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Mindful EM

Is Protocol Medicine Bad Medicine?

Hazan, Alberto MD; Haber, Jordana MD

doi: 10.1097/01.EEM.0000524795.74679.8b
Mindful EM

Dr. Hazanis an emergency physician and the regional medical director of DMS-Envision in Las Vegas. He is the author of the medical thriller Dr. Vigilante and the urban fantasy series The League of Freaks. Find out more about his novels athttp://amzn.to/2sshEUe. He is also a board member withwww.GivingMore.org. Follow him on Twitter @Dr_Vigilante. Dr. Haber is an emergency physician and the director of clinical education at University Medical Center in Las Vegas. She has a master's degree in medical education. Follow her on Twitter @JoJoHaber. Read their past articles athttp://bit.ly/EMN-MindfulEM.

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There is variability in how each of us practices emergency medicine, but we all abide by certain standards. Ordering a CT scan for every patient presenting with abdominal pain or doing a lumbar puncture for every patient with a headache, for example, is far from standard practice. Most of us follow clinical guidelines for the workup of common complaints, which we eventually make our own over years of practice.

Aside from the outliers, many of us practice similar medicine. We listen to our patient's presentation, do a focused physical exam, run through our differential, and order laboratory tests and imaging studies accordingly. We then treat, reassess, reexamine, and decide on a disposition.

But what about when the emergency department is overflowing with patients and you're the only provider? What if 20 patients are triaged within an hour and your relief doesn't arrive for another four hours? Do you let patients linger in the waiting room and see them one at a time, or do you run through the patient's chief complaint and start ordering tests?

Protocol medicine should be considered in emergency settings when your demand is high and resources are low. It can be an effective tool that saves us time, especially during busy shifts. Some of us order routine urinalysis for pediatric patients presenting with abdominal pain. Some of us order routine chest x-rays for patients who have shortness of breath. And we often do this without laying eyes on the patient. We go by the patient's age, chief complaint, and vital signs. We order tests to get the ball rolling if we're busy in the hope that we can disposition him by the time we do the exam.

Certain protocols are critical to patient care, such as an ECG for chest pain, a urine pregnancy test for female patients with abdominal pain, or a fingerstick for diabetic patients presenting with vomiting. We don't need to see these patients to know whether we need to order these tests, and we all agree that delaying these tests can be detrimental to clinical outcomes.

All of us have practiced protocol medicine to some degree, but we should be careful not to rely on it. Shot-gunning orders from the comfort of our doc box is not ideal. Ordering routine blood tests, imaging studies, or medications without laying hands (or even eyes) on the patient predisposes us to all sorts of biases and errors.

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Ordering Carefully

We utilize protocol medicine to start the workup, but patients report they don't feel like they are being cared for until a physician physically sees them and explains the protocols, even if tests have been ordered. Protocol medicine can also lead to the wrong tests being ordered as a result of mistriaging. How often do we see a patient, for example, whose chief complaint is chest pain but who is actually suffering from abdominal pain (or vice versa)?

The goal of protocol medicine is to make us more efficient, but it can also slow things down. You might end up waiting for labs and imaging studies for patients who don't warrant a workup. You can get behind on disposition even though the protocol was meant to expedite times. You also risk having a patient elope with laboratory studies pending, leaving you with the need to contact them if something atrocious comes back (e.g., low hemoglobin, high troponin, a pneumothorax on chest x-ray, or an abdominal aneurysm on the CT).

The bottom line is we need to order carefully. Superfluous tests can lead to patient harm via exposure to radiation, incidental findings, financial expense, increased time in the department, and overall wasted resources. Like everything else in medicine, we must weigh the risks and benefits, and always keep our patients' best interest in mind.

We need more data to see whether protocol medicine benefits patients in disposition time, finances, and patient wellness. Very few studies have been done on the utility of protocols without seeing the patient, but a few show the utility of a rapid medical evaluation and diagnostic testing in expediting disposition times. A recent article in Annals of Emergency Medicine provides some evidence that suggests patients presenting to the ED with abdominal pain will have shorter disposition times, spend less time in an ED bed, and have lower rates of leaving before the completion of their workup if their diagnostic testing begins after the rapid evaluation while they are still in the waiting room. (2017;69[3]:298.)

We would love to hear your thoughts on protocol medicine, specifically on how emergency physicians should utilize it to improve medical care without compromising patient safety.

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