Practical Pearls


  • Better is the Enemy of Good  (Dr Peter Gordon)

  • People with bad asthma have a hard time telling you how bad their asthma is because they can only speak a few words at a time

  • Doing nothing is always the best option if available (don’t just do something–stand there!).  But when confronted with a difficult exigent scenario where, clearly, something needs to be done quickly, and there doesn’t seem to be a right answer, consider the USMC combat decision approach. Quickly formulate three – and only three – of the best action alternatives you can think of. Rapidly consider all three. Then pick one, and go. It may not turn out to be the correct decision by retrospectoscopy, but at least you won’t be wringing your hands while the patient slips away.  (Dr Jonathon Sullivan)

  • If the patient has a revulsion for foods he or she loves…think hepatitis

  • Half of what you learned in medical school will prove to be wrong in ten years (Dr. Sydney Burwell, Dean, Harvard Med School 1935-49)

  • Normal vital signs may very well be abnormal

  • With a sudden interruption of the urinary stream, think  bladder stone

  • The stethoscope can be used as a hearing aid for elderly patients during your exam. It can also be used as a ruler – add marks to the neck piece

  • The pubic symphysis lies at the same level of the greater trochanter – this is why you place a pelvic binder over the greater trochanter when you suspect a pelvic fracture

  • A generalized tonic-clonic seizure is a trauma

  • In patients who present to the ED with a chronic disease, always ask – what is DIFFERENT this time.

  • Always compare prehospital vitals with triage vitals – interventions are done in the field

  • Think thrice about discharging the patient with hip pain.  An occult fracture is lurking.  You must do more than a plain film to rule it out.  A hip contusion is just you being confusioned!

  • Patient’s with bad asthma have a hard time telling you how bad their asthma is because they can only speak a few words at a time

  • The Gray Test:  A patient with abdominal pain that is psychological in origin will close his or her eyes on palpation of the abdomen.  Most patients with organic pain will watch your hand in anticipation of the pain

  • There are very few toxicological problems that cannot be solved through the suitable (and liberal) application of benzodiazepines (Suzanne White, M.D.)

  • In a young person with a new bundle branch block…think Lyme disease

  • Kids < 5-years-old with abdominal pain are a disaster waiting to happen.  They look fine one day and are sick as stink the next (Ethan Weiner, M.D.)

  • You should always know more than one blood pressure in a critical patient (Eric Olsen, M.D.)

  • Treat an upper GI bleed like a gun shot wound to the abdomen (Susie Vassallo, M.D.)

  • Get an airway, get a line, get someone else to handle the patient (Cynthia Aaron, M.D.)

  • Rule out an inferior/posterior myocardial infarct before giving the patient nitroglycerin*

*See comments below

**If you would like to share a Pearl of your own, please Email Me

5 Responses

  1. Shouldn’t it more appropriately be termed “right ventricular” myocardial infarct? Not every inferior or posterior (or combination of the two) is a right ventricular infarct.

    Thoughts or discussion?

    Bob Wahl

  2. I would also add that vital signs are vital and the actual BP is a critical decision point. I would be cautious with NTG and certainly would want to have an IV established prior to giving NTG to a RV infarct. I have given many an inferior, posterior and RV infarct NTG but do so with close monitoring and a good IV established.

  3. Any patient who has never had nitroglycerin (not only those with a right ventricular infarct) can have a drop in blood pressure. Therefore, have an IV in place, if possible, and if the blood pressure does drop (patient may feel faint, become diaphoretic, or vomit) lay the person flat and rapidly infuse normal saline.

  4. Also remember to ask patients, male or female, if they have recently taken any medicine for erectile dysfunction prior to giving them NTG. If the patient has no idea what you’re talking about, use terminology or name brands they will recognize.

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