Dr. Jess' epiphany

Picked this up from Gruntdoc.  Dr. Jess had an epiphany and I applaud him/her.  I thought it was interesting.

Dr. Jess hits on two things which I think are important.  The first is one that is brought up often.  That is: Its easy to second guess an ER Doc's decision the next day.  (12 hours is a long time for a vague shortness of breath to declare itself NOT ACS).  Things are much different during that moment in the ER.  Things are murky.  Stories are incomplete and we have to try and do whats best for patients.

Second, and this is spoken of less often: how much do we need to do in the ER for patients before we send them upstairs?  This is less clear.  Do we need to wait for the Cardiac Enzymes to admit a chest pain rule out? (probably)  Do we really need to start the antibiotics on a pneumonia? (JHACO be damned!)  And what about the sick patients?  Do we have to place a central line in the septic patient? (Manny Rivers says yes, but does it have to be done in the ER or immediately in the ICU?)  Like I said, I dont think the answer is clear.  

One argument would say that once we've identified an admission, we need to get the patient upstairs so we can see more patients!  But doesnt this further the ignorant belief that we're just triage nurses?  

The other argument might be that we must fully stabilize every issue and come to a diagnosis regarding every complaint.  While this allows many to show off their diagnostic and management skills, is it really feasible in a busy ER?

Alas, as with most things, the answer lies somewhere in between.  Isnt that a Dave Matthews song?

Privacy

KevinMD has a post about this MPR piece.

Scalpel has blogged about it too.  The question of patient privacy on these blogs is one that is murky at best and the answer seems to be hotly debated.

The NPR piece is interesting and brings up some interesting points about patient privacy.  I'm not so sure though, that Docs who "vent" on medical blogs need "therapy" as espoused by Debra Peel in the NPR article.  That seems pretty harsh.  I do think that at times, some may need to be a bit more mindful of their tone, though.

Telling the stories I think are interesting and making commentaries that I think are important while trying to avoid coming across as bitter or uncompassionate is something I have struggled with since the beginning of this blog.  The very nature of some of the more "interesting" stories makes sometimes makes it difficult to avoid.   We come into contact with unique and amazing people and situations every day.  This makes for marvelous story telling and interesting blogging.  And it seems the stories which one would find "interesting" are either:

a. inspirational

b. heart wrenching

c. humorous

d. unbelievable

Figuring out how to relate these stories to an interested public can be challenging.  It is easy to tell the stories relating to a and b without sounding condescending or being offensive.  Writing about c and d becomes more difficult.  It is a thin line between entertaining and offensive when we are dealing with others misfortunes or lack of "insight".  It is a fact though that in medicine we come across unbelievable and humorous scenarios nearly every day.  And it is also true that people like to hear these stories.  How else do you explain the whole cottage industry within television dedicated to telling these types of stories?  Your average episode of "ER" or "Scrubs" or "House" (I wont even mention Grey's Anatomy because it is so totally ridiculous)  are filled with cases which I'm sure are composites of actual cases seen by the "writing consultants"  on the show.

So how is this different from the stories told in the blogosphere? (assuming it is done in a manner in which patient privacy is protected)  Most of the blogs have disclaimers which make it clear that stories are not wholly factual and that medical blogs should not be taken as medical advice.  It just seems to me that while bloggers do need to be mindful of their tone and scrupulous in protecting patient privacy, to say that Drs. who vent on medical blogs need "therapy" seems more irresponsible and sensational than even the "harshest" medical blogs.

The Voices in My Head

Ask any ER Doc and they'll tell you.  We hear voices.

It happened to me the other day.  I wont recount the specifics of the case because it is too unique and would easily identify me to anyone who was even tangentially involved.  You'll have to trust me that it was THAT extraordinary and THAT amazing.  What I can tell you though, is that after an incredibly vague history filled with inconsistencies and nonspecific symptoms and a fairly normal physical exam, something just didn't feel right.  The pieces didn't add up.  I had no idea what was wrong, and had no idea of where to go with the case.  Looking back, I could easily have simply done some cursory studies, given some symptomatic treatment and sent the patient home for follow up.  I don't think I would have been "wrong".  And I know many doctors would have done exactly that.

Thankfully, on this occasion, I didn't.  Something just wasn't right and I heard that voice.  Some might call it divine intervention.  Others would say its instinct.  Some might say its the voice of an overly cautious attending.  Others would say its your inner self, picking up on subconscious clues and energy.  Whatever it was, it led me to order a test that ended up unquestionably saving a patients life.  The most ironic part of the case is that this test was probably not even necessarily medically indicated.  I could never and should never have been expected to order it.  Had I done what would have been arguably "medically appropriate" under the circumstances the patient would have died.  But like I said, I ordered the test, and the patient lived.

You would think that I'd be thrilled.  Ecstatic that I fulfilled my destiny as an ER Doc and saved a life.  I wasn't.  And I'm not.  I'll admit, that initially I gave myself a pat on the back and few silent fist pumps.  But after the adrenaline wore off I began asking myself "What if I wouldn't have listened to the voice".  "What if I wouldn't have ordered the test".  More so, "how often do I hear the voice and ignore it"?

  

The difficulty in wading through convoluted, incomplete histories and trying to make sense of vague, seemingly random symptoms and THEN identifying whether or not to listen to that "voice" is incredibly difficult and often comes down to luck.  You see sometimes that voice is correct and all knowing.  However sometimes it is simply paranoia.  And other times it can be filled with bias.  Knowing when to tune it out and when to embrace it is an extraordinarily difficult task that is impossible to understand unless you experience it.  

Our job is a difficult one and we make difficult, sometimes split second decisions every day.  In doing so, we often call upon every skill in our armamentarium.  We remember pearls we've heard, lectures we've had and journals we've read. We try and recall our experiences.  We're cautious.  We're thorough.  We think about specificity and negative predictive values.  We do our best to connect dots that sometimes are unconnectable.

Its amazing in the end, how often it all comes down to the voices in our head.

And a little bit of luck.......

My Advice

There was an article on Time.com this morning which pertains to something I've been thinking about for while.

I would say (without any evidence to back it up) that, in suburbia, roughly 70% of the kids I see in the ER end up being totally healthy with nothing wrong with them other than maybe a cold.  This number was probably even higher in the inner-city.   Because of this, most of my interactions with parents end up consisting of me trying to convince them that their child is ok and suggesting ways to deal with "normal" childhood issues.  I offer tips on how to deal with a crabby 1 year old.  I suggest what to put in their bottle and when its OK to let their child eat table food.  Sometimes I suggest ways to avoid constipation.  Sometimes I simply tell them "your doing a good job with Little Johnny."  (Like I'm Dr. Spock himself)

Most of what I suggest or do is based on either limited personal experience or things I have heard second hand.  Almost none of these "practical parenting tips" are things they teach us in medical school.  Sure we have one or two lectures on child development and maybe even half of one lecture dedicated to "parenting" but in no way am I an expert on simple parenting.

I am trained in "Emergency Medicine".  Yet once I've determined that the child I'm seeing is indeed "healthy" and in no need of emergent intervention, most of what I end up doing is offering "parenting advice".  This just always seemed strange to me.  I suppose its just another example of how our ER's have become one-stop Medical Shopping Marts.  (More on that in my next post)

Nice Guys

"I'm kinda worried, he's got the 'Positive Nice Guy Sign'"........

Those were the words my colleague spoke to me just before his patient coded.  I wont get into the details, but suffice to say, it was very difficult.

As those of us in the medical field know all to well, the "Positive Nice Guy Sign" isnt a good thing.  It was actually mentioned in a comment to one of my earlier posts.  Its amazing sometimes how some of those old medical axioms, uttered often in jest, can be so true, so often.

The "Positive Nice Guy Sign" means simply that the nicest, most congenial patients often seem to be the sickest.  The 21 year old who glows has a headache that ends up being cancer.  The good ol boy with chest pain who says "Yes Ma'am" and "Thank you kindly" ends up going into V-Fib right in front of you.

Its uncanny and unfortunate but it seems to happen often.  Of course it could simply be us in the medical field possessing selective memories.  It could be that we remember the cases where nice people get bad diseases and forget about the cases where the "meanies" get the same.  It could be a self defense mechanism somehow, even though it seems more like a self "flogging" mechanism.  Its probably an interesting comment on the human psyche.  It definitely is one of the things that makes this job tough.

Fever

Here's a link about fever I found on Yahoo today.  It keeps with a theme I've posted on lately.  Its actually pretty good advice.  I wish I had a nickel for every conversation I've had with patients over the last few weeks that echos this article!

I think the most telling part for us in the ER is the last statement:

Fit's Tips: If your fever persists for more than five days, or it goes over 104° F, call your doctor and get some medical advice immediately.

Notice it makes no mention of an Emergency Room.  Interesting.

Now contrast it to this article from Minneapolis, MN.

Imagine being a new mom and reading this article.  How would you react the next time your child woke up in the middle of the night with a fever?  Think you might get worried?

Its a perfect example of the mixed messages the general public gets regarding this stuff.  How do we expect the public to wade through these sensationalistic stories and not become alarmed every time they catch a chill?  The story of a child dying quickly from Influenza is absolutely tragic but why is there a need to broadcast this tragedy?  And if we are going to broadcast it, why not focus more on the fact that the mother truly did nothing wrong.  Talk about how exceedingly rare it is for this to happen.  How it is usually completely appropriate to give your child some tylenol and call your doctor in the morning.  I don't think its an overstatement to say that this sort of journalism is irresponsible.

So the next time its 3am and you see that worried mom with her 5 year old who has a fever of 100.6, think about this article, take a deep breath and repeat to yourself in your best Robin-Williams-from-Good-Will-Hunting voice: "Its not her fault, its not her fault......"

5 Hour Wait Part Deux

So I've been thinking about the "5 Hour Wait" post ever since writing it. One thing I didnt mention (the post was getting quite long) and I dont think it came across in my writing is that I sometimes (most of the time??) actually can empathize with the "non emergencies".

Here's how:  As a resident it used to drive me absolutely BONKERS that people came to the ER for such piddly stuff. I would rage about the "idiots" who didnt know serious from not serious. I would say things like "When I was a kid my mom would NEVER have brought me to the ER for this!" One day, one of our more thoughtful attendings heard me complaining to one of the nurses. She broke in and told me how she used to feel the same way. It used to drive her nuts. What she did though, was start to really empathize and practice looking at symptoms through the eyes of the patients with absolutely no medical training to base it on.  Relying only on horror stories told by friends and the media about the unfortunate few who die suddenly of zebras.  She put herself in their shoes, so to speak.  What she found was that often, she was able to realize how symptoms which were so meaningless to us as physicians could be perceived as serious by a layperson.

Granted, this does nothing for the "hurt finger at 3 am" or the "fever with no fever at midnight". There are certain patients and certain complaints which completely defy any and all attempts at empathy. What I found though, was that by practicing this "visualization" with patients, often I was able to justify the visit. I began to see how the "chest twinge" that is so ridiculous to me could possibly be perceived as serious. The diarrhea for 24 hours, if truly extensive enough might just be enough to worry a "normal person". It made my job easier to not be SO concerned all the time with ridiculous complaints.

Now, before you go start to think too highly of me or my well-grounded attending, let me finish the story.....

The very next shift following my little "talk" with Dr. Compassionate, we had a patient come in on a very slow, beautiful Sunday morning. Chief complaint was "toe pain". The attending and I interviewed the patient together.  She took off her sock and with a look of great concern stared at us and asked: "Do I have cancer???"

Swallowing hard, I looked her right in the eye and said: "Nope, you have a bunion.............."

On the way out of the room I asked the attending how she possibly could justify that one.

She looked at me, her cheeks blushing, and said "You cant empathize with stupidity."