Clinical Decision Making in Emergency Medicine

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Clinical Decision Making in Emergency Medicine
Richard Wolfe, MD Chief , Department of Emergency
Medicine Harvard Medical Faculty Physicians
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Decision Making and Clinical ErrorsIndividual
or System?
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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

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Intuitive and Analytic Thinking
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• What is unique about Emergency Medicine?
• The medical decision process in the Emergency
  Department

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5 Features of Emergency Medicine

• NEED FOR SPEED
• SPECIALIZED KNOWLEDGE
• SHORT TERM VALUE BASED JUDGEMENTS
• LIMITED RAPPORT WITH PATIENTS
• COMMUNICATIONS ARE CRITICAL

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• Traditional approach in primary care
• Comprehensive history and physical exam
• Formulate comprehensive problem list
• Formulate long term diagnostic and therapeutic
  plan

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Primary Care
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What is the Emergency Medicine approach?
GOALS STABILIZATION AND DISPOSITION

• Identify the chief complaints/problems
• Perform a focused history and physical exam
• Immediate recognition and empiric treatment of
  the potential life threats
• Disposition only once all life threats are
  identified, stabilized, or ruled out.
• Ensure a safe follow up plan

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Emergency Medicine
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• 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

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• 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?

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• How do I identify life threats?
• Focused history based on chief complaints
• Focused physical exam
• Critical interpretation of basic labs

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• Vital signs are
• The best objective data we have to identify a
  life threat.
• If they are accurately taken and critically
  interpreted

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• Be aware of normal vital signs that identify
  a life threat. Examples
• Acute asthmatic with a respiratory rate of 12
• A patient in hemorrhagic shock with a pulse of 64
• Elderly patient with a BP 110/80
• Respiratory Rate of 20 br/mn

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• 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?

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• 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.

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• How do I formulate my differential diagnosis?
• What is the most serious possible cause of this
  patients presenting symptoms and signs?

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• 65 year old male with sudden onset of flank
  pain and near syncope?
• Ruptured abdominal aortic aneurysm

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• 57 year old male with epigastric pain, nausea
  and vomiting
• Acute inferior myocardial infarction

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• 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

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• 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

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• 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?

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• A patient with a suspected herniated disc or
  acute lumbar strain should be informed of
• The symptoms and signs of a cauda equina syndrome

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• A patient with abdominal pain of unknown
  etiology should be informed of
• The signs and symptoms of a surgical problem such
  as appendicitis.

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• 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?

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• 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!

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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

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

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Management

• Nasal films normal
• CBC, Lipase normal
• Left shoulder film normal
• Epistaxis resolves with anterior packing
• Received GI Cocktail and Morphine

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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

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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

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Comments by Case Review
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• 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? Wasnt 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

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The Amazing Retrospectoscope
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ERROR IDENTIFICATION
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Causes of Error in the EDFive deadly sins

• Ignorance TECHNICAL ERROR
• Wishful thinking JUDGEMENTAL ERROR
• Selfishness NORMATIVE ERROR
• Distraction SENSORY OVERLOAD
• Deference RESPONSIBILITY ERROR

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Technical ErrorSkills fall short of the task

• Ex Did not know low mechanism could cause
  splenic injury
• Ex Not aware of Kehrs sign. Nasal films
  useless study.
• Other examples
• Closure of a fight bite
• Home dispo Fever IVDA
• Adm Nec Fasc to Medicine
• INDECISION

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Technical Error

• Easy access to information
• Supervision
• Formal Educational Programs
• Clinical Pathways

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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

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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

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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 dont
  care
• Education in Critical Thinking

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Normative ErrorFailure in the eyes of others to
discharge ones role obligations conscientiously.

• Ex Undermanaging a difficult patient
• Ex Less safe dispositions
• Other examples
• Failure to perform LP with severe headache and
  negative CT

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Avoiding Normative Error

• Restore sense of value of the front line provider
• Avoid top down management
• MM and intellectual honesty

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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

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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

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Deference ErrorMisdirection by authoritative
figure or Dogma
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When all else fails,try heuristics
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Golden Rule

• Patients who cant walk, cant leave.

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Golden Rule

• Once a patient is labeled, all thinking stops.
• Dont put a label on that you cant prove.

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Golden Rule

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

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Golden Rule

• Kill as few patients as possible

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Questions or Comments?