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Q: What are two common reasons that a diagnosis for a serious condition is missed?

A: False reliance on negative testing and blaming a less serious condition for symptoms.  You need to know the limitations of your test.  Repeat troponin can be normal in unstable angina.  CT head can be normal in TIA and early CVA.  Testicular ultrasound can be normal in intermittent torsion and torsions less than 360 degrees.  Also, don’t blame a panic attack, gastroenteritis or intoxication for symptoms unless you are confident you have ruled out a more serious condtion.

Source: The Emergency Department Quick Reference Guide,



Q: What two questions should you ALWAYS ask a patient before giving Maalox?

A: “How long has the pain been present?” and “Is the pain improving on it’s own?”  Pain from unstable angina may only last 3-30 minutes or so.  If you give a therapeutic trial of medication to a patient and the pain goes away, you would like to know whether or not it might have resolved on it’s own or not.

Source: Emergency Medicine 1-Minute Consult Pocketbook,



Q: What is a common reason that ACS gets missed?

A: False reliance on negative test results and incomplete history.  Troponin will often not be elevated initially or when repeated in a patient having intermittent episodes of chest pain lasting less than 30 minutes.  Recent literature recommending repeat troponin should not be applied when pain episodes are brief.  Repeat troponin is also a waste of time when the most recent episode of chest pain was more than 6-12 hours ago

Source: Emergency Medicine 1-Minute Consult Pocketbook,



Q: What is a common reason that isolated small PE’s get missed?

A: Normal vital signs.  They lodge distally causing lung infarct only.  They therefore usually cause only pleuritic chest pain but no dyspnea or change in vital signs (no tachycardia or hypoxia)

Source: Emergency Medicine 1-Minute Consult Pocketbook,



Q: What is a common reason that isolated big PE’s get missed?

A: They are often painless!  They do not cause lung infarct and so are often painless.  In addition they often cause EKG, troponin, and BNP changes as well as leukocytosis.  These test findings combined with unstable vitals may mimic sepsis, MI, CHF or other conditions.

Source: Emergency Medicine 1-Minute Consult Pocketbook,



Q:  Other than PE what disease causes pleuritic RUQ pain & elevated D-dimer?

A:  Fitz-Hugh-Curtis Syndrome.  This condition often has no pelvic symptomatology or exam findings, especially if due to chlamydia.  LFT’s will usually be completely normal as well. Test and treat empirically, especially if there has be a recent new sexual partner.

Source: Emergency Medicine 1-Minute Consult Pocketbook pocketbook,



Q:  What part of the history has been implicated as being forgotten and leading to closed claims?

A:  The family history.  The family history is especially important in chest pain (ACS, dissection and PE) and in headache (AVM, SAH) but less so in abdominal pain, fever and most other conditions.

Source: Malpractice in Emergency Medicine – A Review of Risk and Mitigation Practices



Q:  What 5 things should be confirmed prior to discharge from the ED?

AStable vital signs, clinical sobriety, ability to care for oneself, no new complaint and complete evaluation of all documented triage complaints.

Source: Malpractice in Emergency Medicine – A Review of Risk and Mitigation Practices for the Emergency Medicine Provider




Q:  What’s a good trick to examine the eye of an uncooperative child?

A:  Tell the child, “Look at my eye.  What colors do you see?”

SourceTarascon Emergency Department Quick Reference Guide,


Q: Why is Macrobid not recommended in renal insufficiency?

A:   Macrobid:  If creatinine clearance <60 not well concentrated into bladder so increased risk of treatment failure

Source: A to Z Pocket Emergency Pharmacopoeia,


Q:  What’s the definition of doctor shopping?

A:  Obtaining narcotics from >5-7 providers &/or pharmacies in 12 months.

Source: Emergency Medicine 1-Minute Consult Pocketbook pocketbook,


Q:  What is the most likely evolutionary explanation for a vasovagal reaction?

A: To prevent blood loss.  When you are bleeding internally, have a vascular injury, see blood, or experience severe pain you may be less likely to die from ongoing blood loss if you are supine as opposed to upright and if your heart rate and blood pressure are a bit lower.  This may give your body time and a better chance to clot and stop the bleeding.  A friend of mine who works in interventional radiology has noticed when they embolize a bleed the blood pressure suddenly seems to improve.  The volume status and hemoglobin did not change significantly over those few minutes, but the body seems to “know” that it has stopped leaking blood.  I haven’t done a lit search on this, but there must be some reason for a vasovagal reaction.

Source: Theory of mine



Share your wisdom with your Emergency Medicine colleagues.  Just enter your comments using the boxes at the bottom of the page and I’ll turn it into a pearl or leave it as a comment or both.

NOTE: Do not use the “enter” button on your keyboard.  It may cause the comment to fail entirely.  Also, rather than using your name in the “Name” box, please write your TOPIC instead using ALL CAPS.  If you want to sign your name, do it at the end.



Comment from Tool Master
Time: February 15, 2008, 9:58 am


Enough with all these “Rules” already. Now we have the PERC Rules too. We need to use different terminology or the trial lawyers are going to have a field day with us when we don’t follow the rules. Rules are rules, not meant to be broken. Tools are implements you use when they will help you with the task at hand. Other terms such as “Criteria” or “Decision Instrument” are fine too, but can we (especially the researchers) please abolish the word “Rule” from our vocabulary. We all know that we need to be careful and double-check our work, but we also need care for each patient individually and we definitely don’t need to do anything that is going to worsen the current malpractice climate.

Comment from NO MORE TORADOL
Time: June 12, 2008, 2:32 am

Toradol should not be used for anything, including kidney stones. Ibuprofen works just as fast, is a fraction of the cost and has a much better safety profile. Narcotics are even better. Toradol has 27 times the risk of GI bleeding as does ibuprofen and there are cases of acute renal failure after one time injections. Why would you give it to someone with kidney problems? It has been taken off the market in several European countries due to safety concerns.
Let’s all save our patient’s and our country money and nephrons. Stop using Toradol. Ibuprofen and morphine should be the go to drugs for acute renal colic in the ED.

Time: June 12, 2008, 3:08 am

Prophylactic anti-emetics are not recommended routinely when using narcotic analgesics. They add to cost and potential side effects. Less than 1 in 10 patient’s will need them, so save them for those that do, those that are already nauseated or those who know they always vomit with narcotics. For the other 90% of patients just give the morphine or dilaudid “a-la-carte”.

Comment from CT or VQ for PE by Amanda G.
Time: August 31, 2008, 10:46 pm

In PIOPED-2, the sensitivity of multidetector CT was only 83% compared to 98% for VQ in PIOPED-1. In properly chosen patients with a normal chest xray. VQ will be conclusive in 90% of patients, so it is often the test of choice when available. VQ is a better test in the young healthy patient with a normal chest xray and no concern for conditions other than PE because VQ is more sensitive than CT, and has about 1/8th of the radiation dose of CT. VQ is also preferred in renal insufficiency because there is no IV contrast. CT is a better test if the chest x-ray is abnormal or if other conditions such as aortic dissection or occult pneumonia are considerations. In older patients the higher radiation dose from CT is less of a concern, but IV contrast may require more caution. In pregnancy, CT is preferred only because the fetal dose of radiation is lower than VQ. The fetus can be screened by a lead apron for CT, but not in VQ as the radiotracer accumulates in the bladder. Though VQ is better for ruling out PE, CT may be better for ruling it in and, when there is uncertainty clinically, can be used to confirm an indeterminant VQ.

Comment from THE DROPERIDOL STORY by Kevin K.
Time: September 4, 2008, 3:42 pm

Why can’t we use droperidol anymore? Ask Ortho-McNeil-Janssen, makers of Risperdal. They bought the company that made droperidol and then reported a bunch of cases of Long QT related problems to the FDA so they would place the black box and make it easier for them to sell their new expensive drug. Most of these cases were all reported on the same day and almost all are pretty much bogus. Sound familiar? Compazine and Zofran? It’s definitely a conspiracy. Don’t trust those drug companies – not a one. And don’t forget ZOFRAN PROLONGS THE QT INTERVAL ALSO.

Comment from RADIOLOGY BOOK from Brady
Time: May 26, 2009, 7:17 pm

The emergency radiology book I recommend, at least for starters is

Accident and Emergency Radiology, by Raby, Berman, & de Lacey

Comment from CT abdomen – To contrast or not?
Time: January 10, 2010, 1:36 pm

I usually go with CT KUB for most patients, especially if I want to avoid delays (sick patient, end of shift nearing) or if they have risks for an adverse effect of contrast (bowel obstruction, dehydrated, etc.)

I use IV contrast in trauma or for patients with risks for vascular conditions (but not necessarily when looking for a AAA)

When my suspicion is on the lower side or I think the disease process is in its early stages or the patient is young and/or thin, but I”m not comfortable without a CT, I will often go for full contrast, so that when it’s negative, I’m a bit more confident that subtle findings won’t be missed and no one will recommend I repeat the scan.

Comment from ER Pocketbooks
Time: January 13, 2012, 10:27 am


I know it’s the opposite of what Dr. Cunningham recommends, but some colleagues and I have had great success using this method without any sedation at all.

1 – explain to patient pain is mostly from muscles pulling bones together and bone on bone contact. (Periosteum is very sensitive)
2 – get them to try to relax muscles, may do gentle massage a la Dr. C before and during relocation
3 – starting in position of preference of patient apply gentle traction in line with one hand while providing counter traction with your other hand in the armpit
4 – continue to hold traction patiently, shoulder should go in within 3 minutes

Comment from DR. PAIN
Time: January 19, 2012, 4:33 pm

My 2 cents on the chronic pain patient:

I think NO opiate prescriptions for these patients if they keep coming back. They need to get prescriptions from a single doctor or clinic otherwise there is little control of the controlled substance.

Also no IV push opiates. They should get IM/SQ/IVPB or even better oral opiates while they are in the ED.

Finally for conditions where specialists recommend against opiates, we should give other meds:
– Dental pain: NSAIDs and a local block.
– Migraines: triptans, Reglan, Mg, valproic acid, ice pack.
– Chest pain: nitraites or GI cocktail.
– Recurrent abdominal pain: antispasmotics, H2 blockers.

Of course we can always make exceptions when indicated. I’m all for treating pain expertly!

Comment from ER Pocketbooks
Time: August 7, 2012, 1:16 pm

We all know that the “taint” is the perineal area that “taint” anus and “taint” scrotum or vagina.

What should we call the area between McBurney’s point and Murphy’s point? “Right middle quadrant” just doesn’t do it. How about “the abdominal taint” or “McMurphy’s point”?

Comment from Dr. G – I don’t
Time: August 12, 2012, 8:21 pm

I don’t because >50% end up sloughing or having chronic deformity, cold intolerance or skin fissuring if they do take.

Comment from ACP PE Guidelines
Time: January 16, 2016, 7:37 pm

Best Practice Advice 1: Don’t like that they don’t include gestalt. They mention in the body of the paper that it is as good as decision rules for experienced EP’s, but it should be part of their conclusion too. Don’t want the standard of care to include calculating a score

Best Practice Advice 2: like it. Supports PERC

Best Practice Advice 3: like it. Supports D-dimer in low-med risk

Best Practice Advice 4: like it. Supports use of age adjusted D-dimer. Wish they would discuss trimester adjusted D-dimer

Best Practice Advice 5: like it. Don’t image if D-dimer negative

Best Practice Advice 6: Don’t like that they make CTPA the test of choice and VQ the backup. From what I have read VQ has less radiation and is more sensitive when it is read as normal. You just have to know who to use it in: people with no lung disease and a normal CXR, esp if they are young.

Comment from Chuck Pilcher
Time: October 3, 2019, 2:56 pm

Q: What’s the first 3 things you should think of in patients with chest pain?
A: Aortic dissection, PE and ACS. Why not MI? Because by the time you see the patient, any good nurse will have drawn the troponin and handed you the EKG and prevent you from missing an acute MI. Not thinking first of the other 3 major killers leads to disaster.

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