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Ten Commandments of Emergency Medicine Revisited

March 12, 2021

Written by Aaron Lacy

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The original Ten Commandments of Emergency Medicine were published 30 years ago by Wrenn and Slovis. Medicine, especially emergency medicine, has changed in the interim. Here is a modern update on the original classic article.

Why does this matter?
While this classic publication still carries weight 30 years later, the specialty of emergency medicine has grown and matured in its role in the modern medical system. What additions to the original commandments have been needed as times have changed?

Read these modern commandments from your digital tablet, not your stone one

  1. Secure the ABCs, but carefully
    Original: Secure the ABCs
    Comment: While the ABCs are still paramount, and prioritization of their securement is one of the pillars of our specialty, 30 years of research and experience have shown us there is great nuance to safely securing the ABCs. In particular, there has been an emergence of data helping us focus on identifying and mitigating risk in the physiologically difficult airway.

  2. Remember naloxone, glucose, and thiamine (NGT)
    Original: Consider or give naloxone, glucose and thiamine

    • The number of patients presenting with opioid intoxication is growing, and the gentle reversal of patients without severe respiratory depression with naloxone is in the art of medicine – consider starting with 0.4mg and titrate to effect.

    • In contrast to empiric administration of glucose in the altered or ill patient, rapid assessment of glucose level with point-of-care testing is recommended.

    • Thiamine deficiency may be less prevalent than previously thought in intoxicated patients, but we now know that giving 100mg of IV thiamine can benefit other malnourished patients, including those with calorie-malnourishment from cancer, gastric bypass, hyperemesis gravidarum, and eating disorders. Personally, I use the ‘T’ of ‘NGT’ to remind myself not to miss alcohol withdrawal.

  3. Administer a pregnancy test (and sometimes bedside ultrasonography)
    Original: Administer a pregnancy test
    Everyone still gets a pregnancy test, but as reproductive technology advances and the age spectrum of pregnant patients (and their complications) grows, the role of POC ultrasound in the experienced user can quickly help evaluate and screen for pregnancy related emergencies, particularly in unstable pregnant patient.

  4. Assume the worst
    Original: Assume the worst
    Comment: Emergency physicians have always been good at this – but as medicine becomes more specialized and more, sicker patients present to our departments, ED physician recognition and identification of threats is increasingly important.

  5. Do not send unstable patients to radiology, but if you must, do not let them go alone
    Original: Do not send unstable patients to radiology
    Comment: Increased availability of portable radiography and ultrasound should be prioritized in the ill patient. However, the role of CT has increased in diagnosis and disposition for emergency department patients. If you need a CT scan, do not send the patient to radiology alone, and if possible, you should focus on trying to resuscitate the patient before departing the ED.

  6. Seek out the red flags
    Original: Look out for the common red flags
    Comment: Electronic medical records increase accessibility of trending the 5 vital signs and should be routinely checked. The onus of recognizing red flags has shifted from just noticing when they are present to seeking them out by ‘assuming the worst’ and obtaining pertinent social history and planning an appropriate workup. Specific examples include being aggressive in evaluating the aorta in elderly patients with back pain and being wary of the patient who presents with simple alcohol intoxication as the chief complaint, especially if there are abnormal vital signs or hypoglycemia.

  7. Trust no one, believe nothing (not even the electronic health record)
    Original: Trust no one, believe nothing (not even yourself)
    Comment: While electronic health records have revolutionized the amount of data available to physicians, care must be taken to not rely blindly on their data. False information is easily propagated through the EMR; verify as much as you can with patients and their family.

  8. Learn from your mistakes
    Original: Learn from your mistakes
    Comment: Mistakes will always happen. Electronic data has increased opportunities for recognition of errors, and we should create a culture of constructively working through errors, instead of a purely punitive system.

  9. Do unto others as you would your family (and that includes families different from yours)
    Original: Do unto others as you would your family (and that includes coworkers)
    Comment: Make sure to keep an open mind about a patient or their family’s preferences, as it may be outside of your personal or family preference. Be proud of what you do, and make sure you treat people in a way that would make you and your family proud.

  10. When in doubt, err on the side of the patient
    Original: When in doubt, err on the side of the patient
    Comment: This hasn’t changed, but in an increasingly complex medical world with increased recognition of health disparities, always advocate for your patient. Sometimes as an ED provider you may be the only person doing so.

Editor’s note: Prior to clinical retirement, Dr. Slovis used to pound into our brains, “Err in a way the patient suffers the least,” which is a modification of the tenth commandment. I still think about this on many ED shifts. This simple statement can be remarkably clarifying. ~Clay

Evans CS, Slovis C. Revisiting the Ten Commandments of Emergency Medicine: A Resident’s Perspective. Ann Emerg Med. 2021 Mar;77(3):367-370. doi: 10.1016/j.annemergmed.2020.10.013.

What are your thoughts?