Category Archives: EM Mindset

Emergency Department Tips & Tricks for Managing the Suicidal Patient

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident at SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

An adolescent male with a chief complaint of suicidal ideation presents to the emergency department (ED). The 17 year-old patient is lead to a triage room where a nurse checks his vital signs, performs an EKG, and draws blood for initial screening labs. After handing the young man a set of hospital scrubs, the nurse exits, pulling the curtain to allow for limited privacy. Minutes later, a chilling scream echoes through the halls. Personnel rush to the triage center where an attending physician is struggling to remove a disposable latex tourniquet from the, now cyanotic, patient’s neck.

Believe it or not, this is a depiction of recent events witnessed in a community ED. As you stand ready to perform your medical screen and proceed to phone a friend in psychiatry, let’s take a minute to address a few pearls in approaching the suicidal patient.

Epidemiology of Suicidal Ideation

Today more than twelve million annual emergency department visits involve a diagnosis related to mental health or substance abuse; representing nearly one in every eight ED encounters.1 Occurring at a rate of one suicide every thirteen minutes, intentional self-harm represents the leading cause of death among persons greater than 85 years of age. Among American Indians and Alaska natives ages 10-34, and in all U.S. citizens aged 15-34 years, suicide is the second leading cause of death.2 Data currently identify males as four times more likely to commit suicide than females.2 Costs associated with suicide, both medical and related to decreased work productivity, total nearly $51 billion annually.2

The Role of the Emergency Physician

This review will address patient stabilization and provide tips and tricks for use in interviewing and evaluating the suicidal patient. An in-depth discussion of toxic ingestions will be omitted as this content is addressed elsewhere:

FOAMED Resource Series Part IV: Toxicology
Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC)

Stabilize the Patient

Current surveys suggest that approximately one million people in the U.S. engage in intentional self-harm behavior, and that for every death reported by suicide, approximately twelve individuals severely harm themselves.3 Of patients inflicting self-harm, nearly 650,000 are evaluated in the ED each year.4

Patients may present after a failed suicide attempt by gun-shot wound (mechanism in 59.6% of males having committed suicide4), suffering from the affects of an acute toxic ingestion (mechanism in 34.8% of females having committed suicide4), or actively bleeding from an arterial laceration (cutting, burning, and blunt trauma reported by males and females as common mechanisms of self-harm5); therefore, the emergency physician must stand ready to address the ABCs.

Transition the Patient to a Safe Environment

All patients who are hemodynamically stable upon presentation should be taken to an area of the ED that is free of all potentially dangerous medications and equipment. Patients should be searched for weapon/substances and be provided a set of scrubs or disposable clothing to discourage elopement. At no point in time should the patient be left unattended.6

 Perform an Assessment of Suicide Risk

Obtain an appropriate medical history centering on the identification of risk factors for suicide:


A few words on risk factors:

Adolescents: Adolescent patients are most likely to present with injuries secondary to self-harm (ratio of attempted to completed suicides reported as 200:110). Although parental consent is typically required for the treatment of minors (defined as age <18 in the majority of states), evaluation following a serious suicide attempt is mandated according to the Emergency Medical Treatment and Active Labor Act.6

If and when present, parents and caregivers should be questioned regarding impulsive behavior, bouts of aggression, significant family stressors, and inter-personal conflicts, as these can be subtle signs of depression.11

The elderly: Suicidal ideation is endorsed much less frequently in the elderly population,12 however, completed suicides are much more likely to occur later in life (ratio of attempted to completed suicides reported as 4:112,13). Patients >65 years of age should be questioned specifically regarding: recent death of a loved one, perceived poor health, social isolation and loneliness, uncontrolled pain, and major changes in social roles as these are frequently associated with completed suicide.12

 Current psychiatric diagnosis: When controlled for other factors, a previous history of major depressive disorder is the most significant risk factor for completed suicide in males and females.11 Patients with a history of military service should be questioned regarding post-traumatic stress disorder as these individuals are also at increased risk for suicide.11

Substance abuse: Current data identify 19-27% of all suicides as associated with alcohol.14 Specifically, individuals over the age of 18 engaging in heavy episodic drinking (having ≥ 5 alcoholic drinks in a row on one occasion) are noted to have a suicide risk 1.2 times that of their non-drinking counterparts.15 Question patients regarding alcohol consumption.11,14,15

 An assessment of thought content is particularly important in patients with a previous medical history of schizophrenia, mood disorder, bipolar disorder, and substance abuse as these conditions pre-dispose to episodes of psychosis.14 Patient reports of auditory hallucinations, persecutory delusions, or thoughts of external control or religious preoccupation require immediate hospitalization in order to prevent harm to self or others.12,14

 Patients should be questioned regarding prescription drugs (dosing/compliance/regimen changes), the use of homeopathic remedies, and the use of over-the-counter medications. This information is vital if suspecting toxic ingestion, medication withdrawal, or mood alteration secondary to changes in pharmacotherapy.

In interviewing the patient, enquire as to weapons access as this is also an independent risk factor for completed suicide.8

Perform risk stratification:

If you attended a medical school in the U.S., chances are that you’ve had some exposure to the Modified Sad Persons Score:


Originally developed by Hockberger and Rothstein at the Harbor-UCLA Medical Center in 1988, this scoring tool was created to predict the need for hospitalization in individuals at risk for suicide. After analysis of 119 patients, Hockberger and Rothsetin identified a score ≥ 6 as having a sensitivity of 94% and a specificity of 71% for predicting the need for psychiatry directed hospitalization (P<0.001).14 While an excellent reminder of suicide risk factors, the authors’ score is limited in that it was designed to assess the decision-making of behavior of psychiatry personnel at one institution.

The Manchester Self-Harm Rule was published by Cooper et al.17 in 2006 as a mechanism to determine the risk of repeat self-harm or suicide in patients presenting to the ED with the chief complaint of self-injury. Demographic and clinical information from 9,086 patients presenting to 5 emergency departments in Manchester and Salford, England (2001-2007) were utilized to identify the following risk factors:


The Manchester Self-Harm Rule demonstrated 94% sensitivity in the detection of individuals who would perform repeated self-harm or suicide within six months following the initial ED encounter (patients who possessed one or more risk factors).17 Data utilized in developing the Manchester Self-Harm Rule was collected from an urban population with high rates of benzodiazepine use and abuse, thus limiting its generalizability.17 Ultimately, clinical judgement in the evaluation of the suicidal patient is paramount.

Performance of the Physical Exam (Secondary Examination in the Hemodynamically Unstable Patient)

Elements of the physical exam include an assessment of:

  • The patient’s general appearance (emotional status, thought content, and affect).
  • A complete physical examination of the head, body, and extremities with documentation of all visible injuries.

Actively search for signs and symptoms of acute ingestions, toxidromes, and withdrawal symptoms: diaphoresis, hyperthermia, hypopnea, or bradypnea, pinpoint or dilated pupils, hyper or hyporeflexia, clonus, tremor, or altered mental status.18

  • Sympathomimetic toxidrome: agitation, delirium, hypertension, hyperthermia, nausea, and muscle rigidity.
  • Anticholinergic toxidrome: mydriasis, urinary retention, tachycardia and hyperthermia.
  • Serotonin syndrome: altered mental status, autonomic instability, myoclonus, and tremor.
  • Neuroleptic malignant syndrome: lead pipe rigidity, hyperthermia, altered mental status.
  • Monoamine oxidase inhibitor (MAOI) toxicity: severe hyperthermia, nausea, emesis, and cardiovascular collapse. Excessive ingestion of tyramine containing food stuffs during MAOI therapy may result in hypertensive crisis.
  • Patients experiencing benzodiazepine, opiod, and alcohol withdrawal may present with agitation, hypertension, tachycardia, and GI upset.

Primary interventions should address airway, breathing and circulation. Benzodiazepines are the treatment of choice for agitation, anticholinergic toxicity, sympathomimetic toxicity, and serotonin syndrome. Dopamine agonists have been demonstrated to improve symptoms in neuroleptic malignant syndrome. Provide fluid resuscitation in the setting of seizure and muscular rigidity in order to avoid complications secondary to rhabdomyolysis.18

Evaluate for signs and symptoms of medical conditions, and their sequelae, that are commonly associated with psychiatric symptoms:

  • Hypoglycemia (perform a bedside blood glucose assessment)
  • Thyroid pathology (thyroid storm or myxedema coma)
  • Cushing’s
  • Intracranial trauma
  • Infectious etiologies: HIV, syphilis, meningitis/encephalitis
  • Neoplasm (intracranial mass vs. hypercalcemia secondary to metastasis)
  • Degenerative neurologic diseases (Alzheimer’s, Parkinson’s, Creutzfeld-Jacob, Multiple Sclerosis)19

Notes on the agitated patient: if the patient presents a risk to self or others, the utilization of chemical or mechanical restraints should be entertained, bearing in mind that this may worsen hyperthermia and rhabdomyolysis. See Dr. Lulla’s and Singh’s The Art of the ED Takedown for a quick refresher on these interventions:

 Pertinent Studies

Once a thorough history and physical examination are completed, clinical decision-making should be utilized to assess the need for advanced imaging and adjunct studies.

Imaging: A non-contrasted CT head à rule out intracranial mass/abscess, intracranial hemorrhage, hemorrhagic CVA, etc. Consideration should be made for additional imaging as required (CVA: CTA head/neck vs. MRI/MRA, etc.).

EKG: An EKG may be diagnostic in the hemodynamically unstable patient. Sodium channel blockade (tricyclic anti-depressant therapy) often manifests as a rightward axis in the terminal 40-msec of the QRS complex (terminal R wave in aVR).20

Currently there are no data-driven consensus recommendations regarding the appropriateness of routine laboratory screening tests in patients with suicidal ideation. As previously mentioned, the history and physical exam should be utilized to direct evaluation for an underlying organic etiology of depression and suicidal ideation. Studies to consider include21:

  • CBC
  • CMP
  • TSH, FT4
  • HIV
  • Serum ETOH
  • Serum salicylates
  • Serum acetaminophen

The use of urine drug screens (UDS) in the evaluation of suicidal patients is controversial, as numerous studies have demonstrated the results of these screens as having minimal impact on patient care. Given these findings, the American College of Emergency Physicians currently recommends against the routine use of UDSs in the suicidal population.22


After performance of patient stabilization, attainment of a history and physical, and assessment of imaging/laboratory studies as appropriate, medical clearance may be given, and consultation placed for specialist evaluation and treatment.

If the patient appears to be a risk to him/herself or others, or is gravely disabled (unable to provide for his/her basic needs), involuntary psychiatric detention should be pursued. Regulations regarding involuntary psychiatric holds are state specific, therefore the emergency physician must be apprised of local policies and procedures.8 Obtaining collateral information from family and friends will often facilitate this intervention.19

Contracts for safety: While some physicians may elect to create a contract for safety, allowing outpatient evaluation and treatment, this is not advised for the emergency physician. Contracts for safety do not substitute for adequate documentation regarding the risk of suicide, or free the physician of liability in cases of subsequent self-harm and suicide.8

Key Pearls

  • Stabilize as appropriate => a number of patients will present after performing self-harm
  • If the patient is hemodynamically unstable, consider an EKG to evaluate for sodium channel blockade (TCA overdose)
    • Quickly evaluate for signs/symptoms of toxic ingestions
  • In the stable patient, perform an H&P focusing on risk factors for suicide
    • Question patients regarding substance abuse (specifically alcohol)
    • Question regarding access to weapons
    • Use friends/family to corroborate stories
  • During the physical examination, evaluate for findings consistent with toxidromes or organic pathology
  • After seeking out organic etiologies of suicidal ideation, medically clear the patient and consult a specialist
  • Be familiar with state laws regarding emergency detention
  • Avoid the use of safety contracts in the emergency setting

 References / Further Reading

  1. Owens P, Mutter R, Stocks C. Mental health substance abuse-related emergency department visits among adults 2007. Statistical Brief #92. Agency for Healthcare Research and Quality. Available from:
  2. Centers for Disease Control and Prevention. Suicide: Facts at a glance. Available from:
  3. Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS). National Center for Injury Prevention and Control. Available from:
  4. Chang B, Gitlin D, Patel R. The depressed patient and suicidal patient in the emergency department: Evidence-based management and treatment strategies. Emergency Medicine Practice. 2011; 11(9):1-24.
  5. Kerr P, Muehlenkamp J, Turner J. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med. 2010; 23(2):240-259.
  6. Kennedy S, Baraff L, Suddath R, Asarnow J. Emergency department management of suicidal adolescents. Ann Emerg Med. 2004; 43:452-462.
  7. Mendelson WB, Rich CL. Sedatives and suicide: The San Diego study. Acta Psychiatr Scan 1993;88:337–41.
  8. Ronquillo L, Minassian A, Vilke G, Wilson M. Literature-based recommendations for suicide assessment in the emergency department: a review. J Emerg Med. 2012; 43(5):836-842.
  9. American Foundation for Suicide Prevention. Suicide Statistics. 2016. Available from:
  10. Tuzun B, Polat O, Vatansever S, Elmas I. Questioning the psychosocio-cultural factors that contribute to the cases of suicide attempts: an investigation. Forensic Sci Int 2000;113:297–301.
  11. Schwab J, Warheit G, Holzer C. Suicidal ideation and behavior in a general population. Diseases of the Nervous System. 1972;33(11):745–748.
  12. Mitchell A, Garand L, Dean D, Panzak G, Taylor M. Suicide assessment in hospital emergency departments: Implications for patient satisfaction and compliance. Top Emerg Med. 2005; 27(4):302-312.
  13. Parkin D, Stengel E. Incidence of suicidal attempts in an urban community. British Medical Journal. 1965;2(54):133–138.
  14. Canapary D, Bongar B, Cleary K. Assessing risk for completed suicide in patients with alcohol dependence: Clinicians’ views of clinical factors. Professional Psychology: Research and Practice. 2002;33(5):464–469.
  15. Asteline R, Schilling E, James A, Glanovsky J, Jacobs D. Age variability in the association between heavy episodic drinking and adolescent suicide attempts: findings from a large-scale, school-based screening program. J Am Acad Child Adolesc Psychiatry. 2009; 48(3):262-270.
  16. Hockberger RS, Rothstein RJ. Assessment of suicide potential by nonpsychiatrists using the SAD PERSONS score. J Emerg Med. 1988;6:99–107.
  17. Cooper J, Kapur N, Dunning J, Guthrie E, Appleby L, Mackway-Jones K. A clinical tool for assessing risk after self-harm. Ann Emerg Med 2006;48:459–66.
  18. Zosel A. General Approach to the Poisoned Patient. In Emergency Medicine: Diagnosis and Management. 7th ed. Boca Raton: CRC Press, 2016: 292-298.e1.
  19. Knoll, J. The Psychiatric ER Survival Guide. 2016. Upstate Medical University. Available from:
  20. Niemann J, Bessen H, Rothstein R, et al. Electrocardiographic criteria for tricyclic antidepressant cardiotoxicity. Am J Cardiol. 1986;57(13):1154-1159
  21. Russinoff I, Clark M. Suicidal Patients: Assessing and Managing Patients Presenting with Suicidal Attempts or Ideation. 2004. Available from:
  22. Lukens T, Wolf S, Edlow J, Shahabuddin S, Allen M, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006; 47(1):79-99.

Geriatric Trauma and Medical Illness: Pearls and Pitfalls

Authors: Matthew R Levine, MD (Assistant Professor and Director of Trauma Services, Department of Emergency Medicine, Northwestern Memorial Hospital, Chicago, IL) and Lora Alkhawam, MD (Attending Physician, Duke Regional Hospital, Department of Emergency Medicine, Durham, NC) // Edited by: Erica Simon, DO, MHA (@E_M_Simon) and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

An 85 year-old male is brought in by EMS status post MVC. He is confused and unable to detail the events surrounding his accident. When questioned, he has no recollection of his PMHx, but repeatedly states that he is in pain secondary to his c-collar and backboard. Vitals: HR 70 and irregular, BP 110/65, RR 16, O2 sat 94% on room air. Primary and secondary surveys are remarkable only for scant wheezing upon pulmonary auscultation. GCS is 14 without focal neurologic deficits. As you contemplate the next steps in your patient evaluation, you scan your knowledge bank: What critical diagnoses should you be considering? Let’s discuss some pearls and pitfalls in addressing the geriatric trauma patient.



According to 2010 US Census data, adults > 65 years of age account for 14% of the current U.S. population.1,2 It is estimated that nearly one in five Americans will be elderly by the year 2050.1,2 Why is this relevant to the practice of emergency medicine? Approximately 1 million persons aged 65 and older are affected by trauma each year.3  In fact, trauma in the elderly accounts for $12 billion in annual personal and institutional medical expenditures, and $25 billion in total annual healthcare expenditures.4 While elderly patients comprise a small percentage of total major trauma patients (8-12%) presenting to emergency care centers, they represent a disproportionate percentage of trauma fatalities and costs (15-30%).4

To date, numerous studies have demonstrated mortality related to trauma as increasing with advancing patient age.5-7 In fact, the Major Trauma Outcome Study published in 1989 (n = 3,833 > age 65 and 42,944 < age 65) demonstrated mortality as rising sharply between the ages of 45-55 and doubling by age 75.5 This pattern occurred at all Injury Severity Scores (ISS), mechanisms, and body regions.5

Screen Shot 2016-08-20 at 1.43.38 PM

Representation of Trauma Mortality Data5

Today, we also know that advancing age is an independent risk factor for morbidity and mortality, despite lesser severity of injuries.1,2,5 However, while age has value in mortality projections for geriatric trauma patients presenting to the ED, literature suggests favorable functional outcomes for those who survive to hospital discharge.8 Therefore, age alone is not a criteria to deny or limit care in the elderly.9



 This review will highlight important differences in elderly trauma patients with respect to:

  • Triage
  • Pathophysiology in the Elderly
  • Mechanisms and Patterns of Injury
  • Trauma Bay Approach
  • Special Considerations

There will be many citations throughout, but please keep in mind the limitations of research in geriatric trauma:8

  • Few prospective randomized controlled trials
  • No widely accepted age cut-off (“elderly” used to characterize patients ages 45-80)6
  • Lack of a uniform definition of an elderly trauma patient
  • Limited current studies (majority based in the 1980s-1990s)


Triage of the Elderly Trauma Patient

In its statement regarding trauma in the elderly, the CDC notes: “under triage of the older adult population is a substantial problem.”10 Under triage is defined as a failure to transport a trauma patient to a state-designated trauma center.10 Why is this important? Current studies (Zafar et al. and Maxwell et. al, 2015) have identified a significant mortality benefit for elderly patients presenting to trauma centers having had repeat exposure to geriatric trauma.11,12 Zafar et al. reported elderly patients as 34% less likely to die in these trauma centers.11 While it is true that level 1 trauma centers traditionally have longer lengths of stay and higher total costs of care, a large percentage of elderly trauma patients survive discharge from these facilities.11,12 Elderly patients with multiple injuries benefit from trauma center care.11,12 The difficulty here is that standard adult EMS triage guidelines provide poor sensitivity for detecting older adults that require trauma center care.13 The under triage rate is reported as 50%14,15 in patients older than 65, versus 17.8% for those under 65.14 Given this data, several experts have concluded that an age threshold should be established which mandates triage to a trauma center (various age ranges (55-70) have been recommended).6,9,16,17,18

What difficulties are encountered in identifying trauma severity in the elderly population? Potential explanations for under triage of elderly trauma patients are: significant injury secondary to low energy mechanisms, and altered physiologic response to injury with aging.

  • The CDC recommends direct transport to a trauma center for any trauma patient age >65 with SBP <11010
    • What affect does this have on triage of the elderly population? One that is substantial:
      • Substituting SBP < 110 instead of SBP < 90 for patients older than 65 reduced under triage by 4.4%, while only increasing over triage by 4.3%.19

Once an elderly patient arrives at a trauma center, trauma team activation occurs significantly less often for elderly patients (14% vs 29%) despite a similar percentage of severe injuries (defined as ISS>15).l

  • The Eastern Association for the Surgery of Trauma (EAST) recommends a lower threshold for trauma team activation for patients 65 and older evaluated at trauma centers (level 3 evidence).20
    • Some trauma centers use age as mandatory criteria for trauma team activation. This is supported by data that 63% of elderly trauma patients with ISS > 15 had no standard physiologic activation criteria.20

Clinical implications: Have a low threshold for recommending EMS transport of elderly trauma patients to a designated trauma center, especially for patients with SBP < 110. Have a low threshold for activating the trauma team for elderly trauma patients.


Pathophysiology Concerns in the Elderly

No other population is more susceptible to serious injury secondary to low-energy mechanisms (particularly falls) than the elderly. The elderly are less able to compensate for physiologic stresses occurring during injury, and are more likely to suffer complications during treatment and recovery. Key reasons for this are:

  • Less physiologic reserve
  • Occult shock/misleading picture of stability
  • Comorbid illnesses (See Figure below)

Screen Shot 2016-08-20 at 1.49.35 PM

Comorbid Illnesses Contributing to Morbidity and Mortality in the Elderly

It is important to note that in elderly patients, profound shock may be present even in the setting of “normal” vital signs.  Pharmaceutical therapy in the elderly (beta blockers and calcium channel blockers) may prevent typical tachycardic responses in shock states.  Also significant, aging myocardium exhibits decreased sensitivity to endogenous catecholamines.

Blood pressures considered normal in young patients may represent hypotension when compared to baseline BPs in an elderly patient. A landmark article by Scalea et al. assessing early invasive (PA catheter) monitoring in elderly trauma patients demonstrated that the majority of trauma patients experienced profound perfusion deficits despite “normal” vital signs.19 In fact, a HR>90 and SBP<110 have been correlated with increased mortality in the elderly trauma population.19,21 What does this mean for the EM provider? The window to intervene may be narrow; delayed recognition of shock may postpone life-sustaining resuscitation.

What about additional markers of perfusion?

Multiple studies have demonstrated that elevated lactate levels (>2) or abnormal base deficit (<-6) are associated with major injury and mortality in trauma patients.23-25 One such study, performed in 1987, identified a venous lactate > 2.5 as a marker of occult hypoperfusion in 20% of the included geriatric patients.26 Lactate levels or ABG base deficit should be used as an adjunct to vital signs for early identification of perfusion deficits in elderly trauma patients.

Clinical implications: Avoid being falsely reassured by normal vital signs in elderly trauma patients. Use lactate levels or ABG with base deficit as adjuncts to vital signs to detect occult shock and guide resuscitation in unclear cases. Also use ECGs as an adjunct to detect silent ischemia as a response to the physiologic stress of trauma. Have a low threshold for admitting elderly trauma patients to an ICU.


Mechanisms and Patterns of Injury

Which mechanisms and patterns of injury are more concerning in the elderly? They all are.

More specifically, falls from ground level, head trauma, chest wall injuries, pedestrian struck by vehicle, and cervical spine injuries have a disproportionate burden on elderly patients.

Screen Shot 2016-08-20 at 1.51.54 PM

Falls are the most frequent cause of injury in patients > 65 years of age, and are the most common fatal accident in patients > 80 years of age.27 More than one third of elderly patients presenting to the ED post fall return to the ED, or die within one year of initial evaluation.28 Same level falls must not be minimized – they are ten times more likely to cause death in an elderly vs. non-elderly patient (25% vs 2.5%).29 Even falls that seem purely mechanical can be a sign of occult illness. It is imperative that emergency physicians perform a complete H&P for all elderly patients having experienced a fall for:

  • Sudden disturbances in cardiovascular/neurologic function
  • New/progression of underlying conditions or emerging infection
  • Intoxicants/medication effects
  • Environmental safety
  • Impact of injury on functional status/ability to care for self

Why are falls so devastating in the elderly population?

Age-related atrophy of the brain leads to increased potential space and shearing forces on the intracranial bridging veins when exposed to trauma. The risk of intracranial bleeding is also markedly increased with medications commonly prescribed to the elderly (anticoagulants and anti-platelets).30,31 Keep in mind that older patients are excluded from studies that attempt to identify populations in which imaging is low yield = IMAGE the elderly.

 Outside of head trauma, are there any other areas for EM docs to be on the lookout?

Even “minor” chest injuries impair the elderly. Thoracic cage trauma is poorly tolerated secondary to decreased compliance, loss of alveolar surface area, impaired lung defenses, and increased pulmonary bacterial colonization with aging. A rigid C-collar and backboard can further impair chest wall expansion. Elderly patients with rib fractures are at increased risk for pneumonia (31% vs. 17% with 16% increase per rib fractured), pulmonary contusion, and delayed hemothorax.32 Mortality also increases 19% per rib fractured.32

 The elderly spine is vulnerable to fracture from minor mechanisms due to conditions such as cervical stenosis, osteoporosis, and degenerative, rheumatoid, and osteoarthritis.33 High cervical fractures (type 2 odontoid being the most common), and central cord syndromes are also more frequent in the elderly.34

Pedestrian struck by a vehicle is perhaps the most devastating mechanism of injury to disproportionately affect this population. Patients age > 65 account for 22% of pedestrian vs. MVC deaths.33 Current statistics report 46% of these accidents as occurring in crosswalks.33 Factors that predispose the elderly to increased severity of injury include decreased ability to raise or turn the head due to cervical arthropathy, and reduced speed and agility (crosswalk timers often allow for a pedestrian speed of 4 ft/sec).33

Clinical implications: Maintain a heightened suspicion for significant injury (especially intracranial and C-spine pathology) even from ground level falls. Assess elderly patients for medical impairments that may have precipitated the fall. Be liberal with CT scanning for elderly head and neck trauma, and always inquire regarding the use of anticoagulant and antiplatelet medications. Ensure adequate analgesia and oxygenation for chest wall injuries. Remove the collar and backboard as early as safely possible. Maintain a low threshold for admitting elderly patients with rib fractures.


Special Considerations

 ABCs in the Elderly

  • A – Early airway control. Edentulous patients may be difficult to bag; remove dentures for intubation.
  • B – Avoid respiratory decompensation by use of O2; analgesia for chest injuries; suction/pulmonary toilet; clear the C-spine, and remove the backboard as early as possible to prevent respiratory impairment.
  • C – Early transfusion to minimize fluid overload from crystalloids. Recognizing that “normal” BP may be relative hypotension for an elderly patient. Question patients regarding anticoagulant use and consider reversal early in the course.
  • D – Liberal use of head and C-spine CT; GCS is not a sensitive indicator in the elderly trauma patient.
  • E – Assess for signs of comorbidities that may not have been reported (i.e. surgical scars, pacemakers, medications or med lists in patient belongings, medical alert tags, bruising from anticoagulants).

Elder Abuse

No report on elderly trauma is complete without mention of elder abuse. Elder abuse can be very difficult to detect for several reasons:

  • Patient reluctance to identify a loved one
  • Patient dependence on the abuser
  • Perceived frailty limiting the patient from feeling empowered in seeking help
  • Patient mental or memory impairment limits the history
  • Abuse in the form of neglect can mimic cachexia from comorbidities

Clinical implications: When the scenario has stabilized, assess the patient’s social situation. Be wary of wounds or injuries that are suspicious for abuse or do not match the reported mechanism of injury. And of course, ask the patient, preferably in private!

A Quick Word on Anticoagulants

Anticoagulant use is far more prevalent in the elderly population. An increasing portion of the elderly population are being prescribed novel oral anticoagulants, which are not as readily reversible as warfarin. An elderly trauma patient should be questioned regarding anticoagulants ASAP. An irregular heartbeat may be a clue to chronic atrial fibrillation and anticoagulant use. Know your institution’s reversal protocol for the novel anticoagulants. If your institution does not have a protocol, then have a plan in mind. Know which prothrombin complex concentrates are available to you. Know if Praxbind is stored by your pharmacy.

Back to the Case

The patient in the initial case presentation may have been exhibiting his normal baseline mental status or could have been confused secondary to the emotional distress pertaining to the accident, but the provider must assume the confusion secondary to intracranial bleeding until proven otherwise. The patient’s irregular heart rate should alert the clinician to the possibility of aspirin or anticoagulant use, necessitating a plan for reversal should it be needed. In terms of the rest of the vital signs: the patient’s “normal” blood pressure may actually represent relative hypotension. The borderline hypoxia (and wheezing discovered on exam) is likely related to lung injury, aspiration, or an underlying comorbidity (i.e. COPD or CHF). This should serve as a warning – the patient is high risk for respiratory decompensation from chest injury and impaired chest wall motion from the C-collar and backboard. The backboard should be removed as soon as possible, pain from the chest injury treated as applicable, and supplemental oxygen employed. Suction may be considered as an adjunct. If and when the C-spine is cleared, the patient should be placed in an upright position to facilitate gas exchange and decrease work of breathing. The patient may have critical injuries and blood loss despite minimal symptoms so a lactate or ABG for base deficit should be sent. Imaging to rule out internal injuries is a must. Initial diagnostic work-up and resuscitation should be aggressive until the patient’s prognosis and wishes are clear. Volume resuscitation should be minimized, with blood products being the fluid of choice. The clinician should have a low threshold for trauma team activation vs. consultation and admission.



  • Resuscitation of the elderly trauma patient must be thoughtful but aggressive:
    • Heighten awareness that with age, signs and symptoms may be minimal, and that the outcome is often initially unclear, and commonly, but not necessarily poor.
    • Up to 85% of elderly trauma survivors return to baseline or independent function.9
      • This justifies initial aggressive approach which can be reassessed later when patient/family wishes and prognosis becomes increasingly clear.9
    • Less physiologic reserve leaves little time for delays in diagnosis and under- or over- resuscitation.
    • Blood is the fluid of choice.
    • The principles of diagnosis and management in trauma are the same regardless of age, but the incidence of physiologic changes and disease states mandates a different overall approach.
    • You may be the only one in the room who knows how sick the patient really is.


References / Further Reading

  1. Hashmi A, Ibrahim-Zada I, Rhee P et al. Predictors of mortality in geriatric trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2014;76:894-901.
  2. Vincent GK, Velkoff VA, U.S. Census Bureau. The next four decades the older population in the United States: 2010 to 2050. Population estimates and projections P25-1138. Washington, DC: U.S. Dept. of Commerce, Economics and Statistics Administration, U.S. Census Bureau; 2010. Available from
  3. CDC National Center for Health Statistics (NCHS), National Vital Statistics System.
  4. CDC Data and Statistics (WISQARSTM): Cost of Injury Reports Data Source: NCHS Vital Statistics System for Numbers of Deaths.
  5. Champion HR, Copes WS, Buyer D et al. Major trauma in geriatric patients. Am J Public Health. 1989;79:1278-1282.
  6. Bonne S, Schuerer D. Trauma in the Older Adult – Epidemiology and evolving geriatric trauma principles. Clin Geriatr Med. 2013;29:137-150.
  7. Goodmanson NW, Rosengart MR, Barnato AE et al. Defining geriatric trauma: When does age make a difference? Surgery. 2012;152:668-675.
  8. Grossman MD, Ofurum U, Stehly CD et al. Long-term survival after major trauma in geriatric trauma patients: The glass is half full. J Trauma. 2012;72:1181-1185.
  9. Jacobs DG, Plaisier BR, Barie PS et al. Practice Management Guidelines for Geriatric Trauma. The EAST Practice Management Guidelines Work Group. J Trauma. 2003;54:391-416.
  10. Sasser SM, Hunt RC, Faul M et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep. 2012 Jan 13;61(RR-1):1-20.
  11. Zafar SN, Obirieze A, Schneider EB et al. Outcomes of trauma care at centers treating a higher proportion of older patients: The case for geriatric trauma centers. Acute Care Surg. 2015;78:852-859.
  12. Maxwell CA, Miller RS, Dietrich MS et al. The aging of America: a comprehensive look at over 25,000 geriatric trauma admissions to United States hospitals. Am Surg. 2015;81(6): 630-636.
  13. Ichwan B, Subrahmanyam D, Shah MN et al. Geriatric-specific triage criteria are more sensitive than standard adult criteria in identifying need for trauma center care in injured older adults. Ann Emerg Med. 2015;65:92-100.
  14. Chang DC, Bass RR, Cornwell EE et al. Undertriage of elderly trauma patients to state-designated trauma centers. Arch Surg. 2008;143:776-781.
  15. Kodadek LM, Selvarajah S, Velopulos CG et al. Undertriage of older trauma patients: is this a national phenomenon? J Surg Research. 2015;199:220-229.
  16. Caterino JM, Valasek T, Werman HA. Identification of an age cutoff for increased mortality in patients with elderly trauma. Am J Emerg Med. 2010;28:151-158.
  17. Lehmann R. The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis. Am J Surg. 2009 May; 197(5):571-4.
  18. American College of Surgeon Committee on Trauma. Geriatric Trauma. In: ATLS: student course manual. 8th Chicago. 2008:247-257.
  19. Scalea TM, Simon HM, Duncan AO et al. Geriatric blunt multiple trauma: improved survival with early invasive monitoring. J Trauma. 1990; 30: 129–136.
  20. Brown JB, Gestring ML, Forsythe RM et al. Systolic blood pressure criteria in the National Trauma Triage Protocol for geriatric trauma: 110 is the new 90. J Trauma Acute Care Surg. 2015;78:352-359.
  21. Calland JF, Ingraham AM, Martin N et al. Evaluation and management of geriatric trauma: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:S345-S350.
  22. Heffernan DS,Thakkar RK, Monaghan SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma. 2010;69(4):813-820.
  23. Zehtabchi S, Baron BJ. Utility of base deficit for identifying major injury in elder trauma patients. Acad Emerg Med. 2007;14:829-831.
  24. Callaway DW, Shapiro NI, Donnino MW et al. Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients. J Trauma. 2009;66:1040-1044.
  25. Paladino L, Sinert R, Wallace D et al. The utility of base deficit and arterial lactate in differentiating major from minor injury in trauma patients with normal signs. Resuscitation. 2008;77:363-368.
  26. Salottolo KM, Mains CW, Offner PJ et al. A retrospective analysis of geriatric trauma patients: venous lactate is a better predictor of mortality than traditional vital signs. Scan J Trauma Resusc Emerg Med. 2013;21:1-7.
  27. Labib N,Nouh T, Winocour S et al. Severely injured geriatric population: morbidity, mortality, and risk factors. J Trauma. 2011;71(6):1908-14.
  28. Liu SW, Obermeyer Z, Chang Y et al. Frequency of ED revisits and death among older adults after a fall. Am J Emerg Med. 2015;33:1012-1018.
  29. Sterling DA,O’Connor JA, Bonadies J. Geriatric Falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001;50(1):116-119.
  30. Rathlev NK, Medzon R, Lowery D et al. Intracranial pathology in elders with blunt head trauma. Acad Emerg Med. 2006;13(3):302-7.
  31. Li J, Brown J, Levine M. Mild head injury, anticoagulants, and risk of intracranial injury. Lancet. 2001; 357(9258):771-2.
  32. Bulger EM. Rib fractures in the elderly. J Trauma. 2000;48(6):1040.
  33. Bonne S, Schuerer DJ. Trauma in the older adult: epidemiology and evolving geriatric trauma principles. Clin Geriatr Med. 2013;29(1):137-50.
  34. Reinhold M, Bellabarba C, Bransford R et al. Radiographic analysis of type II odontoid fractures in a geriatric patient population: description and pathomechanism of the “Geier”-deformity. Eur Spine J. 2011. Nov;20(11):1928-39

EM Mindset – Louis Ling – Mistakes, Teaching, Connecting

Author: Louis J. Ling, MD (Senior Vice President for Hospital-based Accreditation, ACGME; Professor of Emergency Medicine and Pharmacy, University of Minnesota Medical School) // Edited by: Alex Koyfman, MD (@EMHighAK – Editor-in-Chief; EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Manpreet Singh, MD (@MPrizzleER – Associate Editor-in-Chief; Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)

When I work in the ED, I have to get in the right frame of mind; to psych myself up for the busy, hectic, and chaotic environment that I have grown to love. For the first few years of practice, I dreaded going to work; afraid I was going to miss something or make a mistake.  After two years as an attending, I realized that with the number of decisions that occur during every shift, mistakes and errors were inevitable.  I gave myself permission to make mistakes, but to make them safe mistakes when possible and to learn from my mistakes.  (Safe mistake does not mean overtreatment.)  That is my first mindset that I take to work every shift.

My second mindset is to teach and supervise while not getting in the way of the learners.  Most teachers are so busy telling their learners what to do, they never have a chance to learn; they only regurgitate what they were told.  I now see my role as primarily the hint generator for the “Pit Boss”.  For that to make sense, let me explain the Hennepin layout.

There are three major team centers, each with approximately 15 rooms, staffed with two to three PMPs, primary medical providers and a Pit boss and a faculty.  The Primary medical providers can be PAs, G1 residents of both EM and off service and junior EM and IM residents.  They are the primary contacts for the patients, nurses, and consultants and responsible for the charting. This team is supervised by a Pit boss, a senior EM or EM/IM resident, who also sees every patient but does no charting, except for patients seen with a medical student.  The goal is to have pit bosses make as many decisions as possible without the burden of charting (a dream job).

When I see patients, I will ask the pit boss questions as to the differential and the plan and why or why not certain tests were ordered.  The patient does not have to be managed exactly how I would if the pit boss has reasonable answers that justify their decisions, however, if pit bosses are shot gunning or missing key tests, or generally in need of advice, the management can change.  One of the challenges of being a resident is trying to guess how each particular faculty would manage each patient.  My goal is to let the pit boss manage the patient independently, while avoiding errors, not to manage the patient exactly the way that I would.

I prefer to see patients along with a resident. (I am told this is rare for faculty to observe) This is easiest at the start of each shift especially when the patients and residents are all new, or when a patient is brought in by ambulance or roomed and freshly seen by a resident. When I listen to the history, I assess how the questions flow in a logical order where the resident is trying to raise the suspicion of or to narrow the differential or to rule out possible maladies.   It is common for novices to ask from a checklist without knowing the significance of each question.  Watching the exam is instructive and residents often listen to the heart and lungs, to meet my expectation. I frequently give permission to them to skip the automatic response and simply focus on the problem area but to always examine something (for the patient’s expectation, not mine).  It is common that problem specific exams are incomplete or improperly done, again from a checklist and not to elicit information to rule in or rule out specific conditions.  Examples include joint exams, abdominal and back exams.  When we leave the room, I try to give one positive observation that they should continue and one suggestion on how to improve.  If I am commenting on the exam, I might repeat certain portions to demonstrate and to have them repeat it.  Of course, seeing patients with PMPs is inefficient and I know I will fall behind so when that happens, I resort to cruising the rest of the rooms and seeing patients quickly until I catch up.  Seeing patients with a pit boss can be efficient since they are usually quick and much more focused and this is a good way to develop a plan with the patient present that the pit boss can share with the nurses and the PMPs. We often will discuss the possible dispositions at the same time.  Because I try to actively be involved, I typically get way behind on my charting.  I write short notes emphasizing the thought process and keep current on the patients who are admitted.  For patients who are discharged, I save the charting for after my shift.  Thank goodness for CITRIX.

The Pit Boss also has primary responsibility for all resuscitation and unstable patients in the stabilization room.  (The hope for all pit bosses is to spend the day in the stab room instead of seeing patients with me.)  During those times, I take over the Pit boss role and will manage the patients directly with the PMPs.  Some PMPs are nervous about approaching me directly so I usually ask the PMPs how I can help or how their plan is progressing.  When I see patients as a PMP myself, I have learned to pick the quick and straightforward ones and move them along to decompress the area.  I discovered that when I pick up complicated patients, that despite my best of intentions, I often get distracted from them and their time in the ED is longer than if they had a different PMP.

When I picked emergency medicine as a specialty in 1979, the year emergency medicine became a specialty, I had thought the reward would be saving lives and doing dramatic procedures and never having to provide chronic care.  I now know that those moments are indeed rewarding but much less often than I had imagined.  The surprise diagnosis, solving the puzzle, and the well done procedure is still fun but the day to day reward is connecting with patients as human beings, providing a little comfort and caring, some reassurance and education.  That is a wonderful mindset to have.

When I started working for the ACGME several years ago, I had considered seeing patients in Chicago but realized that I would never become facile with the System-based practice.  The EMR would be awkward and I would be a drag and hindrance to a resident.   I only work one shift a month (and I skip July), so I have tried to minimize my system-based errors by working in the ED that I have spent 30 years, where I understand the culture, I still know the nurses and the consultants, the code to the bathroom and EPIC knows my password.  I always work in the same team center on Saturday and there are always two other faculty present in the ED.

I no longer manage resuscitations.  When I did, I still saw my role as giving hints and whispering in the Pit boss’ ear, but letting them manage the care and direct the traffic.  My other role was to keep the attending surgeon or consultant out of the way when they became meddlesome.  While I miss those cases, it was unfair to take that experience from the full-time faculty, and to care for the sickest of patients when I am no longer at the top of my game.

I often wonder when my clinical skills might become so sclerotic that I should quit clinical care altogether.  When I work with the Pit bosses, senior residents a few months away from independent practice, I realize I may not be smarter than they are but I am still much trickier.  Although I am not as fast and efficient as I once was, I am better than a new graduate.  I have to be extra careful when it comes to up-to-date and new treatment but the essence of connecting with and caring for patients is still there.  I have to ask more questions and rely on others for bedside ultrasound.

So there it is; my mindset of going to do a shift includes 1) realizing that I am going to make mistakes but to try and make them safe mistakes, 2) teaching while staying out of the way of learners’ learning, and 3) remembering to connect with human beings during their time of need.

EM Mindset – Joe Lex – Thinking Like An Emergency Physician

Author: Joe Lex, MD (@JoeLex5 – Clinical Professor of Emergency Medicine, Temple University School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK – Editor-in-Chief; EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Manpreet Singh, MD (@MPrizzleER – Associate Editor-in-Chief; Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)

“Emergency Medicine is the most interesting 15 minutes of every other specialty.”

– Dan Sandberg, BEEM Conference, 2014[1]

Why are we different?  How do we differentiate ourselves from other specialties of medicine?  We work in a different environment in different hours and with different patients more than any other specialty.  Our motto is “Anyone, anything, anytime.”[2]

While other doctors dwell on the question, “What does this patient have? (i.e., “What’s the diagnosis?”), emergency physicians are constantly thinking “What does this patient need?[3]  Now?  In 5 minutes?  In two hours?”  Does this involve a different way of thinking?

The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues.  Yes, we do it on a daily basis, many times during a shift.  Every time I introduce myself to a patient, I never know which direction things are going to head.  But I feel like I should give the following disclaimer.

Hello stranger, I am Doctor Joe Lex.  I will spend as much time as it takes to determine whether you are trying to die on me and whether I should admit you to the hospital so you can try to die on one of my colleagues.[4],[5] You and I have never met before today.  You must trust me with your life and secrets, and I must trust that the answers you give me are honest.  After today, we will probably never see one another again.  This may turn out to be one of the worst days of your life;[6] for me it is another workday.  I may forget you minutes after you leave the department, but you will probably remember me for many months or years, possibly even for the rest of your life.

I will ask you many, many questions.  I will do the best I can to ask the right questions in the right order so that I come to a correct decision.  I want you to tell me the story, and for me to understand that story I may have to interrupt you to clarify your answers.

Each question I ask you is a conscious decision on my part, but in an average 8 hour shift I will make somewhere near 10,000 conscious and subconscious decisions – who to see next, what question to ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, which consultant will give me the least pushback about caring for you, is your nurse one to whom I can trust the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home?  So even if I screw up just 0.1% of these decisions, I will make about 10 mistakes today.[7]

I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio: gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG.  I can recognize and treat those things without even thinking.  If, on the other hand, your problem has a lot of background noise, I am more likely to be led down the wrong path and come to the wrong conclusion.[8]

I am glad to report that the human body is very resilient.  We as humans have evolved over millennia to survive, so even if I screw up the odds are very, very good that you will be fine.  Voltaire told us back in the 18th century that “The art of medicine consists of amusing the patient while nature cures the disease.”  For the most part this has not changed.  In addition, Lewis Thomas wrote: “The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves.  Most things, in fact, are better by morning.”[9]  Remember, you don’t come to me with a diagnosis; you come to me with symptoms.

You may have any one of more than 10,000 diseases or conditions, and – truth be told – the odds of me getting the absolute correct diagnosis are not good.  You may have an uncommon presentation of a common disease, or a common presentation of an uncommon problem.  If you are early in your disease process, I may miss such life-threatening conditions as heart attack or sepsis.  If you neglect to truthfully tell me your sexual history or use of drugs and alcohol, I may not follow through with appropriate questions and come to a totally incorrect conclusion about what you need or what you have.[10]

The path to dying, on the other hand, is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.[11]

You may be disappointed that you are not being seen by a “specialist.”  Many people feel that when they have their heart attack, they should be cared for by a cardiologist.  So they think that the symptom of “chest pain” is their ticket to the heart specialist.  But what if their heart attack is not chest pain, but nausea and breathlessness; and what if their chest pain is aortic dissection?  So you are being treated by a specialist – one who can discern the life-threatening from the banal, and the cardiac from the surgical.  We are the specialty trained to think like this.[12]

If you insist asking “What do I have, Doctor Lex?” you may be disappointed when I tell you “I don’t know, but it’s safe for you to go home” without giving you a diagnosis – or without doing a single test.  I do know that if I give you a made-up diagnosis like “gastritis” or “walking pneumonia,” you will think the problem is solved and other doctors will anchor on that diagnosis and you may never get the right answers.[13]

Here’s some good news: we are probably both thinking of the worst-case scenario.  You get a headache and wonder “Do I have a brain tumor?”  You get some stomach pain and worry “Is this cancer?”  The good news is that I am thinking exactly the same thing.  And if you do not hear me say the word “stroke” or “cancer,” then you will think I am an idiot for not reading your mind to determine that is what you are worried about.  I understand that, no matter how trivial your complaint, you have a fear that something bad is happening.[14]

While we are talking, I may be interrupted once or twice.  See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, trying to clarify an obscure order for a nurse, or I may get called away to care for someone far sicker than you.  I will try very hard to not let these interruptions derail me from doing what is best for you today.[15]

I will use my knowledge and experience to come to the right decisions for you.  But I am biased, and knowledge of bias is not enough to change my bias.[16]  For instance, I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this diagnosis at least half the time it occurs.[17]

And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by recognition or use analytical reason.  Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking).[18]  Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking).[19]  It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.[20]

After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you.  This is essential for me to do so the hospital and I can get paid.  The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier.  The final chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process.  In my eight-hour shift today I will click about 4000 times.[21]

What’s that?  You say you don’t have insurance?  Well that’s okay too.  The US government has mandated that I have to see you anyway without asking you how you will pay.  No, they haven’t guaranteed me any money for doing this – in fact I can be fined a hefty amount if I don’t.  And a 2003 article estimated I give away more than $138,000 per year worth of free care related to this law.[22]

But you have come to the right place.  If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracostomy, I’ll do it.  If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too.  I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter.  I can float your temporary pacemaker, I can get that pesky foreign body out of your eye or ear or rectum, I can stop your seizure, and I can talk you through your bad trip.[23]

Emergency medicine really annoys a lot of the other specialists.  We are there 24 hours a day, 7 days a week.  And we really expect our consultants to be there when we need them.  Yes, we are fully prepared to annoy a consultant if that is what you need.[24],[25]

Yes, I have seen thousands of patients, each unique, in my near-50 years of experience.  But every time I think about writing a book telling of my wondrous career, I quickly stop short and tell myself “You will just be adding more blather to what is already out there – what you have learned cannot easily be taught and will not be easily learned by others.[26]  What you construe as wisdom, others will see as platitudes.”

As author Norman Douglas once wrote: “What is all wisdom save a collection of platitudes.  Take fifty of our current proverbial sayings – they are so trite, so threadbare.  Nonetheless, they embody the concentrated experience of the race, and the man who orders his life according to their teachings cannot be far wrong.  Has any man ever attained to inner harmony by pondering the experience of others?  Not since the world began!  He must pass through fire.”[27]

Have you ever heard of John Coltrane?  He was an astonishing musician who became one of the premier creators of the 20th century.  He started as an imitator of older musicians, but quickly changed into his own man.  He listened to and borrowed from Miles Davis and Thelonious Monk, African music and Indian music, Christianity and Hinduism and Buddhism.  And from these disparate parts he created something unique, unlike anything ever heard before.  Coltrane not only changed music, but he altered people’s expectations of what music could be.  In the same way, emergency medicine has taken from surgery and pediatrics, critical care and obstetrics, endocrinology and psychiatry, and we have created something unique.  And in doing so, we altered the world’s expectations of what medicine should be.

Now, how can I help you today?[28]

References / Further Reading

[1] Accessed 27 December 2015.

[2]  Accessed 27 December 2015.

[3]  From a talk by Reuben Strayer.  Accessed 27 December 2015.  See slide #12

[4] Alimohammadi H, Bidarizerehpoosh F, Mirmohammadi F, Shahrami A, Heidari K, Sabzghabaie A, Keikha S.  Cause of Emergency Department Mortality; a Case-control Study.  Emerg (Tehran). 2014 Winter;2(1):30-5.

[5] Olsen JC, Buenefe ML, Falco WD.  Death in the emergency department.  Ann Emerg Med. 1998 Jun;31(6):758-65.

[6]  Accessed 27 December 2015

[7] Croskerry P.  Achieving quality in clinical decision making: cognitive strategies and detection of bias.  Acad Emerg Med 2002;9:1184–204.

[8] Phua DH, Tan NC.  Cognitive aspect of diagnostic errors.  Ann Acad Med Singapore. 2013 Jan;42(1):33-41.

[9] Thomas L.  Your very good health.  N Engl J Med. 1972 Oct 12;287(15):761-2.

[10] Croskerry P, Sinclair D.  Emergency medicine: A practice prone to error?  CJEM. 2001 Oct;3(4):271-6.

[11] Rosen P.  The biology of emergency medicine.  JACEP. 1979 Jul;8(7):280-3.

[12] Zink BJ.  The Biology of Emergency Medicine: what have 30 years meant for Rosen’s original concepts?  Acad Emerg Med. 2011 Mar;18(3):301-4.

[13] Croskerry P.  Commentary: Lowly interns, more is merrier, and the Casablanca Strategy.  Acad Med. 2011 Jan;86(1):8-10.

[14] Croskerry P.  The cognitive imperative: thinking about how we think.  Acad Emerg Med. 2000 Nov;7(11):1223-31.

[15] Chisholm CD, Collison EK, Nelson DR, Cordell WH.  Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”?  Acad Emerg Med. 2000 Nov;7(11):1239-43.

[16] Croskerry P.  From mindless to mindful practice–cognitive bias and clinical decision making.  N Engl J Med. 2013 Jun 27;368(26):2445-8.

[17] Pineda LA, Hathwar VS, Grand BJ.  Clinical suspicion of fatal pulmonary embolism. Chest 2001;120:791-795

[18] Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121 (Suppl):2–33.

[19] Redelmeier D. The cognitive psychology of missed diagnoses. Ann Intern Med 2005;142:115–20.

[20] Norman GR, Eva KW.  Diagnostic error and clinical reasoning.  Med Educ. 2010 Jan;44(1):94-100.

[21] Hill RG Jr, Sears LM, Melanson SW.  4000 clicks: a productivity analysis of electronic medical records in a community hospital ED.  Am J Emerg Med.  2013 Nov;31(11):1591-4.

[22]—Practice-Management/The-Impact-of-Unreimbursed-Care-on-the-Emergency-Physician/  Accessed 27 December 2015.

[23]  Accessed 27 December 2015.  See pp 44-47.

[24] Johnson LA, Taylor TB, Lev R.  The emergency department on-call backup crisis: finding remedies for a serious public health problem.  Ann Emerg Med. 2001 May;37(5):495-9.

[25] Asplin BR, Knopp RK.  A room with a view: on-call specialist panels and other health policy challenges in the emergency department.  Ann Emerg Med. 2001 May;37(5):500-3.

[26] Norman G, Young M, Brooks L.  Non-analytical models of clinical reasoning: the role of experience. Med Educ.  2007 Dec;41(12):1140-5.

[27] South Wind by Norman Douglas.  THE MODERN LIBRARY; Thus edition (1925).  Page 176.

[28] Wolffhechel K, Fagertun J, Jacobsen UP, Majewski W, Hemmingsen AS, Larsen CL, Lorentzen SK, Jarmer H.  Interpretation of appearance: the effect of facial features on first impressions and personality.  PLoS One. 2014 Sep 18;9(9):e107721..

Clinical Decision Rules Series Part 2: CDR Implementation

Authors: Barry Sheridan, DO (EM Staff Physician and Professor at SAUSHEC) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) & Justin Bright, MD (@JBright2021)

In part 1 of the series, we introduced the potential need for clinical decision rules (CDRs), how they can potentially assist and hurt providers, and most importantly, what makes a CDR clinically helpful.  To catch up before reading part 2, please see part 1 ( In part 2, we will delve further into CDRs, particularly how to incorporate CDRs into everyday clinical practice.

How should a CDR be incorporated into clinical pathways and clinical practice?

As examined in the last post, good CDRs undergo rigorous development and validation. This is where the rubber meets the road. CDRs can make practice more efficient and improve flow within the ED.

What obstacles are present?

There are often multiple roadblocks to incorporating a CDR into clinical practice. These can be broken into the 1) individual provider and 2) the institution.

  1. Emergency physicians are a rare breed, and many of us do not appreciate suggestions on how to practice. Individual providers vary in many regards: training, knowledge, experience, and gestalt. Workups and treatments can significantly differ among providers.  With CDRs, physicians may be hesitant to apply these rules to their own practice. They may feel the rules are too complex, too difficult to remember, or detract valuable time from patient care. Providers often feel that gestalt or experience is better than rules.
  1. Institutions may have habits or a culture for particular conditions that may make it difficult to apply a rule.  Tradition or consultant availability may color the use of CDRs. Unfortunately, the medico-legal environment or funding can also play a large role in the use, or lack thereof, for CDRs.

How to incorporate a CDR into practice…

First, ensure the CDR itself is useful. Does it apply to your practice and how will it impact your practice? If your practice does not have a moderate to high volume of a particular disease process addressed by the rule, it may not be of any benefit.  Know the inclusion and exclusion criteria used for rule development.  What information will the rule give you?

One-way vs. Two-way Rules

Before we go further, we need to discuss what information a CDR provides, specifically one-way and two-way rules. One-way rules are like PERC. This rule is specifically designed to rule out pulmonary embolism. A positive test is not meant to guide clinical decision-making. Instead, a negative test in a low risk patient can be used to stop further testing. On the other hand, a two-way rule is like the Ottawa Ankle Rule, discussed in Part 1 of the CDR series. Application of this rule directs the provider to either order or not order an X-ray.


Once we know how a rule can be applied and the information provided, then move on to CDR incorporation. First, you need buy-in. If you are in a group practice, discuss how the group would like to practice and then incorporate it into everyday use.  This can streamline the care of a particular group of patients thereby providing consistent, quality care that is easy to reproduce on a day-to-day basis and also defend medico-legally.

Remember to keep it simple… perhaps nominate a champion who will review the literature, the rule, and then combine excerpts into a one or two sheet summary that can be easily followed and stored for use when needed. Discuss the rule at staff meetings or in department notifications.  This reflects the need for visibility. Ensure the rule is known throughout the department by all staff, not just emergency physicians, but your clerks, technicians, nurses, and other departments (such as internal medicine, surgery, and radiology).

Also involve your consultants and get their buy in.  This can ensure that they understand how you practice and what you expect coupled with their particular issues (like how to get follow up, or a particular drug or dosage).

And now for an example…

As an example of institutional implementation of a CDR, our department recently instituted a group practice for low risk chest pain patients.  We incorporated the HEART pathway into our daily practice.  This led to more consistent, streamlined, quality care for our patients and made it easier for all our staff, residents, and nursing to follow a particular group practice.  Gestalt is still incorporated and has its place in this rule, as one size does not fit all, but 90% plus of our patients can appropriately be incorporated into the pathway.

The Nuts and Bolts

HEART Pathway Implementation: All staff physicians were given the relevant literature regarding the HEART Score. As a group we sat down in a risk management forum, and we went through the literature, the Pathway as it will be implemented in this institution, and unanimously agreed to the Pathway (essentially making it a local guideline). The Pathway was further vetted through Cardiology and Internal Medicine to sign off on safety and follow up appointments. A Project Improvement (PI) process was set in place prior to the beginning of the pathway and will be continually tracked. Furthermore, an Institutional Review Board protocol has been accepted to study the pathway in an ambispective research design looking back 2.5 years and going forward 5 years. This will show the before and after data since the pathway was implemented.

The Current State

Approximately 150 patients have been placed in the pathway in the last 3 months. To date, our MACE (Major Acute Coronary Event) is <1%.  Before we implemented this CDR, approximately 46% of these patients would have been admitted to the hospital for ACS rule out; however, with this pathway these patients are able to be safely discharged home from the ED with follow-up. Coronary Computed Tomography Angiography (CCTA) use has decreased with the pathway, going from 40 studies per month to 12 studies per month leading to another saving in resource utilization. HEART is sometimes compared to TIMI and GRACE (older ACS scores), but these measure risk of death for patients with ACS. The TIMI and GRACE scores do not do as well telling who has ACS in the first place (which was the question we really want to ask when we see our chest pain patients).

Once the CDR has been in use, refinement and monitoring of rule use are necessary. Feedback and measuring adherence can be beneficial. Continually discuss and refine rule implementation over time.  No launch of a project goes without some issues that need to be addressed and adjusted.

Remember to stress that clinical gestalt at times may override the rule no matter how supported and researched it may be… after all none of them are 100% sensitive or specific.  Make sure to examine why clinical gestalt was opted for as it may be reasonable to incorporate that in other versions of the rule.

There are many ways to institute a CDR, let alone decide which ones you choose to use.  We opted for high risk and a high volume presenting complaint. This gets back to the applicability of the CDR. Common chief complaints are great targets for implementing a CDR/pathway.


– CDRs can benefit emergency departments. Target common conditions managed in the ED.

Identify and address potential roadblocks to CDR use including physicians, ED staff, institution, and culture.

– Keep the rule/pathway simple and easy to use.

– Obtain department and consultant buy-in.

– Keep evaluating the pathway and obtain feedback during use.

Tweak the pathway as needed during implementation and use.


References/Further Reading

  1. Stiell IG, Bennett C. Impleentation of clinical decision rules in the emergency department. Acad Emerg Med 2007;14:955-59.
  2. Stiell IG. Clinical decision rules in the emergency department. CMAJ 2000;163(11):1465-66.
  3. Green SM. When do clinical decision rules improve patient care? Ann Emerg Med 2013;62:132-35.
  4. Adams ST, Leveson SH. Clinical prediction rules. BMJ 2012;344:d8312 doi: 10.1136/bmj.d8312.
  5. Helman A. Episode 56 The Stiell Sessions: Clinical Decision Rules and Risk Scales. Emergency Medicine Cases.
  6. Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency 2013 Oct 3;168(3):2153-8.
  7. Backus BE, Six AJ, Kelder JC, et al. Risk Scores for Patients with Chest Pain: Evaluation in the Emergency Department. Current Cardiology Reviews 2011;7(1):2-8.
  8. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Netherlands Heart Journal. 2008;16(6):191-196.

One Physician’s Advice to the New Grad

**Author’s note: This was originally posted on June 24, 2015

To the Class of 2016 – Congratulations!!  You’ve made it.  After at least 11 years of post-high school education, you have finally reached that proverbial finish line and are ready to transition from resident to attending.  What I would like to share with you is some advice about what life is like on the other side.  Now that you have finished residency, it’s safe to say that you know the medicine really well.  But, I have come to find that your learning about life as a professional is just beginning.

First piece of advice – and I realize it’s as cliché as it comes – you never get a second chance to make a first impression.  You’re walking into a new place and a new culture.  You will know all the newest technologies and latest research fads.  But, you won’t know simple things like, where can I go to the bathroom?  How do I literally get someone admitted?  What service takes care of particular problems at your institution?  I can say with absolute certainty that your stress level will be higher than baseline just by walking in on your first day.  Higher stress correlates with less patience and poorer communication.  Snap at one nurse on your first day and it will take over a year to recover.  That piece of advice is from firsthand experience.  You really need to focus on situational self-awareness.  You need to recognize when you’re running a little hot, and be able to harness it.  Be cordial, grateful, and vulnerable.  Don’t hesitate to ask for help.  People like feeling needed.  Your clerk is going to be your best friend.  Introduce yourself right away and tell him/her, I’m going to need your help getting through the day.  Getting help with the logistics in the beginning won’t undermine anyone’s view of your clinical competence.

This leads me to my second piece of advice – on one of your first shifts, buy pizza for the entire ED staff.  Depending on the size of your shop, it may cost a few hundred bucks.  The investment will be worth 10x that in good will.  The staff will talk about it for months.  You will be the doc that values his staff and wants to show how appreciative you are.

Try your best to learn everyone’s names.  It’s hard – there’s one of you and tons of them.  And our pesky name tag lanyards always seem to turn so the ID is not facing outwards.  I try to memorize one person’s name per week.  The most important names to remember: your security guards and housekeepers.  Be the one doc who values everyone’s role in the department.  I assure you most doctors walk by the housekeepers like they don’t exist.  They keep your department clean and mop up things you definitely wouldn’t want to.  Security guards keep you safe so you can go home to your loved ones.  They deserve to know that you value their role.

After a month or two of work, you’re going to have a moment walking into the hospital where you realize, “this is my life now.”  You will be able to imagine parking in the same spot and walking into the same ED for the next 20 years.  It’s going to be a mixed emotion.  In residency, you had different rotations to break up your ED months, and you were continually being exposed to something new.  Now you’re an attending, and there are no rotations.  There is no finish line you are trying to reach.  There’s just you and your colleagues working a shift and going home.  To make it through residency, you probably kept telling yourself how great attending life was going to be.  You were going to be making a lot more money and it wasn’t going to be nearly as grueling.  While the money part is definitely true, attending life can be every bit as grueling.  It can be hard when your expectation of what the future would be like doesn’t meet your reality.  It’s a totally normal feeling to have.  You are not alone, and it doesn’t mean you chose the wrong specialty, wrong job, or city.  It’s all part of the transition, and it almost always passes.

One of the best pieces of advice one of my attendings gave me was: whenever possible, go to the physician lounge.  Introduce yourself to whoever is there.    Serve on a committee.  Get to know the physicians by their first names.  Take an active stake in the future of the hospital.  Your phone calls will go infinitely better when your colleague has a face to put with a name.  The more involved you become within your department or hospital, the more indispensable you make yourself, and the more job security you will have.

If you want to have a great reputation with your consultants, be cordial with them, be grateful for their ED referrals, and never oversell an admission.  They will know very quickly if you are someone who is clinically competent, or if you are a liar.  I have gotten incredibly soft admits taken care of by saying from the outset, “This is a soft admission, but the patient can’t go home because… here’s what needs to be done on the inpatient side, and I’d be happy to take care of X, Y, Z for you while the patient is in the department.”  They will also appreciate the times you take care of their patient at 2am, get them squared away, and don’t call until 6am to inform them of what you did and that they will be calling the office that morning.  They value their sleep, and they value that you’re awake to take care of their patients.  After a while, they will know that when you’re waking them up in the middle of the night, you genuinely mean it and you need their help just as they have needed yours at other times.

Do whatever you can to resist the urge to pick up more shifts.  In the early years, you will be shocked by the number of zeros you can put in your paychecks.  You will start thinking to yourself, if I work “X” shifts I can pay for “Y.”  You will rationalize it as, I worked this hard as a resident, and I can still do it as an attending.  In the short term, this may be true, but over the long haul, it’s the best way to insure you burn out well before you intended to stop practicing medicine.  Use allotted vacation time.  Give yourself adequate sleep and turnaround time on shifts.  Don’t outspend your means.  Don’t buy a massive house when one half the size would be more than sufficient.  Treat yourself from time to time, but don’t buy every last thing you’ve ever wanted.  The more you spend, the more you become a slave to the shifts, and the cycle is hard to break.

Don’t freak out about your student loans.  Most of us got into this career by going more than $250,000 into debt pursuing our education.  It was an investment in your brain and livelihood.  There is a difference between being in debt and having no means to pay it off versus being in debt and making a 6 figure salary.  You will pay it off.  Just as I stated before, resist the urge to moonlight like crazy to pay off your debt in 3 years.  Do not make yourself cash poor by paying off more than you should in a given month.

You may find yourself working in a department that places a significantly larger emphasis on metrics and patient experience than where you trained.  This will be a tough transition for many.  I have worked for groups that had total transparency with metrics – each month we got data on every member of the group and where we fell on the bell curve.  It felt very threatening at first.  I felt like the group didn’t care about patient care, only numbers.  In truth, they cared very much about patient care.  But they also cared about throughput, efficiency, and how the patient felt about their experience in the department.  While we have altruistic feelings about helping others, we also like being compensated for what we do.  The money comes from patients choosing your department over the one down the street.  Be very aware of this.  The stability of your job and the group’s contract may rely heavily on it.  Be a proactive member and work to improve the experience of your patients; don’t ever publicly complain about it to the very people who have set up that culture of service.

In closing, as I walk into my shifts I find myself striving to live up to what I heard Amal Mattu say once: “Be the Tigger of your department, not the Eeyore.”  When you are on shift, you set the tone.  If you are happy to be at work, promote teamwork, and make sure those that do a great job are recognized, others will follow suit.  If you are slow, negative, and stressed out, the same holds true.  Be the doc that shows up and the nurses go, “Yes!” not the doc that causes nurses to say, “This is going to be a long day.”

We have chosen to work in an incredible specialty.  We get to help people who have nowhere else to turn.  People in their most vulnerable and scared state.  Every once and a while, we even literally bring someone back to life.  We are a specialty trained to run towards problems when everyone else’s instincts tell them to run away.  It is an amazing feeling.  There will be hard days, and no doubt days where you question why you ever chose to become a physician.  Those days are likely to be few and far between.  What you are more likely to feel is elation with the knowledge that you chose the best specialty in the best profession there is.  Good luck to you as you move on with your career.  It is such an exciting time!  Your teachers are very proud of you, and excited to see the physicians you will become.

Reflections on Leadership and Resilience in Emergency Medicine

Author: Justin Bright, MD (Senior Staff Physician, Henry Ford Hospital, Detroit, @JBright2021) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Your department volumes have outgrown your physical plant.  There is not any additional space to build on, and even if there were, there is not any money budgeted for a new department.  It is clear that both logistical and cultural changes need to occur if the department is going to survive the increased growth.  Who is going to lead that change?

An emphasis on patient experience is taking on a continually increasing importance in your health system.  However, your current Press Ganey scores are low.  There is a directive from the C-suite to improve, but how will you do that?  Who will help create the new vision and drive a change in culture?

A mass casualty incident occurs in your town.  Your emergency department takes on the brunt of the victims.  Who in your department will lead the team through the chaos?  Who will the department look to as the team goes through the debriefing and healing process afterwards?

Who are the people you consider the biggest leaders and influencers of change in our profession?  What traits do they have that seem to make them a natural for their role?  How did they get there?  Perhaps even better questions to ask – what makes some people more engaged in their job? Why do some people bounce back from the stress of our jobs better than others do?  Are there common traits that overlap leadership and resilience?

The first thing I am absolutely certain of – title does not mean leadership.  I don’t think anyone reading this would have to think too hard to come up with an example of someone with a leadership title that really didn’t seem capable of the job.  Leaders embody the very best work ethic that everyone else strives to have.  Leaders set the tone in the department and in the boardroom.  Dr. Randy Pausch in his famous “Last Lecture” challenged everyone to be the Tigger, not the Eeyore.  Be positive. Encourage others. Model ideal behavior.  Be willing to outwork everyone else.  That is the key to being seen as a leader.  Don’t strive to be “President” or “Chairman,” strive to be the first person a nurse mentions when asked who she would take her kids to.  That is the ultimate sign of respect, and no leader can lead without the respect of others.

So how do you get respect?  Respect comes when your colleagues see you as someone who practices with integrity and humility.  People see through those who are disingenuous – acting all-in for the team in public while making moves privately that are self-serving.  Moral character can be sniffed out in pretty short order, and nobody will respect someone that they perceive to be dishonest or only “in it” for themselves.  The best leaders are transparent and fair.  The team knows positive behavior will be celebrated, and detrimental behavior will addressed and corrected.  Leaders are accountable, taking responsibility for failures, and they demand equal accountability from everyone else on the team.  Leaders are very quick to deflect personal acclaim when they are successful.  They recognize that the team is the key to achievement, and the best leaders are downright uncomfortable with individual successes.  Using your role as a leader to make sure colleagues are receiving their due for their role in the success reinforces positive behaviors and makes the rest of the team hungry for more of it.  They will work harder to achieve team goals, and be more willing to follow the direction of a leader they know has their back.

Every single text I’ve read on leadership demonstrates that superior leaders are incredibly confident.  Humility is what makes toeing the fine line of confidence and arrogance possible.  A leader has a natural confidence grown from passion and a knowledge that they will ultimately be successful in achieving their goals.  But confidence is more than that.  The best leaders are confident enough to know that there’s also a time to follow.  They seek outside opinion and ideas without feeling threatened.  A confident leader is comfortable saying “I don’t know” without fear that it makes them seem less capable of their job.  Confidence comes from preparation, exploration, and education.  With it, leaders can make decisive decisions in the face of adversity, and swiftly make decisions to adjust course when things occur unexpectedly.

Leaders are passionate about their objectives.  They have an innate ability to motivate others towards a common goal.  They understand how to achieve buy-in from others. The best leaders clearly communicate directives, giving the rest of the team a clear path to success.  Furthermore, leaders value the role of everyone on the team.  There is no “top-to-bottom” or menial role.  Teams with the best leaders feel like every single role is mission critical to ultimate success.  This comes from publically recognizing team members doing great work.  Members of the team also feel valued because strong leaders delegate essential work and continually develop and retain top talent within the unit.

Resiliency is not the same as leadership, but it seems they have some common overlapping traits.  Most prominent is a refusal to give up when faced with a seemingly insurmountable challenge.  Resilient people know that everybody gets knocked down in life, but it is how you get back up that defines you as a person.  The resilient leaders see challenges where others see obstacles.  What’s more, they thoroughly enjoy the journey of the challenge, sometimes even more than the final success.  As a result, they seem to effortlessly change directions or come up with a new plan when first attempts don’t succeed.  The most resilient people are absolutely certain that they will ultimately succeed in their objective because they will outwork their counterparts and continue to look at a problem from different angles until a solution is apparent.

Those that are successful in the face of adversity have a keen self-awareness.  They know their strengths and weaknesses.  The most resilient and prominent leaders keep the company of great people who are able to supplement the areas of their own perceived weaknesses.  In fact, the best leaders purposely seek the council of people with views or knowledge in direct opposition to their own as a way to make sure the problem is evaluated from all-sides.  With information comes power.  With power comes the will to continue on because a resilient leader knows they have both the information and the work ethic necessary for success.

Resilient leaders refuse to give up because they are so invested in the task at hand.  It is not a blind commitment, but rather a devotion to a principle that they see as being greater than themselves.  It is this altruistic, optimistic attitude that often makes the resilient person one of the most engaged and invested people within the group.  The passion and the desire to help others makes them willing to push through hardships and do whatever it takes to overcome a challenge.  With that success comes fulfillment.  It becomes an addictive cycle of finding ways to overcome challenges and motivate others to do the same, and they feed off the high that comes with the success.

But why are some people wired to be this way, while others are seemingly ill-fitted to be a leader?  Why do some people cave at the first sign of trouble?  Is it innate?  Can resiliency and leadership be learned?  I think the answer lies somewhere in between.  There is no doubt that there are certain personality traits people have while others don’t.  Someone’s ability to see the world as half empty, half full, or glass overflowing has to do with the experiences they have had in their life that ultimately shape their view of it.  Some people are just naturally more charismatic and inspiring than others.  But, I also think there’s a choice to be made in all of us.  I think we choose how hard we are going to work.  We choose at what point we are going to give up.  We choose to recognize others and build them up, and we choose when we are going to break somebody else down.  Everything we do in life has an equal effect on someone or something else.  I think this post demonstrates there are definitely leadership traits we can acquire and make a decision that we are going to improve upon.  Transparency, humility, praising and developing others – these are learned behaviors that earn respect and build political currency necessary to lead.  Mix in some innate passion, and imagine the leader you can be.  Imagine the change you can drive forward.  Imagine an engaged workforce of colleagues as invested as you are.  Imagine the possibilities.  Strive to be the Tigger in your department.  Commit to model ideal behavior.  Who knows, one day perhaps we will be talking about you the way we talk about some of the other great and respected leaders in our field.

References / Further Reading

-Freitas, Robert. “Leadership in Emergency Medicine.” Emergency Department Leadership and Management: Best Principles and Practice. N.p.: Cambridge UP, 2014.

-Heath, Chip, and Dan Heath. Switch: How to Change Things When Change Is Hard. New York: Broadway, 2010.

-Giuliani, Rudolph W., and Ken Kurson. Leadership. New York: Hyperion, 2002.

-Merlino, James. “Leading for Change.” Service Fanatics: How to Build Superior Patient Experience the Cleveland Clinic Way. N.p.: McGraw-Hill, 2014.

-Pausch, Randy. “Last Lecture: Achieving Your Childhood Dreams.” Web. 20 December 2007. Web. 29 March 2016. <>

-Prive, Tanya. “Top 10 Qualities That Make A Great Leader.” Forbes. Forbes Magazine, 12 Dec. 2012. Web. 15 Mar. 2016. <>.

-Farrell, Rachel, “23 Traits of Good Leaders.” CNN. Cable News Network, 03 Aug. 2011. Web. 21 Mar. 2016. <>.

-“Gannett Health Services.” Gannett: Qualities of Resilience. Web. 29 Mar. 2016. <>.

-Feloni, Richard. “7 Habits Of Exceptionally Resilient People.” Business Insider. Business Insider, Inc, 05 June 2014. Web. 22 Mar. 2016. <>

Cognitive Load and the Emergency Physician

Author: James O’Shea, MD (Assistant Professor of EM, Emory University / Grady Hospital) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) & Justin Bright, MD (@JBright2021)

“The greatest weapon against stress is our ability to choose one thought over another.”  William James.

This article aims to review cognitive load theory (CLT) as it applies to clinical work in Emergency Medicine (EM). It will introduce key concepts in cognitive load theory, discuss the measurement of cognitive load, and will outline sixteen simple strategies that the working emergency physician can start using today to reduce their cognitive load on shift. These practical strategies will help to free up some of your latent cognitive processing power, allowing you to work more efficiently and with less stress.

You may not know what cognitive load is, but if you work in an Emergency Department (ED) you are probably carrying a ton of it.  Cognitive load refers to the total amount of mental effort burdening your working memory at any given time. Working in an ED can involve extremely high cognitive load, and learning to understand and manage it can make you more efficient and less stressed on shift. In the field of ED management, the ED bed is often described as the ‘Million Dollar resource’. If that is true, then the cognitive machinery of the Emergency Physician has to be the ‘Billion Dollar resource’. Ventilators have some complexity and your EMR can hold and manipulate a generous amount of data (when it works) but by far and away the most complex and valuable piece of equipment in the department is resting between your ears. Intuitively you are probably aware of the individualized capacities and limitations of the caffeine-powered intracerebral supercomputer that you expertly operate during your shifts. However, it is important for the working ED physician to understand the cognitive science behind how that well-trained and maintained machinery deals with (or not) the demands of the work that we do.

The mind of the ED physician at work relies heavily on memory. You may already be familiar with the basic Atkinson and Shiffrin (1) model of memory that includes three primary sub-systems (sensory, working, and long-term memory). Sensory information is stored in sensory memory just long enough to be transferred to short-term memory allowing us to retain impressions of sensory information after the original stimulus has ceased. Long-term memory is a nearly unlimited store where retrievability and accessibility constrain use rather than shear capacity. Working memory is different from the other two in that it is severely constrained by a small storage capacity, and yet it is absolutely vital to learning and performing tasks. It is a single limited cognitive resource that we rely on in a work environment with seemingly unlimited demands.

Excessive cognitive load can lead to psychological stress, which may be defined as the state that occurs when the demands of a situation outstrip our perceived ability to cope with it (2). The nature of ED work can often place a cognitive load on physicians that is beyond our innate ability to process, which can result in errors and stress. There has been a growing interest in Emergency Medicine in recent years on personal organizational efficiency, and these strategies often have the effect of reducing the cognitive load on working physicians. We also learn by hard-won experience to ameliorate the excessive demands of our work by employing learned strategies that temporally distributes that load, but it’s hard not to get overburdened sometimes on shift.

In Miller’s (1956) seminal ‘Magic Number’ paper (3) he found that most people can only hold 7 +/- 2 units of information in their working memory at any given time. In contrast to a limited working memory, there is an almost unlimited long-term memory holding cognitive schemas constructed during the learning process and these are the schemas that give rise to expertise. You could think of these schemas as files in your memory holding nodes of learned information such as ‘EKG findings in pericarditis’. In reality, memories are probably distributed in interconnected neural networks but thinking of them as files in a filing cabinet is a helpful image.

In building on Miller’s work, John Sweller developed cognitive load theory (CLT) (4) in the 1980s. CLT was designed to help optimize learning by considering the effect of how information is presented to learners and it’s resulting effect on intellectual performance. As with Miller’s work, it emphasizes the inherent limitations that working memory load places on your ability to process information.

Sweller’s theory goes on to break cognitive load into three subcategories: intrinsic, extraneous and germane cognitive load.

1) Intrinsic cognitive load is the inherent level of difficulty associated with a specific problem and cannot easily be altered. Adding 239.1 + 67.56 is just intrinsically harder than adding 2+2, although it is possible to reduce the cognitive burden of the first equation by breaking it up into steps. Similarly, the dizzy old lady with multiple co-morbidities is just intrinsically more challenging for an Emergency Physician than a young healthy male with bronchitis. That assumes, of course, that the assumption of diagnostic simplicity is not itself the beginning of a cognitive error!

2) Extraneous cognitive load is vital to understand as an Emergency Physician. This load is made up of distractions and unnecessary processing requirements that take up room in your precious, limited and heavily taxed working memory. The goal for the EP is to keep this precious resource clear and available for the type of high-end processing that makes us valuable, such as the initial assessment of a complex patient, the making of clinical decisions and the ability to maintain situational awareness. These situations should not have to compete in real time for processing capacity with thoughts about your house repairs, the latest cat video you watched on YouTube, or even thoughts about non-emergent work items.

3) Germane cognitive load is that load devoted to the processing, construction, and automation of schemas. We construct new schemas in working memory so they can be integrated into existing knowledge in long-term memory. These schemas represent successful learning; they can be retrieved, added to, and used for further problem solving. As our medical expertise expands through clinical experience and training, schemas change so that relevant tasks can be handled more efficiently by working memory. Being an active learner and investing in your knowledge therefore increases your efficiency on shift. CLT as a learning theory is ultimately about diverting cognitive processing power towards this germane cognitive load by reducing the other two.


Now for some board prep. Which one of the following is the best way to detect an emergency physician’s cognitive load during a shift?

  1. An assessment of skin translucency over the MCPs during coffee cup grip.
  2. When today’s total number of new job searches (completed on shift) is equal to your raw score on the Maslach Burnout Inventory.
  3. Task-invoked pupillary response.
  4. Number of complaints currently being filed against you by patients and nurses.

If you have no idea of the answer, circumvent the intrinsic cognitive load of the problem and just pick C! It would be surprising if muscular tension, interpersonal problems and burnout did not correlate with a chronically high level of cognitive load, particularly if it causes psychological stress. However, the evidence shows that greater pupil dilation is associated with high cognitive load and pupil constriction occurs when there is low cognitive load (5,6), implicating stress physiology in our response to demands on working memory. It is also possible to measure cognitive load by examining ‘relative condition efficiency’, which combines subjective ratings of your mental effort and objective performance scores on a given task (7). A third ‘ergonomic’ approach uses the product of your heart rate and blood pressure as an estimate of load (8), which again reminds us that our physiology changes with load, and that there is a physical cost to carrying the cognitive burden of our work.

These measurement tools are helpful for researchers but are not accessible moment to moment on shift. There might be comedy value in having a staring match with yourself holding a make-up mirror at the bedside while trying to take your blood pressure with your free hand, but I think the efforts at measurement would themselves represent unacceptable levels of cognitive load. Therefore, we will focus on management rather than measurement, and hope that increased knowledge of cognitive load theory will bring with it greater self-awareness of its effects.

According to Clark et al (2006) the goal with CLT is to reduce the extraneous load, maximize the germane load, and manage the intrinsic load (9). So how do we convert this knowledge of cognitive load into workable solutions on shift? While the theory was originally developed for educationalists, I believe that it is directly applicable to our work in the ED whether we are teaching, learning ourselves, or just trying to get through the day. In the next section, I will outline 16 simple strategies that the working emergency physician can use to help reduce and manage the cognitive load of our unique work environment.

16 Strategies for Dealing with Cognitive Load

  • Take advantage of external memory – use written or typed lists as an extension of your working memory. Patient lists can allow you to track multiple bits of information without the stress of having to hold them in memory. They can be used to track care to disposition and ensure your paperwork is done. Smart EMR design can help here and designers of EMRs could improve systems for EPs by being focused on reducing extraneous load. Frequently EMR programming uses computational steps that make sense from a software design point of view, but may actually involve a shift of processing demand from the software onto the physician’s cognitive processing load. EP’s should be actively involved in EMR design to ensure the software is smart enough to help reduce our cognitive load.
  • Minimize interruptions – Be a gatekeeper for your working memory. Just as you triage patients; you must triage the competing extraneous demands on your limited resource. One way is to try to minimize interruptions. Chisholm et al (2000) noted that we are interrupted every 6 minutes and have a ‘break in task’ every nine minutes, with a correlation between these events and number of active patients (10). This can lead to clinical error. Interruptions will inevitably occur, but if necessary politely defer unimportant ones, delegate to a junior or keep a list of started but uncompleted tasks to unload your memory.
  • Use simple algorithms on shift if you can’t write it on the back of a postage stamp, don’t bother, you won’t remember it when it matters. Complexity = increased intrinsic cognitive load.
  • Use aids without guilt – An example is the need to remember formulae that you use infrequently, it’s harmful to try. Use an online tool on your phone without guilt because you, my friend, are not looking it up because you can’t remember, you are looking it up because your working memory works in America and loves freedom. Another perfect example of this is the use of the Broselow tape. In children, cognitive load is increased by the unique component of variability of pediatric age and size (11). Remove the load; roll out the tape, turn on the app, or use MDCalc.
  • Front load to unload – be an active life-long learner and do your thinking and learning before you need to act or make a decision in the heat of battle. If you work hard off-shift to build schemas into your long-term memory, and pregame difficult decision scenarios, you will use up less processing power when it matters, when your fight or flight physiology is trying to rob you of your ability to use your working memory. Incremental increases in your expertise will help you manage intrinsic load and work more efficiently. This will in turn divert cognitive power towards increasing germane load, helping you to learn from your work.
  • Channel your supercomputer – listen to your intuition and answer the questions that it raises, this is the mark of an expert. Most processing is done without your conscious awareness in the interest of mental economy, we just evolved that way (12). That is why we can form impressions within seconds of seeing a patient. Also be aware, that this mental economy leaves us open to error, if things aren’t turning out the way your gut told you they would, reexamine your thinking carefully for common cognitive errors such as anchoring or early closure.
  • Reboot before starting – you need an unburdened mind at the start of your shift to prepare for the inevitable torrent. Working in the ED is the cognitive equivalent of taking a drink from a fire hydrant. If you arrive wound up about your taxes or a difficult interpersonal interaction you had an hour before your shift, you are likely to carry that extraneous load into your first patient encounter, and the second… In order to clear my mind, I meditate for at least 5 minutes before every shift (often in my car) and find that it prepares me mentally for the work ahead.
  • Use ‘When-Then’ and ‘If-Then’ thinking – where possible learn to use decision points in management as triggers, not opportunities for philosophical argument. An example would be Dr. Levitan’s call to use ‘when I can’t intubate or ventilate, then I will cric’. A simpler example would be, ‘if my patient is young and female with abdominal pain, then I will order a urine pregnancy test’. In behavioral psychology this is called ‘The Granny Rule’…’when you pick up all your toys, then you can go and play in the park’.
  • Control your patient volume hard to do I know, but sometimes pushing yourself to take that extra patient when you are stretched can lead to excessive cognitive load, and you, your new patient and your active ones are open to the effects of cognitive error. Eat what’s on your plate before serving yourself more.
  • Tune up your equipment – Faith Fitzgerald, a renowned internist was smoking a cigarette in a meeting one day when she reportedly said ‘Frankly guys, wellness bores me’. Many professional athletes report that having to constantly look after their diet and physical training can become tedious. However, they do it so they can perform at a high level. Be an ED athlete; give the job, yourself and your patients the respect you all deserve. Your cognitive equipment relies on a healthy well-perfused body. Turn up well fed, well hydrated, well rested, and having exercised and your mind and shifts will run smoother.

Please see the following source for more info on this aspect:

  • Use checklists where possible – for the same reason that you use online or physical aids, they free up your mind to think, reduce cognitive load, ensure high standards across changing clinical scenarios and improve patient care (13). A great example is Scott Weingart’s Intubation Checklist (14), (I have no financial interest in Dr. Weingart’s website, and it seems to his great credit neither does he, so we’re all good!).
  • Turn up your speakers – it can be helpful to talk and think aloud because group processing is powerful. Do this with your assembled resus team or one-on-one with a trusted colleague. It generates team cohesion, allows for closed-loop communication and avoids error. The decisions are always yours to make, but it’s ok to check your thinking. Learners also appreciate access to how you think, which is often more useful to their educational progression than simple information.
  • Learn to breathe – the emotions generated by the intensity and nature of our work are not vapors in the wind, they create physiology, cognition, and influence action. If you are anxious, angry, or trembling like a gun dog then your working memory and motor skills are taken over and unavailable to you. Even in a crowded resuscitation room, you can still discretely take a few tactical breaths, center yourself, connect to your body to anchor yourself in the present moment, broaden your awareness to include the room, and the situation you are in. Then act.   Please see the following for more information:
  • Close the loop – dispositions free processing capacity and reduce cognitive load, push yourself to close out cases in order to free your mind for the next challenge. Work hard to definitively finish with issues before moving on. As you move around the ED with tasks being fired in your direction you are like an elephant being shot at by little spears. You can keep crashing through the trees with a certain number of spears in your back but eventually if you don’t brush some off you will be brought to your knees.
  • Touch it once – If you are working on a chart or any other task, do whatever you can to complete it ideally in one go. This is a well-known efficiency principle that also reduces cognitive load. When I was growing up in Ireland my father and I would repair the stone walls on our farm and he taught me that once you pick up a stone, despite its shape, you should never put it back on the ground, find a spot on the wall for it, otherwise you’ll be picking up the same stone all day and, well…stones are bloody heavy.
  • Accept your limits – Unfortunately ‘Subitis Department Hominis’ is not a separate tougher species of human first discovered in a hospital basement 40 years ago, we are just a variant on plain old ‘Homo sapiens’. If you need to alter one of your own schemas due to a hard and surprising clinical experience, give yourself the time and honor to do so, before running headlong into your next patient. The physiological consequences of a stressful clinical encounter are significant and can last for days. This directly affects the working of your cognitive machinery.


We are all unique, and as such, we differ in our cognitive processing capacity. This difference also occurs within ourselves across time as we move from novices to experts. The experience and knowledge that helps us work intuitively from heuristics significantly reduces our cognitive load as we train, and marks out a key difference between the experienced attending and the junior trainee.

Many of us will work directly with residents, medical students or other learners, and they will experience a much higher cognitive load when dealing with problems that you as an expert can complete with hardly a thought. This type of intrinsic load is best dealt with by simple-to-complex ordering of learning tasks and working from a low-to high fidelity environment where possible (15). Interestingly CLT would recommend instruction that de-emphasizes traditional problem-solving, preferring worked examples that provoke the learner to actively explain the problem to themselves. This unburdens the novice learner so that processing can focus on building schemas in long-term memory. The idea is that the learner has to sweat too much to close the gap between the problem and the solution, and much of that load in traditional problem-solving is not devoted to building a retrievable piece of knowledge in long-term memory. The benefit of using more worked examples decreases with increasing expertise, and so the strategies that benefit your intern may be inappropriate for the senior resident.

This reminds us that learners are still constructing the memory schemas that you have already built with hard work and experience during your training. Allow time and support to recognize this reality for them, and for yourself. It is interesting to note that these learned strategies, so vital to our work, find no place in our current model of EM education, and are left to the variable abilities of physicians to put together themselves, which seems to be an important omission in our training.

Communication with ancillary staff and nursing colleagues needs to be clear, collegial, and patient-centered. Clear plans with defined end-points require very little additional cognitive processing. Regular paper or screen rounds with the charge RN can allow problems to be identified and resources to be distributed in ways that avoid sudden surges in demand on your cognitive capacity. Be aware that ED work is a true team sport, and there is a shared team cognitive load that needs careful distribution across members whose cognitive capacity varies, both between individuals and across time.

It is also important to consider the role of cognitive load in our patients. Princeton psychologist Eldar Shafir studies the brain on scarcity and his research group has shown that poverty significantly impedes cognitive function (16). It places a load on our limited cognitive resource that produces what Shafir has termed, ‘bandwidth poverty’. The constant need to focus on what you have a scarcity of, such as money or time, saps your attention and reduces effort. This reduces your ability to make decisions and may be detrimental in the long run.

This is an important fact to remember when providing effective and compassionate care to our patients who struggle with poverty. The demands of being financially stretched, disabled or homeless on a cognitive resource perhaps already limited by drug addiction, physical or mental illness and social isolation is very significant. It also directly affects our personal interactions with patients as we try to process complex social problems. Research has shown that the more cognitive load physicians carry, the more likely they are to allow preformed stereotypes about a patient’s race to influence their opiate prescribing and general medical decision-making (17,18). In addition, the bandwidth poverty described by Shafir’s team could impact our patient’s ability to follow-up with specialists, their primary doctor, or to comply with the advice and medication that we prescribe for them.


Many studies have shown that lack of sleep, stress and anxiety negatively affect our cognitive processing capacity and deplete our working memory. Studies of healthcare providers have found that higher levels of acute and chronic stress, fatigue, psychological distress, depression, and burnout are associated with a greater likelihood of making medical errors and providing suboptimal or poorer patient care (18,19,20,21,22,23,24,25).

Each shift can produce ‘bandwidth poverty’ as a consequence of the cognitive load placed on us. The science of scarcity tells us that we may be prone to thinking excessively about what we don’t have, such as adequate personal time, rest from work demands, time to process the things that impact us on shift, or just time to intentionally plan and develop our careers. This response to scarcity then negatively affects our ability to plan and make positive decisions.

The problems our cognitive machinery deals with on shift are often complex and this complexity won’t change. However, the expert deals with complexity quicker and with efficiency because time has been spent training to deal with them. According to Sweller, this intrinsic load can “only be altered by changing the nature of what is learned or by the act of learning itself”(26). In order to reduce intrinsic cognitive load on shift the EP must continually improve their experience, knowledge and skills, so that a difficulty today can be translated into a greater ease tomorrow. Part of this process is incremental and built-in to our training, but a large part of it is also the individual dedication we bring to bear on our reading, thinking and active processing of clinical experience. Work hard today, and you will be unburdened going forward. This is particularly high-yield in our field because of our exposure to repeated cardinal presentations that allow the active learner to build deep complexity over time into their knowledge schema’s of, for example ‘chest pain’, or ‘dizzy elderly female’.


A knowledge of cognitive load theory can help the overburdened emergency physician reduce their cognitive load, free up space in their working memory, and become more effective and less stressed. In this article, I have introduced the concepts of intrinsic, extraneous and germane cognitive load, discussed them in the context of emergency medicine, and outlined sixteen simple strategies that emergency physicians can start using today. The work we do is uniquely challenging, and learning the knowledge and procedural skills to be an emergency physician is only the beginning of understanding how to do our job well. We should routinely seek out and apply knowledge and strategies from other branches of science to aid us in our work, and I believe that these strategies should be incorporated into our practice and the training of emergency medicine residents.

References / Further Reading

  1. Atkinson RC, Shiffrin RM. (1968). Human Memory: a proposed system and its control processes. In: Kenneth WS, Janet Taylor S, editors. Psychology of Learning and Motivation. New York: Academic Press; pp. 89–195.
  2. Segerstrom, S. C., & Miller, G. E. (2004). Psychological Stress and the Human Immune System: A Meta-Analytic Study of 30 Years of Inquiry. Psychological Bulletin, 130(4), 601–630.
  3. Miller, G.A. (1956). “The magic number seven plus or minus two: some limits on our capacity to process information”. Psychological Review 63 (2): 81–97.
  4. Sweller, J (June 1988). “Cognitive load during problem solving: Effects on learning”. Cognitive Science 12 (2): 257–285.
  5. Buettner, Ricardo (2013). Cognitive Workload of Humans Using Artificial Intelligence Systems: Towards Objective Measurement Applying Eye-Tracking Technology. KI 2013: 36th German Conference on Artificial Intelligence, September 16-20, 2013, Vol. 8077 of Lecture Notes in Artificial Intelligence (LNAI). Koblenz, Germany: Springer. pp. 37–48.
  6. Granholm, E. et al (1996). “Pupillary responses index cognitive resource limitations”. Psychophysiology 33 (4): 457–461.
  7. Paas, F.G.W.C., and Van Merriënboer, J.J.G. (1993). “The efficiency of instructional conditions: An approach to combine mental-effort and performance measures”. Human Factors 35 (4): 737–743.
  8. Fredericks T.K., Choi S.D., Hart J., Butt S.E., and Mital A. (2005). “An investigation of myocardial aerobic capacity as a measure of both physical and cognitive workloads”. International Journal of Industrial Ergonomics 35 (12): 1097–1107.
  9. Clark, R. C., Nguyen, F., & Sweller, J. (2006). Efficiency in learning: Evidence-based guidelines to manage cognitive load. San Francisco: Pfeiffer.
  10. Chisholm, CD, Collison EK, Nelson DR, Cordell WH. (2000). Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med. Nov;7(11):1239-43.
  11. Luten R1, Wears RL, Broselow J, Croskerry P, Joseph MM, Frush K. Managing the unique size-related issues of pediatric resuscitation: reducing cognitive load with resuscitation aids. Acad Emerg Med. 2002 Aug;9(8):840-7.
  12. Gladwell, M. (2005). Blink, The Power of Thinking without Thinking. New York, NY: Little, Brown and Company.
  13. Gawande, A. (2011) The Checklist Manifesto: How to Get Things Right. Henry Holt and Company.
  14. Weingart, S. & Hua, A. (2014). An Intubation Checklist for Emergency Department Physicians. ACEP NOW. March ED: Vol 34 – No 3.
  15. Young, J. & Sewell, J (2015) Applying cognitive load theory to medical education: construct and measurement challenges. Perspect Med Educ. Jun; 4(3): 107–109
  16. Mani, A, Mullainathan, S., Eldar Shafir, E, Zhao, J. (2013). Poverty Impedes Cognitive Function. Science. 30 Aug 2013: Vol. 341, Issue 6149, pp. 976-980
  17. Burgess, D. (2010). Are Providers More Likely to Contribute to Healthcare Disparities Under High Levels of Cognitive Load? How Features of the Healthcare Setting May Lead to Biases in Medical Decision Making. Med Decis Making March/April 2010 30: 246-257.
  18. Burgess et al (2014). The effect of cognitive load and patient race on physicians’ decisions to prescribe opioids for chronic low back pain: a randomized trial. Pain Med. 2014 Jun;15(6):965-74.
  19. Landrigan CP, Rothschild JM, Cronin JW, et al. (2004).Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med; 351:1838–1848.
  20. West CP, Huschka MM, Novotny PJ, et al. (2006). Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA;296:1071–1078.
  21. Williams ES, Manwell LB, Konrad TR, Linzer M. (2007). The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev;32:203–212.
  22. Shanafelt T, Bradley K, Wipf J, Back A (2002). Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med;136:358–367.
  23. Firth-Cozens J, Greenhalgh J (1997). Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med;44:1017–1022.
  24. Dugan J, Lauer E, Bouquot Z, Dutro BK, Smith M, Widmeyer G (1996). Stressful nurses: the effect on patient outcomes. J Nurs Care Qual;10:46–58.
  25. Shirom A, Nirel N, Vinokur AD (2006). Overload, autonomy, and burnout as predictors of physicians’ quality of care. J Occup Health Psychol;11:328–342.
  26. LeBlanc VR, MacDonald RD, McArthur B, King K, Lepine T. (2005). Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator. Prehosp Emerg Care; 9:439–444.
  27. Van Merriënboer JJ, Sweller J. (2010) Cognitive load theory in health professional education: design principles and strategies. Med Educ. 2010 Jan;44(1):85-93.