lex 45 years on the front line
DESCRIPTION
Joe Lex offers up his hard won advice on succeeding as an emergency physician.TRANSCRIPT
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Emergency Medicine
Front Line Tales: Front Line Tales: Been There, Done That Been There, Done That
for 46 Yearsfor 46 Years
Joe Lex, MD, FACEP, MAAEMTemple University School of Medicine
Philadelphia, PA
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Rules to Live By
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Rules to Live ByRules to Live By
� Be curious: find out exactly how and why events happened
� Do not accept diagnoses and conclusions made by others
� Recognize the patient as teacher
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Rules to Live ByRules to Live By
� Form your diagnostic hypothesis, then focus on signs or symptoms that are atypical or incompatible with your diagnosis
� These must be explained, not ignored
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Rules to Live ByRules to Live By
� Savor your successes but then move on: dwelling on them causes overconfidence
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Rules to Live ByRules to Live By
� Learn from your failures but then move on: dwelling on them causes indecision
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Rules to Live ByRules to Live By
� Good judgment is based on experience
� Experience is based on bad judgment
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Rules to Live ByRules to Live By
� Some patients you think will get better will get worse
� Some patients you think will get worse will get better
� Some young people die unexpectedly
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R – E – S – P – E – C - TR – E – S – P – E – C - T
� Respect your colleagues: Be on time for work
� “On time” means 10 minutes early� The third time you are late will get
you a reputation that’s hard to shake
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Rules to Live ByRules to Live By
� Most people in the hospital are afraid of, or intimidated by, the ED and everything that goes on in it. It can be a frightening place – think of your first time there.
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““What’s the Diagnosis?”What’s the Diagnosis?”
� Non-ER doc: “How in the world do you expect me to take care of someone without a diagnosis.”
� ER doc: “Yeah, I treated her and she got better…but I still don’t know what she has.”
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In Other Words…In Other Words…
� Medical school teaches most doctors to figure out “What does this patient have.”
� Emergency medicine alone says “What does this patient need … now, in 10 minutes, in 1 hour, and beyond.”
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Rules to Live ByRules to Live By
� Practicing Emergency Medicine is like living a life: it’s hard for everybody but it’s a lot harder if you’re stupid
� READ!! Every chance you get
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Patient Care
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Develop Good RapportDevelop Good Rapport
� Shake hands with and introduce yourself to everybody in the room, even the children
� Ask who is who: NEVER ASSUME RELATIONSHIPS– The “granddaughter” may be a
spouse, the “mother” may be a cousin
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Develop Good RapportDevelop Good Rapport
� Sit at patient’s bedside to collect a thorough history
� Do not hover or loom over a patient; get your eye level to theirs or lower
� Perform an uninterrupted physical examination
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Develop Good RapportDevelop Good Rapport
� Establishing relationship with patient: not just good manners
� It enhances trust and confidence� It reduces medicolegal risk� It facilitates rapid discharge� It improves patient compliance
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Develop Good RapportDevelop Good Rapport
� Include family members in the history gathering
� Physical contact helps establish rapport
� Inform them if you are using a validated clinical decision rule that indicates if tests are necessary
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Some More RulesSome More Rules
� You can’t sleep through peritonitis� You CAN sleep with a pain that is
“10 out of 10”
– It’s called “escaping the pain”
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Gordon’s Law #65Gordon’s Law #65
Never refer to a patient as an organ or a room number
It has to do with…
…courtesy
… respect
…humanity
…manners
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Watch Your WordsWatch Your Words
� To most patients, PCP is a street drug, not Primary Care Provider
� Many older patients are horrified at taking “narcotics,” but willingly take an “opioid pain reliever”
� 99% of patients think “gastritis” is gas
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Watch Your WordsWatch Your Words
� Ask “Is there any medicine you can’t take?” rather than “Are you allergic to anything?”
� Ask “Is there anything you take every day” rather than “What meds do you take?”
� Always look at Medic Alert bracelets or necklaces
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Watch Your WordsWatch Your Words
� You have been taught to ask the patient, “Is there anything else?”
� Instead, you should ask “Is there something else.”
� This simple change in words will open up worlds of new information
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Watch Your WordsWatch Your Words
� We don’t take care of “cases,” we take care of patients
� Patients on dialysis are not “renal players”
– It’s not a sporting event� If you wouldn’t say it in front of
the patient, don’t say it in front of me
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Watch Your WordsWatch Your Words
� We are human beings who use our senses: we see a rash, hear a murmur, smell a wound, feel a mass
� We appreciate a good night’s sleep, a well-written novel, a thoughtful play, or a gourmet meal
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Ordering TestsOrdering Tests
� Before ordering a test, determine how the result will influence care
� Investigations that will not improve patient outcome are a waste of time and money
� Likely to increase anxiety or provide false reassurance
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Ordering TestsOrdering Tests
� Don’t “screen” with cardiac biomarkers unless you intend to repeat the assays after a time
� Don’t send d-dimer unless you plan to follow-up a positive study
� Don’t send BNPs� Understand the limitations of tests
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Ordering TestsOrdering Tests
� Example: “positive” CT pulmonary angiogram in no-risk / low-risk twice as likely to be false-positive as it is to be true-positive
� Positive CT pulmonary angiogram is life changing event
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Ordering TestsOrdering Tests
Understand these concepts
� VOMITVOMIT – Victim Of Medical Imaging (or Investigational) Technology
� BARFBARF – Blind Acceptance of a Radiologic Finding
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Ordering TestsOrdering Tests
� Every positive test must be further investigated
� By definition, one of every 20 tests ordered will be “abnormal”
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VOMIT and BARF ReduxVOMIT and BARF Redux
� Patient requests more NSAIDs for long-standing osteoarthritic low back pain
� Doc does lumbar x-ray bits of aortic calcium, not in round shape
� Radiology comment “AAA cannot be excluded: suggest ultrasound if clinically indicated”
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VOMIT and BARF ReduxVOMIT and BARF Redux
� No clinical evidence of AAA� US done, rules out AAA…� …but US shows “small cystic
lesion adjacent to kidney, probably benign but suggest CT if clinically indicated”
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VOMIT and BARF ReduxVOMIT and BARF Redux
� No renal signs/symptoms but CT duly done “2-3 cm cystic lesion upper pole right kidney, probably benign, malignancy not excluded”
� Urology referral duly done: “Probably benign but a small chance it COULD be CANCER”
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VOMIT and BARF ReduxVOMIT and BARF Redux
� Patient says, “Take it out take it out take it out.”
� Cyst removed major bleeding� Re-operation nephrectomy,
packing, transfer to ICU
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VOMIT and BARF ReduxVOMIT and BARF Redux
� Packs out on day 2� In ICU for 3 days� In hospital for 10 days� Now has one kidney…
…but the benign cyst is gone
…and now he can’t take NSAIDs any more
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Make a Decision in 4 HoursMake a Decision in 4 Hours
� Recognize the limitations of the ED: we provide episodic acute care to our patients
� Enable a diagnostic strategy that provides you with the information you need to make a decision by four hours into the patient’s visit
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Make a Decision in 4 HoursMake a Decision in 4 Hours
� Beware of asking a patient a question if you do not want to deal with the answer
� Order the necessary tests early � Only order tests that will affect the
patient’s management in the ED
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Don’t Delay UncomfortableDon’t Delay Uncomfortable
� Recognize situations where an uncomfortable decision is inevitable, and where waiting or doing tests will not make it more palatable. Make that decision as soon as possible.
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Concept of “Emergency”Concept of “Emergency”
� If a patient adds non-urgent problems to the main complaint, politely avoid attempting to solve these problems
� An analogy to phoning their accountant or lawyer at 2 am may help
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Consultants
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Know Your ConsultantsKnow Your Consultants
There are three primary reasons to call a consultant:
� You need help or advice� You want to learn something� You want the consultant to
observe the same phenomenon you are seeing
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Know Your ConsultantsKnow Your Consultants
The two biggest mistakes we make when consulting consultants:
� We believe everything they say� We believe nothing they say
Put the opinion in perspective: the physician hasn’t been born who is always right or always wrong
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Know Your ConsultantsKnow Your Consultants
� If you develop good relationships with consultants, patient transfers are likely to be quicker, leaving you with more time for resolving other issues
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Admission DecisionsAdmission Decisions
� You decide which patient requires admission
� You decide which service should care for the patient
� Your consultants are motivated to minimize their workload and will expend much energy to do so
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CommunicationCommunication
When communicating with a consultant, in first minute give…
…bottom line: condition & acuity
…short patient profile
…your clinical impression
…what the patient now requires
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CommunicationCommunication
� Honesty and integrity are keystone to effective relationships with colleagues and consultants
� In cases of conflict, keep conversation focused on patient
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CommunicationCommunication
� Do not consider recommendation of outpatient management simply because “there are no beds”
� Avoid putting consultants’ schedules above patient needs and ED flow issues
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Make Consultations ClearMake Consultations Clear
� If your normal conduct is to make clear, focused, appropriate consultation requests, you will build a bank of goodwill on which you can draw when you simply have no time for intensive, time-consuming workups or procedures
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Make Consultations ClearMake Consultations Clear
� It is inexcusable to call a consultant and say “I don’t know much about this patient…it was a sign-out.”
� Have the chart in front of you and know the results of diagnostic studies
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Gordon’s Law #47Gordon’s Law #47
The quality of the x-ray ordered is directly proportional to the
specificity of the clinical information supplied to
the radiologist.
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Don’t Delay ReferralDon’t Delay Referral
� If consultation or admission is apparent prior to testing, don't wait for results unless they will determine management
� Notifying consultants that referral is imminent helps them choreograph the day
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Consult from AuthorityConsult from Authority
� If flow is backed up, as it often is, it is inappropriate to allow junior staff with no decision-making power to be the consulting service’s first response. Trainees can see new patients on the ward.
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Consult from AuthorityConsult from Authority
� Patient care trumps education, and teaching “need” should not delay the transfer of patients to available beds.
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Other Tips
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Surfing vs. Cherry-PickingSurfing vs. Cherry-Picking
� “Cherry picking” is looking through charts and picking up “easy cases” not encouraged
And Another Thing…And Another Thing…
� When in doubt, wash your hands
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Communicate with RNsCommunicate with RNs
Rule #1: Nurses can hurt doctors far worse than doctors can hurt nurses
Rule #2: You may be a brilliant young doctor, but you are a transient. Most nurses are permanent employees. Know your place.
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Use the NursesUse the Nurses
� Listen to the nurses and respect what they have to say
� Sometimes nurses are right and sometimes nurses are wrong… just like you
� Learn the first name of the nurses who work with you and call those who prefer it by their first names
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UnderappreciatedUnderappreciated
� The most underappreciated member of the ED is usually the ward secretary
� The respiratory therapist is a close second
� Environmental is right up there: think about what they do without complaint daily
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Death NotificationDeath Notification
� The hardest thing you’ll do in emergency medicine is to notify a family of a family member’s unexpected death; nothing else is remotely as difficult
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MultitaskMultitask
� If you know that a patient will need more than one dose of pain medicine (e.g., sickle cell vaso-occlusive crisis, renal colic), order the pain medicine on a “prn” basis and empower the nurse to make the patient comfortable
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Avoiding BouncebacksAvoiding Bouncebacks
� Reasons to make a patient do laps around the Emergency Department before discharge– Nosebleed– Shortness of breath / asthma– Vertigo
– Back pain
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Evaluating BouncebacksEvaluating Bouncebacks
� Red flag and golden opportunity� Assume every bounceback
means something was missed on the prior visit
� Don’t get anchored on prior visit; start fresh
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Don’t Ignore Abnormal VSDon’t Ignore Abnormal VS
� Child who is tachypneic may have pneumonia, despite no cough
� Patient who becomes hypotensive following a traumatic injury is not having vasovagal episode
� Don’t assume anything� Don’t ignore anything
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Don’t Take ShortcutsDon’t Take Shortcuts
� You will miss petechial rash in infant with fever
� You will miss strangulated inguinal hernia or testicular torsion
� You will miss zoster lesions� You will miss Fournier’s in the old
guy in a diaper
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Don’t Wait for ConsultantsDon’t Wait for Consultants
� If you think meningitis, give antibiotics first and do lumbar puncture later
� If you think an elderly person has pneumonia, give a big dose of an IV antibiotic as soon as possible– It doesn’t really matter which one,
just give something
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Don’t Be Health-Care PoliceDon’t Be Health-Care Police
� Know cost of tests you order� Be conscious about appropriate
resource utilization� If you think test appropriate, do it� Don’t let colleagues dissuade you
from ordering a test just because it’s will inconvenience them
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Beware the DrunkBeware the Drunk
� Both history and physical examination in an intoxicated patient are completely unreliable
� Over-investigate these patients� To rule out subdural hematoma,
one CT scan is better than a room full of neurologists
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The Good NewsThe Good News
� As you gain experience in the ED, you will learn answers to many, many questions
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The Bad NewsThe Bad News
� There are more questions without answers than with
� The number of questions without answers never stops growing
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The Bad NewsThe Bad News
� Medicine is an infinite jigsaw puzzle: the best you can do is put an occasional piece into place
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And finally…And finally…
� Data are not facts� Facts are not information� Information is not truth� Truth is not knowledge� Knowledge is not wisdom
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Words to Live ByWords to Live By
“Has any man ever obtained inner harmony by pondering the experience of others? Not
since the world began. He must pass through fire.”
- Norman Douglas
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Ars Longa, Vita BrevisArs Longa, Vita Brevis
“Life is short, art (of medicine) is long; the crisis fleeting; experience perilous, and
decisions difficult.”
- Hippocrates
An incredibly accurate description of Emergency Medicine