The ER Game: A systematic guide to every ER patient

- George Lew, M.D., Ph.D .

The “game” consists of a modified grid, which you fill in (mentally or otherwise) in order to approach each patient in a systematic and organized manner. This way you are less likely to overlook important components of the Emergency Medicine approach to patients.

Is your patient “sick”?

Yes/no

Is your patient “not sick”?

Yes/no

Diagnostics/Differential

Labs/XR

Therapeutics

Includes IV fluids, oxygen

Is your patient staying (i.e. to be admitted)?

Yes/no

Is your patient going (i.e. discharge home)?

Yes/no

Sick or not sick?

These are subjective terms but “sick” in the ER includes patients who:

have markedly abnormal vital signs
have a high risk chief complaint
just look bad
need some sort of emergent intervention

Everyone else is “not sick”. Be careful: every patient who comes to the ER has a COMPLAINT, and your first assumption should be that every complaint is serious and possibly a true emergency.

Diagnostics

This is what you do to rule in or out certain diagnoses. This may include any test, therapeutic maneuver, or possibly the history and physical alone. In Emergency Medicine determining what diagnoses (plural !) a patient DOESN'T have is as important as identifying what a patient DOES have- especially regarding life-threatening etiologies. In order to choose your diagnostics you must develop a differential diagnosis that includes both the likely AND unlikely but catastrophic potential causes.

Therapeutics

People are in the ER for a REASON. Usually a patient will need treatment for something. If they are short of breath give them oxygen; if they have a fever give them an antipyretic; if they have pain give them analgesia; if they are dehydrated give them fluids. Try to figure out what the patient wants or needs and if it is reasonable give it to them.

Staying or going?

This real-time decision is unique to Emergency Medicine, and often must be decided with little information. Emergency Physicians have to make this decision (“the disposition”) quickly and accurately. Remember that every patient who is discharged has to have somewhere to follow up. Answer this question immediately after completing your initial assessment and finalize the decision as soon as possible.

All the boxes in the “ER Game” are mutually exclusive. Sometimes sick patients go home, and sometimes non-sick patients get admitted. Sometimes no tests or therapy need to be done. To make the game more challenging, the whole game is operated under time pressure. There is a ticking clock, but no one knows what the exact countdown is. Be thorough, but be efficient as well.

Games are supposed to be fun. This is no exception. Try to “fill in” the boxes by just looking at an age, vital signs, and chief complaint. See if your answers are the same as your attending. Good luck.

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