Emergentology: Expecting the Expected
2012; Lippincott Williams & Wilkins; Volume: 34; Issue: 3 Linguagem: Inglês
10.1097/01.eem.0000413162.08302.1c
ISSN1552-3624
Autores Tópico(s)Jungian Analytical Psychology
ResumoImageI can't wait to see the new Batman movie. The most recent trailer has me so excited that I really, honestly, don't want to hear anything more about it. I don't want to read a review or see leaked on-set shots or even have a friend tell me how much he liked it. That sets up expectations. And expectations frame just about everything. Expectations are the anticipation of our experiences, from the mundane “What? We're out of milk?” to the emergency department patient's “What? You want to admit me to the hospital?” We as humans like to try to predict the future; it makes us feel more in control of our destiny when we're frequently just bystanders of chance. People love to talk about their cars as reliable because they like having their expectation met that the car is going to start when they turn the key. People will tell you how they got seated at a really nice restaurant without a reservation because their expectation was so low that they would ever get a table. It's really the same in the ED. You read a triage note of a patient with six seemingly unrelated complaints, and your stomach fills with dread. You look at your watch and figure, “Yeah, I've got 30 minutes to spare,” and march in. About 30 seconds in, you immediately realize they're actually all related issues, and you make the diagnosis of carbon monoxide poisoning in five minutes. Low expectations, high yield. Or the patient who the nurse warns you is “all drama,” and you walk in the room, and find the patient actually to be quite reasonable and pleasant. Wow, that wasn't so bad. So why not use this to our advantage? We can set appropriate expectations — for our patients, our colleagues, and even ourselves — to make sure everyone is on the same page, knows what's expected and reasonable, and what may happen in the emergency department. Patients At wit's end, on a busy, post-holiday Tuesday, a patient with a runny nose and cough came up to my friend Lisa to complain about having waited an hour without being seen. In a very direct but polite tone, Lisa told the man, “Sir, if you think that that's unreasonable on a day like today with very, very sick patients, I think you need to adjust your expectations.” (I, of course, started laughing because I'm a jerk like that, but I think Lisa's intent was spot on.) We should make sure patients know a time frame and course, and understand that that time course may change. “Under-promise and over-deliver” is a well known business strategy, but I think it's pretty appropriate in medicine as well. Letting them know that blood work and a CT scan usually takes three hours, but can be longer if we have critically ill or trauma patients gives patients a time frame before they start giving you the stink eye. You can also let patients know immediately that they're going to be admitted regardless of the workup in the ED so that can sink in from the very beginning (especially when they were expecting to go home.) Similarly, I've found that with VIP patients (who are not used to having a stranger direct them and make decisions about them), it also helps to let them know how things work in the ED and set boundaries and limits of what's appropriate to negotiate and what's not up for discussion. Setting expectations with patients may help reassure them as well. Patients with allergic reactions without a clear new exposure, vague neurologic complaints with a negative workup, and even a MRSA abscess prompt me to let them know how commonly I see these things, and the anxiety on their faces melts away as they realize they probably don't have some awful, terrible, fatal diagnosis. And we can let patients know that frequently we don't figure out the cause of belly pain with normal labs and imaging, and that's pretty common as well. Our Colleagues I think out of habit, I frequently go up to nurses after I've seen a patient of theirs and summarize my plan with them, “Oh man, I have no idea what's wrong with this guy, so we'll get some basic labs,” or “I really don't like this EKG. I'm going to have cards seem him, but can you make sure he's got a good IV? I may need to do a CT angio on him.” It makes sure we're on the same page, and frequently the nurses will drop in little extra bits of helpful information they've heard while they're rooming the patient. Different residents need different sets of expectations sometimes. I want the interns to give me a formal, thorough presentation, but the seniors can give me a briefer one. I think even giving them simple feedback by saying, “You need to do a full neuro exam on patients with headache,” teaches them how you evaluate a chief complaint and what they should expect to do on every patient with that complaint. Finally, any good “how to talk to consultants” discussion is really all about setting expectations with them. Being very clear that “I want you to see the patient and drop a note” makes sure everyone knows this is not a curbside question, and asking the consultant what time you can expect him in the ED lets him know you want him there promptly. Ourselves On those post-holiday Tuesdays, walking into a shift knowing you're going to work hard may make your day a little less painful. Or running your board and realizing that you can probably make a disposition decision on everyone in the department may give you the sense of achievement you need to finish that shift when you're getting crushed. Part of why we went into emergency medicine is probably because we like the unexpected. Who and what is going to walk through the door next? Will this patient decompensate? Is this guy going to lose his airway in CT? We prepare for the unexpected all the time. By preparing for expectations, too, we can make our emergency departments an even smoother, more predictable battle zone of — let's be honest here — slightly controlled chaos and random chance. Click and Connect!Access the links in EMN by reading this issue onhttp://www.EM-News.com or in EMN's app for the iPad, available in the Apple app store.ImageDr. Walkeris a fellow in simulation medicine in the Stanford/Kaiser Emergency Medicine Residency Program. He has been blogging since medical school, first at Over My Med Body, and now as the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications (www.mdcalc.com), and The NNT, a number-needed-to-treat tool to communicate benefit and harm (www.thennt.com). FastLinks ▪ Use Dr. Walker's medical calculator at http://www.mdcalc.com and his number-needed-to-treat tool at http://www.thennt.com. ▪ Read all of Dr. Walker's past columns in the EM-News.com archive. ▪ Comments about this article? Write to EMN at [email protected]
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