The Workup Inside the Mind of an Emergency Doctor
Inside look - The ER Workup and What Happens Behind the Scenes
How an Emergency Doctor Thinks
When you come to the emergency department, something feels wrong. You want answers. A name for it. A fix.
The emergency doctor is thinking a little differently.
The primary goal is not perfection. It is protection.
What Cannot Be Missed
Primary care doctors focus on precision and long-term management. Specialists narrow in on one organ system. Emergency medicine is different. The first question is not “What is it?” The first question is “What could hurt you right now?”
A sore throat might be strep. But it could also be a deep neck infection threatening the airway. Chest pain might be reflux. But it could be a heart attack, a blood clot, or a tear in the aorta. Lower abdominal pain might be a urinary infection. But it could be appendicitis or an ectopic pregnancy. The workup begins by ruling out danger.
The Question That Guides Everything
In the back of the mind, there is a constant question:
What am I missing? That question prevents complacency. It guards against anchoring too early on a simple explanation. It keeps the process disciplined.
As a Resident pPysician, I was taught a lesson that felt heavy at the time and necessary ever since: be wary of comfort. In the emergency department, reassurance is everywhere. Patients minimize. Teams stabilize. Consultants advise. The room can feel calm. But danger does not always announce itself. The responsibility does not spread across the team. It rests with you. Do not miss the serious diagnosis concealed behind a common complaint.
Thinking in Patterns
Medicine is pattern recognition built over time. Experienced emergency physicians often have an early sense of direction within minutes of hearing the story and examining the patient. That does not replace testing. It guides it.
Sweating, crushing chest pain in a smoker suggests one pattern. Sharp pain with movement after lifting something heavy suggests another. Diabetic patients with nausea may be having a heart attack without classic chest pain. Patterns are not shortcuts. They are accumulated experience.
Why Multiple Tests Are Ordered at Once
In an outpatient setting, testing can happen step by step. Order one test. Wait. Interpret. Then decide on the next. The emergency department does not always have that luxury. Decisions must be made quickly. Dangerous conditions must be excluded efficiently. That often means ordering several tests at once.
It can look excessive. It is usually strategic. Time matters. Safety matters more.
Why Some Tests Are Not Done
The emergency department is built to rule out life-threatening conditions. It is not designed to complete every long-term evaluation.
An MRI for chronic knee pain. An A1C to fine-tune diabetes management. A detailed autoimmune panel. These may be important, but they are rarely emergent. The workup narrows first to what could cause harm now. The rest becomes part of a follow-up plan.
Who You May See
You may be evaluated by a physician, a physician assistant, or a nurse practitioner. In most emergency departments, care is collaborative. Complex cases are discussed. Serious decisions are reviewed.
The structure may vary by hospital and state, but the underlying goal is the same: safe, thorough evaluation focused on immediate risk.
Important First Urgent First
Emergency medicine is about prioritization. Important conditions are addressed. Urgent conditions are ruled out. Stable problems may still need answers, but those answers sometimes unfold over time, either through admission or outpatient follow-up.
The workup is not random. It is layered. Safety first. Specificity second.
THE BOTTOM LINE
• The emergency workup focuses first on ruling out life-threatening conditions.
• Testing is often broad at the beginning to protect against missed emergencies.
• Stable concerns may require follow-up outside the emergency department.
By Dr. Karim Ali. Emergency Physician