A primer for residents : Do's and don'ts of emergency medicine

Resident Issues




Eric Letovsky, MD



Chief, Department of Emergency Medicine,
The Credit Valley Hospital, Mississauga, Ont.; Associate Professor,
Department of Family and Community Medicine, University of Toronto,
Toronto, Ont.


CJEM 2003;5(2):130-132




After 23 years of practising emergency medicine at both tertiary
care and community hospitals, there are a few things I'd like to share
with you. Many pearls have come from working alongside some superb
emergency physicians -- watching them practise and interact with
patients and allied health personnel in the emergency department (ED).

I've learned important lessons from my mistakes, and from the
mistakes of colleagues. Sitting in on dozens of morbidity and mortality
rounds and being a medicolegal expert on numerous cases has afforded
unique opportunities to see the most common and most serious mistakes we
make. This list of do's and don'ts contains some of my favourite
pearls. It is by no means comprehensive, and is not written in priority
of importance. I hope it helps you to become better and safer emergency
physicians.

Lessons learned


1. Don't ignore abnormal vital signs.


The child who is tachypneic may have pneumonia,
despite the absence of a cough. The patient who becomes hypotensive
following a traumatic injury is probably not having just a vasovagal
episode. Don't assume anything and don't ignore anything.

2. Don't take shortcuts on the physical exam.


It is impossible to pick up a small petechial rash in
an infant with a fever unless you undress the child. If you don't take
off the underwear of a young male with abdominal pain, you may miss the
strangulated inguinal hernia or the testicular torsion. Many zoster
eruptions have been missed simply because the skin was not examined
under the shirt or dressing gown.

3. Don't wait for consultants to give antibiotics to sick patients.


Pneumonia and meningitis are serious diseases that
kill. If you think a patient may have meningitis, give antibiotics first
and do the 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 so much what antibiotic you give, just give
something.

4. Don't be the health care police.


It is important to be somewhat familiar with the cost
of tests that you order and be conscious about appropriate resource
utilization. However, if you think a test is appropriate, order it.
Don't let your imaging or laboratory colleagues dissuade you from
ordering a test you need, just because it's going to inconvenience them.

5. Don't use "pink ladies" to rule out myocardial infarction.


The Canadian Medical Protective Association can give
you a list of patients with missed myocardial infarction (MI) who were
thought to have esophagitis or gastritis simply because they had burning
esophageal pain that was relieved by a "pink lady" in the ED. Remember,
if you give 10 patients with a confirmed MI some arsenic, 3 will feel
better. Relying on a "pink lady" to rule out myocardial ischemia is
dangerous practice, and if you do it, you will end up a medicolegal
statistic.

6. Don't be afraid to wake up a consultant.


Certain things cannot wait until morning. Testicular
torsion, ovarian torsion and any other kind of vascular catastrophe are
all examples where you need to wake up your colleagues, even if they
give you flack over the phone, with the usual "Can't it wait until
morning?" Your quality of care should be just as good at night as it is
during the day.

7. Do pay special attention to the very young and very old.


People at the extremes of ages are at high-risk for
serious disease, don't manifest the same signs in serious diseases and
must be assessed thoroughly and repeatedly. The newborn infant with a
fever has meningitis until proven otherwise. The elderly patient with
severe abdominal pain has either an ischemic gut or abdominal aneurysm
until proven otherwise. The absence of fever or high white blood count
in the elderly does not rule out urosepsis.

8. Do pay special attention to the intoxicated patient.


Both the history and the physical examination in an
intoxicated patient are completely unreliable. Over-investigate these
patients and remember that, to rule out subdural hematoma in an
intoxicated patient, one CT scan is better than a room full of
neurologists.

9. Do get second opinions / consultations if you have concerns or doubts.


If a patient is just not fitting a typical pattern,
and if you can't get a sense of what's going on -- ask someone. You may
be tired, not thinking of something or simply haven't considered a
particular diagnosis. Don't let your pride get in the way of asking for
an opinion from a colleague or a staff physician.

10. Do treat pain early and aggressively.


If there is anything that we should do well in the ED,
it is to treat pain. This is where we show our empathy and our
compassion. Don't forget to do the simple things that relieve pain, such
as ice and splinting, and do give opioids intravenously rather than
intramuscularly.

11. Do communicate well with patients.


More likely than not, your patients are going to
remember very little of what you say. Tell them what you're going to do,
why you're doing it, and how long the process will take. If they've
been waiting a long time for test results, go back and tell them why
things are taking so long. Patients just want to be kept informed about
the causes of the delays.

12. Do communicate well with families.


Families can be a great source of information about
the patient's behaviour, especially for patients presenting with
headaches or neurological symptoms. The only clue that you're dealing
with a brain tumour -- even when the neurological exam is completely
normal -- may be a family member telling you that the patient is "not
quite right" or that he's been a bit confused over the past few weeks .

13. Do treat each other with respect and courtesy.


I believe there is no more stressful nursing job than
ED nursing, and that there is no more stressful medical work than
emergency medicine. We need to treat our coworkers with respect and
courtesy to help make our workplace as healthy as possible.

14. Do compliment your coworkers.


Everyone needs positive feedback. The nurse who
triages a patient well, starts an IV quickly, or gives you a good update
on an ill patient should be complimented on his or her skills.

15. Do consider the worst possible disease for every complaint.


The 50-year-old man with abrupt onset of a severe
headache has a subarachnoid bleed -- not a migraine -- until proven
otherwise. The 50-year-old with severe epigastric pain has an infarct
until proven otherwise, and the 80-year-old with severe abdominal pain
has an ischemic bowel until proven otherwise. Have a wide differential
and make sure that your documentation reflects that you considered the
most serious of your differential diagnoses.

16. Do get trauma patients to trauma centres early.


In trauma cases, don't bother ordering tests that will
only be repeated at the trauma centre, or will unnecessarily delay the
transfer. Talk to the trauma team leader as early as possible.

17. Do give blood early in trauma patients.


As a general rule, no one will fault you for giving
blood too early, but plenty of people will fault you for giving blood
too late. You need to recognize the subtle signs of shock, and don't be
afraid to give either type-specific or O blood.

18. Do keep patients in the ED if they can't drink or eat.


Patients who have been assessed and observed for
abdominal pain or vomiting should have a trial of fluids in the ED to
see if they can keep fluids down. If they can't, don't send them home.

19. Do order pregnancy tests for women with abdominal pain.


You don't want to miss an ectopic pregnancy. Order a
pregnancy test for all women of child-bearing age who are suffering from
abdominal pain or have non-specific complaints of nausea, dizziness and
syncope.

20. Do regional nerve blocks for facial lacerations.


If you want a good cosmetic outcome on the patient's
face, you must avoid infiltrating lidocaine locally and distending the
tissues, which can alter the cosmetic results. Learn to do supraorbital,
infraorbital and mental nerve blocks.

21. Do watch a patient walk, if they have any dizziness or CNS symptoms.


Brain stem and cerebellar infarcts can be subtle.
Always watch a patient walk during the final part of your neurological
examination.

22. Do make sure that patients understand your discharge instructions.


State your instructions clearly and slowly and, at the
end, ask your patients and their families, "Do you have any questions
for me?" You don't want your patients going home feeling that they
didn't have every opportunity to ask questions.

23. Do ensure follow-up for every patient.


Make sure that all the patients you see know what to do if their symptoms persist, return or get worse.

Many of you will have your own list of pearls. If so, please pass
them on to physicians more junior than yourselves, so that your
knowledge and experience helps shape and mold future generations of
great emergency physicians.













Competing Interests:
None declared.









Correspondence to:
Dr. Eric Letovsky, The Credit Valley Hospital, 2200 Eglinton Ave. W, Mississauga ON L5M 2N1; eletovsky@cvh.on.ca