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) When diagnosing a urinary tract infection in a relatively young male, make sure to do a genitourinary exam. Young males don’t typically get UTIs; consider epididymitis, orchitis, prostatitis, STI, etc.

2) Not all elevated lipase = pancreatitis. Consider what brought the patient to the ED. There are a variety of reasons for lipase elevation: decreased clearance, critical illness, intraabdominal (hepatobiliary, gastroduodenal, neoplasms, bowel), drugs, infection, diabetes, among many others. Significant elevations of serum lipase not caused by pancreatitis: a systematic review is a great resource and contains several tables.

3) Young patient + multilobar “pneumonia” + not great infectious story => consider vaping-associated pulmonary injury.

4) The white blood cell count receives a lot of disrespect. At extremes, consider the differential and how it applies to your patient.

WBC >20: severe sepsis/septic shock; hematologic malignancy; stress response in young patient secondary to trauma (diagnosis of exclusion); meningitis; pyelonephritis; necrotizing fasciitis; severe pneumonia / empyema; sick endocarditis; bowel perforation; sick pancreatitis; sick mesenteric ischemia; toxic ingestion.

WBC <4: HIV; active chemo; sepsis; hematologic issue; viral infection; decompensated cirrhosis; decompensated ESRD; occult substance abuse.

5) For ECG with ST-elevation in aVR + diffuse ST-depressions, consider the following: tachydysrhythmia; toxicologic; metabolic; shock (septic, hemorrhagic, cardiogenic, aortic disaster); acute coronary occlusion / triple-vessel disease.

6) The electronic health record can be quite helpful; it can also create anchoring bias (e.g., the last five times the patient came in for COPD exacerbation… that must be why they are short of breath today). Build cognitive checkpoints to avoid this closure and consider a wide differential diagnosis based on historical red flags and the patient’s concern(s) today.

7) Avoid listing gastroenteritis as your diagnosis. You must consider mimics. Most patients have had something to eat around the time of their illness, thus it’s easy for them to attribute this as the cause of their illness. What ultimately pushed the patient to come to the ED? Many emergent/urgent diagnoses may look like this early on (ie, mesenteric ischemia, bowel obstruction, etc.). Build a list and flesh out risk factors in your patient’s history and exam.

8) Alcohol withdrawal can sneak up on us. Some of our patients are in the ED for another reason. When admitting the patient, highlight to the admitting team who’s at risk for withdrawal. Social history helps. Lab markers can be helpful in someone with an unrevealing history (e.g., macrocytic anemia, thrombocytopenia, abnormal LFTs, hypokalemia, hypomagnesemia, etc.).

9) Listing (medication) non-compliance in a patient’s history is not particularly helpful (and many will not appreciate this). Fleshing out a thorough psychosocial history may change the trajectory of care.

10) Pulmonary hypertension is a popular topic currently. When should you consider it? Multiple ED visits for shortness of breath (with exertion) with no clear explanation. Perform a thorough history and exam and an ambulation trial with pulse oximetry. Know CXR and CT findings. Review the whole TTE report if one is available.

References/Further Reading:

EM Mindset

IBCC – Pancreatitis

IBCC – Vaping associated pulmonary injury

Emergency Medicine Cases – STE elevation in AVR

emDocs – Gastroenteritis mimics

EMCrit – Pulmonary hypertension and right heart failure

EM@3AM Pulmonary HTN