EM Thinker: Pearls from the Frontlines

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

Welcome back to The EM Thinker series. This collection will provide important considerations for the practice of emergency medicine.

1) Fluids are medications; be deliberate. Normal saline can still be used (in moderation). Lactated Ringer’s isn’t a magic bullet.

2) Elderly patient: occult EtOH / drug abuse is possible as well as prescribed medication misuse.

3) Don’t get frustrated with the “pan-positive ROS” patient. Verbalize to him/her that the symptoms don’t tie together well and ask them what’s most concerning to them. Also, make sure to consider high-risk / low-prevalence diagnoses (e.g. cervical artery dissection, endocarditis, spinal epidural abscess, toxic ingestion, etc.) as they may be a nice way to tie together all of the complaints.

4) Be honest with yourself and identify how your decision-making capacity changes over the course of the shift, during different shift times, and during different days of the week.

5) Items to keep in mind for the sick burn patient: 1) consider traumatic injuries; 2) consider toxicologic insults; 3) extremes of age – consider abuse; 4) burns evolve and you’re just seeing one snapshot in time; 5) be systematic in your airway approach each time // re-check the tube as resuscitation progresses; 6) fluid resuscitation is important / understand the harms of over-resuscitation.

6) An ED visit for an elderly patient is a big deal! They don’t recover and bounce back from illness/injury the same way a younger patient does. So, if you’re discharging the patient, make sure to set them up for success outside of the department.

7) Avoid calling sterile pyuria a UTI. Consider STI/PID, nephrolithiasis, appendicitis, etc. Interpret the result in the context of the patient and whether the patient has signs or symptoms of a UTI. This is especially true for your older patients.

8) Experience + reflection = development of safe and efficient care.

9) For high-risk/low-prevalence diseases (e.g. aortic dissection, spinal epidural abscess, etc.), create a mental roadmap of what will trigger you to consider them and how you will work them up.

10) For common ED diagnoses (asthma, pneumonia, etc.), create a list of mimics. For each patient, make sure to thoughtfully consider what doesn’t fit.

References / Further Reading:

PulmCrit – Get SMART

Amazon – An Emergency Medicine Mindset

Emergency Medicine Cases – Decision Making in EM

emDocs – Cognitive Load

Emergency Medicine Cases – Burn Inhalation Injuries

emDocs – UTI Pearls and Pitfalls