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PRINCIPLES OF EMERGENCY MEDICINE

It is often said that ED patients "don't read the textbook," meaning that their presentations do not fit nicely into specific textbook diagnoses or classical presentations of illness. However, a cornerstone of an EP's practice is the recognition of patterns in a patient's presentation; therefore, the prudent physician must be a detective and scientist to muddle through the muck of vague signs and symptoms to find the pattern.

The principles of emergency medicine are simply questions that must be answered to provide effective care to patients who have entrusted EPs with their care. The questions are not to be used as a cookbook approach to the management of these often complex medical and psychosocial issues but are to be used as a simple method to guide the prudent EP through the quagmire of clinical emergency medicine.

A. Is the Patient About to Die?

Obviously, this is the first and most important question to answer. Every patient's presentation is quickly prioritized to one of the following acuities:

1. Critical—Patient has symptoms consistent with a life-threatening illness or injury with a high probability of death if immediate intervention is not begun.

2. Emergent—Patient has symptoms of illness or injury that may progress in severity if treatment is not begun quickly.

3. Nonurgent—Patient has symptoms that have a low probability of progression to a more serious condition.

Look for symptoms of a life-threatening emergency, not a specific disease entity. Anticipate impending life-threatening emergencies in the apparently stable patient.

B. What Steps Must Be Undertaken to Stabilize the Patient?

Act quickly to stabilize the critically ill or injured patient. Focus on the primary survey (airway, breathing, circulation, and neurologic deficits) and make necessary interventions as each issue is identified. Do not delay necessary primary interventions while awaiting completion of ancillary testing.

C. What Are the Most Potential Serious Causes of the Patient's Presentation?

Thinking of the worst-case scenario, develop a mental list of the most deadly causes of the patient's presentation by asking, "What will kill my patient the fastest?" Once the list has been developed, the vital signs, history, physical examination, and ancillary assessments should identify or confirm those causes highest on the list.

D. Could There Be Multiple Causes of the Patient's Presentation?

In addition to constant reevaluation and reprioritization of the differential diagnosis, continually ask, "Is this all there is?" For example, is the new-onset seizure and hypoglycemia in an older diabetic patient from intentional or accidental medication overdose or perhaps worsening renal insufficiency? Is the near-syncope and abdominal pain in an apparently intoxicated college coed from a ruptured ectopic pregnancy or perhaps a ruptured spleen secondary to undisclosed physical abuse by her boyfriend? Frequent reassessment and thoughtful inquiry as to the multiple possibilities responsible for each patient's condition is imperative.

E. Can a Treatment Assist in the Diagnosis in an Otherwise Undifferentiated Illness?

Often, in emergency medicine, treatment response foretells a diagnosis. A case in point is the unconscious patient with no available collateral history. The patient's response to empiric administration of naloxone will include or exclude narcotic overdose as a contributor to the obtundation. Referred to as the "diagnostic-therapeutic" concept, it underscores the emergency medicine philosophy that an established diagnosis is not a prerequisite to initiating appropriate treatment. Pitfalls can exist. For example, sublingual nitroglycerin and so-called GI cocktails can relieve symptoms of chest pain resulting from the same cause.

F. Is a Diagnosis Mandatory or Even Possible?

After the emergency issues have been addressed, the patient and EP are often left with an undifferentiated symptom complex. This frequently elicits an uncomfortable response by non-emergency medicine trained physicians. The EP should become accustomed to and comfortable with the notion of determining the disposition for a nonemergency patient—having treated their symptoms and excluding emergency conditions—without a specific diagnosis.

G. Does This Patient Need to be Admitted to the Hospital?

Having appropriately answered the preceding questions, make the bottom-line disposition decision. Once assessments and treatments are under way, decide whether an emergency condition exists. Consider other subtleties. Does the patient have timely, accessible follow-up? How far away from a medical facility does the patient live? Are unresolved abuse or self-care issues involved? Are you, as the EP, comfortable discharging the patient?

H. If the Patient Is Not Being Admitted, Is the Disposition Safe and Adequate for the Patient?

More frequently than not, patients are discharged home from the ED. However, many patients do not receive a specific diagnosis, and some symptoms may persist. Recommend appropriate follow-up and provide written discharge instructions. Invite the patient back. Instruct the patient when to return for further evaluation should symptoms change or worsen. Provide the patient with information regarding treatment and diagnosis as well.

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