How Much to Do
One of the things that intrigues me about Emergency Medicine, and life in general I guess, is that part of what defines you as different from others is how much time and effort you put into each situation. If you shake a person's hand or look them in the eyes a fraction too long or not long enough, it changes the meaning of the act. If you call your friend every 5 minutes it's too much, but every 5 years may not be often enough. If you tell your wife you love her once a month it's not enough, but every minute is too often. So there is a balance that we all must find.
During a shift, of course the balance of time is important as well. I really am not fond of social introductions and formalities, so I prefer to get those out of the way as quickly as possible, which is probably slightly disconcerting for some folks. A quick knock, a rush into the room, forced hurried handshakes all around (I'd rather not, really, but it's an annoying historically important social requirement like saying "bless you" after a sneeze, and so I do it anyway), I look each person in the eye and introduce myself, then it's to the chair or the bedside and let's get to the reason we both came. Whew. Honestly, I'd prefer it if only one family member were there. It saves time, and I get a better story that way, but some families are more touchy-feely than others. I understand.
I prefer to spend the majority of my time with each patient listening to them tell me their complaint, preferably in their own words, while I sit down and watch them intently, observing every expression and studying every nuance of their presentation. As Osler said, "if you listen to the patient, they will usually tell you what is wrong with them." My exam for some complaints is often just a formality, a sort of ritual dance that I must then perform to satisfy the billing system and make the patient feel like I am "doing something." I'll spend as much time as I need on the key areas, but the whole multi-body system exam in a patient who can give a good history is often less valuable in terms of acquired data/sec/joule of expended energy. To me, anyway. For the same reason that the review of systems is important, however, occasionally I will find a something crucial and unexpected on a quick general examination, but more often than not it just creates additional issues to "work up" with laboratory testing. I'm much more likely to dawdle over a key component of the history than to listen intently for a fourth heart sound though.
The clearer the ability to communicate, the less necessary the examination and laboratory studies become. With an unconscious patient or an unaccompanied patient with dementia, all of the time spent at the bedside can be used on the examination, which is sometimes a refreshing change of pace. As the ability to communicate decreases, it becomes necessary to order more tests and it becomes more likely that the patient will be admitted. That includes language barriers, of course. While an interpreter is always appreciated, they are really most helpful in narrowing down a chief complaint or two. I can rarely extract the nuanced features of a history that enable me to make quality diagnoses via an interpreter, but if there is time to spend, I'll give it a shot. Dizziness or "chest pain" are hard enough to figure out in patients who speak English, so sometimes it's better to just order the gamut of tests, admit if possible, and move on. If I'm going to discharge such a patient, even with a good interpreter it is sometimes difficult to be sure the instructions are as detailed and appropriate as necessary.
How much time do you spend on a little girl with a broken arm or a cut on her face, making her feel comfortable before you fix her? How long do you spend telling her parents about the procedure you plan to do, or proposing alternate courses of action? Do you make that courtesy call to the patient's doctor or not? Do you see the chest pain guy first or the backboarded MVA guy? The migraineur or the back painer? Do you just intubate the old lady who can't breathe well and get it out of the way, or try to stabilize her while you talk to the family about "end of life" issues? How much do you tell them about the whole "breathing machine" thingy and what that entails?
Every situation is different, of course, but we all have our own typical style that makes us who we are. Ultimately, the fractures will be splinted, the chest painers will be admitted, the lacerations will be sutured and will probably heal in a similar fashion, the various nonspecific symptoms may or may not be accurately diagnosed and will certainly be treated in myriad ways, but the pathway we take to reach those ultimate destinations might be quite different between physicians.
On a good night, everyone gets what they need.
During a shift, of course the balance of time is important as well. I really am not fond of social introductions and formalities, so I prefer to get those out of the way as quickly as possible, which is probably slightly disconcerting for some folks. A quick knock, a rush into the room, forced hurried handshakes all around (I'd rather not, really, but it's an annoying historically important social requirement like saying "bless you" after a sneeze, and so I do it anyway), I look each person in the eye and introduce myself, then it's to the chair or the bedside and let's get to the reason we both came. Whew. Honestly, I'd prefer it if only one family member were there. It saves time, and I get a better story that way, but some families are more touchy-feely than others. I understand.
I prefer to spend the majority of my time with each patient listening to them tell me their complaint, preferably in their own words, while I sit down and watch them intently, observing every expression and studying every nuance of their presentation. As Osler said, "if you listen to the patient, they will usually tell you what is wrong with them." My exam for some complaints is often just a formality, a sort of ritual dance that I must then perform to satisfy the billing system and make the patient feel like I am "doing something." I'll spend as much time as I need on the key areas, but the whole multi-body system exam in a patient who can give a good history is often less valuable in terms of acquired data/sec/joule of expended energy. To me, anyway. For the same reason that the review of systems is important, however, occasionally I will find a something crucial and unexpected on a quick general examination, but more often than not it just creates additional issues to "work up" with laboratory testing. I'm much more likely to dawdle over a key component of the history than to listen intently for a fourth heart sound though.
The clearer the ability to communicate, the less necessary the examination and laboratory studies become. With an unconscious patient or an unaccompanied patient with dementia, all of the time spent at the bedside can be used on the examination, which is sometimes a refreshing change of pace. As the ability to communicate decreases, it becomes necessary to order more tests and it becomes more likely that the patient will be admitted. That includes language barriers, of course. While an interpreter is always appreciated, they are really most helpful in narrowing down a chief complaint or two. I can rarely extract the nuanced features of a history that enable me to make quality diagnoses via an interpreter, but if there is time to spend, I'll give it a shot. Dizziness or "chest pain" are hard enough to figure out in patients who speak English, so sometimes it's better to just order the gamut of tests, admit if possible, and move on. If I'm going to discharge such a patient, even with a good interpreter it is sometimes difficult to be sure the instructions are as detailed and appropriate as necessary.
How much time do you spend on a little girl with a broken arm or a cut on her face, making her feel comfortable before you fix her? How long do you spend telling her parents about the procedure you plan to do, or proposing alternate courses of action? Do you make that courtesy call to the patient's doctor or not? Do you see the chest pain guy first or the backboarded MVA guy? The migraineur or the back painer? Do you just intubate the old lady who can't breathe well and get it out of the way, or try to stabilize her while you talk to the family about "end of life" issues? How much do you tell them about the whole "breathing machine" thingy and what that entails?
Every situation is different, of course, but we all have our own typical style that makes us who we are. Ultimately, the fractures will be splinted, the chest painers will be admitted, the lacerations will be sutured and will probably heal in a similar fashion, the various nonspecific symptoms may or may not be accurately diagnosed and will certainly be treated in myriad ways, but the pathway we take to reach those ultimate destinations might be quite different between physicians.
On a good night, everyone gets what they need.
posted by scalpel at 12:09 PM
2 Comments:
I'm the guy who takes too long to see the patient. I'm the guy who talks more than I examine. I'm the guy who enjoys when family members are in the room. And, I'm the guy that is called when the patient needs admitted or if the patient can go home and see me tomorrow.
I could never do what you do and you probably could not do what I do. But, that's what's great about medicine! You're right, everyone gets what they need and we all have our own typical style who makes us who we are. Keep up the great work!
I'm the paramedic that used to build up these patients for you...
I talked to them, calmed them down, and made the family feel at ease. I never really thought, until now, that as a doctor, your chaotic job/schedule would inhibit your ability to do the same. I just know that everyone I have ever worked with on the bus worked much harder on social skills than any other skills related to saving lives.
So if you think about it, the patients brought into your department by us just has a higher level of social expectation. (Sorry, had to take that cheap shot!) I always think that we, as medics, only have life saving skills as a back-up; our major duty is simply to calm people down so they can make it to the ER without dying. Most times, that's the case. Some occasions, however, force us to use medicine, but I believe if we have good people skills, that's most important. So don't take it too badly. I'm sure the patients you felt you didn't take the time for had enough sympathy/empathy in the back of my bus. =)
Post a Comment
<< Home