The classic model of history, physical, testing, diagnosis & treatment does not apply to us. I think we do 3 things in emergency medicine:
- Risk stratification
- Care coordination
Resus is the fun sexy stuff that we stay up late at night having twitter arguments about. As much as I love ketamine, I can go a number of shifts without using it, and very little of what we do is resus. Most of what we do is risk stratification and care coordination. Syncope or ACS are good examples: what are the odds that this patient’s symptoms were caused by something dangerous? Is it high enough that they need to be admitted for more workup and monitoring, or can they go home and follow up with their cardiologist? Do I need to call their cardiologist and make them an appointment, or is the patient reliable and the risk low enough that the patient can call themselves tomorrow?
I never use low-acuity diagnoses like costochondritis or gastroenteritis or gastritis. My job is to tell the patient what they don’t have – “I don’t think your chest pain is from a heart attack or a blood clot or anything else dangerous; it’s safe for you to go home and follow up with your doctor in a few days.” The diagnosis is still “chest pain, but safe to go home now” – calling it costochondritis can only get me in trouble.
I work in 3 speeds:
- Patients with simple problems (sore throats, URIs)
- Patients with potentially dangerous problems (chest pain, belly pain)
- Get out of my chair now and stay within 10 feet of the patient (altered mental status, acute resuscitation, etc).
I try to listen to my nurses when they are hinting that I should be at #3 when I’m not. Nurses spend a lot more time with the patient than I do, and their assessment is important and usually more accurate than mine. If the nurse is worried about the patient, I want to know why.
It’s nice to be parsimonious but remember that it’s the first lab or xray that matters. If the patient is already getting a knee xray or basic chemistry, don’t waste time deciding on whether or not they need a tib-fib or LFTs – if you have to spend more than 10 seconds thinking about the second xray or lab, just order it. Your time spent thinking about it is much more expensive than that second lab. The major decision is who needs labs or xrays, not how many once they’re on that pathway.
The 3 levels of patients generally correlate with what level of resources the patient needs. I try to not get labs or spend more time than necessary with the 1s; but once they’re a 2, it doesn’t matter if they get 4 labs or 5 labs. For the level 3s, the only real question is where/who the patient will be admitted to, and what do I need to do make that happen (and give the patient the best chance of surviving).
If I spend more than 5 minutes deciding whether the patient needs to be intubated or admitted to the MICU, then they need it. MICU patients can always be downgraded, but there’s a reason why MICU upgrades are “sentinel events” (or whatever buzzword we use now).
I am busy all the time and therefore anything that isn’t important or isn’t helping is taking me (or the nurse) away from something that is important. This works on a few levels:
- Patient specific – for example: in a UGIB, if the nurse is busy setting up a PPI drip, then they aren’t transfusing blood.
- Between patients: for example, patient A’s unnecessary CT makes patient B wait for their necessary CT.
The less subjective information I can get, the more objective information I need. If the patient is altered or developmentally delayed or in police custody or a victim of assault, I err on the side of more testing.
I try to admit the patient when I’m 80% sure that patient is on that trajectory – I don’t worry about tying them up in a pretty little bow. The resident or hospitalist can check the non-essential lab results, and very few trajectory-changing surprises happen. Skate to where the puck is going to be. And talk to them about what has and hasn’t been done (“I haven’t had time to call Renal, but they shouldn’t need dialysis until tomorrow, are you going to be able to call?”), or what else is on the differential that hasn’t been closed yet.
I try to let everyone know what is going on and where the puck is going. Most patients really only have 2 or 3 things between them and dispo, so I try to make sure everyone knows what the priorities are so that the urine gets collected and the lactate gets sent, etc. For example, a patient with pneumonia needs their CXR, labs (really just creatinine and lactate), antibiotics, and fluids. Other things will happen, too, but make sure the cardinal things happen first and that everyone knows what those cardinal things are.
Doing things half-assed gets me in trouble. I use more local anesthetic than I think I will need. The road to getting mired down in a 2 hour long failed procedure starts with “oh well I can probably just do…” I try to do it right the first time, particularly positioning the patient and myself. The more I prepare, the luckier I get, especially with airway management, particularly positioning the patient and myself.
If your asthma is bad enough to see me, you (nearly always) get 3x duonebs + steroids. Won’t hurt.
I try not to ask consultants questions. Usually what I need from them is something I don’t have: an inpatient bed, a clinic appointment, an OR, a special tool, and the skill to use it.
Some last tips:
-Nobody uses non-invasive ventilation enough, nor early enough. It’s simple, non-invasive (right there in the name!), can always be stopped, and can very quickly alter the trajectory of a sick patient. And if the patient fails NIV, they have declared themselves very, very sick in a way that is impossible to argue with.
-When in doubt, I intubate, run the board again, or start all over from scratch and talk to the patient again
-I never tell a patient how long something will take. I specifically tell them “I’m intentionally being vague because I don’t know how long it will be.” This is particularly important for how long it will take to go upstairs and how long they will be admitted for.
-There should be no task, procedure, or activity that goes on in the ED that you can’t perform while calmly chewing gum*. Except chest compressions.
-Be nice to everyone: it makes everyone’s day better and it pays off.
–Remember: the patient is the one with the disease, and when they see me, it’s usually the worst day of their life. Frequent fliers get sick and die, too.
-Do what’s best for the patients (plural): not only is it the right thing to do, but also people will recognize it (and you’ll get to win more, too).
*but don’t actually chew gum at work.