Archive for the ‘heuristic’ Category

  Ten minute screencast describing an expanded ABCs mnemonic. Mobile phone optimized cheat sheet at Slides. Audio. Resus Room pic.

The Preferred Error

June 11th, 2014
by reuben in heuristic

Last week emcrit proposed that we have lost our nerve: that we fail to act when action is called for, that we tend to commit errors of omission, rather than errors of commission, and so we should toughen up, give ourselves permission to act, provide maximally aggressive care everywhere. A chorus responded with the obvious objection that we are doing way, way too much and that we are causing massive amounts of harm with overtesting, overdiagnosing, and overtreating. I review hundreds of high-risk cases per month, and in patients who have bad outcomes, we do often conclude that the bad outcome could have been prevented by doing more. It really does seem as though there is a reluctance by non-surgeons to perform dangerous procedures, and that this reluctance often results in harm. The easiest way to explain this discrepancy is that maximally aggressive care everywhere might be a reasonable paradigm if everywhere for you is a resuscitation bay (cue Casey).  But of course M.A.C.E., if interpreted as when in doubt, do more is an unreasonable paradigm even in the resus bay–we don’t want to do more, we want to do the right amount. Part of knowing the right amount is knowing medicine, and part of it is knowing yourself. Most of us tend toward overtesting and overtreating, but under-resuscitating (most of us but not all of us–we’ve all run into clinicians whose threshold to do dangerous procedures is too low, they are way scarier). This is why there is a lot of wisdom to contradictory rules…

The Usual State of Readiness

September 26th, 2012
by reuben in heuristic, resus

  Emergency providers are routinely called upon to react to complex scenarios that demand specific life-saving maneuvers, immediately and without warning.  The most important impediment to performing well in these situations is your own catecholamines, and the most important catecholamine reduction strategy is preparation. The extent to which you are prepared to immediately react is your usual state of readiness, and it has two parts: cognitive and material. Cognitive readiness requires that you consider emergency scenarios and decide on a plan. This starts with a textbook (by textbook I of course mean the internet) and reading what others think you should do in a given emergency scenario. The hard part of cognitive readiness is keeping up with the endlessly changing, endlessly disagreeing opinions, and deciding how to shape them into a plan that you like and that works for you in your environment. Logistics are key. As medical knowledge expands forever faster, perhaps the most important knowledge of all is knowing what you need to know, and knowing what you can look up. This is not an either/or so much as a spectrum of how close information needs to be to your brain. There are plans that have to live in your brain (management of a completely obstructing airway foreign body), facts that you can take 30 seconds to look up (weight-based dose of atropine), and lists that you can review at your desk (the differential diagnosis of anisocoria). Memory fails when catecholamines are high; planning for emergency scenarios involves the development and deployment of…

The Precipitants of Everything

October 2nd, 2011
by reuben in heuristic

  A common mistake made by junior emergency physicians (and sometimes not junior emergency physicians) is to identify a problem and address it without considering its precipitant. Recognizing that the patient’s symptoms are due to an exacerbation of CHF, asthma, or COPD, DKA, seizure (the med student thought it was syncope but you know better), atrial fibrillation, hypoglycemia, dehydration, hepatic encephalopathy, uremia, or electrolyte disturbance: that’s fabulous. Knowing how to treat these conditions: phenomenal. But if you really want to impress the opposite sex, or the same sex, or whatever you’re into, figure out why the patient is having this problem, now. Fortunately, the same things cause most of the common afflictions of ED patients. So here they are, the precipitants of everything:   medication changes and, especially, noncompliance recreational intoxicants and other lifestyle choices withdrawal (but why was this patient unable to get his fix today? there may be a further precipitant) infection (lungs, urine, skin, CNS, abdomen, indwelling catheters and devices, soft tissue/bone) ischemia (heart, brain, bowel) arrhythmia pulmonary embolism thyrotoxicosis or hypothyroidism occult trauma / abuse / neglect bleeding (GI bleed, vaginal bleed, urologic bleed, retroperitoneal bleed, abdomen, thorax, thigh, street) pregnancy (if there’s abdominal pain, bleeding, or syncope – don’t forget to rule out ectopic)   That doesn’t mean we ought to do ancillary testing to rule out these precipitants of everything; in most cases a directed history and physical is all you need. Just remember to ask the question, why is this patient having this problem, now?

The virtues and vices of emergency medicine

September 6th, 2011
by reuben in heuristic

    {adapted from a lecture I give to first year med students, at the end of a two-week course where we teach them how to be an effective first responder in a variety of pre-hospital emergency scenarios.}       Emergency doctors staff emergency rooms. We see whatever comes in, as fast as it comes in. We are the front door of the hospital, and we never close our doors. The specialty is defined by several key characteristics, which are virtues or vices, depending on your perspective, and often they are both at the same time. So I’m going to present them as both at the same time, in a sort of pro-con format.   1. The undifferentiated patient No other doctor routinely manages patients she knows nothing about. A typical emergency patient was found on the street in a coma. He could be minutes away from dying, or just really drunk and needs to sleep it off. We’ve got to figure it out without even knowing his name, much less his medical history or the events leading up to his present condition. Making the diagnosis is really fun. However, Uncertainty is the currency of emergency medicine. We have to make important decisions with very little information. We are wrong a lot. Sometimes, when we’re wrong, people die. Learning to be comfortable with uncertainty is difficult.   2. Speed Emergency physicians have to think fast and act fast.  It has been reported that emergency medicine has the highest decision density not just of any…

30 minute presentation on optimal patient assessment in the emergency department. garbled audio resolves at the one minute mark. Slides and Handout.   More recent live version.

Insurance Pays for AMA Patients

March 28th, 2010
by reuben in heuristic

Terrific myth-busting letter to editor in this month’s Annals. “…we retrospectively reviewed 104 consecutive cases of patients with insurance leaving against medical advice in 2008 from a suburban level I trauma center that sees 57,000 ED visits per year. Our review included 19 insurance companies, including HMOs, PPOs, Medicare, Medicaid, and workman’s compensation. We found that all 104 visits where the patient left against medical advice were fully reimbursed by their respective insurance company.” Thank you, Wigder et al. doi:10.1016/j.annemergmed.2009.11.024

61. Chest pain history mnemonic

October 15th, 2007
by reuben in .chest pain, heuristic