CHICAGO—Diane Birnbaumer, MD, FACEP, had a simple piece of advice for emergency medicine physicians wondering whether to order that extra test for a high-risk abdominal patient where something just doesn’t make sense.

Do it.

Do it now.

“High-risk abdomen pain is high risk for a reason,” said Dr. Birnbaumer, senior clinical educator in the Department of Emergency Medicine at Harbor-UCLA Medical Center in Los Angeles, during a session she presented yesterday at ACEP14. Her rapid-fire talk, “The High-Risk Abdomen: Common Complaints and Crashing Patients,” was a medicolegal approach to abdomen pain, one of the more common presentations for emergency physicians.

Dr. Birnbaumer’s suggestions include:

• Order the tests that make sense, regardless of edicts on fewer tests;
• Be as timely as possible with tests and diagnoses;
• Use observation status for high-risk patients when it seems appropriate;
• Document clearly and completely; and
• Read through EHR to see the bigger picture. Don’t use standard EHR templates for high-risk patients.

“You don’t want to practice defensive medicine,” Dr. Birnbaumer said. “[That] is not the way to contain costs. On the other hand, do not be an idiot. Don’t be dumb. We need to learn from the mistakes of what’s out there.”

Dr. Birnbaumer said to first identify high-risk patients, which broadly fit into four categories: the young, the old, the pregnant, and people presenting with atypical symptoms. Then, realize that roughly half of closed claims relate to a failure to diagnose or a delay in diagnosis.

One tip to speed up and improve diagnoses is her “SPIT” technique to approach differential diagnosis. The acronym stands for serious, probable and interesting—three processes of elimination an emergency physician can use to help identify causality in a patient with seemingly abnormal presentations.

“It’s what doesn’t fit that makes our job fun. It’s what makes you a really, really good diagnostician and protects you in court,” Dr. Birnbaumer said. “All the way around, don’t ignore something abnormal. Explain it.”

The “interesting” might seem far-fetched when bandying ideas around, but the technique is meant to identify possibilities, not to fully investigate each one. Plus, she said, timely documentation that notes a physician at least tried to explore all possibilities can help in any ensuing legal case.

“You’re not working them all up,” Dr. Birnbaumer said, “but at least it broadens your differentials, so you don’t miss the weird thing when it happens to be there that day.”

Richard Quinn is a freelance writer in New Jersey.