Introduction to the Emergency Department Patient

Introduction to the Emergency Department Patient A Unique Environment • Time constraints – – – – simultaneous management of multiple pts. patient expectations Vs our expectations need for rapid decision making heavy volume & long waiting times • Lack of information – the critical patient – poor or unreliable recall – old chart unavailable A Unique Environment • Limited therapeutic options – you‟re not the family doctor – ED specific complaint workup • Constraint of disposition – sick or not sick? – treat or not treat? – admit or discharge? Case A 19 year old girl assessed by you for abdominal pain and vomiting is discharged home with “Gastro”. She returns 24 hrs later with appendicitis. Despite appropriate technical case management, her parents write a letter to the VP Medical Affairs and ask that her care be reviewed. How can this scenario be avoided? A Framework for Evaluation of the ED patient • • • • • Introduce yourself (to everyone) Shake hands Sit down when possible Relieve pain early Explain what you are going to do and how long it will take • Provide updates A Framework for Evaluation of the ED patient • Explain your discharge instructions – – – – what you want them to do/take what you have prescribed when to follow-up when to return to the ED • CPSO reports: “Inadequate communications between MD‟s and patients or patients‟ families is still the underlying cause for most of the problems that the CPSO is asked to investigate” • Communication problems most frequently cited in malpractice claims were inadequate explanation of diagnosis or treatment and patients feeling ignored Why do people sue doctors? Lancet 1994;343;1609 Good Communication Skills Are Vital! A Framework for Evaluation of the ED patient • Do I need to act now? – “shoot first, ask questions later” – reversal of traditional approach • treatment, physical, labs, history – decide in 10 seconds • chief complaint • general appearance • abnormal vitals – trust your intuition Minimizing Mistakes If you haven‟t made any errors that have resulted in death or significant morbidity to one of your patients, you haven‟t been in practice very long - M Lipp Errors of Ignorance • Inadequate knowledge to make correct conclusion or provide necessary treatment Getting up to speed • Cramming more facts doesn‟t work – Limited retention if not incorporated into a usable framework to be accessed later • Review and synthesize what is already known • “The essence of learning is not merely doing but thinking about what one is doing” - J. Gale Staying up to speed • More common in experienced physicians • Personalize goals for CME • “It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he can do it” - Sir William Osler Knowing your speed limit • Know when to ask for help, when to look it up, and when to limit the type of problems you take on • Don‟t substitute arrogance for humility Errors of Implementation • Most medical errors are in the implementation of knowledge, not of ignorance A Framework for ED Diagnosis Raising the SHADE... • • • • • Symptoms: focus on chief complaint Hunch: generate initial hypothesis Alternatives: develop differential diagnosis Disease Identification: test the hypothesis Explanation: do cause and symptoms fit in? Case • A 65 year old male develops severe low retrosternal chest pain after eating a large meal. It is associated with nausea and vomiting. He has never had this before. He suffers from hypertension (Rx ramipril), drinks 2-3 beers/day, smokes and takes an aspirin daily “just in case”. He continues to have pain. Physical exam reveals obesity and mild epigastric tenderness only. Apply the SHADE process to this patient • Symptoms – retrosternal chest pain with N/V • Hunch – Acute myocardial infarction • Alternatives – Peptic ulcer disease, biliary tract disease, aortic dissection… • Disease Identification – Acute IWMI identified on EKG • Explanation – post-prandial “steal”, risk factors Pitfalls • Symptoms – premature closure – keep an open mind! • Hunch – incomplete or modified disease patterns • early presentation (appendicitis) • multiple diseases (beware the diabetic!) • partial treatment (OTC ulcer treatment) Pitfalls • Alternatives – medical masqueraders • referred pain (back pain with aortic dissection) • multisystem involvement (lupus) – common diseases with unusual presentations • consider the prevalence of the disease in your differential (fever and malaise  dengue) • atypical presentations of common diseases are more frequent than classical presentations of rare diseases – zebras • consider with complex cases, unusual complaints, striking out with preliminary diagnostic attempts Pitfalls • Disease Identification (Testing) – Failure to use the physical exam as a series of diagnostic tests – incomplete understanding of the implications of „abnormal‟ and „normal‟ tests • pretest probability • 5% are abnormal by definition – over-reliance on test results (CBC in appendicitis, EKG for MI, CT scan for SAH) – observation is not merely delay - reassessment is a diagnostic test!! Pitfalls • Principle of Parsimony: one explanation for disease, symptoms and cause – failure to listen to the patient – failure to consider multiple diseases – failure to acknowledge that you don‟t know Learn to be a Pessimist • Always include the „worst case scenario‟ in your differential Case • A healthy 32 year-old woman suddenly develops a severe occipital headache associated with nausea, vomiting, and neck stiffness. She had a similar episode one week ago, although not this bad. Subarachnoid hemorrhage Case • A 48 year-old man suddenly develops sharp left sided pleuritic chest pain, dyspnea and fever. Pulmonary embolus Case • A 82 year-old man with hypertension, diabetes, chronic renal failure, CHF, and angina passes out at home. He has had syncopal episodes previously without specific etiology. He now complains of some mid-abdominal pain. Ruptured AAA Case • A 28 year-old woman loses conciousness while shopping. It is her seventh time fainting. She hasn‟t been feeling well lately, but chalks it up to her fibromyalgia and irritable bowel syndrome. Ruptured Ectopic Case • A 86 year-old male with hypertension, CHF and atrial fibrillation presents with two days of progressive mid abdominal pain and malaise. Exam is remarkable for diffuse abdominal tenderness without peritoneal findings. Mesenteric ischemia Beware of the high risk patient • • • • The elderly The repeat visit for same problem The intoxicated The patient who provokes a strong emotional reaction in you • The patient who is transferred from another physician especially if multiple transfers of care have occurred Beware of the high risk cases • • • • Missed fractures Extremity wounds Missed MIs Missed surgical conditions – (appendicitis, AAA, ectopic) • Missed neurological conditions( SAH, subdurals) Violence in the ED • 22% of those worried about their safety feared being shot or assaulted in the ED • 50% felt had inadequate security • 1988 survey of 127 ED residencies – 43% > 1 physical attack/month – 32%  1daily verbal threat – 18%  1 threat with weapon/month Why? • • • • • • • • Sick Long waits Loss of control 24-hr availability Available drugs and hostages Psychiatric illness Pain Overcrowding Clues to Violent Behavior • Mental illness – schizophrenia – personality disorders – bipolar disorder • • • • Posture Gait Clenched fists Psychomotor agitation Strategies • • • • • Try reframing Empathy Good listening Confict resolution Negotiation Strategies... • • • • • • • • Door open - use curtain for privacy Spacing Calm voice Announce intentions Do not approach from behind Never turn you back Consider offering food/drink Ask if they would like med to calm them Strategies... • Show of force if necessary • Physical restraint – 5 people – do NOT help • Chemical restraint – Haldol 5-10 mg – and Ativan 1-2 mg IM/IV Leave the room immediately if you feel threatened Your safety comes first! Phone Etiquette Unless you have a specific question, YOU are the patient‟s physician and have determined a course of action the consultant is being asked to come and see the patient, not what they think over the phone. Phone Etiquette • Introduce yourself and your level of training • Explain the reason for your call • Begin with the end no one listens until they hear why you are calling! Phone Etiquette • Briefly summarize the pertinent points of the case • Add details if requested • Be polite and receptive of feedback • Notify ED attending if call is not progressing as planned (BEFORE you hang up!) Take care of yourself • Some residents find the ED a stressful environment • Know when to ask for help – seek staff input early for management – seek staff input immediately for unstable pts – remember the nurses have a wealth of experience • Talk to any of the staff physicians at any time if you are experiencing difficulties HAVE A GREAT TIME OVER THE NEXT BLOCK!!!