Emergency Medicine Aphorisms. . .

[RetNavyPAC]

Good piece by Dr. Robert Solomon in a recent ACEP News.  He's an EM attending in Pittsburgh and ACEP News Editor-in-Chief. 

 

My favorite is #6.

 

Anyway - something to chew on and stimulate discussion.  :-)

 
ED Aphorisms
 
1. Severe acute pain should be treated aggressively, even if you don’t yet know the cause.

2. When you wonder why the patient is here for an apparently inconsequential problem, remember: We are in the reassurance business.

3. Often the parent’s anxiety is worse than the child’s illness. Direct your care accordingly.

4. Do not waste the patient’s time.

5. The patient is an autonomous human being who consults the physician but remains free to follow, or ignore, the doctor’s advice and recommendations.

6. It is hard to make an asymptomatic patient feel better.

7. Schizophrenics are not immortal; even these patients sometimes have serious physical illnesses.

8. The emergency department staff is perceived as all-knowing and all-powerful, solver of all problems – medical, psychological, social, and otherwise. This is a difficult reputation to sustain. Do your best.

9. If you believe you were put on this Earth to make others’ lives better, welcome to the team. If not, please find another line of work.

10. The patient defines the emergency. The triage nurse knows that some patients are better at this than others and has to sort them out.

11. Do not order tests that will not influence patient management.

12. If you order a test you shouldn’t have, and get a result you don’t know what to do with, ignore it.

13. Drug company–sponsored studies may produce meaningful results, objectively interpreted, with sound conclusions, but the odds are heavily against it.

14. There is no free lunch: Food and pens change prescribing patterns.

15. Always use the cheapest drug that will do the job safely.

16. When a patient is referred to the ED for what seems to be utter foolishness, it may turn out to be the right decision for the wrong reason.

17. Abdominal pain in the elderly is a catastrophe until proven otherwise; use "beyond a reasonable doubt" as the standard of proof.

18. If you cannot figure out what the patient is worried about, ask that question directly. You cannot assuage the patient’s worst fear if you don’t know what it is.

19. Neither be the first to use a new drug nor the last to discard an old one.

20. Write legibly. If others cannot read it, the time you spent writing it was wasted.

21. It is good to know guidelines issued by prominent organizations. It is better to know evidence-based guidelines. It is best to know the evidence.

22. Agencies like the Joint Commission, in attempts to improve patient care, sometimes create new problems that are worse than the old ones. They must be educated politely but firmly.

23. When families say they want "everything" done, remember: Not everything that can be done should be done. It is your job to know the difference.

24. Admitted patients belong in inpatient units. Their hallway is just as good as our hallway, and we have more patients waiting for a spot in ours.

25. Emergency physicians and nurses are doing God’s work. Obstacles in their path to performing that work must be removed.

[EMEDPA]

#22 AND #25 HAVE A LOT IN COMMON.....interpret that as you will.....or work night shifts when the administrators are asleep in bed.....night shift rules get pts seen faster, treated better, and stabilized and transfered in 1/2 the time as day shift rules.....night shift rule #1. There WILL be coffee at my work station....that is not negotiable....

[ventana]

well spoken list

 

new grad PA and PAs new to EM or Urgent care.....  should read and understand this....

[Guest JMPA]

i must disagree with #12, i can cost one their license

[GetMeOuttaThisMess]

#11, #15, #11, #16, #11, #17, #11, #18. Did I mention #11? Others that I try to live by:  "Don't order crap that you don't know how to interpret!"; and "Don't ask the question if you don't want to know the answer" (my personal favorite). Just because the physician says something also doesn't mean that it's true. Trust your gut!

[medic25]

#7 and #17 are words of wisdom; one thing I generally tell all of my PA students is that nobody dies from a mental illness.  Every "crazy" ED patient has the potential for physical pathology.

[GetMeOuttaThisMess]

With regard to #17, do not forget mesenteric ischemia as a potential source. If you don't think it, you won't find it, and outcomes can be deadly.

[RetNavyPAC]

i must disagree with #12, i can cost one their license

 

Yes JMPA - I agree with you absolutely on this one.  It's the only one I think that doesn't belong in the company of so many other excellent aphorisms/truths (like a turd in a punchbowl).  If you order a test you ARE responsible for it.  "Ignore it"?! Sure.  At your great peril.

 

It's why we instituted a policy at my shop that Lyme titers, rib series and urine cultures on kids that weren't cath'ed specimens (bagged) will no longer go to the Unresolved Issues queue for the EP On Call to follow-up on. Too much wasted time on crap that doesn't mean anything.  It's now on the individual provider to follow-up on that stuff. 

 

Volume of Lyme titers, rib series and UCx dropped like a stone.

[ajnelson]

I like #11 and #23.   I don't order drug screens on everyone.  I think a lot of docs and PAs that do this end up blowing people off that could potentially have something going on with them because they've used drugs.  I think it brings prejudice into the situation that we just don't need.  If they aren't an overdose or a psych patient needing medical clearance, its usually not necessary. 

As far as #23 goes, I think this is part of the beautiful art of medicine.  And when done correctly, you can see how good the provider is...

[primadonna22274]

#7 and #17 are words of wisdom; one thing I generally tell all of my PA students is that nobody dies from a mental illness. Every "crazy" ED patient has the potential for physical pathology.

Please change your thinking on these one. Mental illness has one of the highest mortality rates of all chronic disease--nearly 50% for schizophrenia and bipolar type 1.

[medic25]

Please change your thinking on these one. Mental illness has one of the highest mortality rates of all chronic disease--nearly 50% for schizophrenia and bipolar type 1.

Sorry Prima, my wording didn't come across as intended. I'm very aware of the mortality associated with mental illness; the conversation with students always covers the comorbidities, decreased life expectancy and physical disease associated with mental illness. The point I'm making is that they should never dismiss a patients physical complaints simply because of their underlying mental illness, which is an issue I see all too often. I review every cardiac arrest in our system for CQI purposes, and the correlation with mental illness is astounding.

[primadonna22274]

Amen to the above...I didn't think that's what you meant :)

[ventana]

Sorry Prima, my wording didn't come across as intended. I'm very aware of the mortality associated with mental illness; the conversation with students always covers the comorbidities, decreased life expectancy and physical disease associated with mental illness. The point I'm making is that they should never dismiss a patients physical complaints simply because of their underlying mental illness, which is an issue I see all too often. I review every cardiac arrest in our system for CQI purposes, and the correlation with mental illness is astounding.

 

 

right on

[medic25]

We recently had a patient in the critical care pod of our ED that demonstrated some of these issues perfectly; thankfully I had a PA student with me that night to see it firsthand.  The patient was a schizophrenic gentleman in his 60's, sent in by his group facility for fatigue and hypotension.  No complaints of chest pain, but his EKG demonstrated that he was having a STEMI.  When the ED went to activate the cath lab, the patient adamantly refused any intervention; he thought since he wasn't having chest pain it wasn't a heart attack, and our staff were trying to trick him.

 

 Despite showing him the changes on serial EKG's, showing him his elevated I-Stat troponin, and a cardiology consult, he continued to refuse intervention.  After an emergent consult from our ED psychiatrist, it was determined that he was competent to make his own decisions and ended up simply being heparinized and admitted to the CCU.  While his schizophrenia may not be the physical ailment that leads to his morbidity (there is no "schizophrenia" lesion sitting in his coronary), it is the tremendous risk factor for worsening the outcomes of his underlying CAD.

[skyblu]

i must disagree with #12, i can cost one their license

I agree! Don't order it if you don't want or need to know. But if you did order it, and it's grossly abnormal, you have to do something about it. Which is why you shouldn't have ordered it to begin with.

 

Also, in my efforts to advocate for our profession, I wanted to register with the ACEP website to post a comment to the author asking to include PA's in #25. When I went to follow the link, I noticed it said "Nurse Practitioners and Physicians Assistant", so I ended up emailing ACEP about the typo. I also just emailed my son's school about a newsletter where they identified a colleague (who kindly volunteered to teach seniors about orthopedic injuries int heir anatomy class) as a Physician's Assistant.

 

The name change for the profession cannot come fast enough! 

 

Anyway, not to derail. Most of these were great! I'm particularly a fan of #7, which should also include habitual drunks and addicts who come in to sleep it off on an almost daily basis. Sometimes they really get sick, too!

 

And to piggyback on everyone else's examples, just yesterday I saw a schizophrenic woman with MR whose sole way of communication was very high pitched screaming and crying. The group home said she'd been doing this for a month. They finally sent her to the ED for eval yesterday simply because she had a regular appointment in an office at the hospital. When I calmed her down (by singing, no less) and was able to try to wade through the screaming, I noticed she kept referring to her right eye, which was closed. When I looked in it, the cornea was totally and completely opaque. Fluorescin revealed herpetic dendrites. I started her on valacyclovir but have a nagging suspicion she has had herpes keratitis for a month and will never recover vision in that eye.

 

All because she's "crazy", and nobody bothered to get through the off-putting screeches to try to get to the bottom of things. It made me very, very angry! (And yes, I contacted DMR about it)