the patient. Often by restarting from square one it is possible to eliminate thought errors and the answer will reveal itself.