fowler's fifteen plus laws of emergency medicine...

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

www.UTSW.ws

www.rayfowler.com

drray@doctorfowler.com

www.UTSW.ws

www.rayfowler.com

drray@doctorfowler.com

Godspeed…

…and be careful…

Godspeed…

…and be careful…

?? oror !!