Lex 45 years on the front line

Emergency Medicine

Front Line Tales: Front Line Tales: Been There, Done That Been There, Done That

for 46 Yearsfor 46 Years

Joe Lex, MD, FACEP, MAAEMTemple University School of Medicine

Philadelphia, PA

Rules to Live By

Rules to Live ByRules to Live By

� Be curious: find out exactly how and why events happened

� Do not accept diagnoses and conclusions made by others

� Recognize the patient as teacher


� Form your diagnostic hypothesis, then focus on signs or symptoms that are atypical or incompatible with your diagnosis

� These must be explained, not ignored


� Savor your successes but then move on: dwelling on them causes overconfidence


� Learn from your failures but then move on: dwelling on them causes indecision


� Good judgment is based on experience

� Experience is based on bad judgment


� Some patients you think will get better will get worse

� Some patients you think will get worse will get better

� Some young people die unexpectedly

R – E – S – P – E – C - TR – E – S – P – E – C - T

� Respect your colleagues: Be on time for work

� “On time” means 10 minutes early� The third time you are late will get

you a reputation that’s hard to shake


� Most people in the hospital are afraid of, or intimidated by, the ED and everything that goes on in it. It can be a frightening place – think of your first time there.

““What’s the Diagnosis?”What’s the Diagnosis?”

� Non-ER doc: “How in the world do you expect me to take care of someone without a diagnosis.”

� ER doc: “Yeah, I treated her and she got better…but I still don’t know what she has.”

In Other Words…In Other Words…

� Medical school teaches most doctors to figure out “What does this patient have.”

� Emergency medicine alone says “What does this patient need … now, in 10 minutes, in 1 hour, and beyond.”


� Practicing Emergency Medicine is like living a life: it’s hard for everybody but it’s a lot harder if you’re stupid

� READ!! Every chance you get

Patient Care

Develop Good RapportDevelop Good Rapport

� Shake hands with and introduce yourself to everybody in the room, even the children

� Ask who is who: NEVER ASSUME RELATIONSHIPS– The “granddaughter” may be a

spouse, the “mother” may be a cousin


� Sit at patient’s bedside to collect a thorough history

� Do not hover or loom over a patient; get your eye level to theirs or lower

� Perform an uninterrupted physical examination


� Establishing relationship with patient: not just good manners

� It enhances trust and confidence� It reduces medicolegal risk� It facilitates rapid discharge� It improves patient compliance


� Include family members in the history gathering

� Physical contact helps establish rapport

� Inform them if you are using a validated clinical decision rule that indicates if tests are necessary

Some More RulesSome More Rules

� You can’t sleep through peritonitis� You CAN sleep with a pain that is

“10 out of 10”

– It’s called “escaping the pain”

Gordon’s Law #65Gordon’s Law #65

Never refer to a patient as an organ or a room number

It has to do with…

…courtesy

… respect

…humanity

…manners

Watch Your WordsWatch Your Words

� To most patients, PCP is a street drug, not Primary Care Provider

� Many older patients are horrified at taking “narcotics,” but willingly take an “opioid pain reliever”

� 99% of patients think “gastritis” is gas


� Ask “Is there any medicine you can’t take?” rather than “Are you allergic to anything?”

� Ask “Is there anything you take every day” rather than “What meds do you take?”

� Always look at Medic Alert bracelets or necklaces


� You have been taught to ask the patient, “Is there anything else?”

� Instead, you should ask “Is there something else.”

� This simple change in words will open up worlds of new information


� We don’t take care of “cases,” we take care of patients

� Patients on dialysis are not “renal players”

– It’s not a sporting event� If you wouldn’t say it in front of

the patient, don’t say it in front of me


� We are human beings who use our senses: we see a rash, hear a murmur, smell a wound, feel a mass

� We appreciate a good night’s sleep, a well-written novel, a thoughtful play, or a gourmet meal

Ordering TestsOrdering Tests

� Before ordering a test, determine how the result will influence care

� Investigations that will not improve patient outcome are a waste of time and money

� Likely to increase anxiety or provide false reassurance


� Don’t “screen” with cardiac biomarkers unless you intend to repeat the assays after a time

� Don’t send d-dimer unless you plan to follow-up a positive study

� Don’t send BNPs� Understand the limitations of tests


� Example: “positive” CT pulmonary angiogram in no-risk / low-risk twice as likely to be false-positive as it is to be true-positive

� Positive CT pulmonary angiogram is life changing event


Understand these concepts

� VOMITVOMIT – Victim Of Medical Imaging (or Investigational) Technology

� BARFBARF – Blind Acceptance of a Radiologic Finding


� Every positive test must be further investigated

� By definition, one of every 20 tests ordered will be “abnormal”

VOMIT and BARF ReduxVOMIT and BARF Redux

� Patient requests more NSAIDs for long-standing osteoarthritic low back pain

� Doc does lumbar x-ray bits of aortic calcium, not in round shape

� Radiology comment “AAA cannot be excluded: suggest ultrasound if clinically indicated”


� No clinical evidence of AAA� US done, rules out AAA…� …but US shows “small cystic

lesion adjacent to kidney, probably benign but suggest CT if clinically indicated”


� No renal signs/symptoms but CT duly done “2-3 cm cystic lesion upper pole right kidney, probably benign, malignancy not excluded”

� Urology referral duly done: “Probably benign but a small chance it COULD be CANCER”


� Patient says, “Take it out take it out take it out.”

� Cyst removed major bleeding� Re-operation nephrectomy,

packing, transfer to ICU


� Packs out on day 2� In ICU for 3 days� In hospital for 10 days� Now has one kidney…

…but the benign cyst is gone

…and now he can’t take NSAIDs any more

Make a Decision in 4 HoursMake a Decision in 4 Hours

� Recognize the limitations of the ED: we provide episodic acute care to our patients

� Enable a diagnostic strategy that provides you with the information you need to make a decision by four hours into the patient’s visit

Make a Decision in 4 HoursMake a Decision in 4 Hours

� Beware of asking a patient a question if you do not want to deal with the answer

� Order the necessary tests early � Only order tests that will affect the

patient’s management in the ED

Don’t Delay UncomfortableDon’t Delay Uncomfortable

� Recognize situations where an uncomfortable decision is inevitable, and where waiting or doing tests will not make it more palatable. Make that decision as soon as possible.

Concept of “Emergency”Concept of “Emergency”

� If a patient adds non-urgent problems to the main complaint, politely avoid attempting to solve these problems

� An analogy to phoning their accountant or lawyer at 2 am may help

Consultants

Know Your ConsultantsKnow Your Consultants

There are three primary reasons to call a consultant:

� You need help or advice� You want to learn something� You want the consultant to

observe the same phenomenon you are seeing


The two biggest mistakes we make when consulting consultants:

� We believe everything they say� We believe nothing they say

Put the opinion in perspective: the physician hasn’t been born who is always right or always wrong


� If you develop good relationships with consultants, patient transfers are likely to be quicker, leaving you with more time for resolving other issues

Admission DecisionsAdmission Decisions

� You decide which patient requires admission

� You decide which service should care for the patient

� Your consultants are motivated to minimize their workload and will expend much energy to do so

CommunicationCommunication

When communicating with a consultant, in first minute give…

…bottom line: condition & acuity

…short patient profile

…your clinical impression

…what the patient now requires


� Honesty and integrity are keystone to effective relationships with colleagues and consultants

� In cases of conflict, keep conversation focused on patient


� Do not consider recommendation of outpatient management simply because “there are no beds”

� Avoid putting consultants’ schedules above patient needs and ED flow issues

Make Consultations ClearMake Consultations Clear

� If your normal conduct is to make clear, focused, appropriate consultation requests, you will build a bank of goodwill on which you can draw when you simply have no time for intensive, time-consuming workups or procedures

Make Consultations ClearMake Consultations Clear

� It is inexcusable to call a consultant and say “I don’t know much about this patient…it was a sign-out.”

� Have the chart in front of you and know the results of diagnostic studies

Gordon’s Law #47Gordon’s Law #47

The quality of the x-ray ordered is directly proportional to the

specificity of the clinical information supplied to

the radiologist.

Don’t Delay ReferralDon’t Delay Referral

� If consultation or admission is apparent prior to testing, don't wait for results unless they will determine management

� Notifying consultants that referral is imminent helps them choreograph the day

Consult from AuthorityConsult from Authority

� If flow is backed up, as it often is, it is inappropriate to allow junior staff with no decision-making power to be the consulting service’s first response. Trainees can see new patients on the ward.

Consult from AuthorityConsult from Authority

� Patient care trumps education, and teaching “need” should not delay the transfer of patients to available beds.

Other Tips

Surfing vs. Cherry-PickingSurfing vs. Cherry-Picking

� “Cherry picking” is looking through charts and picking up “easy cases” not encouraged

And Another Thing…And Another Thing…

� When in doubt, wash your hands

Communicate with RNsCommunicate with RNs

Rule #1: Nurses can hurt doctors far worse than doctors can hurt nurses

Rule #2: You may be a brilliant young doctor, but you are a transient. Most nurses are permanent employees. Know your place.

Use the NursesUse the Nurses

� Listen to the nurses and respect what they have to say

� Sometimes nurses are right and sometimes nurses are wrong… just like you

� Learn the first name of the nurses who work with you and call those who prefer it by their first names

UnderappreciatedUnderappreciated

� The most underappreciated member of the ED is usually the ward secretary

� The respiratory therapist is a close second

� Environmental is right up there: think about what they do without complaint daily

Death NotificationDeath Notification

� The hardest thing you’ll do in emergency medicine is to notify a family of a family member’s unexpected death; nothing else is remotely as difficult

MultitaskMultitask

� If you know that a patient will need more than one dose of pain medicine (e.g., sickle cell vaso-occlusive crisis, renal colic), order the pain medicine on a “prn” basis and empower the nurse to make the patient comfortable

Avoiding BouncebacksAvoiding Bouncebacks

� Reasons to make a patient do laps around the Emergency Department before discharge– Nosebleed– Shortness of breath / asthma– Vertigo

– Back pain

Evaluating BouncebacksEvaluating Bouncebacks

� Red flag and golden opportunity� Assume every bounceback

means something was missed on the prior visit

� Don’t get anchored on prior visit; start fresh

Don’t Ignore Abnormal VSDon’t Ignore Abnormal VS

� Child who is tachypneic may have pneumonia, despite no cough

� Patient who becomes hypotensive following a traumatic injury is not having vasovagal episode

� Don’t assume anything� Don’t ignore anything

Don’t Take ShortcutsDon’t Take Shortcuts

� You will miss petechial rash in infant with fever

� You will miss strangulated inguinal hernia or testicular torsion

� You will miss zoster lesions� You will miss Fournier’s in the old

guy in a diaper

Don’t Wait for ConsultantsDon’t Wait for Consultants

� If you think meningitis, give antibiotics first and do lumbar puncture later

� If you think an elderly person has pneumonia, give a big dose of an IV antibiotic as soon as possible– It doesn’t really matter which one,

just give something

Don’t Be Health-Care PoliceDon’t Be Health-Care Police

� Know cost of tests you order� Be conscious about appropriate

resource utilization� If you think test appropriate, do it� Don’t let colleagues dissuade you

from ordering a test just because it’s will inconvenience them

Beware the DrunkBeware the Drunk

� Both history and physical examination in an intoxicated patient are completely unreliable

� Over-investigate these patients� To rule out subdural hematoma,

one CT scan is better than a room full of neurologists

The Good NewsThe Good News

� As you gain experience in the ED, you will learn answers to many, many questions

The Bad NewsThe Bad News

� There are more questions without answers than with

� The number of questions without answers never stops growing

The Bad NewsThe Bad News

� Medicine is an infinite jigsaw puzzle: the best you can do is put an occasional piece into place

And finally…And finally…

� Data are not facts� Facts are not information� Information is not truth� Truth is not knowledge� Knowledge is not wisdom

Words to Live ByWords to Live By

“Has any man ever obtained inner harmony by pondering the experience of others? Not

since the world began. He must pass through fire.”

- Norman Douglas

Ars Longa, Vita BrevisArs Longa, Vita Brevis

“Life is short, art (of medicine) is long; the crisis fleeting; experience perilous, and

decisions difficult.”

- Hippocrates

An incredibly accurate description of Emergency Medicine

Lex 45 years on the front line

Education