Lex 45 years on the front line

Emergency Medicine
Front Line Tales:Front Line Tales:
Been There, Done ThatBeen There, Done That
for 46 Yearsfor 46 Years
Joe Lex, MD, FACEP, MAAEM
Temple University School of Medicine
Philadelphia, PA

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

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

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.

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

Recommended

Recommended

More Related Content

What's hot

What's hot (14)

Similar to Lex 45 years on the front line

Similar to Lex 45 years on the front line (20)

More from SMACC Conference

More from SMACC Conference (20)

Recently uploaded

Recently uploaded (20)

Lex 45 years on the front line