July 12, 2017

The EM Mindset

Written by Salim Rezaie
REBEL EM

The American College of Emergency Physicians (ACEP) defines Emergency Medicine (EM) as:

“The initial evaluation, diagnosis, treatment, and disposition of any patient requiring expeditious medical, surgical, or psychiatric care.”

I would take this a step further and say these patients are often undifferentiated and come at all hours of the day/night. As the EM physician we are constantly risk stratifying and ruling out life-threatening issues with limited information and time. So what are the things I think will give you a successful EM mindset?

Resuscitation

If you have not heard the talks by Cliff Reid and Scott Weingart on the mind of the resuscitationist you don’t know what you are missing. I will put links to the videos underneath this section, but I want to summarize points that resonate with me in my care of the critically ill.

Don’t forget your safety net… IV-O2-Monitor
Run toward the sick patients, not away from them. The more sick people you see the better trained you will be.
Don’t just follow algorithms, but know when it’s ok to stray from them and think outside the box
Know where your equipment is located. It is better to have it and not need it, than need it and not have it.
Train hard. Use simulation training as the real deal scenario.
If you are running the resuscitation, do not also be the one that is doing the procedures. No one can truly multi-task
When asking people to perform tasks, task a specific person and not the general room

“We do not rise to the level of our expectations, we fall to the level of our training.” Archilochus
Scott Weingart: The Mind of the Resuscitationist
Cliff Reid: Making Things Happen
Cliff Reid: Own the Resus Room

Risk Stratification

I read a great piece on risk stratification by Graham Walker in Emergency Medicine News 2011 and if I can summarize: in emergency medicine it’s not the patient who looks sick or not sick or the decision to admit or not admit that keeps us up at night. It’s the patient somewhere in the middle of that dichotomy that makes us lose sleep (i.e. the grey zone). To me this is the most challenging part of emergency medicine. Patients don’t always follow what we learned in textbooks. Sure there are risk stratification scores (i.e. TIMI, HEART, PERC, Wells, etc…) to help us along, but in the end how do we know we are making the right decision? Do we CT scan everyone and order million dollar work-ups? What I have started doing in my practice is actually more simple than this as I risk stratify patients. Shared decision making, which actually involves the physician to talk to the patient, but it’s cheaper than ordering a CT scan on everyone. Simply discuss the facts that you have, what you think your assessment of them having something bad is, and come up with a joint decision. And of course don’t forget to document, document, document in your chart. Finally, there is no substitute for the tincture of time. Simply observing patients and getting a few more data points could be a very useful thing. This can be done in your own department or in an observation unit.

“Medicine is a science of uncertainty and an art of probability.” Sir William Osler
“The fact is, in emergency medicine, we don’t spend most of our days saving lives, as most people think. Mostly we try to predict risk, especially in gray-zone patients.” Graham Walker, MD (Walker G. Emergentology: Risk Stratification and the Unsweet Spot. Emerg Med News 2011; 33 (9): 21.)

Anyone, Anytime, Anywhere 24-7-365

We are truly the front line of medicine and patient care. Our doors are open every minute of the day, month, or year, regardless of time and holiday. We see all comers regardless of age, complaint, or acuity. We provide a healthcare safety net for uninsured patients as well as patients having a hard time accessing the health care system. Every patient, regardless of complaint is an opportunity to learn.

“Opportunity is missed by most people because it is dressed in overalls and looks like work.” Thomas Edison

Undifferentiated Patient

Part of the art of emergency medicine is making educated conclusions after sorting through information and symptoms of disease in a limited amount of time. Patients don’t always come in with a diagnosis printed on their foreheads. Think of a jigsaw puzzle that you just opened up from a box. As you pour the pieces out from the box you see that the pieces are all of different shapes and sizes, some of the pieces are flipped upside down. You have to organize this chaos of pieces to have a final put together product or diagnosis. This is how I think of taking care of patients in the ED. Getting the history, doing a physical exam, ordering blood/urine tests, and imaging are all pieces of the puzzle. As we start getting enough pieces of the puzzle put together we can start to see what the diagnosis is. In some cases we will just not be able to solve the puzzle (i.e. make the diagnosis) and that is ok and you need to gain comfort with that, but we do need to ensure that we have ruled out life threats.

Avoiding Cognitive Errors

The emergency department is an environment full of distractions. When people are interrupted they can take up to 50% longer to complete tasks, but more concerning is they can make up to 50% more mistakes. Naturally due to the interruptions we face in the emergency department we formulate shortcuts in our minds (heuristics), but some of these shortcuts lead to bad habits, bad habits lead to more mistakes, and more mistakes lead to bad patient outcomes.

The two most common cognitive errors made by emergency physicians are anchoring bias and availability bias. Availability bias is the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind (i.e. cherry picking only a few features of a presenting illness instead of integrating all aspects to confirm what you expect to find by selectively accepting or ignoring information). Anchoring bias is a shortcut in thinking where a person doesn’t consider multiple possibilities but quickly and firmly latches on to a single one.

My solutions to help avoid these biases in a chaotic environment are:

Make a differential diagnosis on every patient, even if it is something straight forward
Ask yourself what are the 2 or 3 worst things this could be (i.e. what is going to kill this patient?)
Re-evaluate your patient, lab results, images, and vital signs before deciding on a disposition. It literally takes 2 – 5 minutes to check on the patient and go back through the chart, and you will be amazed how many things you find that you didn’t realize about your patients.

Listen to Nurses

I like to make the analogy that as physicians we often only get a snapshot of what is going on with our patient, but nurses who are by the patients get a video of their patient. We can often be fooled by a single snapshot, which is why we re-assess our patients, to get multiple snapshots. Involve nurses in your patient work-up, plan of care, treatment, and disposition. I cannot tell you the number of times a nurse has saved my backside in the care of a patient. Finally, when is the last time you helped a nurse out? Trust me when I tell you that even something as small as getting a patient a blanket, or cup of water is worth its weight in gold. Have you ever heard the saying, behind every great physician is a great nurse? Well, I like to think of it, as beside every great physician is a great nurse.

“The trained nurse has become one of the great blessings of humanity, taking a place beside the physician and the priest, and not inferior to either in her/[his] mission.” Sir William Osler

Communication and Compassion

You may be the most brilliant physician in the world, but patients don’t necessarily care about that. What they are impressed with is bedside manner, compassion, and communication. The number one reason EM physicians get sued is due to lack of communication with their patients. Treat all patients with dignity and respect, even if they did something “really dumb.”

“The good physician treats the disease; the great physician treats the patient who has the disease.” Sir William Osler
“Cure sometimes, treat often, comfort always.” Hippocrates