*** The 15 Commandments of EM ***

The 15 Commandments of Emergency Medicine

1. 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
   • 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
   • 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…
   • 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.
3. 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
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)
   • X-ray for scaphoid fracture or knee dislocation: 50% miss rate yet may have associated vascular injury leading to amputation
6. Beware of bandemia, PMN >75% and other sepsis red flags
   • Lots of septic patients have a normal WBC count but few have a normal differential although a high PMN count is not very specific
   • 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.  Ask about recent oral steroid use
7. 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
8. 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.
9. Tunnel vision kills
   • Beware of confirmation bias, diagnostic anchoring, narrow differential diagnostic work ups.
   • If it isn’t in your differential, you won’t be able to diagnose it
   • You may need to work multiple conditions up in parallel, rather than serially as an internist often does.
10. 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
11. 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 antacid does not mean a GI cause; it may be a coincidence.  Unstable angina comes and goes so may seem to respond to antacids
12. 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
    • Don’t forget your other resources: social work, substance use navigator, pharmacist, physical therapy
13. Try to avoid signing out patients but take full ownership of patients signed out to you
    • When you sign a patient out assume they 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
14. Recheck vital signs 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 not consider an infection when there was a low grade temperature?
    • 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
15. 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.
    • 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