*** Rules of the Road for EM ***

Emergency Medicine Rules of the Road

• by D. Brady Pregerson, MD and Christian Jagusch, MD, JD

1. Read the triage note
   • Ideally before you see the patient, but if not then definitely at time of dispo to make sure all triage issues have been addressed
   • If possible talk to medics or get their transport notes, if available, especially if there is no good alternate historian
   • Patients/medics may have told triage nurse something important but forgot to or couldn’t tell you
   • If there is an inconsistency between triage and your history make sure to clarify that
   • Bedside nurses should alert you to new issues once the patient is roomed but the triage nurse will rarely seek you out.
2. History is king
   • It is not the patient’s job to provide a good history; it is your job to elicit one
   • Listen to the patient, but when they get tangential bring back the focus
   • Listen to your bedside nurse if they raise concerns and document your response
   • Know when to dig deeper, like with timing and duration for chest pain
   • Know when talking to family/staff is required: altered or non-verbal patient, suicidal patient…Collateral information can save the day
   • If there is pain always have them show you exactly where by pointing.  This is typically done in abdominal pain but is equally important  with any pain but especially in neck or back pain where thoracic or carotid pathology are often missed because of incorrect assumptions of pain location by the provider.
   • Chest pain and headache patients need a family history for early CAD, dissection, aneurysm, etc.
   • Make sure you patient feels heard
3. Always think worst case scenario first  
   • This is also in the original 10 commandments: LINK or see summary below
   • Reasonably rule out the more rare but more dangerous explanation before landing on the benign one.
   • Although you may end up there, never trust a patient’s or a nurses benign explanation for symptoms such as “stress at work”, “indigestion” or “something I ate”
   • Remember: you are a detective not a gambler and ER patients are guilty until proven innocent
4. Fine tune your physical exam and know when to add bedside ultrasound
   • Know key techniques to have a more sensitive focused exam.  Spend less time on parts that aren’t relevant and more time on parts that are.
   • Listen to EM logic episode 6 for a better lung exam, jolt sign for meningitis, a better neuro exam, the importance of the pedal pulse and other key considerations
   • Bedside ultrasound can expedite diagnosis and treatment of certain critical conditions such as aortic dissection, massive PE, ruptured ectopic, and AAA to name a few.
5. Bounce-backs get bigger workups and/or get admitted
   • Bounce-backs are red flags – avoid diagnostic anchoring
   • Second visit do more: testing, consult, etc
   • Third visit admit for outpatient treatment failure
6. Beware of false negative tests
   • Some diagnoses are primarily clinical so don’t be fooled by normal tests.  See some examples below
   • CT in ischemic stroke: “CT rules out a bleed not a stroke”
   • Troponin in unstable angina or first 5 hours of MI
   • WBC is normal in up to 30% of cases of sepsis or sever infection
   • EKG in first 2 hours of STEMI
   • STEMI criteria in OMI (occlusion MI)
   • X-ray for aortic dissection: don’t trust the radiologist.  Measure mediastinal width yourself.  If >8.0 cm on a portable, order the CT if you haven’t already.
   • X-ray for scaphoid fracture or knee dislocation (50% miss rate yet may have associated vascular injury leading to amputation)
7. Beware of bandemia, PMN >75% and other sepsis red flags
   • Lots of septic patients have a normal WBC count.  Fewer have a normal differential
   • CBC ID red flags: bands, Howell-Jolly bodies (RBC finding in splenectomized patients) toxic vacuoles or granulation, Dohle bodies. low platelets
   • Chemistry ID red flags: unexplained anion gap, hyponatremia or hypoalbuminemia, creatinine bump…
   • Immunosuppressants: ask about infusions if they have Crohn’s, RA, SLE, psoriasis or other autoimmune conditions.  Ask about recent oral steroid use
   • Trust measured fevers at home.
   • Repeat elevated lactate levels
8. Resuscitate before you intubate
   • Avoids BP drops or cardiac arrests
   • Avoids pH drops
   • Ketamine better than etomidate because of kinetics.  Less risk of apnea w/o paralysis early or paralysis w/o sedation late
9. The goal is to diagnose things early rather than late
   • Getting a patient to the cath lab who meets OMI criteria but not necessarily STEMI criteria and still has a negative troponin saves more myocytes and lives
   • Try to diagnose sepsis or DKA early when the lactate or anion gap are borderline rather than frankly elevated
   • Catching cauda equina or spinal epidural abscess in its early stage before severe motor findings means more Foley’s and wheelchairs in stores and fewer in/under patients
   • STEMI, CVA and sepsis all have timing benchmarks.  Try to meet those to stay out of trouble and protect your patient.
10. Tunnel vision kills
    • Beware of anchoring on the first diagnosis you suspect or the most likely diagnosis before you have reasonably ruled out the life or limb threats.
    • Beware of confirmation bias and narrow differential diagnostic work ups.
    • The biggest hindrance to the correct diagnosis is the current diagnosis
    • If it isn’t in your differential, it won’t be in your final diagnostic impression
    • Beware of diagnoses of exclusion: gastritis, anxiety, conversion disorder…
    • You may need to work multiple conditions up in parallel, rather than serially as an internist often does.
11. Short cuts kill
    • Testing: If a patient is supposed to have a test done in the near future or a consult in the near future but they are worried enough to come to the ER for worsening or non-improving symptoms then do the test or consult now if possible.  If you assume it’s safe for them to wait, you may be doing so at their peril.
    • End of shift: If a short cut is unsafe don’t take it; sign the patient out.  Some short cuts may be safe; it that case best to dispo patient yourself
    • VIPs: don’t cut corners.  They may get WORSE care because you change your usual process
12. Response to medication rules out nothing, but no response should make you rethink your diagnosis
    • Better often means partly better, which can mean refractory to treatment
    • Response to therapy does not mean benign.  Opiates can mask progression of disease for 4-5 hours.  Migraine meds may alleviate pain from dangerous headaches
    • Response to antacid does not mean a GI cause; it may be a coincidence.  Unstable angina comes and goes so may seem to respond to antacids
    • However, if a patient does not respond as expected, like no improvement in SOB after albuterol in a patient with a presumed COPD exacerbation, you should expand your differential diagnosis.
13. Don’t carry a coffin alone – when in doubt, reach out
    • Consult with specialists when warranted but don’t necessarily trust their recommendations if you think they are being cavalier, especially not coming in when you think they need to
    • Consult the surgeon or proceduralist for an patient who had surgery or a procedure in the past 6 weeks
    • Clarify any vague requests or recommendations to avoid inaccurate assumptions – use closed loop communication
    • Don’t accept the answer that they will see the patient in the morning when you know they need to see the patient now – advocate for the patient
    • Don’t forget your other resources: social work, substance use navigator, pharmacist, physical therapy
14. Try to avoid signing out patients but take full ownership of patients signed out to you
    • Sign outs are malpractice pitfalls and opportunities for things to fall between the cracks
    • Assume your sign outs will get worse care than if you completed the disposition.  Your relief won’t know as much about the patient as you did and may not take full ownership.  They may cave to the hospitalist and send home a patient that should be admitted.
    • When you take a sign out and determine the disposition take full ownership and assume the patient may actually be sicker than your colleague thought.  Like most of EM you should err on the side of caution
    • Write a note on sign-outs you take
15. Recheck vital signs and “Road Test” before discharge
    • Pulse: is it going up?  Is it >90 without a likely benign explanation like albuterol or fever.  Use 90 not 100 for upper limit of normal in most cases
    • BP: is it stable?  is it <110 without a benign explanation?  Is it >180
    • Temp: did you miss a low grade temperature?  Antipyretics can mask fevers
    • RR: is it >20 or rising during stay?
    • SaO2: is it dropping?
    • Use this literature: Brit Long, et al. JEM 2024 Nov;67(5):e487-e493.   Link: click here
    • Road test: if the patient was vomiting, can they tolerate PO intake after meds?  If the patient fell or was weak can the ambulate safely or at least at their baseline?
16. SMART aftercare is the patient’s safety net: everyone goes home with “SMART” (mnemonic, even for AMA patients)
    • Sedating meds warning: benzos, opiates, antihistamines, etc.
    • MD follow-up: If a specialist isn’t needed then at least your local clinic. Tell them to call the same or next day and let the office know they were referred from the ER
    • Anticipatory guidance: what to expect, disease natural history
    • Return precautions: give them a percent chance they will need to return
    • Test results: most patients have at least one incidental abnormal test result that will need follow-up.  Always recommend and document a follow-up plan for important incidental findings.  Also, if any tests results are pending at discharge give aftercare that patient/PCP are responsible for tracking down results.  Consider not finalizing your chart until these tests are resulted.  If you order it, you own it.
    • Don’t have your own macro?  Use ours: LINK 

Tuesdays with Dr. Henry: A Final Farewell (& some pearls of wisdom)

1. 1. “The white blood cell count is the last refuge of the intellectually destitute.”
   2. “The biggest impediment to the correct diagnosis is the previous diagnosis.”
   3. “There are three great lies in life—the check is in the mail, size doesn’t matter, and all systems reviewed and otherwise negative.”
   4. “When a patient bounces back, they are giving you another chance to get the diagnosis right. If someone comes to the ED three times, then admit them.”
   5. “Your neuro exam is never done until you’ve watched them walk.”
   6. “In medicine and life, don’t ask questions you don’t really want to know the answer to.”

Other Articles

• The Pitt: a show about emergency medicine you need to watch
• The Death of Critical Thinking in Emergency Medicine
• Dr. Pregerson’s case reports with Clinical Advisor