Thinking Like an Emergency Physician (2023)

Emergency Medicine is the most interesting 15 minutes of every other specialty.

Dan Sandberg, BEEM Conference, 2014

Everyone in medicine knows that Emergency Medicine is different, even if they can’t put the reason into words.  We know why.  We work in an environment that is different, in hours that are different, and with patients who are different more than any other medical specialty.  Our motto is “Anyone, anything, anytime.”  No other specialty of medicine makes that claim.

While other doctors dwell on “What does this patient have? – that is, “What’s the diagnosis?” – emergency physicians are instead thinking “What does this patient need right now?  In 5 minutes?  In two hours?”  

The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues. Yet we do it on a daily basis, many times during a shift.  The idea of juggling decisions for several sick people simultaneously is beyond the capabilities of almost everyone else in medicine.  They are used to working with one patient at a time in a linear fashion.

I retired a few years ago after more than 45 years in Emergency Medicine, dating back to my time as an Army medic in Vietnam.  Every time I introduced myself to a patient, I never knew in advance which direction things were going to head.  I never knew whether I could help the patient in 30 seconds or 30 minutes, if at all.  I felt like I should have given this disclaimer.

Hello stranger, I am Doctor Joe Lex.  I will spend as much time with you as it takes to determine whether you are trying to die on me, and whether I should admit you to the hospital so you can try to die on one of my colleagues.  

You and I have never met before today.  You must trust me with your life and secrets, and I must trust that the answers you give me are honest.  

After today, we may never see one another again.  It may turn out to be one of the worst days of your life.  For me, it is another workday.  I may forget you minutes after you leave the department, but you will probably remember me for many days or months, possibly even for the rest of your life.  I will ask you many, many questions.  I will do the best I can to ask the right questions in the right order so that I come to a correct decision.  I want you to tell me your story, and for me to understand that story, I may have to interrupt you to clarify your answers.

Each question I ask you is a conscious decision on my part.  In an average 8-hour shift I will make about 10,000 conscious and subconscious decisions – who should I see next, what question should I ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, and is that really an infiltrate, which consultant will give me the least pushback about caring for you, is your nurse one whom I can trust with the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home?  And so on…  So even if I screw up just 0.1% of these decisions, I will make about ten mistakes today.

I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio.  Gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG, shingles, a dental abscess, an eye foreign body … I can recognize and treat those things without even thinking.  If, on the other hand, your problem has a lot of background noise and vague signs and symptoms, I am more likely to be led down the wrong path and come to the wrong conclusion.  

I am glad to report that the human body is very resilient.  We as humans have evolved over millennia to survive, so even if I screw up, the odds are very, very good that you will be fine.  Voltaire told us back in the 18th century that “The art of medicine consists of amusing the patient while nature cures the disease.”  For the most part, this has not changed.  And Lewis Thomas wrote: “The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves.  Most things, in fact, are better by morning.” On the other hand, the path to dying is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.

Remember, you don’t come to me with a diagnosis: you come to me with symptoms.  You may have any one of more than 10,000 diseases or conditions that we know about, and – truth be told – the odds of me getting the absolute correct diagnosis are small.  You may have an uncommon presentation of a common disease or a common presentation of an uncommon disease.  If you are early in your disease process, I may even miss such life-threatening conditions as heart attack or sepsis.  If you neglect to truthfully tell me your sexual history or your use of drugs and alcohol, I may not follow through with appropriate questions and might come to a totally incorrect conclusion about what you need or what you have.

You may be disappointed when you feel that you are not being seen by a “specialist.”  Many people believe that when they have their heart attack, they should be cared for by a cardiologist.  They think that the symptom of “chest pain” is their ticket to the heart specialist.  But what if the heart attack is not chest pain, but nausea and breathlessness?  And what if the chest pain is aortic dissection?  Or a pneumothorax?  Or a ruptured esophagus?  So, you are being treated by a specialist – one who can discern the life-threatening from the trivial, and the medical from the surgical.  We are the specialty trained to think like this.

We started our training in a state of unconscious incompetence – we were so poor at what we did that we did not even know how bad we were.  We were lucky if we could care for four patients in an 8-hour shift.  But we quickly learned and reached a level of conscious incompetence and multi-tasking – we knew that we were inadequate, but we felt ourselves getting better at our job on a day-to-day basis.  By the time we finished our training we had reached the next level: conscious competence.  We could deal with almost anything, but we still had to think hard about much of our decision making.  After a few more years of practice, we reached our pinnacle of unconscious competence

If you insist on asking “What do I have, Doctor Lex?” you may be disappointed when I tell you “I don’t know what you have, but I do know it is safe for you to go home.”  Sometimes I can do this without doing a single test.  I do know that if I give you a made-up diagnosis like “gastritis” or “walking pneumonia,” you will think the problem is solved.  Worse yet, other doctors will anchor on my false diagnosis, and you may never get the right answers.

Here’s some good news: we are probably both thinking of the worst-case scenario. You get a sudden headache and wonder “Do I have a brain tumor?”  You get some belly pain and worry “Is this cancer?”  The good news is that I am thinking exactly the same thing.  And if you do not hear me say the word “stroke” or “cancer,” then you will think I am an idiot for not reading your mind to determine that is what you are worried about.  I understand that no matter how trivial your complaint, you have a fear that something bad is happening.

While we are talking, I may be interrupted once or twice.  See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, clarifying orders for nurses and technicians.  Or I may get suddenly called away to care for someone far sicker than you.  I will try very hard to not let these interruptions derail me from doing what is best for you today.

I will use my knowledge and experience to reach the right decisions for you.  I know that I am biased, but knowledge of bias is not enough to change it.  I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this condition at least half the time it occurs.

And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by pattern recognition or use analytical reason.  Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking).  Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking).  It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.

After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you.  This is to document what I have found and how I have worked up your complaint, so the hospital and I can get paid.  The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier.  But that chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process.  In my eight-hour shift today I will click about 4000 times.

What’s that?  You say you don’t have insurance?  Well, that’s okay too.  The U.S. government and many other governments in the world have mandated that I have to see you anyway without asking you how you will pay.  No, they haven’t guaranteed me any money for doing this – in fact, I can be fined a hefty amount if I don’t do it.  A 2003 article estimated I give away more than $138,000 per year worth of free care because of this law.

But if you are having an emergency, you have come to the right place.  If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracotomy, I’ll do it.  If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too.  I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter. I can float your temporary pacemaker, I can get that pesky foreign body out of your eye or ear or rectum, I can stop your seizure or your nosebleed, and I can talk you through your bad trip.

Emergency medicine really annoys a lot of the other specialists.  I think that it is primarily because we are there 24 hours a day, 7 days a week.  And we really expect our consultants to be there when we need them.  Yes, we are fully prepared to annoy a consultant if that is what you need.

I saw thousands of patients, each unique, in my near-50 years of experience.  But every time I thought about writing a book telling of my wondrous career, I quickly stopped short and told myself “You will just be adding more blather to what is already out there – what you have learned cannot easily be taught and will not be easily learned by others.  What you see as wisdom, others will see as platitudes.”

As author Norman Douglas once wrote: “What is all wisdom save a collection of platitudes.  Take fifty of our current proverbial sayings– they are so trite, so threadbare.  None the less they embody the concentrated experience of the race, and the man who orders his life according to their teachings cannot be far wrong.  Has any man ever attained to inner harmony by pondering the experience of others?  Not since the world began!  He must pass through fire.”

Have you ever heard of John Coltrane?  He was an astonishing musician who became one of the premiere creators of the 20th century.  He started as an imitator of older musicians but quickly changed into his own man.  He listened to and borrowed from Miles Davis and Thelonious Monk, Coleman Hawkins and Lester Young, African music and Indian music, Christianity and Hinduism and Buddhism.  And from these seemingly unrelated parts he created something unique, something no one had ever heard before.  Coltrane not only changed music, but he changed people’s expectations of what music could be.  In the same way, emergency medicine has taken ideas from surgery and pediatrics, critical care and obstetrics, endocrinology and psychiatry, and orthopedics, and we have created something unique.  And in doing so, we altered the world’s expectations of what medicine should be.

Now, how can I help you today?

Author

Joe LEX

Joe LEX

Joe Lex was involved in Emergency Medicine for more than 49 years – as a Vietnam combat medic, ER Tech, Certified Emergency Nurse, and Emergency Physician. For five years he was Education Chair for the American Academy of Emergency Medicine, which renamed their Educator of the Year Award the “Joe Lex Award.” After 14 years in the community, he joined the Emergency Medicine faculty at Temple University in Philadelphia. He is a “godfather” of free electronic open-access medical education and his website (www.FreeEmergencyTalks.net) taught thousands of people worldwide.

Since he retired in 2016 as a Professor of Emergency Medicine, he does a weekly radio show called “Dr. Joe’s Groove,” featuring 60-year-old news and jazz. He writes an occasional blog called “Notes from Nam” based on 170 letters he wrote home in 1968 and 1969. He is also an amateur cemetery historian and volunteer tour guide for Laurel Hill Cemetery in Philadelphia and West Laurel Hill Cemetery in Bala Cynwyd, in addition to researching and producing their monthly podcasts “All Bones Considered: Laurel Hill Stories” and “Biographical Bytes from Bala: West Laurel Hill Stories.”

Joe and his wife Andrea celebrate 50 years together in June. His publicity picture is quite old – add 15 years and 40 pounds.

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Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Thinking Like an Emergency Physician (2023)," in International Emergency Medicine Education Project, March 20, 2023, https://iem-student.org/2023/03/20/thinking-like-an-emergency-physician-2023/, date accessed: March 22, 2023

How To Present Your Case In The ED

how to present your case in the ED

As a medical student, presenting history and physical exam of a patient to the attending can be nerve-wracking. In the ED, physicians typically prefer an even more succinct presentation than usual, ideally less than 3 min. Case presentations are a great opportunity to show that you understand what the pertinent positives and negatives for the patient’s presenting complaint are and that you can summarize a large amount of information collected in an organized manner. Case presentations are your opportunity to impress your preceptor, so it is an important skill to master. It will also be the mode of communicating with the rest of the healthcare team throughout your career in medicine. Better communication = better patient care!

Ask

Before we get started, it is important to recognize that every physician may have their own preference for how they would like case presentations organized. Some prefer more details, and some prefer a specific order. Therefore, it is always a smart idea to ask your preceptor at the beginning of your ED shift if they have a preference for how they like cases to be presented.

The One Liner

State the patient’s name, age, sex, chief complaint, and any pertinent medical history. E.g., John Doe is a 16-year-old male with a history of eczema presenting with wheezing.

History of Presenting Illness (HPI)

include the details of the chief complaint, as well as any pertinent positives and negatives.
  1. Why did this patient present to the ED today?
  2. What are the details of the chief complaint? I.e. Onset, Duration, Progression, Alleviating and Aggravating Factors, Causes/Triggers, Changes with Position, etc.
    • For pain, it is helpful to describe OPQRSTU – Onset, Position, Quality, Radiation, Severity, Temporal, déjà vU (has it ever happened before).
  3. Any associated symptoms
  4. Any risk factors?
    • Any relevant past medical history (e.g. chronic conditions, hospitalizations, surgeries, etc.), family history, or social history (e.g. habits, living situation, alcohol consumption, smoking history, illicit drug usage)?

Review of Systems

Describe any other symptoms here.

  • Note that some ED physicians may not want a review of systems included in the oral case presentation if it does not include any additional pertinent information, but a review of systems should always be included in your written patient note. 

Medications

Allergies

if the patient states that they do not have any allergies, this can be recorded and/or stated as “NKDA” which stands for No Known Drug Allergies.

Physical Exam Findings

  1. Start off by stating the most updated set of vitals.
  2. Next, state the patient’s general appearance as this helps decide between sick vs. not sick. E.g., patient is alert, oriented, and in no apparent respiratory distress.
  3. Then, delve into the pertinent details of the physical exam. E.g. for a cardiac complaint, it is important to include the specific details of the cardiovascular exam and respiratory exam, but not of all the other systems.
  4. A brief overview of the other systems that a physical exam was conducted for can be useful, but be as concise as possible, and organize information in a head-to-toe fashion if needed. If there were no other findings, you can state that the remainder of the physical exam was unremarkable. 

Summary

In 2-3 sentences, gather the main findings of your history and physical exam. Be sure to restate the initial one-liner sentence, other pertinent positives and negatives, and any important test results so far.

Impression/Assessment

State your differential diagnosis for each problem.

  • Start off by stating what you think the most likely diagnosis is, and why you think it is the most likely.
  • Then, state any other likely diagnoses you are suspecting.
  • Lastly, state the deadly diagnoses that could be possible with this patient’s chief complaint. In some cases, this can be the first thing you may want to say. It is important to specify why you do or do not feel confident in ruling these out. E.g., in a baby presenting with fever of unknown origin, it is important to state why you are not (or are) suspecting meningitis, encephalitis, malignancy, or autoimmune conditions.
  • Many medical students will shy away from stating their impression of what could be going on in terms of differential diagnosis, but this is an important thing to attempt. Preceptors will appreciate your effort in synthesizing what could be going on and be impressed by it, even if your impression is incorrect. This is often what sets apart students that “meet expectations” vs. students that are considered “outstanding”.

Plan

What do you want to do next?

  • Plan includes anything from the tests you want to order (including repeat vitals, bloodwork, and imaging), immediate treatment (including analgesics and fluids), and referrals you want to make (including consults, admission/discharge plan, and referral to allied health professionals such as social work, speech-language pathology, occupational therapy, and physiotherapy).  
  • Do not forget to take the patient’s social history into account when deciding what to do next.

Congrats – you have now completed your oral case presentation! This is a skill you will continue to develop with practice, so do not worry and keep working at it. It is also a good idea to always ask your preceptor for feedback on your case presentation once it is complete, as that will help you identify your strengths and weaknesses.

References and Further Reading

Cite this article as: Sheza Qayyum, Canada, "How To Present Your Case In The ED," in International Emergency Medicine Education Project, December 7, 2020, https://iem-student.org/2020/12/07/how-to-present-your-case-in-the-ed/, date accessed: March 22, 2023

More Blog Posts By Sheza Qayyum

Unmasking communication during COVID-19

Unmasking communication during COVID-19

As face masks become ubiquitous in our health-care practice due to the COVID-19 pandemic, communication between the patient and health-care provider has become harder than ever before. The challenges posed by COVID-19 have highlighted various areas of deficiencies in the health care industry as well as heightened anxiety among health-care providers as well as patients. Communication with patients has become particularly challenging and ever so more important than before.

Imagine the plight of a patient struggling to breathe, being greeted by someone in full PPE, struggling to understand your muffled speech through the mask amidst the background noise of oxygen hissing through a breathing mask. Earlier, your smile would have worked to ease some of the anxiety by coming across as approachable and friendly; however, your face mask has cost you a brave soldier in your battle of gaining trust. The situation is worse in the elderly, frail, and cognitively impaired patients who may rely on lip-reading and facial expressions to communicate.

Health care workers are forced to have difficult conversations of do-not-resuscitate orders, advance care planning, and break bad news while wearing a face mask and PPE, creating a barrier for effective communication with patients and their family members.

If you have previously relied on a firm handshake and a smile to lessen the anxiety of patients but are now finding it challenging to have clear communication, here are few ways to improve communication with patients.

Unmasking communication during COVID-19
Cite this article as: Neha Hudlikar, UAE, "Unmasking communication during COVID-19," in International Emergency Medicine Education Project, August 10, 2020, https://iem-student.org/2020/08/10/unmasking-communication-during-covid-19/, date accessed: March 22, 2023

A Lens Beyond Emergency Medicine

A lens beyond emergency medicine

The emergency room constantly presents challenges, and physicians always have to act with urgency. Patients, on the other hand, fear diagnoses they will hear, being unprepared to deal with the consequences, let alone mustering the strength to inform their loved ones. In this chaotic and busy environment of the emergency department, healthcare professionals often overlook a core value: to facilitate healing beyond medicine.

Physicians strive to express compassion when faced with life and death matters, but doctors are human too! They suffer from many emotions their patients go through, sometimes more than their hearts can contain. On top of that, they are expected to provide care continuously, so they may reach a threshold where dying patients and crying family members seem to not affect them. The danger is physicians’ becoming “machines” lacking human emotions, consideration or care.

The importance of not losing our humanity cannot be overemphasized. Physicians are not only healthcare providers but they are leaders and health advocates. When conventional medicine fails to provide treatment, physicians have a responsibility to assure patients that they will be with them every step of the way. We are responsible for our patients’ lives from the day we take care of them. Let’s not mistake this for disregarding patient autonomy. Patients are entitled to decide for themselves, but a caring practitioner -one that listens and engages in conversation- will make the difference. Our responsibility is to make patients feel empowered. We can make a clinical difference by touching our patients beyond the physical.

Physicians must expand their perspective to see beyond emergency medicine. Conventional medicine has taught us to observe the patient for signs and symptoms but deemphasized patients’ expressions, feelings, ambitions, and dreams. Why should we see patients from just one lens? Medical students, physicians, and other healthcare professionals in the emergency department should remind themselves of perceiving a more subjective but meaningful aspect of patient care, which lies beyond the physical. True healing requires a multidisciplinary effort, including familial, environmental, and socio-economical aspects of care.

Social aspects of medicine play a crucial role and should never be neglected. Our utmost responsibility is to foster solidarity, peace, and humaneness in this world. Compassion must be the center of our every action as we concentrate on understanding the patient as a human, rather than the diseases. Physicians that mind the interconnections between medicine, emotions, and humans, make a difference.

Cite this article as: Leah Sarah Peer, Canada, "A Lens Beyond Emergency Medicine," in International Emergency Medicine Education Project, April 10, 2020, https://iem-student.org/2020/04/10/a-lens-beyond-emergency-medicine/, date accessed: March 22, 2023