Dr. Reuben Strayer - Emergency Thinking

Main Ideas, Concepts, and Lessons

• Purpose of the talk: Reuben Strayer argues that the classic med-school (“bottom-up”) diagnostic system is inadequate for emergency department (ED) practice, and proposes a more appropriate “top-down” emergency approach.

Core Distinction

• Bottom-up approach:

  • Start broad: history, physical exam
  • Build a wide differential diagnosis
  • Use sequential tests to confirm/exclude until the final diagnosis is reached and treatment begins

• Top-down approach:

  • Start with what the patient needs now in the ED environment
  • Focus on dangerous conditions
  • Apply the limited set of interventions that address what matters immediately

Why Bottom-up Fails in EDs

• ED patients may deteriorate while clinicians sequentially gather information and rule out causes.
• Strayer describes a personal example (a patient severely short of breath) where following a classic internal-medicine style pathway delayed life-saving action, ultimately requiring intubation.

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Emergency Medicine’s Responsibilities (Priority Ladder)

Strayer proposes 8 responsibilities, in descending importance. The lecture elaborates on several of them:

1. Public health role (lower priority but impactful)

   • Examples:
     • Tetanus and HIV screening
     • Intimate partner violence screening
     • Smoking cessation
     • Other teachable moments
   • He contrasts this with an ED tendency toward “more exciting” resuscitations.
   • He highlights universal triage vitals: even low-acuity visits can reveal major issues (e.g., unexpected hypertension/renal failure).

2. Resource stewardship

   • Clinicians may be incentivized (by systems and culture) to over-test and over-treat.
   • Proposed solution: departmental/institutional care maps for common presentations.
   • Example: a pathway for low-risk chest pain with cardiology input, protecting appropriate cases when rare dangerous diseases slip through.

3. Customer service

   • ED care is also a “customer service business.”
   • Key principle: “Making the patient happy” is separate from “good medical care,” and both must be managed.
   • Strategies:
     • Figure out what the patient wants (agenda/true reason for visit)
     • Use open-ended questions to uncover concerns
     • Acknowledge uncertainty honestly while focusing on what has been ruled out
     • Manage expectations about delays using under-promising/over-delivering
     • Avoid making precise timing promises when workflow is unpredictable
     • Provide alternatives while waiting (e.g., explain CT cannot be sped up; offer comfort measures)
     • Use the mindset of a “flight attendant” to manage flow and distress

4. Disposition decisions and level of care

   • Admitting vs discharging isn’t enough: ED physicians decide where patients go (ward vs ICU vs telemetry) based on how sick the patient is and trajectory.
   • He stresses holding patients longer when:
     • their course is unclear, and
     • discharge risk is marginal
   • Discharge planning tools:
     • Return instructions (e.g., “come back tomorrow”)
     • Low-barrier contact options (e.g., voice mailbox systems)

5. Symptom relief

   • Pain control (and other symptom management) should be done and is often operationally “easy” (e.g., ask about pain medication early).

6. Protecting patient safety (core responsibility)

   • Two parts:
     • Resuscitate unstable patients
     • Identify dangerous conditions in everyone else

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Methodology: The “Top-down Approach” (Detailed)

A) The “Two Wheels” System

1. Wheel 1: Dangerous Conditions (harm near-term)

• Concept

  • Emergency physicians should operate inside a mental “wheel” containing ~13 dangerous conditions (not necessarily fully exhaustive in his count).

• Method

  • Use a directed history and physical (not undirected).
  • Ask only questions and do only exam maneuvers that efficiently eliminate slices (dangerous-condition possibilities).

• Principle

  • Treat patients as “slices” of possible dangerous conditions.
  • Each focused question/exam/appropriate test should cut away slices until only low-risk possibilities remain.

• Examples of wasteful / non-slice-cutting actions

  • Asking irrelevant questions (e.g., “is this the worst headache of your life?”)
  • Detailed testing that doesn’t reduce dangerous-condition uncertainty
  • He also notes that repeatedly “oscultating the heart” is often not helpful in some contexts.

2. Wheel 2: Interventions (ED tools for what matters right now)

• Concept

  • ED practice includes a large menu (he mentions ~130+ routine items), but only a small subset applies to each patient.

• Method

  • Choose interventions based on what’s most likely to matter immediately after assessing danger.
  • Provide empiric treatment when appropriate while diagnostics proceed.

• Example framing

  • For “very sick” patients, thinking resembles ACLS:
    • compressions
    • electricity
    • epinephrine
  • Then the “danger wheel” (H’s and T’s) helps focus reassessment.

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B) Applying Top-down Thinking Across Common ED Scenarios

• History and Physical (H&P) from top-down

  • Strayer’s technique:
    • treat the H&P as filling a series of “empty boxes”
  • Leave the obvious for last
    • Don’t forget important non-obvious elements
    • Example (abdominal pain): you won’t forget to examine the abdomen, but you might forget medication history (e.g., digoxin) or an exam area (e.g., groin for an incarcerated hernia)
  • Intended benefit:
    • reduces “misses” by lowering backtracking and downstream harm

• Knee pain example: why “why it hurts” is not the ED job

  • ED doctors shouldn’t aim to explain the cause at a deep level.
  • ED goal: rule out dangerous conditions using a limited set of decision points.
  • Typical decision pattern:
    • Do we need an X-ray or aspiration (“tap”)?
    • If key tests are negative, transition to:
      • symptom control/supportive care
      • appropriate follow-up planning
  • More severe patients:
    • care becomes more intervention-driven than danger-slice elimination.

• How the approach should feel for resuscitation and trauma

  • Use structured memory aids:
    • expanded ABCs for resuscitation
    • trauma “what must happen before CT” checklist-type thinking
  • Goal:
    • reduce cognitive overload and delays during stressful high-acuity care

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C) Efficiency and Workflow Tactics Supporting Top-down Work

• Plan for negatives at the outset

  • During initial assessment, identify:
    • “What will we do if testing is negative?”
  • Rationale: positives often lead to straightforward next steps; uncertainty peaks when tests are negative.

• Know where each patient sits on the stability spectrum

  • Three groups:
    1. Clearly unstable → go to resuscitation area
    2. Stable but risky → may deteriorate soon
    3. Stable and likely fine → lower urgency
  • Include unseen patients in this categorization to allocate attention during overload.

• Interruptions management (core to “multitasking” myths)

  • Strayer argues simultaneous attention is not truly possible.
  • ED “multitasking” is mostly interruption management.
  • Workflow rule when an actionable task arrives:
    • Stop and attend, or
    • Delegate, or
    • Set a reminder (sign-out checkbox, chart note, post-it, etc.)
  • Avoid relying on memory in a frequent-interruption environment.

• Run your list routinely

  • He repeatedly “runs the list” before/while seeing patients:
    • ask what the patient is waiting on to achieve disposition
  • Reported benefit: faster dispositional timelines.

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D) Documentation: How It Fits Into ED Goals

• Three purposes of documentation:

  1. Billing (separate goal; optimize efficiently)
  2. Communication
  3. Risk management (protect physician and patient safety record)

• Key risk-management idea

  • Good charting should show appropriate evaluation/management and that bad outcomes were not due to negligence.
  • A behavioral feedback effect: better documentation often improves clinician practice.

• Examples of recommended documentation practices

  • Frequent short progress notes (even brief ones showing evolution)
  • Don’t defer documentation until after shifts—write as part of the encounter

• Caution about benign diagnosis labeling

  • Be careful asserting certainty (e.g., costochondritis/anxiety/stress reaction/GERD/migraine) without confirmation.
  • Prefer phrasing like:

    “I think you have X and we’ll treat for it, but if you worsen, come back—hidden dangerous causes are still possible.”

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Speakers / Sources Featured

Speaker

• Dr. Reuben Strayer (main speaker)

Sources mentioned

• Rosen (referenced for the differential/approach example for shortness of breath)
• ACLS (used as an example for intervention-focused thinking in sick patients/“H’s and T’s”)
• Paper in CJM (Canadian Journal implied; Strayer mentions a 5-page CJM paper listing ~40 strategies for ED efficiency)
• Ontario emergency medicine context / Ontario license (mentioned during Q&A)