Thank you to Reuben Strayer for allowing me to reproduce his awesome content here. Check out his website at emupdates – return if worse for more emergency medicine content. Email me with comments or questions at Aaron@PracticalEMS.com
All right guys. Thanks for checking out this episode. So this is part two of several part series I’m going to do on how to think like an emergency physician. Again, thanks to Ruben Strayer, this is his content that he’s graciously allowed me to use and I think it is super valuable. It is super pertinent to your job, either as a paramedic or an emergency medicine provider. I think new nurse practitioners, new PAs in the ER can really benefit from this and new paramedics as well. Cause I think the mentalities and the content that he has in here really crystallizes how you should be approaching a patient encounter. So in the last episode, we kind of finished with what he describes are the four physician responsibilities in emergency medicine resource stewardship, something we have a little bit of control over, but not a lot customer service, which again has to do with making sure that you’re tactfully approaching patients, making sure they feel heard, making sure you’re talking with family and not just stepping around them.
(01:10)
The third is symptom relief. And this is something that as emergency medicine providers, we just simply forget to do because it’s not our goal. Our goal is to diagnose the patient and treat the patient. And a lot of times we just forget to treat their symptoms while we’re waiting for a workup or while we’re transporting them to the hospital. And symptom relief matters way more to the patient. They’re in pain, they’re feeling the pain, they’re vomiting, and we have all these medications at our disposal to actually treat the patient’s symptoms. And so that third criteria we have a little bit more control over. So that brings us to the fourth criteria, which is patient safety. And this one’s the big one. This is the one that we spend most of our time on and it’s the bulk of our work in emergency medicine. It’s the art of practicing medicine is the patient safety aspect.
(01:57)
So if you miss the first episode covering all that, please watch it kind of sets the stage for this one a little bit. So again, patient safety comes down to two major roles and that’s identifying dangerous conditions or like I like to say, emergent pathology and resuscitation. Whether you’re a paramedic nurse practitioner, pa, emergency medicine provider, we all like to tell the patient what they have. We all like to arrive at a final diagnosis that kind of puts a nice bow on the whole package experience and tell them what they have. But a lot of times this is just not our role and it’s not even in our abilities in emergency medicine to diagnose what the patient has. We need to know what the patient needs and that’s where our focus should be. Ruben Strayer has this really good dangerous conditions wheel that he has.
(02:43)
And this emergency conditions or dangerous conditions wheel is a really good visual aid. If you look at the wheel he’s got, he says 126 different conditions around this wheel and you don’t have to know all of ’em. It’s more the concept that’s important. But there’s only so many conditions that we are worried about in emergency medicine. We’re not worried about costochondritis, we’re not worried about an abrasion, we’re not worried about gastroenteritis. These are not diagnoses we need to arrive at, even though that might be what’s going on with the patient. We are concerned about what the patient doesn’t have, which is all these conditions on the wheel. And they don’t all come into a play in every patient encounter, depending on the chief complaint, we’re narrowed down to a handful of differentials that we’re really concerned about. So in chest pain, you won’t find costochondritis on this wheel, but you will find, will find pulmonary embolism, you will find pneumothorax and things like that because those are the things that we are concerned about and we wanna rule in or out in our workup.
(03:43)
An example is abdominal pain. So when I approach this patient is not to diagnose what is causing their abdominal pain because if it’s gastroenteritis, I don’t really care if that’s their end diagnosis, although that might be what they have. What I want to know is that they don’t have a appendicitis, they don’t have pancreatitis, cystitis, small bowel obstruction. Those are the things that I care about. So when you begin to obtain your history and then move into your physical exam, every question you ask, every part of the exam that you perform should be ruling in or ruling out these different diagnoses. It’s very goal directed. So with these differentials in mind, if I’m approaching our abdominal pain patient, I ask where the pain is, they say left side, I’m like, okay, it’s not tender over there. They’re not tender in the right lower quadrant. I’m not really concerned about appendicitis.
(04:28)
If I’m ruling out small bowel obstruction, are they vomiting? Are they having normal bowel movements? Have they had surgery before? Are they tender on exam? If the answer is no to a lot of these things, I’m not really concerned about small bowel obstruction. But every question I ask is really with those differentials in mind, the point is to narrow down and narrow down that list of differentials with every question you ask and with every physical exam finding that you look for. Another big example of this is the short of breath patient. So if someone’s very disp, they can’t answer your questions all day long, they can’t answer and have a super long conversation with you, they can’t typically speak in complete sentences. So you really need to get down to your differentials and ask them very few questions so you can kind of get on with the treatment plan before the patient starts to decompensate.
(05:14)
So I’ll ask the short of breath Patient, are you having any chest pain with this? No. Okay, I’m less concerned for a pulmonary embolism. What history do you have? C O P D, asthma. C hf. C hf. Okay, let’s do a physical exam. I hear rails in the lower lobes. I see some peripheral edema. I know what this patient needs. Now they need some diuretics. They need C P A P or BiPAP. If we’re in the er, again, we’re not starting with a huge list of differentials. There’s a hundred different things that can cause someone to be short of breath. We’re worried about the five or six that are going to kill them. And so all my questions are going to rule inter rule out those six different diagnoses. Then I go to what the patient needs and the interventions. And then we can get x-rays lab work to kind of narrow down our focus a little bit more.
(05:57)
But I’m starting with what the patient needs. So that brings us to the next part of the patient encounter, which is interventions. And this is what the patient needs, this is what we can do for them in the er. Obviously we have a little bit more tools in our tool belt than we have than you have on the ambulance, but you’ll have only a certain number of interventions. And depending on the patient’s chief complaint, that narrows your interventions list even more. So for the short of breath patient, you have breathing treatments, you have oxygen, you have in intubation, you have suction. And keep this list in your mind for the short of breath patient and narrow it down. Which of these does the patient need, if any of them? So Ruben Strayer has another wheel, the second wheel, which is the interventions wheel. And again, there’s 130 odd items on this interventions wheel.
(06:41)
But the point is the concept is depending on the patient’s chief complaint, there’s only a handful that will apply. So you don’t have an unlimited number of things that you can do for this patient. You have a narrowed focus and you need to pick amongst these to treat the patient. So Ruben Strayer gives an example in his presentation of the knee pain patient. So there’s a million causes of knee pain and we’re not orthopedists, we’re not going to diagnose every single cause of knee pain. That’s not our job. An emergency medicine, we’re worried about several differentials, infectious arthritis, dislocation fracture, patella dislocation, quadriceps tendon rupture, D V T, soft tissue infection, that’s it, right? Five or six things that we need to rule in and rule out in the ER. And on our interventions wheel, we have even fewer treatment options for the causes of knee pain.
(07:31)
So we can do, arthrocentesis can aspirate some fluid to diagnose. If this is infection, we can get an x-ray, we can immobilize them, we can give them pain medications, we can refer them to orthopedics and we can give them crutches. And so again, five or six things that we’re able to do for the patient with knee pain. And my job with obtaining history and a good physical exam is to narrow down this list. Not every patient needs all of these different interventions. So every question I ask the patient, every physical exam finding that I look for should be narrowing down these lists narrower or narrower until we figure out what the patient needs. And on the ambulance, your interventions wheel for a knee pain patient’s even smaller, do you need to immobilize a joint because you’re worried about dislocation or fracture? Do you need to reduce a dislocated patella if that’s what you think is going on?
(08:19)
And you need to provide the patient with pain medications and you need to transport them to the hospital at all. And an important point that he makes is the sicker the patient is, the less you’re going to use the wheel of differentials. The wheel of dangerous conditions, the more you’re going to use the wheel of interventions. And you know this intuitively because when you have a very sick patient, you’re not spending a ton of time obtaining history, you’re going immediately to interventions. So again, it’s the top down approach, not the bottom up approach. We don’t have tons of time in emergency medicine. We care what the patient needs, not what the patient has. And likely you’re doing a lot, lot of these things if you’re an experienced provider unconsciously. So I’m going to wrap up this video with a mnemonic that Ruben Strayer provides and it’s has to do with less with the identifying dangerous conditions role and more of the resuscitation role.
(09:09)
And he actively uses this, so I feel it’s a really good utility. So the P mnemonic is dc, DC A B C D E U. So it’s very long, but it’s very quick to go through. D is for danger. So is it safe to approach the patient in the er? A lot of times this is kind of a no-brainer if the patient’s there usually we’re in a safe setting, but it’s more pertinent to you on the ambulance. Are you on a safe scene? Is this patient safe to approach? The first C stands for call for help. And that is if I’m in the ER and a patient is decompensating, do I need to get nursing staff in there? Do I need techs? Do I need respiratory therapy to come? And you know, what resources do we need at the bedside for this patient? The second D is for defibrillate.
(09:51)
So if you have an un unconscious unresponsive patient, you need to put the defibrillator pads on ’em, figure out what rhythm they’re in and assess from there. The second C is C spine. This one gets overlooked a lot, but if you’re concerned about trauma, apply a C collar. A of course is airway. This one we all know. And again, there’s only a limited number of things you’re going to do for airway. Does the patient need positioning in intubation, suction, cricothyrotomy, there’s only a handful of interventions for that that need to be running through your mind. Second is breathing. Do we need to apply oxygen? You can get lung sounds. Do they need a bvm? Do they need a chest x-ray? And then circulation vitals, ekg, give IV fluids. D is for disability. So this is where your assessment comes in a little bit more. Do we need to get a glucose?
(10:37)
Are they hypoglycemic? Should we check their pupils? Have they overdosed on something? Check their mentation, do a neuro exam. Are they having a stroke? E is for exposure. So this is a full trauma exam. Expose all their skin. Are we missing an infection somewhere? Are we missing a traumatic injury somewhere? He also talks about using this as an opportunity to obtain a rectal temperature check, rectal tone and a hemoccult. The last letter is you, which is ultrasound. So check for a pericardial effusion, do a quick fast exam, look for free fluid and insert a central line if needed while you have the ultrasound there. So this pneumonic is very helpful if you’re getting overwhelmed on the patient that needs emergent resuscitation. And a lot of times these are ones that you’re seeing in their house that are unresponsive and you do have to go through all these things.
(11:25)
But if you find yourself freezing and not sure what to do, I think this is a very helpful mnemonic and I don’t want to go into any more depth in this video. The reason I’m breaking this up is cause I think this content is super important. So go back, watch the first one, watch this one over again. I think the content that Ruben Strayer provides and the mentality and the approach to the emergency medicine patient is super important. So I’m hoping you guys are finding this valuable. I’m going to do another video on this to go more in depth into his thinking process and his system, and I think it’ll be super valuable. So if you guys got some value out of this episode, please share it with people. Subscribe, like, comment, email me. I’ll provide my email down below. Let me know if there’s anything I can do better. If there’s things that you like, the more you guys can get involved with this stuff, the more content I can provide, check out Ruben Strayer’s website, em updates.com. I’ll link that down below as well. His content is really, really good and I think it’s super helpful, especially for new emergency medicine providers. Guys, thanks for checking this one out. Look for the next, how to think like an emergency medicine physician episode. I hope you guys are getting value from this and let me know what you think. We’ll see you on the next one.
