Clinical Decision Making in

Emergency Medicine

Richard Wolfe, MDRichard Wolfe, MD

Chief , Department of Emergency MedicineChief , Department of Emergency Medicine

Harvard Medical Faculty PhysiciansHarvard Medical Faculty Physicians

Decision Making and Clinical Errors

Individual or System?

How do we make clinical decisions in medicine?

• Chief Complaints Basic Data Collection

• Pattern Recognition

• Workable Differential Diagnosis

• Process to prove the correct diagnosis and exclude the incorrect etiologies

• Management of the Working Diagnosis

• Disposition

Intuitive and Analytic Thinking

What is unique about Emergency Medicine?

The medical decision process in the Emergency Department

5 Features of Emergency Medicine

1. NEED FOR SPEED

2. SPECIALIZED KNOWLEDGE

3. SHORT TERM VALUE BASED JUDGEMENTS

4. LIMITED RAPPORT WITH PATIENTS

5. COMMUNICATIONS ARE CRITICAL

Traditional approach in primary care

Comprehensive history and physical examFormulate comprehensive problem listFormulate long term diagnostic and

therapeutic plan

Primary Care

What is the Emergency Medicine approach?

Identify the chief complaints/problemsPerform a focused history and physical examImmediate recognition and empiric treatment of the

potential life threatsDisposition only once all life threats are identified,

stabilized, or ruled out.Ensure a safe follow up plan

GOALS STABILIZATION AND DISPOSITION

Emergency Medicine

How do I identify the chief complaints/problems?

What brought you to the ED *now* ?What has you worried, what is new?What are others worried about?How can we help?Wait for an answer

What is the key question to ask a patient with a chronic complaint such as headache or abdominal pain?

Is this pain different from your previous pain?If so, how is it different?

How do I identify life threats?

Focused history based on chief complaintsFocused physical examCritical interpretation of basic labs

Vital signs are:

The best objective data we have to identify a life threat.

If they are accurately taken and critically interpreted

Be aware of “normal” vital signs that identify a life threat. Examples:

Acute asthmatic with a respiratory rate of 12A patient in hemorrhagic shock with a pulse of 64Elderly patient with a BP 110/80Respiratory Rate of 20 br/mn

Basic labs are:

The delayed objective data we have to identify a life threat.

If they are accurately ordered and critically interpreted But they can also mislead Before ordering ask: Will this test alter my

management?

Feed Me!!

How do I approach the life threatened patient?

Perform technical procedures and administer medication before diagnostic modalities

Tube thoracostomy before chest X-ray in tension pneumothorax

Antibiotics before lumbar puncture for meningitis Airway management before the crashing patient looks sick.

How do I formulate my differential diagnosis?

What is the most serious possible cause of this patient’s presenting symptoms and signs?

65 year old male with sudden onset of flank pain and near syncope?

Ruptured abdominal aortic aneurysm

57 year old male with epigastric pain, nausea and vomiting

Acute inferior myocardial infarction

What is the most common error made in formulating a discharge diagnosis?

Giving the patient a benign diagnosis that cannot be supported by the medical record. Examples:

Gastroenteritis Gastritis

Is the diagnosis possible or necessary on all patients seen in the ED?

No, and it is appropriate and ideal to state this in the assessment or diagnosis. Example:

Abdominal pain of unknown etiology

What is the question to ask when I formulate a discharge plan?

What is the most serious complication of the evolving disease process that can occur?

A patient with a suspected herniated disc or acute lumbar strain should be informed of:

The symptoms and signs of a cauda equina syndrome

A patient with abdominal pain of unknown etiology should be informed of:

The signs and symptoms of a surgical problem such as appendicitis.

What questions should I reflect upon prior to discharging a patient?

Is it safe?

Have I made the patient feel better? If not, did I provide an explanation as to why?

52 yo ♂presents after slipping in his bathroom and falling onto a sink. He remembers striking his nose. He is complaining of nasal trauma and epistaxis.He is also complaining of epigastric pain, low back pain, and left shoulder pain. He has been seen many times for pain related complaints.PMH: Hepatitis, HIV

He wants medication for the pain NOW!

Added information Nursing Notes

• Epigastric pain and left shoulder pain new following the fall.

• Admits to binge drinking, last drink 3 hours ago

• Lives alone

• HR 110 BP 100/84 RR 20 T 37.2• Physical Exam unremarkable• Smells of alcohol but clinically sober.

Management

• Nasal films normal

• CBC, Lipase normal

• Left shoulder film normal

• Epistaxis resolves with anterior packing

• Received GI Cocktail and Morphine

ED Course

• Increasingly hostile with nurses

• 20 patients in the waiting room

• Discharged with ibuprofen for pain.

• DC Diagnosis: Nasal Contusion, Back Strain, Gastritis

• Follow up with personal MD as needed

2 days later

EMS called for man found down. Patient found at home in cardiac arrest.• GEN: Pale, pupils dilated, non reactive• EXT: Cool and clammy• Monitor: Asystole• Unable to resuscitate in Emergency Department.

Post Mortem: Cause of Death:Massive Intraperitoneal Hemorrhage, Splenic rupture

Comments by Case Review

• New onset abdominal pain and left shoulder pain after trauma: Obvious splenic injury. Abdominal life threat not assessed.

• Tachycardia not addressed?

• Why did he fall? Wasn’t he too intoxicated to provide an exam or be sent home?

• Vital signs not repeated

• Unsafe follow up plan

• Ibuprofen in patient with bleeding and possible coagulopathy

• Missed diagnostic studies:

– INR

– CT Head

– FAST Ultrasound

– Abdominal CT

• No follow up for anterior pack

The Amazing Retrospectoscope

ERROR IDENTIFICATION

Causes of Error in the EDFive deadly sins

• Ignorance: TECHNICAL ERROR

• Wishful thinking: JUDGEMENTAL ERROR

• Selfishness: NORMATIVE ERROR

• Distraction: SENSORY OVERLOAD

• Deference: RESPONSIBILITY ERROR

Technical ErrorSkills fall short of the task

• Ex: Did not know low mechanism could cause splenic injury

• Ex: Not aware of Kehr’s sign. Nasal films useless study.

Other examples:

• Closure of a fight bite

• Home dispo: Fever + IVDA

• Adm Nec Fasc to Medicine

• INDECISION

Technical Error

• Easy access to information

• Supervision

• Formal Educational Programs

• Clinical Pathways

Judgmental ErrorsIncorrect strategy is chosen

• Ruling out abdominal injury with physical exam only because of low mechanism

Other classic examples:

• Not intubating a critical patient because they look good

• Treating wide complex tachycardia as an SVT

“The greatest derangement of the mind is to believe in something because one wishes it to be so.”

Judgmental Error•Diagnostic Anchoring•Faulty Logic•Brain freeze•Fatigue

Avoiding Judgmental Errors

• Start with the chief complaint and take small pathophysiologic steps to catagorize the problems

• Explain anything that does not fit the picture

• Keep asking why until the answer is “I don’t care”

• Education in Critical Thinking

Normative ErrorFailure in the eyes of others to

discharge one’s role obligations conscientiously.

• Ex: Undermanaging a difficult patient

• Ex: Less safe dispositions

• Other examples:– Failure to perform LP with severe headache and

negative CT

Avoiding Normative Error

• Restore sense of value of the front line provider

• Avoid top down management

• M&M and intellectual honesty

Distraction ErrorFailure to incorporate all the problems

into the plan

• Epistaxis vs. abdominal pain

• Boston Marathon: Near amputations vs. shrapnel

• Ex: Medication errors, wrong side or wrong patient, Delays in treatment

Distraction Error

• Causes: – Excessive Workload/provider– Poor information support systems– Poor communication between providers

• Solutions:– Work redesign: Staffing patterns, staffing roles– Information system enhancement– Team Training

Deference ErrorMisdirection by authoritative

figure or Dogma

When all else fails,try heuristics

Golden Rule

• Patients who can’t walk, can’t leave.

Golden Rule

Once a patient is labeled, all thinking stops.

Don’t put a label on that you can’t prove.

Golden Rule

• Assume the worst case scenario and proceed to rule it out

Golden Rule

• Kill as few patients as possible

Questions or Comments?