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 series will provide important considerations for the practice of emergency medicine. Today’s post provides pearls on a variety of topics including biases and cognition.

1) Always explain the etiology of an anion-gap metabolic acidosis. KULT is one approach.

2) Ambulate and PO challenge every trauma patient prior to discharge; occult injuries will declare themselves.

3) Ambulate every patient who presents with a pulmonary or musculoskeletal complaint prior to discharge. This “walk of life” is essential. It looks sloppy when you just discharged someone and they couldn’t walk out of the hospital.

4) Beware silent toxicologic killers: acetaminophen, salicylate, TCA, iron, etc.

5) Severe sore throat + benign posterior oropharyngeal exam, think epiglottitis, retropharyngeal abscess, parapharyngeal abscess, or Lemierre’s.

6) Anaphylaxis: use epinephrine early and often. If discharging, don’t forget about a script for epinephrine autoinjector and appropriate instructions on how to use it.

7) Little Old Lady Phenomenon: the elderly female makes or breaks your shift. The humor, stories, wisdom, kindness, and tincture of history are all worth it.

8) If you’re worried enough to pre-order labs/imaging, get out of your chair and see the patient.

9) Master delivering bad news. This will stick forever with patients and families.

10) A top-notch ED nurse is engaged and curious. By default, they spend more time at the bedside and may point out something you’ve missed that’s important. Set the tone of psychological safety and allow others to help you.

References/Further Reading:

Tox & Hound – Kults

EM Mindset

emDocs – Silent Killers

emDocs – Anaphylaxis

First10EM – Bad News