Good advice
- Thread starter GiJoe
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Ignore the obvious, Ignore your gut feeling- go for the wide ddx - every chest pain demands a r/o workup, every HA gets a CT.
This is actually my favorite. Just read it in a throw away journal:
"Don't just do something, stand there."
Q
"Don't just do something, stand there."
Q
That's one of the "rules of medicine" from 1978:
1. If what you're doing is working, keep doing it
2. If it's not working, stop doing it
3. If you don't know what to do, don't do anything
4. And, above all, never let a surgeon to your patient!
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Rules of EMS (from a handout a friend and former instructor gives out)
1. If you drop the baby, pick it.
2. When in doubt, drive faster.
3. Air goes in and out, blood goes round and round, the chest goes up and down; any variation on one or more of these is a bad thing
4. If a patient says they are going to puke, die or that the baby is coming NOW, believe them.
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I was told "In EM, there is no night, there is no day, there are no holidays, there is no work week, there are no weekends. There is 'on shift' and 'off shift'. Don't mix the two."
You should make that into a T-shirt and then sell it at ACEP in Seattle.
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No... CT AND LP.
Kidding aside, in the ED you need to force yourself to a) think about all of the pertinent possibilities rather than just grabbing on the first and most comfortable thing that comes to your mind and b) systematically exclude the life threatening diagnoses in #1 by H&P or testing. This means neither dismissing everything but the first thing that comes to your mind nor giving everyone the million dollar workup. It's about cultivating judgement and making a conscious effort to look for diagnoses in our innate blind spots.
Kidding aside, in the ED you need to force yourself to a) think about all of the pertinent possibilities rather than just grabbing on the first and most comfortable thing that comes to your mind and b) systematically exclude the life threatening diagnoses in #1 by H&P or testing. This means neither dismissing everything but the first thing that comes to your mind nor giving everyone the million dollar workup. It's about cultivating judgement and making a conscious effort to look for diagnoses in our innate blind spots.
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Worst First...
An EM mantra.
Take care,
Jeff
An EM mantra.
Take care,
Jeff
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Judgement - exactly. I work with one attending who by fear or self doubt, does mega workups on most of her patients. She certianly does rule out most of the bad things to the few patients that she sees She consults the hell out of everything. She rarely misses a critical dx. But...... The waiting room fills up and the whole place goes to hell until the residents pick up the slack or another attending comes onboard to clean up the mess. Emergency medicine is also about "moving the meat" . If you cant make a call without relying on an extrodinary amount of testing and consults - you are in the wrong business.
You dont need a weathervane to know which way the wind blows
- Bob Dylan
You dont need a weathervane to know which way the wind blows
- Bob Dylan
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The problem is that you can test everyone for everything and a)kill people with your good intentions (create as much cancer as you catch by ordering all those unnecessary scans) b) still miss stuff, because none of the tests you order are 100% sensitive for everything. Even if you scan everyone with chest pain for a PE you will still miss one eventually, because the sensitivity of a CT is never 100% in real world use (or in a vast majority of the literature either).
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The problem with emergency physicians is that we go to medical school...
seriously!
In medical school, you are taught to consider the four or five most likely things that a particular presentation could be and then work to rule them in. If you determine that the condition is something else, keep checking the more and more rare conditions until you find the cause.
In emergency medicine we consider the four or five most deadly or injurious things that a presentation could be and work to rule them out. If we stumble across a diagnosis along the way - GREAT! If not, we have to be comfortable saying "I've got no idea, go see your PCP".
This different approach is the hardest thing to learn and is why "other" doctors never understand the pit.
- H
seriously!
In medical school, you are taught to consider the four or five most likely things that a particular presentation could be and then work to rule them in. If you determine that the condition is something else, keep checking the more and more rare conditions until you find the cause.
In emergency medicine we consider the four or five most deadly or injurious things that a presentation could be and work to rule them out. If we stumble across a diagnosis along the way - GREAT! If not, we have to be comfortable saying "I've got no idea, go see your PCP".
This different approach is the hardest thing to learn and is why "other" doctors never understand the pit.
- H
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I use a variation on this daily - "I don't know what it is, but I know what it isn't." I recall when I was prelim, and I was derided by an attending, who said that "you ER guys only look for the big stuff that will kill patients, and ignore the rest", and I said, "Well, yeah!"
Another aphorism that I use - "I patch the tire, but I don't replace the tube".
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I'm guessing we all have our little speach on this down pat. I give it many times each shift.
It seems that about 1/2 the time the patient gets it and is reassured that, even though they aren't leaving with a definitive diagnosis, the condition isn't bad and they have plenty of time to see their PCP.
The other 1/2 think I'm a complete quack because I can't tell them the exact cause, with effective treatment, for their malady that they've had for 15 years and have seen 100 other specialists for.
Somewhere about half-way through second year, I was able to clearly see the contempt for me in the eyes of this second half. This bothered me greatly.
The next shift, although I could still see the contempt, I no longer cared.
Take care,
Jeff
It seems that about 1/2 the time the patient gets it and is reassured that, even though they aren't leaving with a definitive diagnosis, the condition isn't bad and they have plenty of time to see their PCP.
The other 1/2 think I'm a complete quack because I can't tell them the exact cause, with effective treatment, for their malady that they've had for 15 years and have seen 100 other specialists for.
Somewhere about half-way through second year, I was able to clearly see the contempt for me in the eyes of this second half. This bothered me greatly.
The next shift, although I could still see the contempt, I no longer cared.
Take care,
Jeff
