Emergentology
2018; Lippincott Williams & Wilkins; Volume: 40; Issue: 5 Linguagem: Inglês
10.1097/01.eem.0000533735.30683.17
ISSN1552-3624
Autores Tópico(s)Infant Health and Development
Resumopatient care: patient careFigureIt is obvious why many of our patients come to the ED: Something happened to them (they were hit by a car) or they developed some acute symptom (six hours of right lower abdominal pain), and they're seeking answers—diagnosis, treatment, or both. Because we emergency physicians know our resources and our scope, it's easy for us to understand their motivations, and we work them up and treat them as needed. But it is not readily obvious to us why some of our patients presented: “Six months of abdominal pain,” “URI symptoms; has two siblings with the same,” “rash times seven years.” These patients always confuse and bewilder me. More often than not, they seem just as dissatisfied after the ED visit as they did before. I've tried all kinds of questions to sort them out: In residency, I would sometimes smarmily ask patients, “What is your emergency today?” It felt vindicating, especially when the patient's chief complaint was “sore throat for 20 minutes,” and she's in the exam room eating a toasted Quizno's sub. I've also tried asking people, “Oh, what has your primary care physician said about this?” (when I know they have a primary care physician). They usually look back at me perplexed, confused by the suggestion that their primary care physician could handle most of these issues. And adults, I find, don't like the questions that typically work in pediatrics: “What's your biggest concern today?” or “What are you worried about?” I imagine that these patients don't respond well to “concern” or “worry” because they're not really worried about the rash on their side; they just want it gone. As I matured, I tried asking people, “What made you come in today if it's been going on for three years? Did it get worse? Did something change? Did you have a new symptom? Or were you just tired of it?” The vast majority of patients typically shrug and choose the last answer, almost to the point of suggesting that it was pure fate, and they had no free will or choice in deciding to register in the ED. None of these questions really ever seemed to get the answers I was seeking: What did the patient expect from me, what did the patient want from me (they're not always the same thing), and what would it take to satisfy him? Then I came across the phrase that seemed to sum up all of this: How were you hoping I could help you today? A Dose of Reassurance This is best used with patients who have chronic complaints, but it works quite well with the patients who have already correctly self-diagnosed: “I think I have a cold;” “I think I sprained my ankle;” “I scraped my knee;” “I want an abortion.” The magic of this phrase is that it also engages the patient, revealing any hidden anxieties he may have and letting you reassure him. It also lets you instantly know how realistic or delusional they are about what will or won't or can or can't happen in the emergency department. You immediately know, “OK, this is going to be an easy one,” or “Oof, this is going to take some teamwork to set expectations and come up with a plan, and even after that, it may not go smoothly.” Take any one of the many patients I saw last week with the three to four days of the flu, many of which stated outright, “I think I have the flu.” Ask the magic question, and you'll get a variety of responses, most of which require a variety of solutions. “How were you hoping I could help you today?” “I've been sick all week, and I have midterms on Monday.” Ta-da, here's your school/work note. “I'm worried it's not the flu. I take Tylenol, but then my fever comes back.” Ta-da, education about fever and a recommendation to add ibuprofen. “I've seen my doctor for this twice already this week, and I'm still not feeling better. I only have one kidney, so I'm worried I'm dehydrated.” Shared decision-making about other testing like a chest x-ray and labs (which, of course, turned out totally normal; diagnosis: flu). “I have a newborn at home, so I'm worried I might give this to him.” Education about hand washing, masks, and lots of new parenting advice, as well as gathering information about the infant's age, taking an infant's temperature, etc. Discussion about risks/benefits of oseltamivir. You'll notice that only one of these four scenarios required much in the way of medical workup or even medical care; it's much more about targeted education and reassurance (because you've already taken a history, examined the patient, and deemed his condition not to require any testing). It's far better to spend an extra five minutes with the patient doing a thorough physical exam and answering all of his questions and then being able to discharge him than to order unnecessary testing, come back an hour later, announce, “Good news. The x-ray is normal!” and then have him leave annoyed. Even worse is then having him ask you or the nurse five minutes of additional questions. And the ultimate fail is having the patient re-triage an hour later for the same complaint, already worked up and annoyed for your colleague to see. (That being said, sometimes you don't have five minutes to spare for patients with minor complaints, or tests have already been ordered in triage.) Give the phrase a try. I promise you at least a patient a day will be easier for you to handle, understand, empathize with, and disposition. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].
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