The Art of Decision Making: Emergency Medicine Style

Author: Justin Bright, MD (@JBright2021; EM Senior Staff Physician, Henry Ford Hospital, Detroit, MI) // Editor: Alex Koyfman, MD (@EMHighAK)

It’s 3pm on a Monday after a holiday.  The department is bustling, and you feel like there are patients crammed into every conceivable space.  Alarms are going off on patient monitors.  You’re in the midst of discussing a case with a resident when a nurse puts an ECG in front of you to review and sign.  Just as you finish reviewing the ECG, you turn back to your resident, only to get a phone call from the radiologist notifying you of an abnormal finding on another patient’s CT scan.  After looking through the scan, you help guide your resident through an appropriate plan and disposition of the patient they saw, and decide it’s time to round on a few patients you need to see.  As you rise from your chair, your EMS phone goes off, and you get word of a cardiac arrest that will arrive in 5 minutes.  It’s just then that you realize you have to pee so bad it hurts.  Sounds like a typical emergency department shift for many of us, doesn’t it?

When I was asked to write a post about how I make decisions in the emergency department, I started to think about all the decisions we make in a given shift.  Some are huge – decisions to end a resuscitation and when to intubate come to mind.  Others are just as important but occur so often that we don’t really think about it – examples include interpretation of lab results and disposition decisions.  There are interpersonal decisions we make every day – when should we escalate an argument with a nurse or consultant, and when should we let it roll off our back and move forward?  Simple personal decisions also get factored in – when can I use the bathroom?  When should I find something to eat?  When do I need to take a lap around the ambulance bay to refocus?

It occurred to me that we make hundreds of decisions a shift.  We have become the masters of balancing multiple tasks and continuously reassessing and reshuffling what is most important.  Our brains process so many different stimuli that it feels like we’re Russell Crowe in “A Beautiful Mind” as equations are floating all around him.  But, how did we learn to do this?  How did we evolve from an intern on July 1 struggling to handle the details of managing one patient to an attending physician capable of smoothly running an entire department while being bombarded from all sides?

While we are trained life savers, the number of patients we see on the verge of death is few and far between.  I would argue that the biggest thing we do as emergency medicine physicians is decide who is sick enough to stay in the hospital and who ultimately is well enough to go home.  This is your “Spidey sense” – your innate ability to sense that something is wrong.  I believe that 85% of the time, I have made my disposition decision on a patient before I’ve said a word to them – based on chief complaint, age, vital signs, risk factors, and how the patient physically looks when I walk in the room.  Of course, testing is important, but we definitely send home patients with abnormal test findings, and we admit patients with perfect tests.  Deciding your disposition up front allows you to efficiently work towards a defined end point without repeatedly chasing your tail.  The caveat being, you cannot anchor on the disposition you just set.  You must allow room for the patient to declare themselves – sometimes a period of observation, some additional information, or a particular intervention dramatically changes your view of the patient.

When I walk into a room, I mentally say to myself, “is this patient going to die right in front of me?”  If the answer is “yes,” then I go into ABC/ACLS/ATLS mode.  If my answer is “no,” then I ask myself, “is this patient sick enough to stay, or well enough to go?”  If they are going to be admitted, then I need to figure out what tests to order so I can initiate treatment.  I am also trying to make the patient look appealing to the provider who will be accepting her for admission and to the insurance company that’s going to pay for it.  If the patient is going to be discharged, then I need to figure out what the worst possible conditions are based on the patient’s chief complaint, and come up with a way to systematically cross them off the list so I can feel warm and fuzzy about discharging them home.  In addition, I need to figure out how to make the patient feel better and anticipate resources they may need post-discharge.

There are definitely patients that fit perfectly into diagnostic boxes.  Classic crushing substernal chest pain with radiation to the left arm with shortness of breath, diaphoresis, and ECG changes.  Back pain with clear cut neurologic changes.  Septic patients with clear source and characteristic vital signs.  We don’t miss those.  We miss the atypical presentations.  The subtle variations.  The patients coming in saying one thing is wrong when after examining them, clearly they have a whole other issue altogether.  How do we sift through it all while the department is bustling all around us?  I find that I am constantly trying to resist algorithmic or cookbook medicine.  I want to be the one person in the room who asks, “Could this be something else?”  I find this to be particularly important in time-sensitive cases where everyone is focused on getting things done as quickly as possible.  I have caught aortic dissections in supposed STEMIs that way.

Sometimes I feel like Sherlock Holmes piecing subtle clues together.  Focusing on chronology is important.  A lot of times the story the resident or student tells me just doesn’t add up.  They do a great job telling me about the symptoms, their location, and severity.  But what they often forget to figure out is, why are they in the ED today? This is particularly true if an issue has been going on for more than a few days.  The longer a symptom or issue has persisted, the more curious it becomes on the day the patient finally comes to the ED for an evaluation.  I have come to realize that the most important question I ask is, “If these symptoms have been going on for X days/weeks/months, what was it about today that made you decide to get it checked out?”  You can really get to the crux of the issue that way.  Did the symptom get worse?  Did their spouse finally find out about it?  Did they read something on the internet or hear something on Dr. Oz?  Asking that question can really help define your end point with a patient with symptoms that you can’t cleanly put into one box.

In the end, I think our innate “Spidey-sense” comes from melding intellect, preparation, and experience together into a cohesive thought process.  We become excellent multitaskers by constantly pushing our boundaries of what we can manage.  I tell my residents to keep picking up patients until they feel like they’re on the verge of spinning out of control.  The goal is to continually push that breaking point.  The more we are exposed to, the less shocking it becomes.  We learn how to delegate so we can figuratively be in more than one place at the same time.  Without even realizing it has happened, we learn how to read an ECG while on the phone with a radiologist while also eyeballing the next patient getting wheeled by our desk.  The chaos of the department runs in slow motion.  We see things less experienced providers do not.  We evolve from novice interns to seasoned veterans.  We are emergency medicine physicians.  We keep coming back for more because amongst the bedlam is where we feel most at home and most in control.