Clinical Emergency Medicine Algorithms: Vaginal Bleeding in Early Pregnancy (Less than 20 weeks).

“Clinical Emergency Medicine (EM) Algorithms” was born out of my frustration with the educational process in medicine. Throughout medical school, professors teach us by a disease-based system. We read textbooks and learn about Takayasu’s Arteritis and Diphyllobrohtium latum. We then enter our clinical rotations with such confidence that we know the minutiae about the most uncommon disease processes, and that is when it hits us--patients don’t walk into the hospital saying they are having acute mesenteric ischemia in the distribution of their superior mesenteric artery; they say their stomach hurts. This is when we learned of the “differential diagnosis,” which lists the diseases that cause a certain symptom. This is just what I needed, a patient with low back pain and I see zebras like Scheurmann’s disease on the same list next to common entities like Spondylolisthesis, which is next to emergent entities like Abdominal Aortic Aneurysm. I am no better off in my understanding of how to approach these complaints. What I need is an algorithm but when I look through different textbooks for algorithms, I become even more confused. Algorithms seem so complicated with arrows in every direction. This is where the concept of “Clinical EM Algorithms” was born. The goal was to structure them in a way that an emergency physician thinks about a patient’s complaint. They are very simple in their structure and comply with the EM mantra of “worst first.” In constructing them, I have found that each complaint is approached in its own unique way and that “one size does not fit all.” They are not meant to be all-inclusive, but rather to provide a framework upon which to build future knowledge. They are ideal for those new to medicine or just beginning emergency medicine training. They can even help more experienced practitioners to be more thorough and more efficient The Approach There is no set structure for each algorithm, much like an emergency physician will approach each chief complaint (Chest pain, Syncope etc.) differently. While each algorithm is structured based upon how an emergency physician thinks about each complaint, there are some general guidelines. The primary boxes in black ask general questions about the complaint, usually starting with ABCs and primary resuscitation. The secondary boxes in gray expand on questions from the primary boxes. For many complaints, you rule out life-threatening disease processes using the History & Physical. These aspects are portrayed in the boxes with the darkened outline. At certain points throughout the algorithm there are numbers in brackets. These refer to the numbers on the accompanying text page that will expand on that item. For example, in the vaginal bleed algorithm, the number [4] next to the (+) Ectopic refers to the ultrasound findings in ectopic pregnancy and statistics. The text page includes evidence-based explanations along with encountered pitfalls. The goal of the algorithms is to provide a basic framework upon which to build. It starts with a very simple broad algorithm but allows the reader to delve into controversial evidence-based decisions.