1. Make a “bullet proof” chart

The average emergency physician will get sued at least once, if not several times in his or her career. The best defense against litigation, says Dr. Stephen Colucciello, is a “bullet proof” chart. The first step is to read the chief complaint and nurse’s notes to ensure that everyone is on the same page and that the chart is internally consistent. Then, anticipate the worst possible diagnosis and explain why you ruled it out. This can be done through statistics showing that your pre-test probability of a life threat based on history and physical alone is less than 1-3%. If the probability of a life threat is greater than this, then further testing will be needed. Also, pay great attention to vital signs and consider obtaining them upon discharge. If you’re particularly concerned about a patient then ask another doctor to see them or get a consultant on board. You can also get them close follow up such as a next-day appointment or even call them yourself the next day. Most importantly, act as if you were treating a family member.

2. When should I order a CT scan for my patient with pancreatitis?

The first indication for ordering a CT in a patient with pancreatitis, says Drs. Mel Herbert and Stuart Swadron, is if you’re unsure of the diagnosis. Lipase is a good test for pancreatitis but it is still not 100% sensitive. Therefore, in patients with a high index of suspicion for pancreatitis but with a low lipase level, CT will improve your diagnostic yield. If the diagnosis of pancreatitis has already been made, a CT should be considered in the ill-appearing patient. This can further guide management and act as a prognostic tool. Fluid collections around the pancreas are initially sterile but may become infected as evidenced by air within the peri-pancreatic fluid from gas forming organisms. At this point, the surgeon and interventional radiologist may become involved to culture the fluid and determine the need for surgery. More importantly, CT may show necrotic foci within the pancreas that will appear unperfused by the IV contrast. This will change ED management because broad spectrum antibiotics, which have been shown to decrease mortality, should be instituted immediately.

3. ALT elevation may be most predictive of a biliary origin of pancreatitis

The priority in evaluating any patient with pancreatitis is to rule out surgically correctable causes of pancreatitis, namely gallstone pancreatitis. A review article from the Journal of Clinical Gastroenterology 1999, Volume 28(2) states that ALT may be “the most useful predictor of a biliary origin of pancreatitis”. In patients without a history of alcoholism, elevation of ALT two to three times above normal is 95% predictive of biliary origin of pancreatitis. Conversely, a normal ALT level does not rule out gallstone pancreatitis and further imaging should be obtained in most cases. An ED ultrasound may be appropriate for well-appearing patients with a low Ranson’s score, although a formal ultrasound should be ordered in patients that are ill-appearing. ERCP may be done in cases where the diagnosis remains uncertain, although this procedure may worsen pancreatitis.
4. “Airport malaria” may affect travelers to non-endemic areas

In a patient whom you highly suspect may have malaria, it might be necessary to obtain both the patient’s and the plane’s travel histories. “Airport malaria” are cases of malaria in and near international airports, among persons who have not recently traveled to areas where the disease is endemic. These represent cases of importation of infected Anopheles mosquito aboard an aircraft. This may be particularly dangerous because the physician has little reason to suspect malaria, particularly if there has been no recent travel to endemic areas. This delay in diagnosis may lead to a protracted course and death, especially in cases of Plasmodium falciparum. As a response, many aircrafts are “disinsected” if there has been recent travel to areas where vector borne diseases are endemic.

5. Indications for rabies prophylaxis

One of the new indications for rabies prophylaxis, says Dr. Billy Malone, is if a bat is found in the house. It is theorized that the virus may be aerosolized in the bat guano and subsequently inhaled. Therefore, it is recommended that everyone present in the house with the bat should receive vaccination. Interestingly, Dr. Malone states that “rabid dog” may be a misnomer because only 50% of dogs have the furious type of rabies, the other half being the paralytic type. Instead, “rabid cat” should probably be used because over 90% of cats have the furious type of rabies. What is reassuring is that there has been no dog-related rabies in the U.S. in over 30 years. However, beware of the limping dog in the third world. Any rabid animal bite in the third world is considered a trip-ender because of inadequate vaccine supplies in most third world countries.

6. Four clinical criteria can help predict failure of noninvasive ventilation
1,033 patients across multiple institutions were studied to assess which factors led to noninvasive ventilation failure versus success (Eur Respir J 2005;25:348-55). A prediction chart using four criteria (pH, APACHE score, GCS, and respiratory rate) was constructed to assess failure rate. If all four of the criteria were abnormal on admission, the failure rate was 82%. Conversely, if all four criteria were reassuring, then patients had only a 6% chance of noninvasive ventilation failure. What was found to be more predictive was reassessment at 2 hours. If all four indices were negative at that time, then the failure rate was virtually 100% compared to 100% success rate if all four of the indices were reassuring. Therefore, a trial of noninvasive ventilation may be initiated on patients that are ill and may appear to require endotracheal intubation on initial assessment. If these patients do not significantly improve at the 2 hour checkpoint, then a definitive airway should be strongly considered.

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