EM Thinker: Pearls From The Frontlines

Authors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Following in the footsteps of the EM Mindset and EM Collective Wisdom series, emDocs is proud to introduce The EM Thinker series. This series will provide important considerations for the practice of emergency medicine.

1) Beware geographic bias. Needles in haystacks exist in the designated lower acuity area.

2) Decision making rules are good to know, but they shouldn’t replace experienced clinical acumen. Know limitations / pitfalls of the rules you’re using. Have a peripheral brain to look things up: MDCalc.

3) If the patient can’t acutely ambulate, keep digging and don’t discharge in a wheelchair or with a cane.

4) Discharge instructions matter, as we see a lot of embryonic disease. Get good at them: succinct, easily understandable, action and time specific.

5) It’s ok to admit the patient prior to all labs resulting and with a working diagnosis. Not every patient can be delivered in a gift box with a red bow and golden flakes sprinkled on top.

6) Sometimes the best option for follow-up for our patients is to return to the ED for clinical re-exam. If you’re working in that timeframe, let them know.

7) Some patients simply want to be heard and for their fears allayed. Not each case requires a myriad of orders behind a computer screen. We mostly perform reassurance, while training our minds in resuscitation and differential diagnosis.

8) Understand why your patient isn’t taking his/her medication(s). Don’t judge, be creative: call a close family member, engage Social Work, find online pharmacy coupons, pick generics, etc.

9) In an era of metrics and faster/better, it’s ok to pump the brakes and allow the patient more time in the ED to arrive at diagnostic clarity. Your first evaluation is a single point on the timeline of a disease course. One of the luxuries we have is for the patient’s pathology to declare itself.

10) Think twice about diagnosing the elderly patient with constipation or gastroenteritis; consider deadly mimics. These patients have much higher rates of surgical disease and morbidity/mortality compared to other populations.

References / Further Reading







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