10 Commandments
BMJ 1995;310:642-648 (11 March)
Education and debate
Recent Advances: Teaching in accident and emergency medicine: 10 commandments of accident and emergency radiology
Robin Touquet, consultant in accident and emergency medicine,aPeter Driscoll, senior lecturer in accident and emergency medicine,bDavid Nicholson, consultant radiologist b
a St Mary’s Hospital, London W2 1NY, b Hope Hospital, Salford M6 8HD
Correspondence to: Mr Touquet.
One of the many attractions of accident and emergency medicineis the wide and varied opportunities it provides for education.This is because of the acute nature of the work, which necessitatesprompt and accurate decision making. However, in many instancesthe decisions have to be made by inexperienced senior houseofficers. Departments therefore need a safe system of practicethat can be remembered and adhered to under stress. The 10 commandmentsis one such system for analysing emergency radiographs of allthe regions of the body. This system lays down guidelines toprotect both staff and hospitals from the inevitable mistakesthat inexperienced doctors will make.
More than half the patients attending accident and emergency departments in the United Kingdom have a radiograph taken. But radiological interpretation can be poor–for example, in onestudy 39% of clinically important abnormalities were missedby accident and emergency senior house officers.1 In additionpoints dealing with radiology are involved in over half of allcases of litigation concerning the standards of care in accidentand emergency departments (Brian Capstick, personal communication).It is therefore essential to improve the training of seniorhouse officers in interpreting emergency radiographs.
Many accident and emergency departments now run induction courses for junior doctors.2 When teaching emergency radiology, however,it is easy to go over several “radiological pitfalls” and endup simply showing mistakes that have been made by previous incumbents.This only increases anxiety as the doctors realise the multitudeof possible errors. It is better to formulate a system thatwill enable senior house officers to detect abnormalities, touse a book constructively for reference,3 and to know when toask for help.4 5
This article provides a system that is applicable to doctorsof all specialties who request and review emergency radiographs.Use of the 10 commandments will make mistakes much less likelyand when mistakes do occur everyone following the system will,to a large extent, be protected from litigation.
1. Treat the patient, not the radiograph
It is essential to understand both the injury and its natural course. If the condition is immediately life threatening treatment should be started straight away without waiting for a radiographto confirm the clinical diagnosis. Two examples of such conditionsare a tension pneumothorax and a severely displaced fracturedankle, where the skin is at risk from hypoxia and fracture blisters.6
The diagnosis of certain injuries is dependent on the clinical findings (box). In such cases the radiograph does not providethe diagnosis but excludes other abnormalities. Even if no radiological abnormality is found the appropriate treatment based on theclinical findings should be started.
In some situations it is difficult to obtain a history and examine the patient, and even more difficult to obtain radiographs of adequate quality–for example, a drunk patient. Nevertheless,the doctor will be blamed for missing a diagnosis if the patientsuffers resultant harm.7 Under these circumstances the mostserious clinical diagnosis must be considered and appropriateaction taken. Drunk patients with a head injury require a minimumof active observation, with prompt computer tomography if markedclinical deterioration occurs. Patients with more minor injurieswho can go home safely should be asked to attend the accidentand emergency review clinic for reassessment of the injury andpossibly radiography. For drunk patients it may well be appropriateto refer them to an agency for alcohol abuse.8
Examples of conditions whose diagnosis relies mainly on clinical findings * Fracture of the base of the skull * Scaphoid fracture * Epiphyseal injuries–for example, Salter-Harris type I without shift * Pulled elbow of a toddler
2. Take a history and examine the patient before requestinga radiograph
It is important to consider the patient as a whole and not just the most obvious symptom or sign. Before requesting a radiographyou should establish the mechanism and force of injury and usethis information to deduce which resultant abnormalities arelikely.6
When examining a seemingly isolated injury, you should be awareof likely associated injuries (box). Trauma victims with multiple injuries present particular difficulties. Standard practiceis to take radiographs of the lateral cervical spine, chest,and pelvis in the resuscitation room.5 If the secondary survey(the head to toe detailed examination) is not completed or thenecessary views cannot be carried out in accident and emergency,such omissions must be recorded in the patient’s notes.
Examples of associated injuries * Head injury with diminished level of conscious- ness–cervical spine injury * Pain in arm–nerve root entrapment in the neck * Colles’ fracture–concomitant fracture of radial head * Pain in the knee–slipped femoral epiphysis * Ankle injury–fracture of styloid process of fifth metatarsal
3. Request a radiograph only when necessary
A useful investigation is one whose result (positive or negative) will alter the patient’s management; many requested investigationsdo not.9 This discipline is delineated systematically in theABC of Emergency Radiology,3 but the following are common exampleswhere radiographs may be requested unnecessarily: trauma tothe coccyx9; a clinically fractured nose (management dependson appearance, the presence of a septal haematoma, and the positionof the septum)3 10; skull radiographs in patients with a headinjury who require computed tomography of the brain.
In addition, for patients with fractured ribs, a chest radiograph is appropriate only to detect abnormalities to the underlyingsoft tissues.3 11 Oblique rib views requested solely to determineif and where a rib is fractured are inappropriate because theywill not necessarily show the fractured rib. Providing thatthere is no underlying injury, even if a fractured rib is identifiedthe management of the patient will not be altered.12
A supine radiograph of the abdomen in isolation has few indications,although two are an ingested sharp or pointed foreign body13 and penetrating injury.14 Gas under the diaphragm is best shownin an erect chest radiograph, but in 30% of perforations nofree gas is visible even when the patient has been kept erectfor 5 minutes to allow free gas to rise.3 11 If immediate radiologicalreporting in the accident and emergency department is possiblea supine film alone may safely enable the correct managementdecision to be made. However, without radiological trainingit is unreasonable to expect a young doctor to be this skilledin image interpretation.11 Consequently accident and emergencydepartments must have protocols and guidelines for senior houseofficers to follow. In suspected cases of intestinal obstructionor perforated viscus supine and erect (or a lateral decubitus)plain abdominal views may therefore need to be taken.
4. Never look at a radiograph without seeing the patient, and never see the patient without the looking at the radiograph
Irrespective of grade or experience, you should always insiston seeing the patient when asked to interpret a radiograph.6 This is particularly important when patients are transferredto the care of another medical team or handed over at the endof a shift. The receiving doctor can then correlate the radiological findings with the clinical examination, which helps to reducethe chances of missing an abnormality or perpetuating an error(fig 1). If a patient reattends always look at any radiographstaken previously, or at the least obtain the radiologist’s report.Do not accept the accident and emergency radiological interpretationwritten on the medical record. This applies to patients makingboth spontaneous return visits and booked return visits to theaccident and emergency review clinic.
View larger version (125K): [in this window] [in a new window] FIG1–(Top) Radiograph of patient with a posterior dislocationof the right shoulder after an epileptic convulsion. The radiographwas muddled with that of a patient with left lower lobe pneumoniawho had sustained an anterior dislocation of the left shoulder40 years previously, which had never been reduced (bottom).The doctor attempted to reduce the shoulder of the second patient,rather than of the first patient because of inadequate handoverfrom one senior house officer to another
5. Look at every radiograph, the whole radiograph, and the radiographas a whole
It is easy to rush and take short cuts in the pressured environmentof accident and emergency. But every radiograph must be adequatelyassessed in a calm manner with a proper viewing box. An additionalbright light and reduced ambient light are also essential as they help in interpreting low density areas such as the softtissues and overexposed parts of films.
A common mistake is to focus immediately on severe abnormalities or on particular areas of the film. This may lead you to failto inspect the whole film and consequently to miss additional abnormalities. This mistake can be avoided by having a methodfor inspecting the whole radiograph, and we recommend the ABCsapproach (box).3 The system is further modified for regionssuch as the abdomen and chest, where it is important to standback and look at the film as a whole.3 Studying radiographsclose up, in a well lit, noisy room with many distractions,increases the chances of missing abnormalities.
ABCs method for interpreting radiographs * A–Adequacy * A–Alignment * B–Bones * C–Cartilage and joints * s–soft tissues
The first step in assessing adequacy is to check the name anddate on each film as it is easy for films to be put back intoa packet belonging to a different patient. Once the correctradiograph is identified you should check that all of the areaof interest can be seen–for example, for views of the cervicalspine, the base of the skull, and the upper aspect of T1 mustbe visible.3 15
Note the alignment of the patient to the radiograph becausethis affects the appearance of bone and soft tissue. For example,the density of the hilum and the dimensions of the heart canbe greatly altered if the patient’s chest is rotated when thefilm is taken. Variations in alignment of joints are also importantas they may obscure abnormalities. For example, if the hip jointis externally rotated the position of the greater trochantercan obscure a fracture of the neck of femur.16
Assess the bones by following the cortical lines and notingany breaks, white lines (indicating overriding bones), or steps.The medullary component of the bone should then be checked for abnormalities in the trabecular pattern. Next inspect all thejoint spaces and articular surfaces and note abnormal calcificationof cartilage and ligaments.
Finally assess the soft tissues as these can indicate an underlyingskeletal injury–for example, the prevertebral shadow in the lateral radiograph of the cervical spine3 15 or lipohaemarthrosisof the knee. Lipohaemarthrosis, with the fat-blood interfaceshown in the horizontal beam lateral radiograph of the knee,indicates an underlying intra-articular fracture that may notitself be visible radiologically.3 17 Once each film has beeninspected systematically the different views need to be collatedso that the region can be considered as a whole.18
6. Re-examine the patient when there is an incongruity betweenthe radiograph and the expected findings
If the radiograph does not show what the clinical signs have already suggested, check that the correct part and side of thebody has been taken. Re-examine the patient to confirm thatthe site of injury has been identified correctly (fig 2). Ifsuch checks confirm that no mistakes have been made specialviews or investigations may be needed to identify the injury.In elderly patients who have fallen and subsequently cannot walk it is wise to assume that there is a fracture of the neckof femur or pelvis until it is proved otherwise; a bone scanor magnetic resonance imaging may be needed to confirm the diagnosis.
View larger version (98K): [in this window] [in a new window] FIG2–Fracture of proximal shaft of the left humerus with butterfly fragment. This film was taken when the patient reattended becauseof persistent pain. The previous day a radiograph of only thenormal left elbow had been incorrectly requested.
7. The rule of twos
This is an easy discipline to remember and follow.
Two views–Because of its alignment, a fracture may be visiblein only one view. Consequently two views at right angles (orthogonal)to each other must be taken. Two views of a radio-opaque foreignbody clear from bone are needed to localise it.13
Two joints–Because of the risk of associated dislocation or subluxation when a fracture is suspected, the radiograph mustinclude the joint at either end of the long bones (fig 3).
View larger version (48K): [in this window] [in a new window] FIG3–Plated Monteggia fracture with radial head still dislocated.
Two sides–An abnormality can be detected more easily if you compare the normal and injured side, both clinically and radiologically.In children even subtle epiphyseal injuries can be detectedin this way. Consequently a child with limited extension ofthe elbow after injury should have radiographs taken of bothelbow joints for comparison at the outset. There are six differentepiphyses around the elbow joint which appear between the agesof 6 months and 12 years.
Two occasions–The natural course of certain conditions makesit necessary for radiographs to be repeated at a later dateto show the abnormality. Examples include stress and scaphoidfractures where early callus or rarefaction will not be visiblefor 10-14 days.
Two radiographs–Certain fractures, such as the neck of thetalus, are difficult to identify radiologically. However, whenthe radiograph is compared with a known normal film, the fracturecan become much more obvious. It is good practice to have anaccessible library of normal radiographs in the accident andemergency department as well as reference books that show normalvariants.19 20
8. Take radiographs before and after procedures
Removal of foreign body–As patients have been known to replace foreign bodies in wounds deliberately, it is important that radiographs are taken to confirm that all the pieces have been removed. The patient must be informed, and this documented,if the foreign body cannot be found or its removal is judgednot to be in the patient’s best interest. However with the eye,if the history suggests an intraocular foreign body the patientmust be referred as an emergency immediately even if the radiographsof the orbit appear normal.6
Dislocations–It is essential to confirm that reduction is complete.Joints can redislocate, and the radiograph is the evidence of successful reduction. Associated fractures may be more obviousin films taken after reduction.
Reduction of fractures–It is necessary to confirm that the position of bones is satisfactory because fractures can moveafter reduction.
9. If a radiograph does not look quite right ask and listen:there is probably something wrong
Inexperienced doctors will inevitably come across injuries that they have never seen before. In these cases it may not be possibleto make a diagnosis but you will notice that the films do notlook quite right. Good examples of this are lunate and perilunatedislocations of the hand. It is important to seek senior adviceand also to listen to the radiographer. Many departments operatea “red dot” system, in which the radiographer flags up an abnormality.An experienced radiographer may be as good as or even betterthan a junior doctor at interpreting films.
The problem with this system is that the absence of a red dotdoes not necessary mean that there is no abnormality. This isimportant to remember because the final responsibility lieswith the doctor, and not the radiographer. Therefore never acceptpoor quality or inadequate films.
10. Ensure you are protected by fail safe mechanisms
All accident and emergency doctors must be specific when they request radiographs, giving the force of injury, the site ofinjury, and the clinical diagnosis on the request card. Despiteimproving education, radiological diagnoses will inevitablybe missed by all grades of staff.1 6 Consultants must thereforeset up systems to minimise the effect of these clinical errorson the patient and in so doing protect staff, the hospital,and themselves (box). To miss an injury radiologically may notbe negligent, but it is negligent not to have a system in placeto provide for this eventuality. The fail safe mechanisms shouldbe audited regularly. It is much more feasible to run this systemeffectively if the accident and emergency department has middlegrade staff.
Conclusion
s
The most practical way to instil these 10 commandments into successive teams of senior house officers is with an inductioncourse followed by ongoing teaching using patients in the department–that is, situational teaching.21 The fact that the doctors have faceda diagnostic dilemma, defined the problem, and sought (selfdirected learning) or asked advice, means that they will retainthe knowledge for longer.
Quality control system for interpreting radiographs * On reviewing the films, the doctor records the radiological diagnosis on the request (or return) card * All emergency radiographs must be reviewed by a radiologist, and the report returned, within three working days. Many would now advocate immediate (within 24 hours) reporting as a good standard of practice * The radiologist’s report should state clearly whether he or she agrees or disagrees with the radiological diagnosis of the accicent and emergency doctor * All radiographs must be reviewed if the report states disagree. The radiologist must contact the department at once if a serious injury has been missed
The number of complaints from patients is increasing,22 so itis vital that accident departments have adequate staffing levels,23 facilities,24 education,6 and fail safe mechanisms that areaudited regularly.25 If these basic prerequisites are not providedhospitals, and perhaps purchasers, make themselves vulnerable.
We thank Mr Sapal Tachakra, director of the Central Middlesex induction course for accident and emergency senior house officers, where this paper is presented biannually. We also thank Dr Teresa Challoner for editorial guidance.
The ABC of Emergency Radiology will be published in April 1995.
- Vincent CA, Driscoll PA, Audley RJ, Grant DS. Accurate of detection of radiographic abnormalities by junior doctors. Arch Emerg Med 1988;5:101-9. [Medline]
- Tachakra SS, Beckett MW. An induction course for casualty officers. Br J Accid Emerg Med 1987;2:8.
- Nicholson DA, Driscoll P, ABC of Emergency Radiology. London: BMJ Publishing 1995.
- Morris F, Cope A, Hawes S. Training in accident and emergency: views of senior house officers. BMJ 1990;300:165-6.
- Perry NM, Lewars MD. Radiological assessment. In: Skinner D, Driscoll P, Earlam R, eds. ABC of Major Trauma. London: BMJ Publishing, 1991.
- Touquet R, Fothergill J, Harris NH. Accident and emergency departments; the speciality of accident and emergency medicine. In: Powers S, Harris NH, eds. Medical negligence. 2nd ed. Oxford: Butterworths, 1994.
- Hill G. A and E risk management. London: Medical Defence Union, 1991.
- Touquet R, Priest R. Management of alcohol abusing patients in accident and emergency departments. J R Soc Med 1994;87:720. [Medline]
- Royal College of Radiologists. Making the best use of a department of clinical radiology. Guidelines for doctors. 2nd ed. London: RCR, 1993.
- Logan M, O’Driscoll K, Masterson J. The utility of nasal radiographs in nasal trauma. Clin Radiol 1994;49:192-4. [Medline]
- Craig JOMC. Pitfalls in diagnostic radiology. Part 3. London: Medical Protection Society, 1993.
- DeLuca SA, Rhea JT, O’Malley T. Radiological evaluation of rib fractures. Am J Radiol 1982;138:91-2. [Abstract/Free Full Text]
- Remedios D, Charlesworth C, de Lacey G. Imaging of foreign bodies. Imaging 1993;5:171-9.
- Jelinek GA, Banham NDG. Reducing the use of plain abdominal radiographs in an emergency department. Arch Emerg Med 1990;7:241-5. [Medline]
- Landon BA, Driscoll PA, Goodall JD. An atlas of trauma management. London: Parthenon Publishing, 1994.
- Williams P, McCutcham J, Barrington N. Pitfalls in diagnosis of femoral neck fracture. Injury 1992;23:140-1. [Medline]
- Knottenbelt JD, Ferguson J. Lipohaemarthrosis in knee trauma: an experience of 907 cases. Injury 1994;25:311-2. [Medline]
- Guly H. Diagnostic errors in trauma care and how to avoid them. Bristol: Clinical Press, 1992.
- Keats TE. Atlas of normal roentgen variants that may simulate disease. 4th ed. Chicago: Year Book Medical Publishers, 1988.
- Grech P. Casualty radiology. London: Chapman and Hall, 1981.
- Touquet R, Barker A. Personal view. BMJ 1986;293:1168.
- Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994;343:1609-13. [Medline]
- British Association of Accident and Emergency Medicine. Medical staffing, accident and emergency departments. London: Royal College of Surgeons of England, 1994.
- Harris NH. Medical negligence in trauma and orthopaedics. In: Powers S, Harris NH, eds. Medical negligence. 2nd ed. Oxford: Butterworths, 1994.
- Craig JOMC. The Knox lecture: radiology and the law. Clin Radiol 1989;40:343-6. [Medline]
(Accepted 12 December 1994)
EDITOP ALS
The Ten Commandments of
Emergency Medicine
INTRODUCTION
Emergency physicians approach
patients differently than their counterparts
in other specialties because
of time constraints and because they
deal with critically ill patients without
the benefit of an ongoing relationship.
The potential for error is
therefore great. We developed the following
ten commandments of emergency
medicine to help others avoid
these errors. We believe that remembering
these commandments could
improve patient care, physician-patient
relations, and risk management.
SECURE THE ABCs
The emergency physician should
initially direct attention to the patency
of the patient’s airway, the adequacy
of the patient’s breathing, and
the assurance of cardiovascular stability.
Securing the ABCs in every patient
every time is essential, whether
the patient appears to have trivial
complaints or is severely ill.
We have expanded the ABCs to
ABC2DEFG 2. The steps represented
by the letters A through E are well
understood by emergency physicians.
“F” stands for fetal heart tones because
the vital signs of a pregnant patient
are not complete without listening
for fetal heart tones. Likewise,
in pregnant patients, the need for
rhogam (the first “G”) should always
be considered. The second “G” represents
the guard rails on the
stretchers, which are all too often left
down. Even alert patients may roll
off a bed; the elderly or confused patient
is guaranteed to “go to ground.”
Emergency physicians are often the
worst offenders when they leave the
bedside after examining a patient.
CONSIDER OR GIVE
NALOXONE,
GLUCOSE,
AND THIAMINE
The need for naloxone, glucose,
and thiamine (NGT) should be assessed
in every patient with altered
mental status. A single 2-rag IV dose
of naloxone almost never causes toxicity
in an adult emergency department
patient. Blood glucose should
be assessed immediately by an accurate
and rapid fingerstick method, or
D5oW should be administered in the
rare event that a fingerstick blood
glucose cannot be performed. Rapid
IV administration of 100 mg thiamine
has been demonstrated to be
very safe and should be provided to
any cachectic or malnourished patient,
including all chronic alcoholics,
patients with malabsorption
or cancer, and young patients with
AIDS or anorexia nervosa.
GET A PREGNANCY TEST
Because the reproductive, contraceptive,
and menstrual histories of
patients in their child-bearing years
are unreliable, it is necessary to consider
obtaining a pregnancy test in
every patient who has a functioning
uterus. It is difficult to treat most
complaints of reproductive-age
women if their pregnancy status is
unknown. Likewise, inappropriately
obtaining radiographs in patients
who are pregnant can be dangerous.
The easiest way to rule out an ectopic
pregnancy in the ED is with a
pregnancy test.
ASSUME THE WORST
We must always rule out the most
serious potential cause of a patient’s
symptoms and be certain that adequate
attention has been given to the
most catastrophic probabilities, even
if they are unlikely. Then, and only
then, can we ascribe a patient’s complaint
to a less severe and more
likely possibility.
One of the most insidious serious
errors is to diminish the magnitude
of the patient’s complaint. Often this
happens because there is peer pressure
to not admit patients. At other
times, a patient’s complaint is downplayed
because of a negative attitude
toward his “emotional overstatement”
of pain. During the initial
evaluation, we should take all complaints
at face value and not make
subjective judgments. It is a bad idea
to project our expectations onto our
patients.
DO NOT SEND UNSTABLE
PATIENTS TO RADIOLOGY
Portable radiographs are not as
good as radiographs performed in the
radiology department. Radiologists,
however, do not treat unstable patients
as frequently as do emergency
physicians. Their skills may be rusty,
and life-saving drugs and equipment
may be inaccessible in the radiology
department. Unstable patients who
must have films in radiology must be
accompanied by a person trained to
manage their condition should it deteriorate.
LOOK FOR THE COMMON
RED FLAGS
Because the ED evaluation of a patient
must take place quickly, it is
important to keep some recurring
“red flags” in mind. First and foremost,
there are the four vital signs;
all four must always be evaluated,
and any abnormal vital sign must be
explained in writing. Emergency physicians
must be careful in interpreting
axillary and oral temperatures
that may be misleadingly low. Orthostatic
blood pressure and pulse measurements
must be considered in any
patient at risk for volume depletion
or acute blood loss. Orthostatic vital
signs, however, are never indicated in
a hemodynamically unstable patient.
Second, age, especially extremes of
age, should alert the clinician to the
presence of potential comorbid conditions.
The presence of HIV risk factors
is another red flag that signals
the need for an aggressive workup.
HIV risk factors are present in all socioeconomic
levels and ages. Emergency
physicians must ask the “era-
20:10 October 1991 Annals of Emergency Medicine 1146/137
EDITORIALS
barrassing” questions about sexual
preference and activity as well as
those concerning the use of illicit
drugs.
Third, any unscheduled return to
the ED for the same complaint is another
red flag. The initial problem
may have been inappropriately or incorrectly
treated, and for patients to
be seen again in the chaos of the ED
setting gives special significance to
the complaint.
Last, there are three questions that
must be asked of every ED patient; a
negative answer to any one represents
a red flag. First, “Have you ever
had this complaint before?” If the
complaint is new, it clearly requires
a different approach diagnostically
than if the complaint is chronic. Second,
“Can the patient take adequate
nutrition by mouth,” and third, “Can
the patient walk?” If the patient is
unable to provide for himself but
could previously, he should not be
routinely discharged home.
TRUST NO ONE,
BELIEVE NOTHING
(NOT EVEN YOURSELF)
Errors are often made when we depend
on assumptions. Important decisions
must be based on facts, not
hearsay or someone else’s perception
that is presented as “fact.” A physician’s
or nurse’s words are not a substitute
for written medical records.
An ECG or radiographic report is not
a substitute for viewing the tracing
or film.
This commandment is also meant
to be a caution against blind trust in
the expertise or opinions of others. It
is always comforting to have the advice
of a subspecialist, but emergency
physicians must remember
that they often know the most about
the patient at that time.
It is important to keep an open
mind. Many of our worst errors have
occurred when we adopted a mindset
about the patient and refused to let
other opinions or data change our
initial perception. Emergency physicians
should not be afraid to ask for
help or admit uncertainty. Family,
friends, nurses, and medical students
often provide very cogent observations
that can positively alter the
course of the patient’s illness. No advice
should be rejected out of hand;
hubris is a physician’s worst enemy.
Institutional tradition and lore are
areas that commonly introduce an element
of bias. Institutions tend to
become inbred. There is often more
than one way to approach a specific
complaint, and old traditions die
hard. Lore must be validated by the
scientific method. Always maintain
an element of skepticism about old
adages or new trends.
LEARN FROM YOUR
MISTAKES
We all make mistakes of varying
severity, regardless of our level of experience.
The key to dealing appropriately
with mistakes is not to deny
them but rather to embrace them and
learn from them. It is not healthy to
dwell on mistakes; it is healthy to
use a mistake to become an expert in
a particular area. No one is immune
to mistakes. As a colleague, it is also
incumbent to not be too judgmental.
We should learn from each other’s
mistakes, not use them to impugn
one another.
DO UNTO OTHERS
AS YOU
WOULD YOUR FAMILY
(AND THAT INCLUDES
COWORKERS)
When confronted with a difficult
decision or an ethical dilemma, we
should consider how we would like
one of our family members to be
treated. Patients are not the enemy.
At times they may have habits or behaviors
that we do not like, but every
patient must be treated within the
context of his illness. Unfortunately,
the illness may have many comorbid
contributors, including psychiatric
disease, addiction, family problems,
and job stresses. Our lives are molded
by stresses. We are here to treat, not
to judge.
The “do unto others” commandment
also applies to coworkers.
Treating colleagues, interns, residents,
nurses, aides, emergency reedical
technicians, and secretaries with
respect should be integral to our approach.
Treating anyone with disrespect
might return to haunt you.
WHEN IN DOUBT,
ALWAYS ERR ON THE
SIDE OF THE PATIENT
There is no getting away from an
element of uncertainty in medicine,
particularly in emergency medicine.
As physicians, our ultimate goals
should be relief of symptoms and optimal
patient outcome. When significant
uncertainty exists, emergency
physicians must be sure that their
decisions take into account the potential
for a bad outcome. We should
always err in a way by which the patient
will suffer the least. Decisions
to admit or discharge, perform another
test, or call a consultant should
always be made with the patient’s
best interests and safety as the major
deciding factors. Our ultimate goals
should not be to save money, keep
hospital beds open, or protect our
peers.
CLOSING
THOUGHTS
These ten commandments are an
outgrowth of our experience as emergency
physicians. As with the original
Ten Commandments, no one will
be able to observe all of them all the
time. There are probably many examples
of exceptions and additions
to these commandments. Exceptions
are fine, as long as they are made
with awareness. The number of exceptions
any physician makes should
relate directly to his level of expertise.
We welcome input on what we
may have overlooked. It is our belief
that keeping some form of these ten
commandments in mind will prevent
mistakes and improve patient care
and satisfaction.
Keith Wrenn, MD, FACP
Corey M Slovis, MD, FACEP, FACP
Division of Emergency Medicine
University of Rochester School of
Medicine
Rochester, New York
138/1147 Annals of Emergency Medicine 20:10 October 1991
Back to topThe Derriford twelve commandments of emergency medicine: a model for good practice in a changing world, or a survival guide for new medical staff
J E Smith, I Higginson, H R Guly, I C Grant, P Belsham, A Hicks, D Alao, D Boon
Emergency Department, Derriford Hospital, Plymouth, UK
Correspondence to: Dr J E Smith, Emergency Department, Derriford Hospital, Plymouth PL6 8DH, UK; jasonesmith@doctors.org.uk
Accepted 13 May 2008
ABSTRACT TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES Time is a precious commodity and with more junior doctors coming through our departments for shorter periods of time it has been useful to lay down some ground rules to facilitate their induction. These are presented in the form of the twelve commandments of emergency medicine. The emergency department (ED) at Derriford Hospital in Plymouthsees approximately 85 000 patients every year. We have doctorsof various grades and experience, with (at the time of writing)41 new junior doctors passing through our department on rotationevery year, spending between 4 and 6 months with us. Time forinduction is precious and we have found it useful to set outsome ground rules for practising emergency medicine. These are given to the junior staff at induction in the form of the twelve commandments of emergency medicine.
Advice has been given in the form of commandments before, notably with regard to emergency radiology1 and for the North American2 and Australasian3 ED. However, the practice of emergency medicinemay vary in different countries and we felt a set of commandmentsrelevant to UK practice would be of benefit. We hope they proveuseful for other departments facing the task of keeping patientssafe, staff happy and a department functioning smoothly.
COMMANDMENT 1: SOME PATIENTS ARE THERE TO FOOL YOU TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES You need to be cautious when seeing certain groups of patients,as many before you have made (at times, fatal) errors. Be particularly vigilant when seeing elderly patients with abdominal pain, loinpain (you think renal colic, they may have an abdominal aorticaneurysm), acute confusion or collapse and atypical chest pain.Beware of patients you diagnose with constipation, especiallyif they are elderly (see above). Remember the intoxicated patientwith a head injury sometimes has a significant intracranialproblem. Patients who cannot communicate because of languageor other difficulties need special attention.
Beware those patients who look sicker than you expect, as they usually are. If a patient is in more pain that you would expect,or cannot weight bear when you expect they should, you haveprobably missed something.
Patients do not always have a single injury and remember to examine the joint above and below an injury. When examininglimbs, compare left with right but beware the bilateral injury.Do not forget that there may be a medical reason for the fallthat caused the injury.
Patients do not read textbooks. Atypical presentations are common and it is common to see rare things in an ED. Have an enquiringmind, or you will miss occult pathology such as child abuse,elder abuse and artefactual disease.
Some other important reminders are listed in box 1.
Box 1 Points to remember
- A normal electrocardiogram does notexclude ischaemic heart disease
- A normal computed tomographyscan does not exclude subarachnoid haemorrhage
- A normal x raydoes not exclude a fracture in a patient in whom you have highclinical suspicion
- The presence of chest wall tenderness doesnot exclude myocardial infarction nor pulmonary embolism
- Justbecause someone says they are not pregnant does not mean theyare not
COMMANDMENT 2: SEEKING ADVICE TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES The ED middle grades and consultants are available for advice,but it will help you learn if you have a coherent differentialdiagnosis and provisional management plan ready. Do not seekadvice without first seeing the patient, as the advice is likelyto be: “see the patient”. Notify the senior doctor about anyproblems, both clinical and administrative. If we do not knowabout problems, we cannot solve them.
Seek advice from the senior ED staff before you refer to other teams, and when you phone other teams, always be polite, evenif provoked. It is possible to be both polite and assertive.When you phone other teams, be clear whether you are askingfor advice or making a referral. Do not accept advice when youthink you should be making a referral. If you have asked foradvice, record who you have spoken to and what they said.
If you have asked for advice, it is usually wise to follow it;do not canvas opinion until you get the advice you think youwanted in the first place. If you are offered advice withoutasking for it, there is usually a reason. If an experiencedmedical or nursing colleague advises you to do something, thinkVERY carefully before ignoring that advice.
COMMANDMENT 3: INVESTIGATIONS TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES For the 10 commandments of emergency radiology, see Touquetet al.1
With regard to performing blood tests, do not do a battery of investigations in the hope that one of them will be abnormalso you can admit the patient. Do not do a coagulation screenunless it is needed, do not do a D-dimer without doing a pretestprobability first, or do a C-reactive protein unless you reallythink it will change management. Adopt Bayesian thinking andperform a test only when it will alter the pretest probabilityof a disease. Have a very low threshold of doing a pregnancytest on female patients aged between 12 and 50 years. If youdo blood cultures make sure you take enough blood and if youask for an investigation, it is your responsibility to checkthe result.
Take care when taking blood (especially for cross-matching).Check the patients identity from their wrist band. Thereshould be a policy for labelling samples from unidentified patients.
COMMANDMENT 4: PAPERWORK AND DOCUMENTATION TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES Write legibly, printing the date, the time, your name and your designation every time you write in the notes. Keep your notesin the proper place and do not leave them lying around. Completeyour notes when you discharge the patient and discharge themon computer at the same time.
Take great care over the words Left and Right, and do not abbreviatethem.
When you write to the patients GP, ensure that you includeall relevant information such as what you have prescribed. Writeconcise and focussed notes; patients with sprained ankles donot need a three page clerking, but complex patients in themajors area may do.
You or your consultant may have to write a report, or defendyour actions, based on a patients clinical notes. Ifyou do not document it, it did not happen. Remember to documentwhat was said during telephone calls. For patients who allegethey have been assaulted, remember that you may have to preparea police report based on your notes.
COMMANDMENT 5: PRESCRIBE CORRECTLY TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES Use UPPER CASE for legible prescriptions. Check doses in theBritish National Formulary if uncertain. Check for drug interactionsand contraindications (especially in pregnancy, renal and hepatic disease). Avoid non-steroidal anti-inflammatory drugs (NSAID)in the elderly, in patients with ischaemic heart disease andin patients on warfarin. Prescribe oxygen (in appropriate doses),particularly for chronic obstructive pulmonary disease patients.On the ED record write what you have prescribed, eg, diclofenac50 mg tds for 5/7, not NSAIDs.
Do not self-prescribe.
COMMANDMENT 6: SEEING CHILDREN TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES When seeing children, always document who attends with the child, what their relationship is with the child and who gives thehistory. If they present with an injury, carefully documenthow the injury is said to have happened and who witnessed it.Always consider child abuse and if you suspect it seek senioradvice. Use caution when prescribing for children and prescribethe dose according to weight. Do not do the calculations inyour headwrite them down.
COMMANDMENT 7: USE THE CLINICAL DECISION UNIT APPROPRIATELY TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES Many departments now have a clinical decision unit (CDU) with short-stay beds. Remember a CDU is a clinical decision unit,not a clinical indecision unit or a “cant decide” unit.All patients admitted need to be discussed with a senior EDdoctor and need to have appropriate admission and pathway documentationcompleted. The CDU is not an excuse to avoid referral to inpatientteams, or for inpatient teams to avoid admission. Patients whoare unlikely to be discharged within the designated time scale(48 h in our department) are not suitable for the CDU, whichusually means that patients with underlying complex medicalproblems are not suitable.
COMMANDMENT 8: TARGETS TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES We live in a target-driven world. UK ED have national and local targets to meet, not only administratively, but also clinically. These targets often relate to clinical standards and best practice, such as giving pain relief to patients in pain. It is your responsibilityto help us achieve the targets that relate to emergency medicinewhile working in the ED.
As a result of a national government target, patients shouldbe registered, assessed, treated and either discharged or admitted within 4 h of arrival in the ED. The only exceptions are patientswho need to remain longer for clinical reasons. To help achievethis, refer patients as soon as you know it will be necessaryand do not wait for the results of investigations if they willnot change anything. If you do not know what to do with a patient,seek advice from one of the ED senior medical staff. Do notdo tests in the hope of finding something abnormal, do not admitto the CDU to avoid a decision and do not arrange ED clinicfollow-up to avoid making a diagnosis.
Patients should be assessed for pain and given pain relief if necessary on arrival in the ED. If this has been omitted whenyou see the patient then rectify it as soon as possible.
COMMANDMENT 9: TURNING UP TO WORK TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES You are a professional. Be on the shop floor when your shiftis due to start, dressed and ready for action, not coming throughthe door needing a shower after your cycle ride to work. Dressin the way that patients expect doctors to dress and wear sensibleshoes. Shorts, bare midriffs and miniskirts are not appropriateattire in a UK ED. If you are a man, either have a shave orhave a beard.
Do not go home until your colleague on the next shift has arrived or until told to do so by the senior doctor on duty. Try towork with a full stomach and an empty bladder. Take your breaksbut do not get lost during them, particularly at night, andinform someone if you leave the department.
If you are sick let the department know as soon as you know,not just before your shift starts. Let us know when you arelikely to be fit to return.
Follow the department procedures for booking leave and swapping shifts. Rosters are uncompromising things and need to be carefully worked out in advance.
COMMANDMENT 10: TREAT PATIENTS AS YOU WOULD LIKE TO BE TREATED YOURSELF TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES Wear your name badge and introduce yourself, being polite toall patients and relatives (despite occasional provocation).Avoid transmitting infection: follow trust policy with regardto infection control (for example, bare arms below the elbow)and wash your hands before and after every patient contact.
You need to learn to assess patients rapidly without takingshort cuts, and if you can genuinely say that you have treatedevery patient to the best of your ability you will sleep withan easy conscience. However, do not take risks with patientslives. They may only have a 2% chance of a myocardial infarctionbut would you be prepared to take that degree of risk if youwere the patient?
Do not ration pain relief, there is plenty to go round. If treatmentneeds starting, go ahead and start it. Arrange suitable patient admission or discharge and appropriate follow-up. Consider wherea patient lives before asking them to return for review.
Ensure that patients understand the advice you give them, documentingthe advice you have given and give written advice when available.Warn patients about possible complications from either their injury or treatment. Do not let your professional standardsslip for those who have sustained an injury as a result of inebriationor as a result of engaging in illegal activities. Even if apatient has attended inappropriately, point out the error oftheir ways politely.
If you make a mistake, apologise (and mean it). If you makea big mistake, speak to the duty consultant.
COMMANDMENT 11: TREAT OTHER MEMBERS OF STAFF AS YOU WOULD LIKE TO BE TREATED YOURSELF TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES If you treat a colleague, they must be booked in and treatedin exactly the same way as any other patient.
Dispose of all sharps in the yellow bins; do not cause a needlestickinjury to another member of staff. Clean up after you have finished,as the nurses are not there to clean up after you. If you would like someone to do something in the resuscitation room or majors area, speak to them in person. If you cannot find a nurse speakto the coordinator.
If you find a piece of equipment that is not working, reportit so that it can be fixed or replaced. If you use the lastspatula or speculum, report it so that supplies can be replenished.Keep the department tidy; if you see rubbish on the floor, pickit up and throw it in a bin. If there is blood on the flooror trolley, report it so it can be cleaned up appropriately.
When relevant, keep the nurse in charge informed with regardto your patients, for example if you have referred them, orif they are sick and need urgent treatment.
COMMANDMENT 12: WORK EFFICIENTLY AND DO NOT BE AFRAID TO MULTITASK TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES See patients in the correct order; do not cherry-pick. If thereis something interesting in the resuscitation room, go and learn,but do not spend too long if it is not your patient and othersare waiting. If you have bleeped someone, you can do other thingswhile waiting for a call back. You can see other patients whilewaiting for x rays. You should be able to see at least three”minor” patients per hour. Social chat is fine, but not whenthe department is busy and patients have been waiting hoursto see you.
SUMMARY TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES Although these commandments may not be applicable to all ED,we hope this paper may be of some use to, or at least strikea familiar note with, the readers of the EMJ. Feel free to borrowthem, or modify them, as you see fit.
ACKNOWLEDGMENTS The authors would like to thank Dr Simon Judkins for sendinghis 10 commandments for Australian emergency physicians.
FOOTNOTES Competing interests: None.
REFERENCES TOP ABSTRACT COMMANDMENT 1: SOME PATIENTS… COMMANDMENT 2: SEEKING ADVICE COMMANDMENT 3: INVESTIGATIONS COMMANDMENT 4: PAPERWORK AND… COMMANDMENT 5: PRESCRIBE… COMMANDMENT 6: SEEING CHILDREN COMMANDMENT 7: USE THE… COMMANDMENT 8: TARGETS COMMANDMENT 9: TURNING UP… COMMANDMENT 10: TREAT PATIENTS… COMMANDMENT 11: TREAT OTHER… COMMANDMENT 12: WORK EFFICIENTLY… SUMMARY REFERENCES
- Touquet R, Driscoll P, Nicholson D. Teaching in accident and emergency medicine: 10 commandments of accident and emergency radiology. BMJ 1995;310:6425.[Free Full Text]
- Wrenn K, Slovis CM. The ten commandments of emergency medicine. Ann Emerg Med 1991;20:11467.[Medline]
- Judkins S. Hear ye, hear ye. Emergency department 10 commandments (letter). Emerg Med Australasia 2005;17:526.
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