EM Thinker – Hollanderisms
Author: Judd Hollander, MD (@juddhollander) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)
Welcome back to The EM Thinker series! Today, we have the privilege of hosting thoughts from Judd Hollander, or ‘Hollanderisms’.
1) Sick or not sick. That is the question. Every blog about emergency medicine should begin with that statement.
2) Have your head (and your body) in the ED when you are in the ED. When you have non-clinical responsibilities, they should only happen during non-clinical times. Patients count on you to have a clear head and have it near them.
3) Only do if-then tests. If both a positive and negative test lead to the same next step, skip the test. If you are getting a CT on a stable patient and aren’t going to skip it regardless of the ultrasound results, that time (and money) is better spent seeing the next patient, rather than getting the ultrasound on this one.
4) Procedures are fun but not without risk. If your patient doesn’t need a central line don’t be spending time and associated risks putting one in.
5) You cannot do everything for everybody. That includes patients as well as consulting or admitting teams. When you have to choose between competing priorities, make sure the patients always win, including those in the waiting room. Manage the whole ED. Do what you need to, then move on to the next patient.
6) Sometimes the simplest things are the things that have the largest impact. The 2cm facial laceration that you squeeze in between patients stays with that patient for the rest of their life. Every day, every time they look in the mirror, every time someone else looks at them.
7) Get patients naked. See their skin. Sometimes you find surprises. Picked up 4 petechiae on an ankle in someone with epigastric pain – no fever, no headache. Turns out they evolved to being clear cut meningitis. Luckily hadn’t discharged her due to the skin findings. Those surprises sometimes save lives.
8) Don’t make up diagnoses. If you aren’t 100% sure, send them home without a diagnosis. The diagnosis lives in the medical record forever and will stop other people from thinking further about these symptoms. It’s diarrhea – not gastroenteritis. It might just be Crohn’s. Keep the door open.
9) Our job is not to make the diagnosis – it is to determine the next action and make sure we don’t miss a critical step. We don’t always know what’s wrong, but we should know whether a test is needed, what test is needed, whether a consult is needed or whether the patient can be referred safely for outpatient care.