fowler's fifteen plus laws of emergency medicine...
TRANSCRIPT
Fowler’s
“Truths of Emergency Medicine”
Fowler’s
““Truths of Truths of Emergency MedicineEmergency Medicine””
Raymond L. Fowler, M.D., FACEPRaymond L. Fowler, M.D., FACEP
Associate Professor of Emergency MedicineThe University of Texas Southwestern
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Chief of EMS OperationsThe Dallas Metropolitan BioTel System
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Co-Chief in the Section onEMS, Disaster Medicine, and Homeland Security
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Attending FacultyParkland Memorial Hospital
Department of Emergency Medicine--------------------
Associate Professor of Emergency MedicineAssociate Professor of Emergency MedicineThe University of Texas SouthwesternThe University of Texas Southwestern
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Chief of EMS OperationsChief of EMS OperationsThe Dallas Metropolitan The Dallas Metropolitan BioTelBioTel SystemSystem
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CoCo--Chief in the Section onChief in the Section onEMS, Disaster Medicine, and Homeland SecurityEMS, Disaster Medicine, and Homeland Security
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Attending FacultyAttending FacultyParkland Memorial HospitalParkland Memorial Hospital
Department of Emergency MedicineDepartment of Emergency Medicine--------------------
www.utsw.wswww.utsw.wswww.utsw.wswww.rayfowler.comwww.rayfowler.com
1.We have two responsibilities in
emergency medicine:(1)Is there an emergency present?
Corollary, is it a life-threatening emergency, and
(2) What is the best diagnosis you can make?
1.We have two responsibilities in
emergency medicine:(1)Is there an emergency present?
Corollary, is it a life-threatening emergency, and
(2) What is the best diagnosis you can make?
2. Find out what the REAL emergency is2. Find out what the REAL emergency is
3. Be a fierce advocate for the needs
of your patient
3. Be a fierce advocate for the needs
of your patient
4. A patient with a painful condition
HAS a painful conditionuntil proven otherwise…
…and failure to treat pain appropriately
is mal-treatment
4. A patient with a painful condition
HASHAS a painful conditionuntil proven otherwise…
……and failure to and failure to treat pain appropriately treat pain appropriately
is malis mal--treatmenttreatment
5. When in doubt, take more history...5. When in doubt,
take more history...
History Taking:This seems to be a “lost black art” for
so many medical providers
What happened?When?LOC?
Major system symptoms?Co-morbid conditions?
Above all: RISK???
History Taking:This seems to be a “lost black art” for
so many medical providers
What happened?When?LOC?
Major system symptoms?Co-morbid conditions?
Above all: RISK???Above all: RISK???
We are, after all,a specialty:
We are, after all,a specialty:
Emergency Emergency MedicineMedicine
The difference betweena “specialist” and a“generalist” is in the
RIGOR of the applicationof a differential diagnosis
The difference betweena “specialist” and a“generalist” is in the
RIGOR of the applicationof a differential diagnosis
6. DEVELOP a physical exam that you trust,
and ALWAYS do it
6. DEVELOP a physical exam that you trust,
and ALWAYS do it
Assessment skillsare NOT
geneticallyacquired
Assessment skillsare NOT
geneticallyacquired
The “art” of medicineis missing from
so many practitioners…
…are they not looking,or have they lost interest?
The “art” of medicineis missing from
so many practitioners…
…are they not looking,or have they lost interest?
Approaching thePatient
Approaching thePatient
“See what you see!”“See what you see!”
“People look, but theydon’t see”
…A. Fowler, Jr.
““People look, but theyPeople look, but theydondon’’t seet see””
……A. Fowler, Jr.A. Fowler, Jr.
Alertness? Level of distress?Noises?Respirations?The pulse rate?Skin?Obvious things (bleeding)
Alertness? Level of distress?Noises?Respirations?The pulse rate?Skin?Obvious things (bleeding)
Part of excellenceis performing
superior medicalhistories and
physical exams
Part of excellenceis performing
superior medicalhistories and
physical exams
Elements of ourprimary and secondary
surveys are oftenjumbled orforgotten
Elements of ourprimary and secondary
surveys are oftenjumbled orforgotten
Primary SurveyPrimary Survey
LOC/Airway/CspineRespiratory Rate and Labor
Pulses, Neck and WristSkin CMT/CRT
Neck appearance, NVD, TracheaChest appearance
Breath sounds present and equalBrief exam of abd, pelvis, LE, UE, Back
LOC/Airway/CspineRespiratory Rate and Labor
Pulses, Neck and WristSkin CMT/CRT
Neck appearance, NVD, TracheaChest appearance
Breath sounds present and equalBrief exam of abd, pelvis, LE, UE, Back
Secondary SurveySecondary SurveyHeadNeck
Chest/CVAbd
PelvisExtrBack
HeadNeck
Chest/CVAbd
PelvisExtrBack
Third SurveyThird SurveyLOC
AirwayBreathing: R & Q
Circulation: Pulse, BP, CMT/CRT
…and any other pertinent positive or negative identifiedin the primary or secondary
LOCAirway
Breathing: R & QCirculation: Pulse, BP, CMT/CRT
…and any other pertinent positive or negative identifiedin the primary or secondary
Blood pressure =Blood pressure =
(Cardiac output) x(Volume) x
(Peripheral resistance)
(Cardiac output) x(Volume) x
(Peripheral resistance)
Signs of ShockSigns of ShockWeak, thirsty, lightheaded
Pale, then sweatyTachycardiaTachypnea
Diminished urinary output
Weak, thirsty, lightheadedPale, then sweaty
TachycardiaTachypnea
Diminished urinary output
HypotensionAltered LOC
Cardiac arrestDeath
HypotensionAltered LOC
Cardiac arrestDeath
Early(compensated)
Early(compensated)
Late(decompensated)
Late(decompensated)
ShockShock
CardiogenicRapid pulseDistended neck veinsCyanosis
CardiogenicRapid pulseDistended neck veinsCyanosis
Volume LossRapid pulseFlat neck veinsPale
Volume LossRapid pulseFlat neck veinsPale
VasodilatoryVariable pulseFlat neck veinsPale or pink
VasodilatoryVariable pulseFlat neck veinsPale or pink
If you don’t look for cyanosis,you won’t see it
If you don’t look for cyanosis,you won’t see it
If you don’t LOOK
for JVD,you won’t see it
If you don’t LOOK
for JVD,you won’t see it
Ruling out“positive intrathoracic
pressure”is one of the most
vital points incritical care
Ruling out“positive intrathoracic
pressure”is one of the most
vital points incritical care
And, my goodness,what DO we DOwith waveformcapnography in
the future of EM??
And, my goodness,what DO we DOwith waveformcapnography in
the future of EM??
Only with excellence inphysical assessment and
commitment to patient service,can the best possible care
be given
Only with excellence inphysical assessment and
commitment to patient service,can the best possible care
be given
“The Demise of thePhysical Exam”
Sandeep Jauhar, MD, PhDNEJM 354:548-551
February 9, 2006
“The Demise of thePhysical Exam”
Sandeep Jauhar, MD, PhDNEJM 354:548-551
February 9, 2006
“The Stethoscope and theArt of Listening”
Howard Marken, MD, PhDNEJM 354:551-553
February 9, 2006
“The Stethoscope and theArt of Listening”
Howard Marken, MD, PhDNEJM 354:551-553
February 9, 2006
7. "It isn't what it isn't…
…it's what it MIGHT be that will
get you in trouble…
…and hurt your patient"
7. "It isn't what it isn't…
…it's what it MIGHT be that will
get you in trouble…
…and hurt your patient"
Beware ofabdominal pain AT REST,
especially in the older patient…
…especially with co-morbid illnesses
and (in hospital)elevated WBC’s
Beware ofabdominal pain AT REST,
especially in the older patient…
…especially with co-morbid illnesses
and (in hospital)elevated WBC’s
“The general rule can be laid downthat the majority of severe
abdominal pains which ensue inpatients who have been
previously fairly well, and whichlast as long as six hours, are caused by conditions
of surgical import”The Early Diagnosis of the Acute Abdomen
Sir Zachary Copepp 5, Oxford Medical Publications, 1921
“The general rule can be laid downthat the majority of severe
abdominal pains which ensue inpatients who have been
previously fairly well, and whichlast as long as six hours, are caused by conditions
of surgical import”The Early Diagnosis of the Acute AbdomenThe Early Diagnosis of the Acute Abdomen
Sir Zachary Copepp 5, Oxford Medical Publications, 1921
The difference betweena “specialist” and a
“generalist” is inthe rigor of theapplication of a
differential diagnosis
The difference betweena “specialist” and a
“generalist” is inthe rigor of theapplication of a
differential diagnosis
What are our abilitiesto diagnose patients
in the ED?
Are there limits?
What are our abilitiesto diagnose patients
in the ED?
Are there limits?
What diagnosticlimits do
YOUgive yourself?
What diagnosticlimits do
YOUYOUgive yourself?
8. We are not heroes...8. We are not heroes...
You do not have to PROVEthat your patient will do okay
outside of the hospitalAsk yourself,
might the patient NOT do well?There is no “rite of passage”contrary to what you learn
from your buddies“…ah…she’ll probably
do okay at home”
You do not have to PROVEthat your patient will do okay
outside of the hospitalAsk yourself,
might the patient NOT do well?There is no “rite of passage”contrary to what you learn
from your buddies“…ah…she’ll probably
do okay at home”
9. If a person is an insulin-dependent diabetic
and has a potentially major problem
with another major organ system,
strongly consider hospital admission
9. If a person is an insulin-dependent diabetic
and has a potentially major problem
with another major organ system,
strongly consider hospital admission
10. Once the patient is “out the door”,
(or non-transported)you have lost control
of the situation...
10. Once the patient is “out the door”,
(or non-transported)you have lost control
of the situation...
11. Always explain a tachycardia...
Corollary: Don't depend on the presence of a tachycardia to determine that
an emergency is present
11. Always explain a tachycardia...
Corollary:Corollary: Don't depend on the presence of a tachycardia to determine that
an emergency is present
A “physiological response”
A “physiological response”
Remember:
The Maximum Sinus Tachycardiafor a patient is
about 220 - age
Remember:
The Maximum Sinus Tachycardiafor a patient is
about 220 - age
Baby = (220 – 0) = 220
Snerd = (220 – 54) = 166
Aunt Minnie = (220 – 70) = 150
Baby = (220 – 0) = 220
Snerd = (220 – 54) = 166
Aunt Minnie = (220 – 70) = 150
What is this rhythm?What is this rhythm?
Correct answer:“It COULD be sinus tach”
Correct answer:“It COULD be sinus tach”
220 – 55 = 165220 – 55 = 165
If you forget everythingelse that I say:Remember that patients havingnear maximum
sinus tachycardiaat rest
are dying!
If you forget everythingelse that I say:Remember that Remember that patients havingpatients havingnear maximumnear maximum
sinus tachycardiasinus tachycardiaat restat rest
are dying!are dying!
Hemorrhagic shockSepsis
TensionTamponade
Ruptured aortaRuptured ectopic
Massive P.E.
Hemorrhagic shockSepsis
TensionTamponade
Ruptured aortaRuptured ectopic
Massive P.E.
Hemorrhagic shockSepsis
TensionTamponade
Ruptured aortaRuptured ectopic
Massive P.E.
Hemorrhagic shockSepsis
TensionTamponade
Ruptured aortaRuptured ectopic
Massive P.E.
Something mobilizing a
massivephysiological
response
Something Something mobilizing amobilizing a
massivemassivephysiological physiological
responseresponse
Your job isto determine ifa rapid rhythm
MAY be sinus tach
Your job isto determine ifa rapid rhythm
MAY be sinus tach
If it is, you must take action
If it is, If it is, you must take actionyou must take action
What is this rhythm?What is this rhythm?
220 – 60 = 160220 – 60 = 160
Correct answer:“This HAS to bean arrhythmia
Correct answer:“This HAS to bean arrhythmia
What is the ambient temperature?
What is the ambient temperature?
What is the patient’s blood pressure?
What is the patient’s blood pressure?
The most common causeof tachycardia in Parkland ER
is probably albuterol……followed by
amphetamine, cocaine,sepsis, DKA…
The most common causeof tachycardia in Parkland ER
is probably albuterol……followed by
amphetamine, cocaine,sepsis, DKA…
The most common causeof bradycardiain Parkland ER
is probably beta blockers…
…probably ISN’T greatphysical conditioning…
The most common causeof bradycardiain Parkland ER
is probably beta blockers…
…probably ISN’T greatphysical conditioning…
The incidence of bradycardia
post-hemorrhage,especially
intraperitoneally,is published to be
as high as 7 to over 20%
The incidence of bradycardia
post-hemorrhage,especially
intraperitoneally,is published to be
as high as 7 to over 20%
12. If it's blue, it's broken...
12. If it's blue, it's broken...
If someone “FOOSH’s”,
AND you find swelling OVERa bone of the
involved extremity,that is a fracture
If someone “FOOSH’s”,
AND you find swelling OVERa bone of the
involved extremity,that is a fracture
A doughy edema over the distal forearm
of a kid after a fall(even with a normal x-ray)
is a fracture
A doughy edema over the distal forearm
of a kid after a fall(even with a normal x-ray)
is a fracture
And,you haven’t cleared a neckuntil you’ve seen T1
And,you haven’t cleared a neckuntil you’ve seen T1
And, don’tassume thatsomething potentiallyserious isan anatomicalvariant untilyou’ve proved it
And, don’tassume thatsomething potentiallyserious isan anatomicalvariant untilyou’ve proved it
And, don’tchase afinding ona studyuntil thestudy isdonecorrectly…but don’t waste time if it may be dangerous!!
And, don’tchase afinding ona studyuntil thestudy isdonecorrectly…but don’t waste time if it may be dangerous!!
“Diseases ofthe great vesselsmakehumble menof proudphysicians”
…Osler
“Diseases ofthe great vesselsmakehumble menof proudphysicians”
……OslerOsler
Don’t beafraid tolearn to read aplain skullfilm…
“old medicine maystill be good medicine”
Don’t beafraid tolearn to read aplain skullfilm…
“old medicine maystill be good medicine”
Just rememberthat a normalplain skull andspine film reallymeans NOTHING!!!
Just rememberthat a normalplain skull andspine film reallymeans NOTHING!!!
13. Never send home (or non-transport) a sleepy baby
that doesn't come to full wakefulnessCorollary - If the baby
vomits his dose of medication,
be careful unless you've seen
the LP results
13. Never send home (or non-transport) a sleepy baby
that doesn't come to full wakefulnessCorollary - If the baby
vomits his dose of medication,
be careful unless you've seen
the LP results
14. Give the first dose of medication
before the patientis released from care...
…whether transporting or NOT!
14. Give the first dose of medication
before the patientis released from care...
…whether transporting or NOT!
The most closelyassociated factor
affecting morbidity andmortality of patientsseen in the ED with
pneumonia isTIME TO FIRST DOSE
OF ANTIBIOTICS!
The most closelyassociated factor
affecting morbidity andmortality of patientsseen in the ED with
pneumonia isTIME TO FIRST DOSETIME TO FIRST DOSE
OF ANTIBIOTICS! OF ANTIBIOTICS!
15. A normal EKG rules out nothing15. A normal EKG rules out nothing
16. AMS ALWAYS means that
something is wrong...
…until you prove it otherwise...
16. AMS ALWAYS means that
something is wrong...
…until you prove it otherwise...
The “computer” will come to “full on”
in everybodyunless there is a
chemical or structuralabnormality…
The “computer” will come to “full on”
in everybodyunless there is a
chemical or structuralabnormality…
Corollary -If a patient, post head trauma, is lying quietly and thenSTOOLS IN THE BED,
the patient has a subdural hematomauntil proven otherwise
Corollary -If a patient, post head trauma, is lying quietly and thenSTOOLS IN THE BED,
the patient has a subdural hematomauntil proven otherwise
…and, perhapsmost importantly…
…and, perhapsmost importantly…
17. You have to lookHARD for a reason
NOT to give a dose ofAtivan to a patient in Parkland ER!!
17. You have to lookHARD for a reason
NOT to give a dose ofAtivan to a patient in Parkland ER!!
Other postulates• “Back pain,
leg weakness, stat MRI”
• “Don’t you want to get a pregnancy
test before that abdominal x-ray, doctor?
Other postulates• “Back pain,
leg weakness, stat MRI”
• “Don’t you want to get a pregnancy
test before that abdominal x-ray, doctor?
Violence in theEmergency Department
Violence in theEmergency Department
AnticipateAnticipate
Do NOTINFLAME
the Situation
Do NOTINFLAME
the Situation
EvaluateEvaluate
Get enough helpGet enough help
Sedate as needed:
Versed is good – IM, IN, IVOther sedatives
TASERSux Blow-dart
Sedate as needed:
Versed is good – IM, IN, IVOther sedatives
TASERSux Blow-dart
ALWAYS Remember:
Once you’ve taken somebodydown, you are fully
responsible for them
ALWAYS Remember:
Once youOnce you’’ve taken somebodyve taken somebodydown, you are fullydown, you are fully
responsible for themresponsible for them
Finally!!Finally!!
Hell for EP’s and Staff
who areRUDE
to EMS Crews
Hell for EP’s and Staff
who areRUDE
to EMS Crews
The Golden Ruleof Survival in
HOSPITALEmergency Department
Life
The The Golden RuleGolden Ruleof Survival inof Survival in
HOSPITALHOSPITALEmergency Emergency Department Department
LifeLife
The Nurses RUN the Hospital!!
The Nurses RUN the Hospital!!
When in doubt,re-read the rule!When in doubt,re-read the rule!
Survival isthe key…
…wining “skirmishes”
means nothing
Survival isthe key…
…wining “skirmishes”
means nothing
Bribery doesnot work, andyou’ll only be
fooling yourself
Bribery doesnot work, andyou’ll only be
fooling yourself
Godspeed…
…and be careful…
Godspeed…
…and be careful…
?? oror !!