Key questions

WHAT IS THE THREAT TO LIFE?

Perhaps the most important principle of emergency medicine is to search for and assume that the most potentially serious problem for each patient may be present, even if it is statistically improbable. Thus the key question will lead you away from an untimely focus on diagnosis. This question is: What is the threat to life? Always ask: are there any life threats, and am I missing something? For example, if a patient comes to the emergency department with chest pain, you should attempt to prevent a cardiac arrest, extension of the infarction, or worsening of the patient's disease instead of ordering an immediate ECG to prove the diagnosis of myocardial infarction. Thus your first response must be to place an intravenous line, start the patient on oxygen and consider anti arrhythmic drugs before proving or disproving the diagnosis.

DOES THE PATIENT NEED ADMISSION?

The second key question is: does the patient need admission? If you start with the perception that the patient is very ill, not only do you increase the diligence of the search for a cause, but you are also prevented from reaching through tunnel vision for a specific diagnosis that may in fact be incorrect. For example, a patient may look nearly normal after receiving intravenous fluids, but if the patient was in shock in the pre-hospital setting, more time will be needed to recover than you can arrange in the emergency department. Moreover you need to communicate to the physician who will be responsible for the in patient care of the patient, the perception that the patient is truly ill.

CAN THE DIAGNOSIS BE SUPPORTED BY THE EVIDENCE AVAILABLE?

One normal ECG tracing does not eliminate the diagnosis of an acute myocardial infarction, nor does a normal white cell count rule out a diagnosis of appendicitis. Can you prove what you believe the patient has, or will the diagnosis require other tests that are not available within the emergency department? For instance, more than one patient has been diagnosed as having reflux oesophagitis as an explanation for the "indigestion", that was actually a reflection of an inferior myocardial infarction. A barium swallow upper GI Xray study is not readily available in most emergency departments, but an ECG is. Also surprisingly common are cases in which all the evidence to support a serious diagnosis and mandate admission is present, but is ignored in favour of a trivial diagnosis

that cannot be supported by, but is compatible with the discharge of the patient. An example is sending the patient home with a diagnosis of gastroenteritis when the patient has no nausea, vomiting or diarrhoea but does have a tender abdomen and absent or diminished bowel sounds and is in the age group most common for appendicitis.

WHAT IS THE MOST SERIOUS DIAGNOSIS?

What is the most serious diagnosis that could apply to the patient's condition, and have I ruled it out? Many doctors appear to have an unwillingness to recognize serious disease, but unless they constantly search for it, it will never be found. Many patients are much sicker than they initially appear, which deceives even experienced physicians who are used to seeing patients late in the course of their disease rather than early on. Wishing that bad diseases do not occur in anyone is human nature, but the ability to be suspicious is integral to the safe and effective practice of emergency medicine

HAVE I ARRANGED A SATISFACTORY DISPOSITION?

In no other phase of medicine is it so critical to consider the circumstances under which a patient's disease is going to evolve and to obtain more than one point on a curve to determine if a patient is getting better or worse. Physicians sometimes make a definitive diagnosis in circumstances where it would be preferable to beg the question and see the patient again after some time. At this point many disasters in emergency medicine would be avoided. To either arrange to see the patient again personally or to ensure that the patient is seen by a consultant the next morning, or to keep the patient under observation prevents the all too common occurrence of the patient being sent back home to die or decompensate with a terrible outcome.

Many times the diagnosis, management and predicted outcome of a disease state is foiled by the failure to provide a satisfactory disposition: for example, sending a child with a fracture caused by non accidental trauma back to the same environment that produced it in the first place. This example may see to be extreme, but it occurs because the physician either does not recognize the child abuse or is content to report it to an appropriate agency and not pursue the next step of trying to address the environment.

Doctors also have difficulty using a hospital environment for something other than sophisticated diagnosis and treatment. This has been compounded by the health planners, insurance planners, and restrictions on admission. However, some patients need the help of a hospital to recover, and we must overcome our reluctance to do this for sociological reasons. One may be able to prescribe adequate analgesia for an elderly patient with a stable pelvic fracture, but if that patient lives alone and must climb the stairs, discharge is not going to be a satisfactory disposition for the patient. Similarly, a young adult can usually recover from pneumonia when treated as an outpatient, but if that patient is a

mother with three young children, she will not have any rest without being placed in hospital.

HAVE I PERFORMED A PERTINENT AND THOROUGH WORKUP?

Along with getting fooled by the early subtleties of disease, doctors tend to take short cuts when they become busy in the emergency department. You may conclude that the patient is not seriously ill and neglect to perform the rectal or pelvic examination that would provide useful information and perhaps steer you in the direction. You cannot practice perfect medicine, but if you use safe diligence, rarely will a problem remain unrecognized and unidentified.

WHY IS THE PATIENT HERE? HAVE I MADE HIM OR HER FEEL BETTER?

Many patients overestimate the magnitude of their illness, but more commonly, many people underestimate the magnitude of their problems. The frustration of trying to deal with illness during the day may drive some people to seek attention at night. No emergency department is without inconvenience, pain and expense, and to be there means one has a need requiring attention. 

We as doctors should understand that most patients would prefer to be somewhere other than in an emergency department. Many times doctors may be content with making a diagnosis such as viral syndrome and forget that knowing what is wrong does not necessarily help patients to feel better. Instead doctors should ask if I can lower a temperature, restore some fluids, relieve pain, and provide reassurance? These things are often overlooked in the pressure to "treat and street patients".

With inpatient services, physicians spend much less time with individual patients than do nurses, and in general are unaware that a large part of recovery from any illness is independent of invasive procedures. Doctors are sometimes fooled by subjective improvements in the patients' conditions. It is well known that a ruptured appendix may cause relief from the intense agony experienced while the appendix was under bursting pressure. The patient may therefore describe a feeling of subjective improvement, but objective findings will not support this. Have the patient's vital signs improved, have the positive physical findings that were so well described by the triage nurse on the initial examination improved, is there an explanation as to why the patient is better?

WAS I ANGRY WHEN I MADE MY DECISION?

Anger is an emotion that almost always guarantees faulty decision making. It is therefore wise to understand the cause of anger before committing the patient to a final disposition. At times anger originates from personal life circumstances rather than the professional workplace. Sometimes an irritating colleague inspires anger, sometimes patients themselves are angry or provoke anger. You do not need to like a patient to deliver professional and competent care, but you must rid yourself of anger and frustration to accomplish this. Learn to reserve judgement on the patients in the emergency room.

DOES THE CHART REFLECT MY THINKING?

Charting and writing progress note on patients is an essential component of emergency care.

The purpose of charting is to provide points on the curve that measure the natural history of the patient's disease. If a single measurement has been taken, a prediction of the shape and slope of the curve can be made. The emergency department record is not the lengthy text of the medical student's internal medicine work up. It is terse and pointed and contains important negatives and positives. The best way to remember what is important is to ask 'what am I seeing, and am I communicating this to someone else in the future?' For example in the infant with diarrhoea, how can one indicate the state of hydration without describing the general appearance of the baby, the presence or absence of tears, diaper wetting, skin turgor, fontanelle appearance and mucous membrane moisture? This description does not take much space or time, and when combined with the number of stools will assist in assessing the degree of hydration, and the need for admission. An error that many physicians fall into is to list every possible item in a differential diagnosis, to be "complete". List only those significant diseases that must be considered, as well as how you ruled them out in your mind. Only in this way can you draw a reasonable picture of what you are seeing and thinking.

DEALING WITH GRIEF

One of the responsibilities that the emergency physician finds the most difficult is dealing with the grief that is constantly being generated by the difficult problems of emergency medicine. Each specialty has its own unique failures, but for emergency medicine it almost certainly is the sense of failure that develops when the physician is not capable of preventing death. Physicians are so conditioned to thinking that because they can prevent some untimely deaths, they can prevent all deaths. Therefore they may think that the failure to do so is attributed to poor practice, lack of knowledge or weaknesses of the team. 

Physicians also are not taught to manage grief properly, and therefore the task is uncomfortable. They tend to avoid it by saying they are too busy or that it is the job of the pastors, social workers, nurses, or anyone other than themselves.

However, emergency physicians do have the responsibility and they can ensure that the grieving process will be healthy if they approach it correctly. If they shun the responsibility, not only do they increase the risks of making the grieving process a pathologic one, but also increase their own sense of failure, raise the prospects that their care will be held responsible for the outcome, and produce problems where they need not exist.

Many people will not believe the details of care, nor will they have an ability to form a realistic impression of how their relative or friend has died if they have not talked to the physician involved in the care. The suddenness of the illness, the lack of prior contact with the emergency staff and the emotional turmoil of needing to deal with sudden, undesired and intense loss conspire to produce a delicate balance between sadness and rage. The balance can too easily shift towards rage when the process is not understood or dealt with effectively.

The emergency physician's first responsibility is to come to terms with ones own mortality. This task is much easier for older physicians who may have experienced serious personal disease. The younger person who cannot conceive of personal mortality is much less willing to accept the reality that not all death is preventable with appropriate medical care. Many gravely ill or injured patients are being brought to the emergency department in a critical state due to improvements in pre-hospital care and the rapid transport times now being achieved. They have not completed the act of dying, and because they appear to be serious but salvageable, much anger and guilt can be induced in the emergency staff.

Each physician has particular areas of emotional vulnerability; for some it may be mutilating injury, for others death in childhood. Whatever your vulnerabilities, you can be sure to encounter them in a busy emergency department. It does help to think about those problems; to realize that other members of the team are probably experiencing similar feelings; and to realize that the hardened, cynical, apparently sophisticated façade that the more experienced members of the team seem to possess is probably a defence against emotions that threaten to be overwhelming.

If time permits, discuss emotionally troublesome cases, as well as medically difficult ones among personnel. It is sad that more emergency departments do not have a structure that permits such discussion on a regular basis.

Attempt to lessen the psychic pain of relatives or friends during a resuscitation attempt, by either the nurse or the doctor explaining the gravity of the situation whilst the attempted resuscitation is going on. Even if the relatives cannot be reached until after the event, attempt to prepare them by saying " I have some very bad news for you". Even a few moments of preparation is better than nothing. If possible, try not to inform relatives over the telephone. There is no good way to attenuate the pain other than to be direct and clear in the communication.

The experience of grief never appears to be absent, even when the patient has died from a long-term and very debilitating illness. It appears to be an almost universal human response to death.

One of the additional emotional responses to death is guilt. We often think that if we had just taken an appropriate action, we could have prevented this from happening. Deal directly with this guilt so that it will not become misdirected to other members of the family or the emergency personnel. Where doubt about guilt exists, such as in suspected child abuse, it is advisable to be non-judgmental as the emergency team rarely knows all the circumstances. Tailor the facts to each situation.

Guilt may be replaced by anger in certain circumstances and this may be misinterpreted by emergency personnel. By not understanding and by reacting negatively to the anger, the physician or nurse may cause the relative's grief and anger to be directed towards themselves. Help the relatives express their anger by allowing some time for ventilation and by carefully reinforcing that medical tasks were carried out appropriately.

In most cases, the relatives will wish to view the body, which should be done after cleaning up some of the mess of the attempted resuscitation. 

Regarding the issue of sedatives for grieving persons: these generally prolong the grieving process.

There is no "normal" response to grief; some people will experience insomnia, some sleep more; some are anorectic, others experience great hunger. If sedatives are given, these should generally be for a short duration only. The relatives should always have a contact person to whom they can go to for any major psychological problem thereafter. Relatives often express a fear that a relative who is not present is "too ill" to hear bad news. Offer to break the news and inform the relatives that one cannot hide a death forever.