Be curious. Always be a skeptic and confirm what you read and hear. Don’t fall prey to confirmation bias. The best work a physician can do is at the patient’s bedside. If initial synthesis of information doesn’t make sense, get up and gather more data, including from the patient, family/friends, EMS, and/or nurses. Consider this the second H&P. Ask the patient about the biggest concern that brought him/her to the ED at this moment. It’s incredible what you’ll learn. Their reason for being there may not match the chief complaint. Review the triage note(s) and nursing documentation during the patient’s stay. Nursing notes can make or break a case. Always acknowledge and explain discrepancies. Review prehospital information. Even better: take time to listen to their focused report. They were at the scene and may have picked up on other important information. Thank them and highlight positive behaviors. Listen, don’t anchor, and confirm data offered.

No matter how we slice it, Emergency Medicine (EM) is a young field. In the 1960s, the U.S. public began to clamor for the need of its existence. In September 1979, it became the 23rd recognized medical specialty (note: ‘23’ is a pretty special number in sports history). In 1980, the first American Board of Emergency Medicine certification examinations were offered. In September 1989, EM received primary board status. In comparison, Internal Medicine (IM) was recognized in 1936 and Surgery in 1937. As one can imagine, as medical schools were filling their ranks, the predominant teaching faculty trained in IM and Surgery. The clinical approaches and thought processes taught across the four years were unsurprisingly IM- and Surgery-centric and mostly still are. We can all easily agree that EM calls for a different approach. The hope of this book is to explore and leave the reader with an understanding of EM decision-making and as an advocacy tool for our crucial field.

Head trauma is a significant cause of death around the world, especially in patients 1–45 years old.1–5 Close to 80% of patients are managed in the emergency department (ED).1.2 Head injury not only causes initial primary injury, but it is associated with several secondary injuries.1–5

Hemorrhage is a leading cause of death in trauma, following head injury. Shock is defined by inadequate tissue perfusion with hemodynamic instability and organ dysfunction.1–10 In trauma, the most common cause of shock is due to acute hemorrhage. Advanced Trauma Life Support (ATLS) describes four classes of hemorrhage,1 but these are not relevant to real world practice, due to different injury types (blunt vs. penetrating), age (due to blunted physiologic responses in the elderly), comorbidities, and medication use (beta blockade reduces the chance of tachycardia in response to decreased blood pressure).6–14 Bradycardia may also be seen in hemorrhage, due to several causes including vagal stimulation and failure to mount a tachycardic response.13,14

Cardiac trauma is a critical injury, with penetrating cardiothoracic injury accounting for up to a third of traumatic deaths.1–4 These injuries often involve the heart or great vessels and include traumatic insertion of a foreign body, including invasive iatrogenic injury.1–8 Blunt cardiac trauma occurs in a wide range of patients, with 8–71% of patients with cardiothoracic trauma demonstrating signs of cardiac injury.1,2,8 Blunt cardiac injury encompasses all types of injury associated with blunt thoracic trauma to the heart.8–13 Up to 20% of deaths from motor vehicle collisions (MVCs) are due to this type of injury. Patients with thoracic great vessel injury due to penetrating injury have a high mortality rate (over 90% die at the scene),14,15 and blunt injury to the thoracic vessels is commonly due to motor vehicle accident.12,13,16,17 These injuries can result in chest, upper abdominal, back, arm/shoulder, or lower neck pain, as well as hemodynamic instability, nausea/vomiting, and shortness of breath.