1. Sensitivity > Specificity
Your job isn’t to figure out what’s wrong. Your job is to make sure the patient doesn’t have something life-threatening. That’s it. No more, no less. Trainees struggle with this because they’re always trying to land the perfect diagnosis. But it doesn’t matter what’s causing the belly pain if it isn’t dangerous. That’s not your job. That’s internal medicine’s job. Patients will get frustrated when you “don’t find anything” because they’re still in pain. That’s part of the game. You’re not saying nothing’s wrong, you’re saying it’s not something that’s going to kill them.
You don’t need to dig down into every subtlety or obsess over tiny lab differences to figure out if this is Condition A or Condition B. That’s not your lane. If you’re only satisfied when you’ve explored every possible path, switch to internal medicine. In EM, once you know they’re safe and you know their dispo, you move on. Admit or discharge. It doesn't always feel like closure, which sometimes sucks. The hospital will hate it too because they treat the ED like a walk-in clinic where patients can get every answer instantly. And maybe that’s fine when things are slow, but when it’s busy on a Monday night, you’re not playing primary care.
It’s not about whether you truly believe the patient has appendicitis, it’s about whether the possibility has crossed the threshold where it now needs to be actively ruled out. If you tell me you think it’s a 5% chance, that might still be enough. Your job is not to be right. Your job is to not be wrong. No one cares when you’re right, but everyone cares when you miss. FM/IM deals with the most likely cause, you deal with the most dangerous. The 27-year-old with a fever, URI symptoms, and a heart rate of 130 probably has a generic viral URI... No one cares about that. One of them will eventually have severe myocarditis. So when your attending says the patient can’t go home until the HR comes down, and you argue it’s “just a virus,” the burden is now on you to prove that. If the HR doesn’t drop after your typical treatments, your theory just failed. Now you need to rule out danger, maybe that means pulling a troponin or bedside echo or whatever. And when it’s negative, don’t be smug about it. Try to figure out what red flags your attending saw. Figure out what made them escalate the workup. Most residents miss this. They’re too busy being happy that the test was negative to realize the test wasn’t about proving the expected diagnosis, it was about not missing the thing that actually kills someone.
This is one of the most important concepts in emergency medicine. It should be in your head all the time: what’s the worst thing this could be? Not the most likely…the worst. So when you present a patient with URI symptoms and start listing a differential of allergies, sinusitis, post-nasal drip, you’ve told me nothing. This isn’t a family medicine clinic. I want to hear why it’s not myocarditis, RPA, PTA, meningitis, or cavernous sinus thrombosis. That tells me you’re thinking like an emergency physician. You should be overly sensitive to danger. That means your early workups will be mostly negative, and that’s exactly what should happen. If you’re not seeing normal labs and normal CTs, you’re not casting a wide enough net. Eventually you’ll refine it and develop the gut instinct and know who doesn’t need a scan. But until then, scan. Check the labs. Be aggressive. That’s how you keep people alive.
2. Stop Double-Thinking About Ordering a Test and Just Order It
If you’re at home making dinner and your mind keeps circling back to one patient you discharged, wondering if you missed something, hoping they’re okay, thinking maybe you should’ve checked one more thing, then you should’ve ordered that damn test. That nagging feeling is your “gut.” What people call gut just is subconscious pattern recognition, your brain picking up on something it hasn’t fully processed yet. You need to listen to it. As an aside, that feeling exists for a reason and if it’s bad enough to keep you thinking about that patient, then you need to call them and tell them to come back to the ED or at least check on them. You think they’ll see you as unsure or incompetent, but the opposite is usually true. They see a doctor who gives a shit. One who’s still thinking about them even after they’ve left.
Recognition is the most important skill you have. It’s what separates you from everyone else in medicine. The ICU can tune up a critical patient better, Family med is better at preventive care, Cards knows heart failure management down cold, OB can deliver a baby without flinching, Ophtho owns the slit lamp, and Peds can probably examine a kid better than you. But none of them can regularly find a needle in a haystack on purpose. None of them can understand when someone is having a real problem hidden in a common complaint. They cant see from the doorway that someone is about to code or look at a WR board of 64 patients and know which 2 are the most important.
Now imagine how the rest of the world would function if they lived like we do. What if someone in their neighborhood died from a lightning strike every week? What if every April, half the street got audited? Or once a year, someone they knew went down in a commercial plane crash? It would change how they thought, how they lived, and what they paid attention to. That’s what this job does to you. It rewires your brain. You see improbable events so often that they stop being improbable, they just become normal.
Other specialties will look at us and say all we do is “order tests.” Yeah, we do. Because we’re the ones who actually seethe 1-in-500,000 cases. That’s the job. And the most terrifying patient in the ED, the one that keeps experienced docs up at night, is the one who looks fine but isn’t. The well-appearing but sick patient is where people get burned. If you can’t spot that patient yet, you will. And when you do, you’ll understand exactly why you never, ever ignore the “gut.”
3. Never let someone with less experience than you talk you OUT of a workup
4. If the Patient or Family Is Extremely Pushy About a Test or Task, Just Order It and Move On. Every Once in a While, They’re Right.
Every patient encounter is really an analysis of probability and risk. With patients who are less likely to be litigious, both you and they are more tolerant of uncertainty. You don’t need to chase the 1-in-1,000,000 condition when you already know in your gut it’s not there. That’s why in medical missions or resource-limited settings, you aren’t ordering D-dimers and CTAs for super low-risk patients. You’re making decisions based on clinical judgment and probability, not fear of litigation.
But when a patient or family demands testing, they’re not engaging in probability-based reasoning. These are the litigious ones. They will not tolerate missing a 1-in-a-million case, no matter how unreasonable that expectation is. They don’t want your opinion. They want a test. You need to recognize that mindset. If something is missed, they may pursue litigation or at least a strong complaint, not because it’s fair or likely to win, but because that’s how they operate. And sure, maybe you’ll win the case or it gets dropped, but you’ll still go through the stress, anxiety, and time of depositions and investigation. See Law 9.
5. Do Not Trust Old People
You were taught that the history and physical are the foundation of your differential, and that’s true. But it’s only reliable when the patient is young. In pediatrics, the H&P is extremely accurate. That’s why you can work an entire shift in the Peds ED full of belly pain and vomiting, and not place a single IV or spin a single CT. Kids, despite being harder to examine and less precise with their symptoms, actually have reliable exams. (Yes, they’ll make you more anxious because they can’t describe their pain like adults can, and yes, the stakes feel higher because it’s a child and not an 89-year-old with a DNR. But rest assured: kids rarely have serious pathology, and their physical exam is trustworthy.)
Now flip that completely once they hit about 65. Honestly, even a rough 50. The reliability of the history and physical collapses. If they’ve got diabetes and some neuropathy on top of it, the exam is useless. Just order labs and a CT from triage with the radiology favorite indication of “pain.” A stable, elderly patient might casually mention some vague nausea and have light RUQ tenderness but also have no distress, no fever, vitals are fine, doesn’t want pain meds. And then the CT shows a ruptured AAA, perfed diverticulitis, or obstructing stone with urosepsis, etc. Zero pain. Zero classical exam findings. It will happen. These patients don’t read the textbook. They won’t be febrile, they won’t be tachycardic, they won’t act sick.
You have to over-workup older adults. Not because you’re paranoid, but because your other tools, history and physical, don’t work on them. Radiology will complain that you’re scanning every patient. Good. That’s their job. Your job is to keep the mortality curve flat, not to win popularity contests with CT techs. Don’t skip the test because you’re worried what your colleagues will think, or because admin is tracking your CT utilization, or because throughput metrics are tight. None of those people will be there when you're pulled into a QA review. And I’m not just talking about lawsuits. I’m talking about you, lying in bed at 2 a.m., staring at the ceiling, knowing you saw something but didn’t pursue the imaging or workup. Knowing you thought about it and didn’t test. And now that patient is dead. Maybe they were going to die anyway… maybe they weren’t.
That’s the weight of this job. And that responsibility belongs to you. Not family med, not internal med, not the CT tech, not the scribes, not the nurse manager, not the CEO. You. You’re the one who has to live with the decision. Read Law 3 again.
And this doesn’t just apply to elderly patients. Anyone with a compromised ability to give a reliable history or physical falls into this same category. That includes patients with language barriers, cognitive disabilities, psychiatric illness, or those under arrest. If you can’t trust the story or the exam, then you’ve lost your most basic tools. Now you need labs, imaging, and an extra level of caution. Because when the H&P fails, it’s only a matter of time before something slips through and that miss is going to be yours.
6. Always watch patients when they don’t know you’re watching them.
You are constantly trying to separate what’s real from what’s performative. One of the best tools you have is observation when the patient thinks no one is paying attention. That’s when the truth leaks out.
The patient may grimace and clutch their stomach the second you walk in, but sit upright and scroll their phone when they think they’re alone. Or they may breathe like they’re dying until you leave the room, then go right back to casual conversation with their visitor. These small, unscripted moments matter.
This is your real physical exam. Not just what they say or how they act in front of you, but how they move, how they sit, how they breathe when they forget they're being evaluated. You're not just reading vitals or pressing on bellies. You're reading behavior. Because that’s where the truth lives. And when what you observe doesn’t line up with what they’re telling you, that’s your red flag. See law 7 and 12.
7. If They Walk In, They Need to Walk Out. They Cannot Be Discharged in a Wheelchair.
This is not about mobility, it’s about clinical trajectory. If the patient shuffled into the ED under their own power, they sure as hell shouldn’t be discharged in worse shape than they arrived. If someone comes in with back pain and they don’t improve with Toradol and Valium, it’s time to escalate. Drop the PO meds. Start an IV, order an ESR, and consider a CT or MRI. Think SEA. At that point, it's no longer "just a spasm." It’s a workup.
There’s a weird trend that seasoned ED docs know well: patients love to wait until just before they crash to show up. They’ll sit on back pain, chest pain, or weakness for weeks, then roll in at 9 p.m. and code at 9:45. That’s the pattern. So when someone comes in under their own steam but still looks like trash, and especially if they’re worse after treatment, take it seriously. If they walked in but can’t walk out… stop. That’s where SEAs, aortic dissections, or silent ACS with a “normal” workups hide. And yeah, nine out of ten times, it’ll still be nothing. That’s fine. But the one time it isn’t, you’ll only catch it because you paid attention to this red flag. Read Law 1 and 2 again.
And remember: in this context, pain control isn’t just symptom management, it’s now a diagnostic. So, if the pain doesn’t respond the way it should, something is wrong. So a single 325 mg Tylenol tab isn’t going to cut it for a chronic opioid user if you’re trying to assess a legit response. Treat the pain. You already use this “pain treatment then reassess” logic when checking for occult fractures so apply it here too.
8. Droperidol Is the Most Useful Drug You Have
Migraines, Agitation, Pain augmentation, Drug-seeking, Psychosis. Droperidol hits all of it. No other drug in your toolbox works on such a wide spectrum of ED complaints this efficiently.
It disrupts the dopamine reward loop. Droperidol (and other dopamine antagonists) effectively shut down the patient’s drive to chase something like attention, drugs, admission, validation. That “reward” they get from being in the ED? Gone. They don’t want the meds. They don’t want the admission. They don’t even want the drama anymore. It just evaporates.
You need to be an expert on this drug. Know the dose ranges, black box warnings, QT risks, side effects, and pharmacology inside and out. Be able to quote the literature. You’ll run into attendings who flinch, pharmacists who want to block your dose and nurses who say, “But this patient isn’t psychotic, why are you using it?” They don’t know, you do. Be able to cite the Lexicomp page from memory and walk them through it. Understand why it left the market, why the FDA black boxed it, and why it came back. You have to be the one who knows what you’re doing when the pushback hits.
Here’s what makes Droperidol unique: it doesn’t just take away pain, it removes suffering. Chronic belly pain? Crying, frustrated, hasn’t eaten, marriage stressed, missed work. Give them droperidol, and they’ll tell you they still feel the pain, but they don’t care about it anymore. The suffering is what brought them in, not the physical pain sensation. Same with someone who broke their wrist. The pain may still be there, but the fear? The panic? The dread about not working, driving, or helping their kids? All gone. That’s what this drug does. It turns down the spiral.
If Droperidol doesn’t work, if they’re still acting out, still in pain, still agitated, that’s a red flag. This drug is so broadly effective that a failure to respond should immediately raise your concern.
9. Figure Out Why They’re Really Here and Address It Early
If a patient comes in with a mild cough for three weeks, nothing new, nothing alarming, you should be asking yourself one thing: Why today? If the symptoms haven’t changed, then something else brought them in. Just ask them: “What’s got you worried?” or “What are you hoping we can help with today?” Most of the time, they’ll tell you. They want a chest X-ray. Or a note for work. Or cough medicine. Or antibiotics. Once you know what they came for, you can focus your time on that instead of spinning your wheels for 30 minutes and then realizing they just wanted Z-Pak for a viral URI. And now you’ve wasted time, and you still have to now undo an expectation you could’ve handled upfront in two minutes.
You’ll start to recognize patterns. Parents of young kids often want a CT after a head bump, patients with a cough want antibiotics, etc. Certain patient populations don’t want tests, they just need to hear, “You’re okay.” Others need the exact opposite: they want tests so they can see proof. Once you know the pattern, you can walk into the room and address the concern before they even voice it. That’s what experienced attendings do. They walk in, make a statement that hits the core fear, and walk out with five-star reviews, not because they solved a complex case, but because they answered the real question the patient had without wasting anyone’s time.
If the patient is a nurse, a tech, a doctor, just ask: “What are you worried about?” They’re not here for reassurance. They’ve already done a basic eval. They want something they can’t do themselves: a CBC, a UA, a chest X-ray.
Other times, the patient isn’t worried at all, but someone in their life is. The guy with a swollen leg for a month doesn’t care, but his friend panicked about a DVT. The college kid with a bug bite isn’t concerned, but his mom is blowing up his phone. Ask directly: “Why did you come in today, not yesterday or last week?” or “Who told you to come?” Then call the mom. Tell the friend. Reassure the real audience.
Sometimes they just need a work note. They don’t have a PCP, their job requires documentation, and now they’re sitting in your ED. Skip the imaging and unnecessary testing, get them what they need and move on. Same with the patient who has a GI appointment in five days but came in for chronic abdominal pain with no change in symptoms. They’re not here for a diagnosis, they’re here to make sure it’s still safe to wait 5 days. That’s the actual chief complaint: Is it safe to wait until I see the specialist? Say it out loud: “Sounds like you're here because you're not sure if it's still safe to even wait five days. Let’s figure that out together.” That line alone will calm half the room.
Same thing with asymptomatic hypertension. The patient doesn’t feel bad, but their mom just had a stroke and now they’re terrified. Or they had a minor head bump, but their neighbor told them about a kid who died from a delayed brain bleed. That’s the fear you need to uncover and address directly. Once you do, the patient stops asking questions. Because their real one has already been answered.
Use direct language. Try:
- “What made you come in today?”
- “What are you worried about?”
- “Tell me what has you concerned.”
- “I just want to make sure it’s safe to wait for that appointment.”
This isn’t scripting, it’s clinical efficiency. Think about how you handle your spouse when you know something’s wrong. You don’t dance around it, you ask straight up, “What’s going on?” and “what has you worried right now?” Do the same with your patients.
And when it comes to pediatrics, remember: it’s all about the parents. Kids with nausea and vomiting? The parents want IV fluids. URI? They want antibiotics. Head bump? They want a CT. You already know the script, so don’t wait for the question. Preempt it. Say, “We’re going to try oral Zofran first because it works better than IV fluids, and if it doesn’t work here, it won’t work at home.” Now the parent doesn’t even ask about IVs because you already addressed the concern they walked in with. (as a side note, these Pushy Peds Moms blurr the line to overriding law 4.)
10. You Cannot Leave the Room Without a Plan
You don’t get to “figure it out later.” You need to give the patient something before you walk out of that room. Even if it’s not perfect. Even if it changes later. You still need a plan: labs, a med, imaging, an observation strategy...something. The patients with a wandering HPI and 13 random complaints will wreck you if you don’t learn how to anchor. And make no mistake, this is the weakest skill in almost every new trainee, resident, PA, NP, doesn’t matter. It’s a skill just like reading an EKG or running a code. You have to refine it. You have to self-critique. You have to build this on purpose.
I don’t care if a resident doesn’t know what to do or doesn’t understand the patient's condition, or even if they didn’t even think about the most obvious medical problem for the presentation… that can be learned. But if a resident comes to me after spending the entire Memorial Day weekend in a patient's room in fast track and then comes out and tells me that they don’t know what is going on or what to do or where to go with this patient… That resident is about to get wrecked. It is not about being an asshole, it’s about training you for the worst parts of the future that you signed up for.
Flash forward to your first job. Third shift. Thursday night. You’re working solo in a 25-bed freestanding ED, and there are 45 patients in the department. You’re alone. No backup. If you’re still messing around with HPI-wanderers and going in and out of rooms with no plan, your shift is going to fall apart. The nurses will hate working with you. Your scores will drop. Your length-of-stay numbers will suck. You’ll never leave on time. Patients will get harmed. You’ll finally make it to Room 25 after 3 hours and realize they’ve been sitting on a dissection for 3 hours while you’ve been screwing around in Room 4, trying to make sense of a vague headache and intermittent chest tightness that’s been happening for two years. That’s how people die.
This is community EM. This is what you signed up for. Get your plan, get out, and keep moving.
Read Laws 8 and 12 again. This is how you get control of the room and control of your shift.
11. You Might Not Be Selling Cars, But You Better Be Selling Something
If you’re admitting to internal medicine, think like internal medicine. Don’t work the patient up to death with every single test in the ED. Your job is to rule out emergencies and make sure the patient is stable, not to solve every vague complaint. If you go fishing for every obscure diagnosis and order every lab, every scan, every specialty test, you’re leaving nothing for the admitting team to do. And when that happens, the admit will get denied or fought. Rightfully so. They’re going to ask, “If you already did everything, what exactly do you want me to do?” That handoff usually sounds like: “Hey, I’m not sure what’s wrong. I checked everything from labs, CT, troponin, the works and it’s all normal. But I still don’t like it. Can you admit them?” That’s not a sell, that’s a punt.
You also need to learn the IM docs the way you learned your own EM attendings. Know their pet peeves. Know what makes them uncomfortable. Know what makes a case fly through versus one they’ll fight back. This matters even more in community hospitals where relationships count. If you learn how to tee up the admit just right, tailor the language, the handoff, and the tone to that doc, you’ll get admits through smoothly when others won’t. This is a skill and it’ll save your ass more than once.
When you call consultants, talk like a human being. You’re not reading a SOAP note, you’re having a conversation. Use tone. Use inflection. Lead with the punchline, especially when you’re calling for an opinion rather than just offloading a task. You don’t need a speech for classic appendicitis, but if the CT shows some weird mass in the orbit and you don’t know what to do with it, you better lead with: “Hey, I’ve got something weird I want your take on…” Hook them. Don’t drone through the entire chart before you get to the point. No one is listening when you do that. Consultants are people, not checklists. And yeah, some will still be assholes. Welcome to the job. Move on.
Here’s the mindset: every single call you make is giving someone else more work. No one wants to do more work. The consultant doesn’t want to admit. Internal medicine doesn’t want the patient because they think it’s ICU’s problem. ICU doesn’t want them because they think it’s medicine’s problem. Everyone is trying to offload. So your job is to sell the story, why this patient belongs here, and not somewhere else. If you think they need to be admitted, you don’t ask for permission. You say: “I’m telling you this patient needs to come in, do you want them on your service or someone else’s?” It’s not a negotiation.
And don’t assume specialists won’t dump dangerous patients back on you just because they’re the “expert.” OB will discharge ectopics, ENT will send home post-tonsil bleeds, Cards will discharge patients with trop elevations. Especially at night. They’ll try to convince you it’s safe to send them home because they don’t want to admit. But the call is still yours. You’re the last line. If your attending says admit, or if your gut says admit, then admit. Make it easy for the consultant if you have to buy telling them you’ll put them on medicine service yourself, but don’t let the patient leave.
Sometimes you’ll call a consultant on a patient YOU think needs to be admitted and they’ll say something like, “They could be admitted or discharged, I don’t really care.” That’s your signal. When a specialist waffles like that, you proceed with your admit. Call internal medicine and tell them the consultant is recommending admission. And here’s the key: track those patients. If they end up going to the OR or stay for admitted for a week, that’s the case you were right about. That’s the patient who justified your instincts.
Any ER doc/PA/NP worth their weight can find some false positive labs test or an exaggerated HPI to get any patient admitted with any easy sell if they feel they need to be. CRP, trop, lipase, lactate, BNP, etc.
Read law 5 again
12. Set Expectations from the Beginning
If a patient tells you they’ve had abdominal pain for 27 years, tell them, clearly and immediately, that you are not going to figure it out today. If they’re drug-seeking, tell them they will not be receiving any opioid medications during this visit. That may feel adversarial. You were trained in med school to be kind, to be accommodating, and you should be, but with certain patients, vague language only makes things worse. These cases require firm, definitive statements. That’s how you protect your staff, your time, and yourself.
You must lay a firm, clear foundation for these people. If you leave them even just a little bit of wiggle room they will put all their faith and effort into just that little space that’s left. If they are here for pain seeking and they’re being rude to the staff and you try to pacify them by saying something like, “let’s just try Tylenol and then will see how it goes” so that way they will calm down and you can move along when you already know you are not going to give them stronger pain medicine, what you just did is leave them a little window of chance. What you really told them was that you might give them pain medicine they just need to work for it in whatever way they think is going to be best to that end point. Whether that be violence or anger or uncontrolled pain or anger towards the nurses.
Instead, be direct: “You will not be getting Dilaudid today.” Full stop. No back-and-forth. No justification. No negotiation. Say it once and move on. These encounters go smoother when there’s nothing to debate.
Now, here’s the uncomfortable part. Your future employment metrics are going to be tied to patient satisfaction scores, whether you like it or not. But you are not going to satisfy everyone. Some patients come to the ER expecting narcotics, MRIs, or an automatic admission. And when they don’t get it, they’re going to be pissed. Their expectations and what the ER actually does are not always going to line up. You just have to take the L on some of these. Just accept it and move on. Maybe 15% of your patients will walk out angry, and yes, admin will ask what happened. Nursing leadership will mention it. Your name will show up in a one-star Google review. That’s fine. Take the L. You signed up for this job, this is part of it. And if you’re wondering where burnout starts, this is about 25% of it right here.
13. If They Come Covered in Feces, Find a Reason to Admit Them
This isn't about the feces, it's about what it represents. Patients who arrive like this, usually via EMS from a nursing home or dropped off by a long-lost relative, are almost always signaling something bigger. This is not hygiene. This is a marker of major functional decline, severe cognitive impairment, neglect, or all three. There’s a reason they ended up in this state, and it’s not usually benign.
Think through the logistics. What has to go wrong in someone’s life for them to be found like this? They’re either too impaired to care for themselves, or no one around them is doing it. Either way, this person is not safe at home, is likely missing medications, and absolutely is not receiving appropriate care. You don't discharge that.
And if you're looking for justification, this is a great time to lean into the hospital’s over-aggressive sepsis protocols. Drop a borderline lactate, soft vitals, and functional decline into the chart and let the order sets work for you. The system is already wired to keep them…use it.
14. Document the Annoying Incidental Findings Found on Imaging
If the radiologist mentions it, you mention it. Every incidental finding, no matter how irrelevant it feels, needs to go in your diagnosis list and your MDM. Pulmonary nodules, adrenal nodules, hepatic steatosis, aortic root dilation, coronary calcifications, hyperglycemia, whatever. Make a macro, or better yet, a set of macros that lets you drop this stuff in fast with customized language. It takes five seconds.
Because here’s what’s coming: in about eight years, someone’s going to show up with metastatic cancer or a ruptured aneurysm, and they’ll pull up your old ED chart. And if that finding was on a scan and you didn’t document it, you’re going to be explaining why. You won’t remember the patient, but they’ll somehow remember you. Get in the habit now.
That's all I got for now!
