Emergency medicine: it's a different way of thinking/practicing

In this post I wanted to touch on some of the things that make emergency medicine a bit different from routine/elective/non-emergency (!) medicine.

Now we know that in veterinary – and indeed human – medicine not all patients that present as ‘emergencies’ are emergencies in the sense that they are facing life-threatening or even significantly debilitating problems but nevertheless. I am not going to say any more about this here – seems more suited to a separate blog post – but I would make two points:

• Pain/perceived pain is a very valid reason for emergency presentation (obviously it depends to a degree on the severity and acuity but you get my point).
• Seeing a patient as an emergency regardless of the problem because the carers are very worried is a valid reason for presentation (within reasonable limits of course but again, you get my point).

The essence of emergency medicine

Emergency practice needs to be more time-focused and this changes how we think; our main intention is to drill down into how we can best help the patient in the most efficient and expeditious way. The workflow that may work in other circumstances, i.e. take a complete history, do a full examination, have some thinking time to consider differentials, then do something…is not really how we roll!

“A little less conversation, a little more action”

No one is saying that taking a history is not important, it is. And of course with the growth of out-of-hours providers, many vets will also be seeing patients whose clinical notes they are not party to. However what we are saying is that when the history is taken needs to be modified according to the individual patient’s circumstances and in a number of cases initial assessment and stabilisation measures should and can be done without a history being known. Furthermore the history can be staged, i.e. get a very brief capsule summary at the outset, then go back and probe in more detail once patient management is under way. Emergency practice is not necessarily meant to be holistic in the sense that our priority is what the patient has come in for today; our interest in their history is more about trying to focus on those things that are relevant to the current presenting complaint(s).

Emergency medicine is more about so-called ‘hypothetico-deductive reasoning’ or in more clear terms (!), it is about trying to focus our history and patient evaluation to answer specific questions.  Those specific questions relate to excluding the most life-threatening problems associated with a presenting complaint and then working backwards. We want to start by ruling out life-threatening/severe problems that the patient may have first, ruling out what they don’t have rather than necessarily being concerned by exactly what they do have. We do not necessarily need to answer all the questions and an episode of care for an emergency patient does not have to end with a diagnosis being made. It is perfectly acceptable to say to the pet’s carer: “I know what he/she hasn’t got, and I have made him/her feel better, but I am not sure what he/she does have” – clients are not always happy with this of course but hopefully they will get some comfort from knowing that you have not found anything life-threatening or that is likely to cause an acute decompensation.

How we implement the philosophy

When presented with an emergency patient we start by answering some high level essential questions:

• How severely affected are you?
• Is your life in immediate danger?
• Do you need urgent interventions to stabilise your condition and avoid deterioration into a life-threatening situation?
• Are you moderately-severely painful?

We answer these questions by first triaging the patient and then completing a more extensive major body systems examination (cardiovascular, respiratory, central neurological) and pain assessment, i.e. the primary survey. What we do not do is perform a head-to-tail examination!

On the basis of this initial assessment, we may or may not be prompted to perform some interventions. The top three interventions we need to consider in the context of initial stabilisation are resuscitative fluid therapy, oxygen supplementation and pain relief. In a select population of patients early antibiotic administration is also very important but this needs to be rational based on sufficient index of suspicion of a clinically significant infection (another future blog post!). And note that we do not need to have made a diagnosis before these initial interventions are provided, before we take steps to make the patient feel better – and indeed, we very often do not know the diagnosis at this stage!

What do I do next? The primary survey is then followed by a secondary survey where we continue to evaluate other important sites/parameters, most notably evaluation of the abdomen, body temperature measurement, hydration assessment. Again this evaluation may or may not prompt some further interventions.

At some point we may go on to complete the physical examination – or depending on where you work and how things are structured, someone else may complete this more complete physical examination.

One thing to note is that focused ultrasound performed on emergency patients is gaining increasing traction and for very good reason. More and more emergency clinicians are using this modality to augment and often improve on their physical examination. Undoubtedly the greatest use to date has been for the detection of free fluid especially in the abdominal cavity. Physical examination is a crude way of detecting peritoneal fluid with a relatively large volume being needed and both false positives and especially false negatives occur. Ultrasound will also allow pleural effusion to be detected and there are myriad other emergency uses that I will not go into here – again, no doubt another blog post in the future.

One other thing to comment on is the role of blood tests. For the longest of time now we have spoken of the ‘emergency database’, sometimes divided into a ‘minimum’ and ‘extended’ emergency database. As time has gone on and the ability of practices to perform both point-of-care and other in-house blood tests has developed, exactly what the emergency database can and should constitute is open to some discussion. However the bottom line clearly has to be that in terms of prioritising what we test for and when we test for it, we should parallel our clinical evaluation of the patient. What blood test results do you think will aid you in your initial assessment and stabilisation of the patient? What would you like to know now versus what would you like to know going forward? Remember that blood tests are not a treatment in and of themselves and in the first instance we should be focused on answering the questions that allow us to help make the patient feel better.

Overview of emergency approach

Getting real

Now I realise that the above description of emergency workflow does not account for ‘real life’ in the sense that we do not treat patients in an vacuum/bubble and there are some potential constraints/influences that will impact on what we do, when we do it, how we do it etc. Clearly the pet’s carer is the major one in terms of what they want and especially what they can afford (assuming they are paying for their pet’s care). The equipment, facilities, staffing and expertise of your environment are other potential influences that will come into play. Nevertheless I do think that it is important that emergency patients are approached with a sound philosophy and thought processes that can then be modified on an individual patient/practice basis.