30 y/o male, goes to ER with vomiting and weakness. Sent home with Dx of flu. Pt found dead at home the next morning. Autopsy revealed Addison's disease. The BP (<90) was not acted upon by ER staff.

50 y/o lady brought by ambulance weak, dyspneic, no chest pain. Heart rate 150, sinus tachycardia. Died after 3 hours in ER. Dx - ruptured spleen. Attention in ER was directed to her heart. Hgb was 5 gm, but had not been reported to the providers. They did not notice its absence. Pt had been in the hospital a few days earlier and had a minor fall.

Principles:

1. Facilitate good care for unstable patients.
   
2. Efficient & meaningful information transfer.
   
3. Portray the patient's course during the ER stay
   (patient data, nurses, resp. tech., and physician interventions).

Emergency room care of unstable patients, e.g. severe pain, dysrhythmias, respiratory distress, heat illness, altered mental status, multiple injuries, drug OD, etc., while caring for other not-seriously ill patients(1) can be difficult.

The amount of data that accumulates in the first hour, and the challenge of communicating the course of events to the next provider is taxing. Sending 10+ pages of data does not communicate the course of events. With the plethora of data and multiple people providing care, a common vehicle/tool is needed to track and respond to data.

I have used flow sheets on patients since 1957(2). As an ER physician for the past 15 years, I have made modifications of the tool for the ER situation.

A powerful tool in differential diagnosis is the Problem Knowledge Coupler(R) (3), a computerized software program designed to integrate patient findings with the literature. This gives the user (physician, nurse practitioner) and patient the opportunity to consider all the diagnostic possibilities that their unique set of symptoms/findings and the literature suggest, not merely the "top 5". Information on this system is the available on a web page: http://www.pkc.com

1. Cross, Lawrence A. Pressure on the Emergency Department: the expanding right to medical care. Ann Emerg. Med 1992;21:1266-1272.
2. Bjorn, JC & HD Cross. Problem Oriented Practice. Chicago, Mc-Graw Hill. p. 57-63. 1970.
3. Weed, Lawrence L. New Connections between Medical Knowledge and patient care. BMJ 1997;315:231-235 (26 July).