The EM Thinker #1

Authors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Following in the footsteps of the EM Mindset and EM Collective Wisdom series, emDocs is proud to introduce The EM Thinker series. This series will provide important considerations for the practice of emergency medicine.

1) Be curious. Always be a skeptic, and confirm what you read and hear. Don’t fall prey to confirmation bias.

2) The most good by a physician can be done at the patient’s bedside. If initial synthesis of information doesn’t make sense, get up and gather more data, including from the patient, family/friends, EMS, and/or nurses.

3) Ask the patient about the biggest concern that brought him/her to the ED at this moment. It’s incredible what you’ll learn.

4) Review the triage note(s) and nursing documentation during the patient’s stay. Nursing notes can make or break a case. Always acknowledge and explain discrepancies.

5) Review prehospital information. Even better: take an EMS timeout to listen to their focused report. Thank them and highlight positive behaviors.

6) Complete set of vital signs are crucial. Don’t overlook hypothermia or bradycardia. Thoughtfully explain the cause of tachycardia. For blood pressure, know the patient’s baseline. Confirm the respiratory rate; don’t always assume another’s count is accurate. Know the patient’s baseline oxygen saturation. Use capnography. If an intervention was performed for a vital sign abnormality, step back and make sure it makes sense to you in the context of the patient’s presentation.

7) We are trained to be superior in resuscitation and high-risk/focused differential diagnosis. For most of our patients, we are there to listen and provide symptom control. It’s amazing how much good we can do by listening and improving patient symptoms.

8) Most important question to answer: sick or not sick followed by keeping it safe with appropriate disposition. We don’t always figure out exactly what’s wrong with the patient. Explain to the patient up front that your job is to evaluate for life-threatening diseases and not necessarily determine the exact issue. Remember, our job is to not lose.

9) Know your cognitive load and when to ask for a fresh set of eyes for input on a case. Always work to decrease your cognitive load (ie, discharge a patient and open a bed), rather than adding more.

10) Know your limitations, when to say “I don’t know”, and when to ask for help. Make diagnostic certainty / uncertainty clear at sign-out and in front of the patient you’re taking care of.

References / Further Reading:

First 10 EM – Curiosity

First 10 EM – Cognitive Errors

First 10 EM – Mitigating Errors

Book – EM Mindset

EM Updates – How to think like an emergency physician

emDocs – Cognitive Load

First 10 EM – Communicating Uncertainty