It's taken me a few weeks but I've figured out the secret of success in the Emergency Department. First, some necessary background. There are two halves to the ED: A side and D side. On arrival, all patients are triaged into either A or D. You go to A if you are likely to require admission to hospital. You go to D if you are likely to be discharged after being seen.
My secret is this: always discharge everyone on the A side and admit everyone on the D side. It doesn't matter how flimsy your justification is, or how ludicrously risky it is for the patient - the important thing is that you are creating a vibe, a persona, an imago, that will live forever and guarantee you'll pass.
Of course, you won't always be successful in executing this plan, since you need consultant approval. But again, the key point is that you go into that conversation with the consultant with this firm recommendation and really shake things up.
Scenario #1, A side: Little old lady who lives alone with chronic renal failure comes in having been nauseous and ill for the past week. Her potassium is up the wazoo, ECG changes, uraemic flap, confused and disoriented.
Your position: Discharge. She'll be less confused at home, she has a renal clinic appointment next week anyway, all she needs is a litre of fluid over half an hour before we send her on.
Impression: You're a strong minded independent thinker who isn't afraid to voice their own plan. Possibly somewhat confused and disoriented when it comes to clinical work, but at least you have the courage of your convictions.
Scenario #2, D side: Man comes in with bruise on toe that he dropped a block of wood on last week. No disability but he had the day off so he thought he'd come in and get it x-rayed because he's never had an x-ray before.
Your position: Admit under orthopedics. No wait, under plastics. Get a CT foot done, then a follow-up MRI to assess for soft-tissue injury. Run a panel of thrombophilia screens to alert the surgeons to your awareness of how serious DVT is. Get three or four large bore cannulas in and a flatus tube for good measure.
Impression: You're a strong-minded independent thinker who demands the absolute best for your patients and won't take no for an answer.
If you're not in ED at the moment, the general principle is the same. Do the unexpected. Nobody remembers the guy who was always boring and playing it by the book. Step out there and make your mark!