* The 12 Commandments of EM *

The 12 Commandments of Emergency Medicine

1. Always think worst case scenario first  
   • This is also in the original 10 commandments: “Think worst first”
   • 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”
   • You are a detective not a gambler.  ER patients are guilty until proven innocent
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
   • 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…
3. Read the triage note
   • Do it before you see the patient and again at time of dispo to make sure all triage issues have been addressed
   • Patients/medics may have told triage nurse something important but forgot to or couldn’t tell you
   • If there is an inconsistency make sure to break the tie
4. Bounce-backs get bigger workups and/or get admitted
   • Also from Tuesdays with Dr. Henry
   • Second visit do more: testing, consult, etc
   • Third visit admit: SMV/PUD story, CSVT stories
5. Beware of false negative tests
   • CT in ischemic stroke: “CT rules out a bleed not a stroke”
   • Troponin in unstable angina or first 5 hours of MI
   • EKG in first 2 hours of STEMI
   • STEMI criteria in OMI (occlusion MI)
6. Tunnel vision kills
   • Beware of confirmation bias, diagnostic anchoring, narrow differential diagnostic work ups.
7. 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 short cuts.  If unsafe, sign patient out.  If safe then better for all patients if you dispo patient yourself
   • VIPs: don’t cut corners.  They may get WORSE care because you change your usual process
8. Beware of bandemia and other sepsis red flags
   • CBC ID red flags: bands, Howell-Jolly bodies (RBC finding in splenectomized patients) toxic vacuoles or granulation, Dohle bodies
   • Chemistry ID red flags: unexplained anion gap, hyponatremia or hypoalbuminemia
   • Immunosuppressants: ask about infusions if they have Crohn’s, RA, SLE, psoriasis or other autoimmune conditions
9. Resuscitate before you intubate
   • Avoids BP drops or cardiac arrests
   • Avoids pH drops
   • Ketamine better than etomidate because of kinetics
10. Response to medication rules out nothing
    • Better often means partly better, which can mean refractory to treatment so far
    • 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 antacic does not mean a GI cause; it may be a coincidence.  Unstable angina comes and goes so may seem to respond to antacids
11. Recheck vital signs before discharge
    • Pulse: is it going up?  Is it >90 without a likely benign explanation like albuterol or fever
    • BP: is it stable?  is it <110 without a benign explanation?  Is it >180
    • Temp: did you not consider an infection when there was a low grade temperature?
    • RR: is it >20 or rising during stay?
    • SaO2: is it dropping?
12. SMART aftercare is the patient’s safety net: everyone goes home with “SMART” (even AMA patients)
    • Sedating meds warning: benzos, opiates, antihistamines, etc.
    • MD follow-up: everyone gets a referral and tell them to call the same or next day and let 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 care.  Always recommend and document follow-up plan for incidental findings.  Though many of these are not dangerous, some are.  Also, if any tests results are pending at discharge give aftercare that patient/PCP are responsible for tracking down and acting on results. (I have this in my aftercare macro).  Consider not finalizing your chart until these tests are resulted.  If you ordered it, you own it, but it is good to have a backup plan.
    • Don’t have your own macro?  Use ours at: https://www.erpocketbooks.com/documentation/

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.”

The Pitt: A show about emergency medicine you need to watch

The Death of Critical Thinking in Emergency Medicine

Some of my prior case reports with Clinical Advisor