I was asked to write about a “typical day in the life of a scribe.” While reflecting about this, I came to a pretty cool realization: there is no typical day in the life of a scribe. Sure, there are constants: maneuvering your computer-on-wheels through the Scylla and Charybdis of rushing nurses and hulking ultrasound machines; cramming down high-energy snacks in the fusty break room; and internally weeping over patients with 42 medical allergies, to name a few. But working in the emergency department is, almost by definition, an exercise in flux and flexibility. So instead of describing a fake typical day, I decided to compile a list of some scribing constants, in convenient alphabetical form:
A is for Appendicitis: It’s the classic reason to go to the emergency department. And as a scribe, I see my fair share of appendicitises (appendiciti? appendicites?). But it’s rarer than you’d think. There are about a million possible diagnoses for abdominal pain, and the emergency department sees them all. What’s more, some people with appendicitis don’t even have abdominal pain. Appendicitis is, for me, a great reminder of just how complicated good emergency care is.
B is for Best Friends: I don’t mean to be a giant cheeseball here, but the scribe community is really cool, and if you work as a scribe for long enough, you’re going to end up making friends for life. I’m talking, visit-each-other-in-med-school-even-though-one-of-you-is-in-New-York-and-the-other-is-in-Arizona-and-both-of-you-are-broke friends. That’s real love.
C is for Chart: This is the electronic record you’re making for each patient you see. It comprises: the patient’s medical history (medications, allergies, medical conditions, surgeries, family history, and social history (marital status, tobacco use, etc.)information about the patient’s current complaint (History of Present Illness (see H) and physical exam findings) a summary of the patient’s time in the emergency department (procedure descriptions, lab and imaging results, medications received, and a brief narrative)he plan going forward (the dictation (see D), the diagnosis, and the disposition (home, admit, transfer, etc.))
D is for Dictations: Once a patient has been sent home or admitted, the doctor dictates a brief explanation of their decision-making. It’s the scribe’s job to type this up and add it to the patient’s chart. Once you get over the initial stress of frantic typing, dictations are hugely informative. They teach you about medical decision-making, common and totally whacky medical conditions, and the tests doctors use to diagnose them.
E is for EPIC: EPIC is the insanely powerful medical software we use to document patient care and look up patient records. It’s not always intuitive, but becoming familiar with it gives you a definite leg-up in medical school.
F is for Foreign Body: You’re going to see a lot of patients with foreign bodies in THEIR bodies. Enough said.
G is for Google: Often, while dictating or otherwise discussing a patient, doctors will throw out words and acronyms that are totally foreign to their scribes: “cell and flare,” “CAGE,” or “leuk est.” Or, a patient will state, “I take something for my reflux…it starts with an R.” In these cases, Google is your best friend.
H is for History of Present Illness/HPI: Also known as one of your most important responsibilities as a scribe. The HPI is a paragraph (or two, for complicated patients) at the start of a patient’s chart, detailing the past and current symptoms bringing them to the emergency department. You write it after visiting a patient and listening to their story. It’s important to include timing, descriptive language, and pertinent positive and negative symptoms. And, if possible, it should flow. It’s an art form, really.
I is for Idiosyncrasies: As a scribe, you work with a lot of different doctors, all of whom have different work styles. Some doctors like to give you physical exam details while in the room with patients; others prefer to go over their exams after leaving the room, or at the end of the shift. It’s important–and easy–to keep track of the different idiosyncrasies, so that you can best serve whichever doctor you’re working with.
J is for Jimjams: Scribes, like most medical professionals, wear scrubs. Scrubs are, in essence, glorified pajamas. This is one of the greatest perks of the medical field; don’t let anyone tell you otherwise.
K is for Keister: One of my persistent struggles as a scribe is choosing a good word to describe patients’ rear ends. Butt? Too lewd. Bottom? Too childish. Derriere? Too racy. Tush, bum, fanny, cheeks…it’s all bad. And “buttock pain” just sounds ridiculous.
L is for Life of the Party: As in, what you’ll be once you start scribing. Working in the emergency department provides lots of crazy stories, from the thumb amputation to that one patient who swore she wasn’t pregnant while actively in labor.
M is for Mapping: Scribe mapping is twofold: first, you have to know your way around the emergency department. Your rolling workstation is unwieldy, and you quickly learn the best passages for navigating between rooms/people/equipment. Second, a good scribe is adept at mapping out their HPIs (see H). Patients often relate their stories in confusing ways–with a scrambled timeline, or missing key symptoms. It’s your job to reorder the facts into a coherent story, with the most pertinent information first and foremost.
N is for Napping: Some days you work 8 am – 4 pm, like a normal person. Some days you work 3 pm – 11 pm, or overnight. While being an excellent napper isn’t a job requirement, it’s a definite plus.
O is for Overnights: The emergency department doesn’t sleep. And for 1-4 nights each month, depending on whether you’re part-time or full-time, neither do you. It’s really not as bad as I anticipated when I started scribing. The nighttime ER has a feeling of intense camaraderie, with shared snacks and friendly commiseration over lost sleep. Plus, night patients tend to be pretty wild.
P is for Patient Care: My favorite thing about being a scribe is seeing how different doctors interact with patients. Most of the doctors have excellent patient care strategies, and I’m excited to imitate them when I have my own medical degree. As for the doctors with less impressive habits, well…that’s a learning experience too.
Q is for Quandary: As in, the moral and ethical variety. Should a 90-year-old patient with end-stage lymphoma undergo intensive life-saving measures? Should a pregnant woman with blood clot symptoms be exposed to the radiation of a diagnostic CT scan? And how many Percocet should you give to a patient with a history of drug-seeking behavior? Watching doctors and patients navigate these questions can be heart-wrenching, but in my experience, it makes you more empathetic, which in turn will make you a better doctor/person.
R is for Rig: ED-speak for ambulance. As you might expect, a fair number of the patients that scribes see every day come in on the rig. Sometimes it’s totally merited (a cardiac arrest, for instance) and sometimes it’s head-scratching (hemorrhoids). Whatever the cause, when a patient comes in on the rig, it’s important that the scribe doing the charting get some sort of report from paramedics. It can be written or verbal, but we need to note down patient vitals en route, medications given, paramedic observations, etc.
S is for Snacks: There are no lunch breaks in the emergency department. At least, no hour-long leisurely lunch breaks like most of the working world gets to enjoy. Scribes get used to snarfing protein bars in the brief downtimes between patients, and can inhale coffee with the best of them. Again: great training for med school.
T is for Triage Shifts: Most shifts, you work in the emergency department proper. Sometimes, you work in Triage, which is an offshoot area for patients with less acute problems (pink eye, strep throat, etc.). Even though the excitement level is generally lower on Triage shifts, I still enjoy them. They give you insights into the importance of both medical reassurance (“Your child will not die of strep throat”) and patient education (“A ‘fever’ of 99.0 does not require emergent medical attention”). And because you’re working in a small area with just one doctor and a nurse or two, Triage shifts can be really great bonding experiences.
U is for Underserved Populations: ERs have a well-deserved reputation for serving as safety nets for patients who have somehow fallen through the cracks. These patients often don’t have a regular doctor, and come to the ER for primary care. In Minnesota, common underserved populations include Native American Indians, immigrants (especially Hmong and Somali), the elderly, the homeless, and the mentally ill. Serving these patients is a humbling experience, and gives deep insight into the American medical system.
V is for Vocabulary: If you know what a cholecystectomy is, color me impressed. I had no idea what this word meant, or even that this word existed, before I started scribing. Now I’m fairly well versed in medical terms, including human anatomy, common medications, and procedures. (A cholecystectomy, for future reference, is the surgical removal of the gallbladder. This is great for parties. Just kidding. Don’t bring up cholecystectomies at parties.)
W is for WOW (also known as the Workstation On Wheels): The Cadillac of the emergency department, better described as a somewhat clunky computer rover that you wheel into all patient rooms. Fun fact: it used to be called a COW, for Computer On Wheels, until a patient overhead a doctor ask a scribe, “Where’d you leave that COW?” and lodged a complaint (she thought they were referring to her).
X is for X-ray (a cop-out, I know): Lots of patients in the emergency department get x-rays, or other more advanced imaging like CT scans and MRIs. Most imaging is completely indecipherable to people without medical training (read: me), but ER doctors are generally happy to go over patient scans with you. Whether you’re looking at an x-ray of pneumonia or an MRI of a brain