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Emergency Medicine
Front Line Tales:Front Line Tales:
Been There, Done ThatBeen There, Done That
for 46 Yearsfor 46 Years
...
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
conc...
Rules to Live ByRules to Live By
Form your diagnostic hypothesis,
then focus on signs or symptoms
that are atypical or inc...
Rules to Live ByRules to Live By
Savor your successes but then
move on: dwelling on them
causes overconfidence
Rules to Live ByRules to Live By
Learn from your failures but then
move on: dwelling on them
causes indecision
Rules to Live ByRules to Live By
Good judgment is based
on experience
Experience is based on
bad judgment
Rules to Live ByRules to Live By
Some patients you think
will get better will get worse
Some patients you think
will get w...
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...
Rules to Live ByRules to Live By
Most people in the hospital are
afraid of, or intimidated by, the ED
and everything that ...
““What’s the Diagnosis?”What’s the Diagnosis?”
Non-ER doc: “How in the world do
you expect me to take care of
someone with...
In Other Words…In Other Words…
Medical school teaches most
doctors to figure out “What does
this patient have.”
Emergency ...
Rules to Live ByRules to Live By
Practicing Emergency Medicine is
like living a life: it’s hard for
everybody but it’s a l...
Patient
Care
Develop Good RapportDevelop Good Rapport
Shake hands with and introduce
yourself to everybody in the room,
even the childr...
Develop Good RapportDevelop Good Rapport
Sit at patient’s bedside to collect a
thorough history
Do not hover or loom over ...
Develop Good RapportDevelop Good Rapport
Establishing relationship with
patient: not just good manners
It enhances trust a...
Develop Good RapportDevelop Good Rapport
Include family members in the
history gathering
Physical contact helps establish
...
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...
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
… resp...
Watch Your WordsWatch Your Words
To most patients, PCP is a street
drug, not Primary Care Provider
Many older patients are...
Watch Your WordsWatch Your Words
Ask “Is there any medicine you
can’t take?” rather than “Are you
allergic to anything?”
A...
Watch Your WordsWatch Your Words
You have been taught to ask the
patient, “Is there anything else?”
Instead, you should as...
Watch Your WordsWatch Your Words
We don’t take care of “cases,” we
take care of patients
Patients on dialysis are not “ren...
Watch Your WordsWatch Your Words
We are human beings who use
our senses: we see a rash, hear a
murmur, smell a wound, feel...
Ordering TestsOrdering Tests
Before ordering a test, determine
how the result will influence care
Investigations that will...
Ordering TestsOrdering Tests
Don’t “screen” with cardiac
biomarkers unless you intend to
repeat the assays after a time
Do...
Ordering TestsOrdering Tests
Example: “positive” CT pulmonary
angiogram in no-risk / low-risk
twice as likely to be false-...
Ordering TestsOrdering Tests
Understand these concepts
VOMITVOMIT – Victim Of Medical
Imaging (or Investigational)
Technol...
Ordering TestsOrdering Tests
Every positive test must be further
investigated
By definition, one of every 20
tests ordered...
VOMIT and BARF ReduxVOMIT and BARF Redux
Patient requests more NSAIDs for
long-standing osteoarthritic low
back pain
Doc d...
VOMIT and BARF ReduxVOMIT and BARF Redux
No clinical evidence of AAA
US done, rules out AAA…
…but US shows “small cystic
l...
VOMIT and BARF ReduxVOMIT and BARF Redux
No renal signs/symptoms but CT
duly done  “2-3 cm cystic lesion
upper pole right...
VOMIT and BARF ReduxVOMIT and BARF Redux
Patient says, “Take it out take it
out take it out.”
Cyst removed  major bleedin...
VOMIT and BARF ReduxVOMIT and BARF Redux
Packs out on day 2
In ICU for 3 days
In hospital for 10 days
Now has one kidney…
...
Make a Decision in 4 HoursMake a Decision in 4 Hours
Recognize the limitations of the
ED: we provide episodic acute
care t...
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...
Don’t Delay UncomfortableDon’t Delay Uncomfortable
Recognize situations where an
uncomfortable decision is
inevitable, and...
Concept of “Emergency”Concept of “Emergency”
If a patient adds non-urgent
problems to the main complaint,
politely avoid a...
Consultants
Know Your ConsultantsKnow Your Consultants
There are three primary reasons to
call a consultant:
You need help or advice
Y...
Know Your ConsultantsKnow Your Consultants
The two biggest mistakes we make
when consulting consultants:
We believe everyt...
Know Your ConsultantsKnow Your Consultants
If you develop good relationships
with consultants, patient transfers
are likel...
Admission DecisionsAdmission Decisions
You decide which patient requires
admission
You decide which service should
care fo...
CommunicationCommunication
When communicating with a
consultant, in first minute give…
…bottom line: condition & acuity
…s...
CommunicationCommunication
Honesty and integrity are
keystone to effective relationships
with colleagues and consultants
I...
CommunicationCommunication
Do not consider recommendation
of outpatient management simply
because “there are no beds”
Avoi...
Make Consultations ClearMake Consultations Clear
If your normal conduct is to make
clear, focused, appropriate
consultatio...
Make Consultations ClearMake Consultations Clear
It is inexcusable to call a
consultant and say “I don’t know
much about t...
Gordon’s Law #47Gordon’s Law #47
The quality of the x-ray
ordered is directly
proportional to the
specificity of the clini...
Don’t Delay ReferralDon’t Delay Referral
If consultation or admission is
apparent prior to testing, don't
wait for results...
Consult from AuthorityConsult from Authority
If flow is backed up, as it often is,
it is inappropriate to allow junior
sta...
Consult from AuthorityConsult from Authority
Patient care trumps education,
and teaching “need” should not
delay the trans...
Other Tips
Surfing vs. Cherry-PickingSurfing vs. Cherry-Picking
“Cherry picking” is looking
through charts and picking up
“easy cases...
Communicate with RNsCommunicate with RNs
Rule #1: Nurses can hurt doctors
far worse than doctors can hurt
nurses
Rule #2: ...
Use the NursesUse the Nurses
Listen to the nurses and respect
what they have to say
Sometimes nurses are right and
sometim...
UnderappreciatedUnderappreciated
The most underappreciated
member of the ED is usually the
ward secretary
The respiratory ...
Death NotificationDeath Notification
The hardest thing you’ll do in
emergency medicine is to notify a
family of a family m...
MultitaskMultitask
If you know that a patient will
need more than one dose of pain
medicine (e.g., sickle cell vaso-
occlu...
Avoiding BouncebacksAvoiding Bouncebacks
Reasons to make a patient do
laps around the Emergency
Department before discharg...
Evaluating BouncebacksEvaluating Bouncebacks
Red flag and golden opportunity
Assume every bounceback
means something was m...
Don’t Ignore Abnormal VSDon’t Ignore Abnormal VS
Child who is tachypneic may have
pneumonia, despite no cough
Patient who ...
Don’t Take ShortcutsDon’t Take Shortcuts
You will miss petechial rash in
infant with fever
You will miss strangulated
ingu...
Don’t Wait for ConsultantsDon’t Wait for Consultants
If you think meningitis, give
antibiotics first and do lumbar
punctur...
Don’t Be Health-Care PoliceDon’t Be Health-Care Police
Know cost of tests you order
Be conscious about appropriate
resourc...
Beware the DrunkBeware the Drunk
Both history and physical
examination in an intoxicated
patient are completely unreliable...
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 ...
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
Know...
Words to Live ByWords to Live By
“Has any man ever obtained
inner harmony by pondering
the experience of others? Not
since...
Ars Longa, Vita BrevisArs Longa, Vita Brevis
“Life is short, art (of medicine)
is long; the crisis fleeting;
experience pe...
Lex 45 years on the front line
Lex 45 years on the front line
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Lex 45 years on the front line

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Joe Lex offers up his hard won advice on succeeding as an emergency physician.

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Lex 45 years on the front line

  1. 1. 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
  2. 2. Rules to Live By
  3. 3. 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
  4. 4. Rules to Live ByRules to Live By Form your diagnostic hypothesis, then focus on signs or symptoms that are atypical or incompatible with your diagnosis These must be explained, not ignored
  5. 5. Rules to Live ByRules to Live By Savor your successes but then move on: dwelling on them causes overconfidence
  6. 6. Rules to Live ByRules to Live By Learn from your failures but then move on: dwelling on them causes indecision
  7. 7. Rules to Live ByRules to Live By Good judgment is based on experience Experience is based on bad judgment
  8. 8. Rules to Live ByRules to Live By 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
  9. 9. 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
  10. 10. Rules to Live ByRules to Live By 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.
  11. 11. ““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.”
  12. 12. 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.”
  13. 13. Rules to Live ByRules to Live By 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
  14. 14. Patient Care
  15. 15. 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
  16. 16. Develop Good RapportDevelop Good Rapport 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
  17. 17. Develop Good RapportDevelop Good Rapport 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
  18. 18. Develop Good RapportDevelop Good Rapport 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
  19. 19. 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”
  20. 20. 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
  21. 21. 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
  22. 22. Watch Your WordsWatch Your Words 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
  23. 23. Watch Your WordsWatch Your Words 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
  24. 24. Watch Your WordsWatch Your Words 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
  25. 25. Watch Your WordsWatch Your Words 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
  26. 26. 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
  27. 27. Ordering TestsOrdering Tests 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
  28. 28. Ordering TestsOrdering 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
  29. 29. Ordering TestsOrdering Tests Understand these concepts VOMITVOMIT – Victim Of Medical Imaging (or Investigational) Technology BARFBARF – Blind Acceptance of a Radiologic Finding
  30. 30. Ordering TestsOrdering Tests Every positive test must be further investigated By definition, one of every 20 tests ordered will be “abnormal”
  31. 31. 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”
  32. 32. VOMIT and BARF ReduxVOMIT and BARF Redux 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”
  33. 33. VOMIT and BARF ReduxVOMIT and BARF Redux 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”
  34. 34. VOMIT and BARF ReduxVOMIT and BARF Redux Patient says, “Take it out take it out take it out.” Cyst removed  major bleeding Re-operation  nephrectomy, packing, transfer to ICU
  35. 35. VOMIT and BARF ReduxVOMIT and BARF Redux 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
  36. 36. 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
  37. 37. 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
  38. 38. 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.
  39. 39. 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
  40. 40. Consultants
  41. 41. 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
  42. 42. Know Your ConsultantsKnow Your Consultants 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
  43. 43. Know Your ConsultantsKnow Your Consultants If you develop good relationships with consultants, patient transfers are likely to be quicker, leaving you with more time for resolving other issues
  44. 44. 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
  45. 45. 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
  46. 46. CommunicationCommunication Honesty and integrity are keystone to effective relationships with colleagues and consultants In cases of conflict, keep conversation focused on patient
  47. 47. CommunicationCommunication Do not consider recommendation of outpatient management simply because “there are no beds” Avoid putting consultants’ schedules above patient needs and ED flow issues
  48. 48. 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
  49. 49. 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
  50. 50. 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.
  51. 51. 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
  52. 52. 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.
  53. 53. Consult from AuthorityConsult from Authority Patient care trumps education, and teaching “need” should not delay the transfer of patients to available beds.
  54. 54. Other Tips
  55. 55. 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
  56. 56. 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.
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. Avoiding BouncebacksAvoiding Bouncebacks Reasons to make a patient do laps around the Emergency Department before discharge – Nosebleed – Shortness of breath / asthma – Vertigo – Back pain
  62. 62. 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
  63. 63. 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
  64. 64. 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
  65. 65. 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
  66. 66. 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
  67. 67. 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
  68. 68. The Good NewsThe Good News As you gain experience in the ED, you will learn answers to many, many questions
  69. 69. The Bad NewsThe Bad News There are more questions without answers than with The number of questions without answers never stops growing
  70. 70. The Bad NewsThe Bad News Medicine is an infinite jigsaw puzzle: the best you can do is put an occasional piece into place
  71. 71. And finally…And finally… Data are not facts Facts are not information Information is not truth Truth is not knowledge Knowledge is not wisdom
  72. 72. 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
  73. 73. 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

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