Hey guys, thanks for checking out this episode. I’m super excited for this one. I think it’s a super important topic that will benefit paramedics and new emergency medicine apps, whether it’s nurse practitioners or physician assistants and that is how to think like an emergency physician. When I first started as a emergency medicine PA a couple of years ago, one of the doctors I worked with directed me to a video and it’s by Ruben Strayer. And this video at the time, I thought it was really good. I was like, Dr. Strayer’s content’s really good, but I didn’t see the full value of it until really in the last six months as I became more confident practicing emergency medicine, the first year and a half to two years of practicing, I felt I was just treading water. Everything was kind of difficult. I didn’t know what patients could be discharged.
I didn’t know what workups really needed to be ordered, and it was a very steep learning curve for that couple of years. And so I didn’t really realize the value of his content really until the last six months when I watched his video again. And his concepts and the way that he thinks about being a emergency physician is super critical to doing the job well. And I think a lot of paramedics that have been practicing for a while do this unconsciously. And same with emergency physicians and providers. I think after a while you learn to do these things unconsciously, but I think he does a really great job of crystallizing how to think an emergency physician. And so I feel like it’s very beneficial to learn this information. So I wanna present it in a couple of episodes because I really want to give you the ability to digest this information and not throw it all to you at one time.
So when you’re on a call or seeing a patient in the er, you can kind of understand these concepts and apply them to your everyday job in how you think about patients and how you take care of patients. And I think it’ll make it a lot easier and I think it’ll be super valuable to you. I’m super honored that Dr. Strayer gave me permission to use his content and I would also like you guys to check out his website, which is em updates.com. I’ll send some links down below so you guys can check out his website. He has great emergency medicine information and you can watch his original video from there as well. I think this is important because when I was a new paramedic, I kind of just stumbled through calls with no clear delineation of the different types of calls or the different steps in a call, and he really brings a lot of that to the forefront of your mind so you kind of understand the steps that you’re in and how you should be thinking and approaching each individual patient.
I would spend some time just talking to the patient, talking to the bystanders, talking to family, and kind of getting a history from all those sources. And maybe I would throw some physical exam in there while I’m obtaining history, listen to lungs, push on their abdomen, do a neuro exam, and a lot of it was fairly haphazard. And when you get confronted with a critical patient or somebody who’s completely unresponsive on the ground, you kind of have to approach that patient completely differently. You can’t get a full history from the patient, you just kind of have to go into a different mode. And I think the way that he approaches emergency medicine really makes all of that very clear, and I think it’s very valuable. I think this content will really help you create a system that you can use in every situation so that you kind of know where you’re at and what you need to do on a call and what interventions you need to do for a patient, if any.
So the traditional approach that we’re all taught, be it in medical school, PA school, or in paramedic school, is the bottom up approach. And this approach teaches us to start with obtaining a history. So that’s your gathering of information from the patient, the bystanders, the family, and allow them to give you all the information that they possibly can. And then you move on to your physical exam. So if it’s a trauma patient, you check them all over for signs of trauma. If it’s a medical patient, you’re listening to lung sounds, you’re doing a neuro exam, you’re pushing on their abdomen, you’re checking heart tones, you’re looking for edema you’re looking for rashes, everything that you can possibly think of you do on the physical exam. Then you move to possible differential diagnoses. So whether it’s a list of a hundred things or a list of 10 things, you think of all the possible differentials that could possibly be going on with this patient.
Then you move into testing and in the ambulance, this is going to be a little bit more limited, your ability to obtain tests. Now, if you think you have no tests, you’re wrong, you do have a few, you can get a glucose, you can get an ekg, and these are going to be kind of some of your diagnostics that you can get on the ambulance. Obviously in the er we’ve got a whole different tool set. We can do imaging x-rays, CT scans, MRIs. In some situations we have a ton of lab work that we can get and you order everything you can think of to try to figure out which of these differentials is going on with the patient. Then hopefully at the end of all that you’ve arrived at a diagnosis and you can decide how you’re going to treat the patient and you base the treatment based on this final diagnosis.
That’s a very long and arduous process, and that’s not how we should be thinking about approaching a patient in an emergency setting. We have to think differently and we have to think much more quickly in a lot of situations. So Dr. Strayer comes up with the top down approach and this approach basically begins with what does the patient need? That is the primary question that I’m going to say over and over again because that’s how we should be approaching these patients. We don’t necessarily care what the patient has, we care what the patient needs. So let’s think of an example. Let’s talk about a shortness of breath patient. So in the top down approach, we start with the diagnosis. So shortness of breath, the diagnosis is acute dyspnea. How do we approach that patient? We think initially about treatments. So what treatment, what treatments do you have at your disposal For acute dyspnea, you have oxygen, you have breathing treatments, you have nebulized epi, you have nebulized albuterol and adjuvant, you have innovation, you have the ability to perform cricothyrotomy
These are all the interventions you have for your short of breath patient, and you need to determine what does the patient need and from what does the patient need. You go to these interventions, you decide which interventions you want to start with, and then you can move into testing and a more specific treatment based on a diagnosis. So in the er, when a patient comes in with shortness of breath, that’s what I’m thinking. I’m thinking, what does this patient need? Because I don’t necessarily have to arrive at a final diagnosis, and if I wait until we’ve come up with a final diagnosis, this patient could be in way more significant distress or significantly decompensate in that amount of time. So the question is, especially the more sick the patient is, what do they need? What breathing interventions can we give this patient while we’re working them up and then we can further refine our treatment plan based on a more specific diagnosis, but we can’t start by trying to find the diagnosis or the patient care will suffer.
So then he starts to talk about the four responsibilities of the emergency medicine physician. The first of those is resource stewardship. And I think this is actually an aspect you can control a little bit more on the ambulance than we can even in the ER on the ambulance, you have the ability to see the patient determine their lower acuity and you can call a BLS unit to transport them to the hospital. You can call the behavioral health team to come and assess the patient and get your rig back in service using a couple of these different modalities. You can’t always do that and you need to transport the patient even if that’s not the best use of resources. But you do have a couple options there. And in the er, I feel like we have even less. It’s a very litigious society, so we have the obligation to kind of overorder tests testing in a lot of cases, and depending on which physicians you’ll talk to, there’s varying opinions on how much testing is really needed in a lot of scenarios.
Some physicians that I work with order a lot of tests, some order fewer. I like to think that I’m somewhere in the middle when I’m coming up with what testing I want to do but the fact remains that we do have to order. We do have to over-order testing in a lot of cases because we don’t wanna miss something. And of course some patients in the ER don’t need a lot of tests, they don’t need lab work and they don’t need imaging. And just based on their history and a good physical exam, I can determine that that patient is safe to go home and follow up with their primary care physician. And that does happen a lot. We don’t order tests on every single patient out of fear of getting sued. A lot of patients, I can get a really good history and do a thorough physical exam and say, I don’t think we need any testing and I can prescribe the medication for whatever diagnosis I think is going on, and they are safe to go home.
But resource stewardship is a difficult aspect to control and it’s not one that we wanna focus on because a lot of it is outside of our control and you have to do the standard of care wherever you’re practicing. So it’s certainly not something to waste any emotion over. It’s not something to get angry about. Ultimately, if the patient wants to come to the hospital, you bring ’em to the hospital whether you have a better answer for them or not. This isn’t something that we can control so it’s not worth agonizing over. The second aspect of emergency medicine physician responsibilities that he brings up is customer service. You can be a super great paramedic and provide the best emergency medicine you’ve ever provided and bring the patient back from the dead and still provide poor customer service if you were rude to the family members on your way into somebody’s house.
And when we’re in the er, it’s the same thing. I can work up a patient, use great evidence-based medicine, and if I was rude to the patient when I was in the room or I didn’t give them enough time to talk, I failed at customer service. And that’s what the patient sees. So like it or not, customer service is a big part of our job and if you wanna practice as an emergency provider, be it a paramedic or a physician assistant for any length of time, you do have to confront this difficulty with customer service one way or not if you want to be happy with your job. So great evidence-based medicine does not equal good customer service, so just be cognizant of how you talk to family members, how you talk to the patient. Part of good emergency medicine is talking to the family and talking to the patient in such a way that they do feel cared for and don’t feel like you’re brushing them to the side even if you’re providing great medicine, what the patient sees is how you’re interacting with them.
So just keep that in mind. If you want to stay in emergency medicine for any length of time, this is a huge deal. And sometimes this is as simple as just explaining to the patient what’s going on. If they have something emergent going on or they’ve been involved in a traumatic accident and you need to go lights and sirens to the hospital, just explain to them what you’re doing. And that can go a long way. That way they don’t have all these question marks and they’re feeling super sick or they’re in a lot of pain and they’re wondering what’s going on. Just fill in some of those question marks by explaining what you’re doing to the patient while you’re doing that in the er. That comes more into play with giving the patients updates like, Hey, we’re waiting on a CT scan. We’re waiting to get your lab work back.
Sorry, it’s taking hours, that kind of stuff. And then if we arrive at a diagnosis, going in and explaining to the patient what we think is going on with them and explaining them to them, explaining to the patient the admission process or the outpatient follow-up process that all comes into play when you are providing good customer service, the patient doesn’t necessarily care that you found a diagnosis. They care how you are communicating to them about that diagnosis. Another way to improve the customer service aspect of our job is to find out what the patient wants. A lot of times people come to the ER and they’re concerned about something specific, they’re worried they’re having a heart attack if they’re having chest pain. So asking the patient what they’re worried about and what they want out of the encounter can actually be super helpful. And a lot of patients won’t volunteer that information, but if you ask them specifically, they’ll actually give you some really good insight into what they’re concerned about.
And an example I can give about that is a chest pain patient. Let’s say it’s a younger person having chest pain and they have family history of cardiac problems and they’re coming in cuz they’re worried they’re having a heart attack like their dad did and his sixties or something and asking them specifically what they’re worried about and they say it’s a heart attack. You can say, well, that’s great. We can actually get some lab work and get an EKG on you and we can decide that this is not a heart attack. And managing patient expectations is super important, especially early in the encounter. This comes into play a lot in the er. So let’s say I do get this younger person that’s having chest pain. A lot of the things that I’ll tell them initially to manage their expectations are I will say, Hey, we’re we’re in the emergency medicine setting and we’re really good at finding the emergent diagnoses.
We’re really good at finding if this is a heart attack or a blood clot in your lung or a collapsed lung, we’re really good at finding all that stuff. If all that stuff’s negative, we’re probably not going to get a clear answer today, what exactly is going on? But what I wanna be able to tell you is this isn’t a heart attack, this isn’t a blood clot, this isn’t a collapsed lung, this isn’t pneumonia. And set the expectations so that they don’t expect a clear answer of what’s causing their chest pain because a lot of times we’re not going to get a clear answer. And a diagnosis like costochondritis is not really something we make in the er. Costochondritis, if you don’t know, is a clinical diagnosis. It’s something that can cause chest pain, but it’s very benign and it’s not going to kill the patient.
So we really don’t make a habit of diagnosing cost osteochondritis because again, we don’t care what is actually causing the patient’s chest pain. We care about the list of dangerous things that’s not causing the patient’s chest pain. Another big question to ask the patient to improve your customer service is, do you want anything for pain while we’re waiting to get this workup complete? That brings me into the third subject that he brings up regarding the responsibilities of the emergency medicine physician. And that is symptom relief and it’s very easy to get caught up in all the other things we have to do as emergency medicine providers, the obtaining CAT scans and x-rays and lab work and putting in the orders and seeing other patients. A lot of times symptom relief is something that gets put on the back burner, but that’s actually the thing the patient cares about the most.
They care that they’re having pain and while I don’t really care about the patient’s pain, I care what’s causing the patient’s pain. It’s a super important role that we have is to relieve the patient’s symptoms regardless of what the underlying cause is. And it’s as simple as asking the patient if they would like something for pain. So while it’s important to diagnose the patient, like let’s say we’re evaluating an abdominal pain patient, it’s important to diagnose a small bowel obstruction and not miss that diagnosis. But it’s also important to be treating the patient’s pain while you’re waiting on imaging and lab work to make the diagnosis. And I still see this in some field crews, and I was guilty of it myself when I was a paramedic, was writing patient’s pain off the patient’s pain is very real to them and whether you think there’s something emergent causing it or not, a big part of our job is pain relief and you have the ability to relieve pain on the ambulance.
So if you think someone’s faking pain or having real pain, it really doesn’t matter what the patient wants, is their pain controlled? And you’re not going to get someone addicted long-term to opiates by giving them a dose of pain medication in the ambulance. So I do see it occasionally that crews will not give pain medication when it’s certainly warranted. So just be mindful that a big part of your job is just symptom relief and you have the ability to relieve a lot of symptoms on the ambulance unless there’s a huge contraindication to giving a patient pain medications. A lot of times it’s a very easy thing to do and it’s certainly well within your role as a paramedic and certainly in our role in the ER to treat patients pain, treat them with Zofran for their vomiting. There’s lots of medications we have to treat patient symptoms while we’re waiting on a larger workup.
So the part I’m going to finish this episode with is the fourth final criteria that he really talks about that’s in the rules of the emergency medicine physician. And we’re going to end on this one because it’s huge and we’re going to go into more depth because it’s the patient aspect that is the bulk of our job and the art of practicing emergency medicine, and that is patient safety. There’s two ways that we manage patient safety, and that is with resuscitation and identifying dangerous conditions. And this is the most important topic I think, and that’s why we’re going to end on this so I can go into it in more detail in another video. So the big takeaways from this that I want you to get and please watch it back again just to drive home some of these points is in emergency medicine, we use the top down approach.
We don’t start by a huge list of differentials. We ask what we don’t care necessarily what the patient has going on. We care about the things that they don’t have going on. And I’ll have a bunch of examples of this in the next episode just to make it clearer but I don’t want to belabor the point and just make a super long episode. My hope with this is if you’ve been practicing for a while, a lot of this you probably do unconsciously, and it might be kind of crystallizing the mentalities that you already have and that’s great. And if you’re new to emergency medicine, I’m hoping that this kind of helps you think about the patient the right way so that there’s less confusion on scene and you don’t have to kind of stumble through calls like I did so many times. I hope you guys found this valuable today.
If you did, enjoy it, please share with people, subscribe, comment like check out my website and just let me know what you think of this. My email will be down below as well. So let me know if you found a lot of value in this. Let me know if there’s things I could be doing better, things that I could be doing more of and that’ll allow me to make more of this content. Also, definitely check out Ruben Strayer’s website, em updates.com. I’ll link it down below as well. His content is phenomenal and again, I’m super thankful that he is letting me use it today.
