Clinical Decision Making in
Emergency Medicine
Richard Wolfe, MD
Chief , Department of Emergency Medicine
Harvard Medical Faculty Physicians
Decision Making and Clinical Errors
Individual or System?
How do we make
clinical decisions in medicine?
Chief Complaints  Basic Data Collection
Pattern Recognition
Workable Differential Diagnosis
Process to prove the correct diagnosis and
exclude the incorrect etiologies
• Management of the Working Diagnosis
• Disposition
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Intuitive and Analytic Thinking
What is unique about Emergency Medicine?
The medical decision process in the
Emergency Department
5 Features of
Emergency Medicine
1. NEED FOR SPEED
2. SPECIALIZED KNOWLEDGE
3. SHORT TERM VALUE BASED
JUDGEMENTS
4. LIMITED RAPPORT WITH
PATIENTS
5. COMMUNICATIONS ARE
CRITICAL
Traditional approach in primary care
Comprehensive history and physical exam
Formulate comprehensive problem list
Formulate long term diagnostic and
therapeutic plan
Primary Care
What is the Emergency Medicine
approach?
GOALS STABILIZATION AND DISPOSITION
Identify the chief complaints/problems
Perform a focused history and physical exam
Immediate recognition and empiric treatment of
the potential life threats
Disposition only once all life threats are
identified, stabilized, or ruled out.
Ensure a safe follow up plan
Emergency Medicine
How do I identify the chief complaints/problems?
What brought you to the ED *now* ?
What has you worried, what is new?
What are others worried about?
How can we help?
Wait for an answer
What is the key question to ask a patient
with a chronic complaint such as headache
or abdominal pain?
Is this pain different from your previous
pain?
If so, how is it different?
How do I identify life threats?
Focused history based on chief complaints
Focused physical exam
Critical interpretation of basic labs
Vital signs are:
The best objective data we have to identify a
life threat.
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If they are accurately taken and critically
interpreted
Be aware of “normal” vital signs that
identify a life threat. Examples:
Acute asthmatic with a respiratory rate of 12
A patient in hemorrhagic shock with a pulse
of 64
Elderly patient with a BP 110/80
Respiratory Rate of 20 br/mn
Basic labs are:
The delayed objective data we have to
identify a life threat.
If they are accurately ordered and critically
interpreted
 But they can also mislead
 Before ordering ask: Will this test alter my
management?
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Feed Me!!
How do I approach the life threatened patient?
Perform technical procedures and administer
medication before diagnostic modalities
Tube thoracostomy before chest X-ray in tension
pneumothorax
 Antibiotics before lumbar puncture for meningitis
 Airway management before the crashing patient looks
sick.
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How do I formulate my differential diagnosis?
What is the most serious possible cause of this
patient’s presenting symptoms and signs?
65 year old male with sudden onset of
flank pain and near syncope?
Ruptured abdominal aortic aneurysm
57 year old male with epigastric pain,
nausea and vomiting
Acute inferior myocardial infarction
What is the most common error made in
formulating a discharge diagnosis?
Giving the patient a benign diagnosis that cannot be
supported by the medical record. Examples:
Gastroenteritis
 Gastritis
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Is the diagnosis possible or necessary on
all patients seen in the ED?
No, and it is appropriate and ideal to state
this in the assessment or diagnosis. Example:
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Abdominal pain of unknown etiology
What is the question to ask when I
formulate a discharge plan?
What is the most serious complication of the
evolving disease process that can occur?
A patient with a suspected herniated disc or
acute lumbar strain should be informed of:
The symptoms and signs of a cauda equina
syndrome
A patient with abdominal pain of unknown
etiology should be informed of:
The signs and symptoms of a surgical
problem such as appendicitis.
What questions should I reflect upon prior to
discharging a patient?
Is it safe?
Have I made the patient feel better?
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If not, did I provide an explanation as to why?
52 yo ♂presents after slipping in his
bathroom and falling onto a sink. He
remembers striking his nose. He is
complaining of nasal trauma and
epistaxis.
He is also complaining of epigastric
pain, low back pain, and left shoulder
pain. He has been seen many times for
pain related complaints.
PMH: Hepatitis, HIV
He wants medication for the pain NOW!
Added information
Nursing Notes
• Epigastric pain and left shoulder pain new
following the fall.
• Admits to binge drinking, last drink 3 hours
ago
• Lives alone
• HR 110 BP 100/84 RR 20 T 37.2
• Physical Exam unremarkable
• Smells of alcohol but clinically sober.
Management
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Nasal films normal
CBC, Lipase normal
Left shoulder film normal
Epistaxis resolves with anterior packing
Received GI Cocktail and Morphine
ED Course
• Increasingly hostile with nurses
• 20 patients in the waiting room
• Discharged with ibuprofen for pain.
• DC Diagnosis: Nasal Contusion, Back
Strain, Gastritis
• Follow up with personal MD as needed
2 days later
EMS called for man found down.
Patient found at home in cardiac arrest.
• GEN:
Pale, pupils dilated, non reactive
• EXT:
Cool and clammy
• Monitor: Asystole
• Unable to resuscitate in Emergency Department.
Post Mortem:
Cause of Death:
Massive Intraperitoneal Hemorrhage, Splenic rupture
Comments by Case Review
• New onset abdominal pain and left shoulder pain after trauma: Obvious
splenic injury. Abdominal life threat not assessed.
• Tachycardia not addressed?
• Why did he fall? Wasn’t he too intoxicated to provide an exam or be sent
home?
• Vital signs not repeated
• Unsafe follow up plan
• Ibuprofen in patient with bleeding and possible coagulopathy
• Missed diagnostic studies:
– INR
– CT Head
– FAST Ultrasound
– Abdominal CT
• No follow up for anterior pack
The Amazing Retrospectoscope
ERROR IDENTIFICATION
Causes of Error in the ED
Five deadly sins
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Ignorance: TECHNICAL ERROR
Wishful thinking: JUDGEMENTAL ERROR
Selfishness: NORMATIVE ERROR
Distraction: SENSORY OVERLOAD
Deference: RESPONSIBILITY ERROR
Technical Error
Skills fall short of the task
• Ex: Did not know low mechanism could
cause splenic injury
• Ex: Not aware of Kehr’s sign. Nasal films
useless study.
Other examples:
• Closure of a fight bite
• Home dispo: Fever + IVDA
• Adm Nec Fasc to Medicine
• INDECISION
Technical Error
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Easy access to information
Supervision
Formal Educational Programs
Clinical Pathways
Judgmental Errors
Incorrect strategy is chosen
• Ruling out abdominal injury with physical
exam only because of low mechanism
Other classic examples:
• Not intubating a critical patient because
they look good
• Treating wide complex tachycardia as an
SVT
Judgmental Error
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Diagnostic Anchoring
Faulty Logic
Brain freeze
Fatigue
“The greatest derangement of the
mind is to believe in something
because one wishes it to be so.”
Avoiding Judgmental Errors
• Start with the chief complaint and take
small pathophysiologic steps to catagorize
the problems
• Explain anything that does not fit the
picture
• Keep asking why until the answer is “I
don’t care”
• Education in Critical Thinking
Normative Error
Failure in the eyes of others to
discharge one’s role obligations
conscientiously.
• Ex: Undermanaging a difficult patient
• Ex: Less safe dispositions
• Other examples:
– Failure to perform LP with severe headache and
negative CT
Avoiding Normative Error
• Restore sense of value of the front line
provider
• Avoid top down management
• M&M and intellectual honesty
Distraction Error
Failure to incorporate all the problems
into the plan
• Epistaxis vs. abdominal pain
• Boston Marathon: Near amputations vs.
shrapnel
• Ex: Medication errors, wrong side or wrong
patient, Delays in treatment
Distraction Error
• Causes:
– Excessive Workload/provider
– Poor information support systems
– Poor communication between providers
• Solutions:
– Work redesign: Staffing patterns, staffing roles
– Information system enhancement
– Team Training
Deference Error
Misdirection by authoritative
figure or Dogma
When all else fails,
try heuristics
Golden Rule
• Patients who can’t walk, can’t leave.
Golden Rule
Once a patient is labeled, all thinking
stops.
Don’t put a label on that you can’t prove.
Golden Rule
• Assume the worst case scenario and
proceed to rule it out
Golden Rule
• Kill as few patients as possible
Questions or Comments?