Start with watching this video by Ruben Strayer from Mt. Sinai in NY. The first part starts garbled but quickly improves.

During your rotation, we hope to teach you our approach to patients. Our patients are different than those you’ve seen on the hospital floor or physician’s office, so our strategies differ as well. In order to take into account these differences, our approach varies from what you’ve been previously taught.

What you were taught What we do in the ER

Review VS




Primary survey (are they dying?)



Tests + Tx

Maybe a Dx

Bottom-Up Approach Top-Down Approach

This is what Ruben Strayer (Mt. Sinai, NY) calls a bottom-up approach, and it works if your goal is to figure out what the patient has and you have a lot of time and resources in which to do this. This doesn’t work in the ED. Why does our process differ? Our patients differ:

  • We don’t have a past relationship with them
  • We often don’t have the results of any of their prior testing
  • They are more likely to have an acute illness requiring intervention
  • Patients keep arriving, so we need to be quick yet thorough
  • Our patients are more likely to decompensate quickly

So we use a top-down approach. In the Emergency Department, our main job is to make sure our patients don’t die. And we do this in two main ways:

1. Rescuscitation

First we ensure the patient isn’t currently about to die. If they are, INTERVENE! This is resuscitation. Intubate. Defibrillate. Give them blood. Perform chest compressions. Bag-valve-mask ventilate the patient.

2. Identifying dangerous conditions

Then we create a differential diagnosis that we fill with diseases that will kill or maim the patient. Use your history and physical to convince yourself they have none of those disease processes. If you’re unable to do so with H&P alone, then judiciously use testing. Treat any dangerous conditions that may exist.


  2. Dr. Strayer’s Handout