The Ten Golden Rules of Emergency Medicine

Two or three times a year in the busiest Emergency Department in Australasia, of which I was privileged to be the Clinical Head, we would have an influx of new doctors-in-training.  We would hold an induction and orientation, to spell out “the way we do things round here.”  The amount of information to be disseminated was potentially vast and covered matters clinical, ethical, and administrative, issues relating to Health and Safety and Risk Management, as well as more mundane house-keeping notices pertaining to rostering, meal breaks, and the minutiae of day-to-day life in a big department in a big, and crazily busy hospital.   Over the years I came to realise that too much information would not be absorbed and was counterproductive, that most of it could be put into a reference manual, and that the most important thing to do was to create a template of what the specialty of Emergency Medicine was, a model and an outline which could be enhanced and embellished in due course, but which would function as a mainstay which would keep doctors and nurses and patients safe.  I created and developed The Ten Golden Rules of Emergency Medicine.  Here they are:

1. Remember: Emergency Medicine bites!
2. Be on time.
3. Practise the ritual of courtesy.
4. Believe the history.
5. Expose the injured part.
6. Plan for the worst possible scenario.
7. Keep a good record.
8. If in doubt, ask.
9. If you want to panic, think “ABC”.
10. Ignore any of the above rather than have a nervous breakdown.

If you are at all familiar with medical practice you will note that the ten golden rules are in a specific order, which relates to the medical consultation.  The medical consultation is a holy and sacrosanct thing which must be cherished and protected at all costs.  An emergency physician’s shift is a series of medical consultations.  It seemed to me that the best way of orientating a doctor new to our department was to imagine the doctor coming to work and embarking on the first consultation of the day.  If you adhered to the ten golden rules, you would not be immune from trouble, but you would be less likely to fall foul of it.  My induction talk was an expansion of the rules:

1. Remember you are working in a high risk environment. It pays to be on a high state of alert for the unexpected, the perverse, and the malignant.
2. The handover between shifts is critical. Be there early.  The specialty of emergency medicine is defined by time.  Treatment of the decompensating patient is time-critical.  Be aware of where you are in “the golden hour”.  Every intervention has a “rate limiting step”.  Take that step early.
3. Treat colleagues and patients with kindness and consideration. Introduce yourself, and shake hands.  Many mishaps arise out of poor communication, which starts by getting off on the wrong foot.
4. History taking is by far the most powerful tool in the emergency physician’s armamentarium. You ask, “What happened?” and then you listen without interrupting.  You go into a trance and step into the patient’s shoes.  For a moment, you become the patient.  “I was walking along the road and it was as if a giant crept up behind me and kicked me in the back of the head.  I fell down and was sick.”  You scoff.  “Aye right.  What a drama queen.”  The patient handed you the diagnosis on a plate and you didn’t notice.  This is the phenomenon of “interference”.  Some preconception, some ingrained prejudice, has interfered with the process of history taking.
5. The patient must be undressed and in a hospital gown. Don’t practise “keyhole medicine”.  If you don’t look, you don’t see.
6. Tailor your investigations according to the information gleaned from history and examination. Rule out the sinister end of the spectrum, if you can.
7. Write it up so as to communicate your train of thought to a colleague. Think from first principles and avoid jargon.
8. If you’re not sure, ask a senior colleague. The act of presenting the case itself will help you towards the solution.
9. If your patient starts to decompensate, keep calm and think, “Airway, breathing, circulation…” The great triad of decompensation comprises respiratory embarrassment, shock, and diminished consciousness.  They are reflected in the vital signs – respiratory rate, pulse and blood pressure, temperature, and Glasgow Coma Scale.  The order of actions in cardiopulmonary resuscitation (“ABC”) is known as “the primary survey” and is the same for all emergent patients.
10. With the best will in the world, you will make a mistake. Be honest and candid, learn from it, and don’t beat yourself up.

Medical monsters, people who set out deliberately to harm their patients, are very rare.  Most medical misadventures arise from some mishap within the construct of the medical consultation.  Only this week a family member went to see his doctor and was greeted with a harassed, “You’ve got ten minutes!”  The doctor broke Golden Rule 3.  And a friend involved in a road traffic crash (who happens to be a surgeon – that in itself is a risk factor) had delayed diagnosis of two injuries additional to the main injury which had distracted the doctor.  He hadn’t been adequately undressed and Golden Rule 5 was broken.

Then a hospital not a million miles from where I live got subject to a cyber-attack and – I could hardly believe it – patients were advised to stay away.  Modern medicine has convinced itself that it cannot function without sophisticated IT systems.  The art of the beautiful medical consultation is being lost, and that is why we are in such a mess.