Emergency Medicine Rules of the Road (first few)

- Read the triage note
  - Patients/medics may have told triage nurse something important but forgot to or couldn’t tell you
  - If there is an inconsistency between triage and your history make sure to clarify that
  - Bedside nurses should alert you to new issues once the patient is roomed but the triage nurse will rarely seek you out.
- History is king
  - It is not the patient’s job to provide a good history; it is your job to elicit one
  - Listen to your bedside nurse if they raise concerns and document your response
  - Know when to dig deeper, like with timing and duration for chest pain
  - Know when talking to family/staff is required: altered or non-verbal patient, suicidal patient…
  - If there is pain always have them show you exactly where by pointing.
- Always think worst case scenario first
  - This is also in the original 10 commandments: LINK or see summary below
  - Reasonably rule out the more rare but more dangerous explanation before landing on the benign one.
  - Remember: you are a detective not a gambler and ER patients are guilty until proven innocent
- Fine tune your physical exam and know when to add bedside ultrasound
  - Know key techniques to have a more sensitive focused exam. Spend less time on parts that aren’t relevant and more time on parts that are.
  - Listen to EM logic episode 6 for a better lung exam, jolt sign for meningitis, a better neuro exam, the importance of the pedal pulse and other key considerations
  - Bedside ultrasound can expedite diagnosis and treatment of certain critical conditions such as aortic dissection, massive PE, ruptured ectopic, and AAA to name a few.
- Bounce-backs get bigger workups and/or get admitted
  - Also from Tuesdays with Dr. Henry: LINK or see summary below
  - Second visit do more: testing, consult, etc
  - Third visit admit: SMV/PUD story, CSVT stories
- Beware of false negative tests
  - CT in ischemic stroke: “CT rules out a bleed not a stroke”
  - Troponin in unstable angina or first 5 hours of MI
  - WBC is normal in up to 30% of cases of sepsis or sever infection
  - EKG in first 2 hours of STEMI
  - STEMI criteria in OMI (occlusion MI)
  - X-ray for aortic dissection: don’t trust the radiologist. Always view and measure mediastinal width yourself. If >8.0 cm and dissection is on your list, order the CT.

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