You've Been Served
It was more than 32 years ago that I naïvely went to my first ED shift, hardly imagining that it was anything more than a way to pay the bills while I figured out my real future.
Let's set the stage. The first CT scanner was opening in my city, cephalosporins consisted of a total of two drugs (both were first and only generation), and nearly anyone could practice emergency medicine. Being an American made me as good a candidate as any even though the only post-graduate training I had was an orthopedic internship. Unbelievably, during that very first ED shift in 1980, my new ED director helped me perform an open thoracotomy a few hours in. I was too ignorant to appreciate that this was not an everyday event. That weekend brought an additional two chest tubes and more adrenergic boluses than your average meth addict. I guess I had found a home, thrill-seeker that I am.
I would later do a residency in emergency medicine, but my total emergency medicine training at that point was a brand new course called ACLS and a brief read of the single book I could find on the subject. I was lucky enough to have an emergency medicine-trained boss who gently mentored me and an ED group that required ACEP membership. There was so much I had to learn from the talented emergency physicians and nurses with whom I worked. Fortunately, I had the good sense to be humble. I also figured out early on that the ED nurses were a different breed from those I had encountered previously. An honest and accurate appreciation of how little I knew led me to pitifully (but wisely) throw myself on the mercy of those doctors and nurses and beg for their tutoring.
Now, as my career winds down, I can't help reminiscing about some of the better moves I have made and even more about some of the mistakes. I've had the benefits of knowledge passed on to me by a multitude of wiser physicians and nurses. It only seems fair for me to pass a little of that to tomorrow's EPs. It is difficult for you to imagine now, but the day will also come when you will do the same.
- A stat urinalysis takes longer to get than a plain brain CT. That has been true nearly everywhere I know of for at least the past decade. Make sure you really want the urinalysis before you order it.
- Asking a consultant for his talented help gets a better response than demanding their attention.
- Don't ever be afraid to say those magic words, “I don't know.” It works a whole lot better than arrogance, and takes the wind out of the sails of those who would love to argue with you.
- “What do you think?” similarly implies that your colleague's opinion has value, which it almost surely does. Not as much as our opinion, but why quibble?
- A great phrase to use in discussions with a colleague who sees things differently from you is, “That hasn't been my experience.” It says in a nonconfrontational way that you disagree but leaves open the possibility that you really don't know it all.
- Treat everyone, be it the hospital CEO or the housekeeping crew, with respect and camaraderie. True class is shown by how one treats those who have the lowest stations rather than those whose position is likely to aid one's career.
- There is almost no test that can be done in a hospital ED in less than one hour.
- Sometime mid-career, I started asking my patients what they do for living. It is an open-ended question that can yield tons of info that will help in assessment, evaluation, and disposition. It gives patients a chance to tell me something about themselves, and most seize the opportunity to do so. Some of my patients were hard-pressed to come up with any answer at all. One of the most common answers at the inner city hospital where I ended my career was “nuthin,” itself a very useful though depressing bit of information.
- A handshake while introducing oneself is often a good way to start an interaction. There is something about squeezing the flesh that helps create a bond of trust. It shouldn't be a chance to demonstrate one's strength, but neither should it be a weak handshake. Just make it a firm one while looking the patient, coworker, or consultant in the eye while you introduce yourself. That is how someone who is proud of his actions would act. Be that person.
- Giving a business card to patients, consultants, and families multiplies that sense of accountability many times. Their cost is nominal, and the benefit is palpable.
- You will definitely lose at the business of keeping up with technology and medical knowledge in time. That's inevitable and not nearly as important as the ways you will become a better doctor.
- Life experiences will make you a better doctor as you get older. I'm a better doctor now for having had children, siblings, a wife, nieces, and nephews. I'm also a better doctor for having buried my parents, having had a suicide in my family, having gone through a painful divorce, and having had my own share of serious physical ailments. I've had the usual fears and problems with childrearing, and experienced the great joys that they also bring. Some experiences fall into the “the club no one wants to join,” but there is no question that having been in the shoes of the afflicted gives tremendous insight and empathy.
- On the other hand, nothing cures a case of self-pity like a shift in the ED. I invariably come away thinking that my own ailments are minor nuisances while “these patients have some real problems.”
- Think very hard before putting restraints on the kind of patient you least like to have in your ED for the rest of your shift and beyond. There is no level of serum ethanol that is legally “intoxicated.” There is only an alcohol level above which one cannot legally operate a motor vehicle. Sometimes it works when you inform the spitting, screaming patient that a short period of “good behavior” can lead to discharge. A brief clinical assessment — hop on one leg, name the president, and the route and means to get home — is adequate assuming you don't give him car keys — his or yours.
- A tremendous bond is immediately formed like no other when you are able to truthfully tell a patient that you really do know what he is going through.
- A sympathetic ear can be the next best thing when you can't have empathy. Sometimes that is all the patient is seeking.
- People can be very interesting. It makes work so much more pleasant to talk to them as you would a new neighbor or acquaintance. They love it, too. I once met a Medal of Honor recipient in for a kidney stone. That wasn't on his chief complaint.
- Early in my career, I had the attitude that I knew best what the patient needed and was rigid and conceited in my plan. Now I know that there is no one way to do things, and we are there to provide a service to our patients after all. That doesn't mean we should order CT scans on demand or provide patients with whatever drugs they desire, but it is true that a workup and disposition that is right for one may not be right for all.
- There's no reason to take offense at our patient's opinion that he knows best. It's his life, after all. Maybe the last vestige of American liberty is right of ownership of one's own body. Proceed with Plan B if your initial plan is vetoed.
- Same goes for patients who leave against medical device. I was told and I used to argue to my advantage the myth that one's insurance would not cover an ED visit that ended this way. It was only after I looked at that objectively, and realized that such a policy made no sense either financially or morally that I was able to put my injured ego aside to recognize that there are many ways to skin a cat and that my particular method was neither the only one or even the best one for a given patient.
- One approach with which I found success in my clinical practice is to incorporate the patient's opinion into the whole workup and disposition plan. I make an effort after a brief history and physical exam to explain my thought process and proposal, and I ask for the patient's feedback. What I have found is that many fewer patients than I predicted have a desire for extensive testing, and most are happiest with “less now” and a plan for more aggressive testing and treatments if things don't improve. I don't believe this is bad medicine or a liability. I simply briefly document our discussion in the chart.
- I usually end with the sincere statement, “I hope you get better very quickly” for admitted and discharged patients.
- You obviously need to hospitalize an intoxicated, distraught patient making suicidal statements and who is really at risk. If, however, he is the more common animal, you can wait until he is sober, and get a psych consult who will tell you the now-sober patient denies suicide ideation and doesn't recall even making those statements (four to 14 hours). Or when the patient is even a little sober, tell him that a lot of people say things they don't mean when drunk. If he still makes the same statements, he will be hospitalized for his own safety, against his will, if necessary. If, however, after sobering up he says it was just the alcohol talking, and he denies suicide ideation, he will be able to be released (one to six hours). You get to choose.
- I leave discharged patients with, “If things don't get better or even get worse, you know where we live.” That invariably gets a smile and also effectively delivers my message loud and clear.
- My youthful naiveté and arrogance once led me to believe that my best mentors were the ones who knew the highest tech diagnostics and treatments, and could cite contemporary literature all day. I used to laugh at the old doctors who used an array of outdated technologies and meds. I called them chicken-soup-and-vitamins doctors based on their prescribing habits. I thought it was only because they were deceptive to their patients that they had such a loyal and plentiful practice. Now I know that they loved ol' Doc Jones because he was practical, sincere, and usually right in his clinical skills. They couldn't care less about the academic stuff. They loved his advice, his empathy, and his calm, confident reassurances. I'd bet they lived at least as long and a lot happier than their high-tech neighbors.
- Earlier in my career, I would not have allowed myself to be so human by showing much in the way of emotions. I thought it was unprofessional. Now I know that a genuine hug after telling someone the worst possible news is not just allowed, it's almost always well received and appreciated. The longer I practiced, the more hugs I gave.
- If an encounter with an elderly, moribund, contractured, bedridden relative in extremis asking for family guidance gets you a response of “they want us to do everything,” then you didn't ask the right way. It's not just OK, it's mandatory that you advise the patient's family in this difficult decision. Most families interpret DNR as giving up on their loved one and doing nothing. Buoyed by TV expectations, they often come with the opinion that there is hope for full recovery when a monitor is making noise. We need to help them with the decision and not leave them with a lifetime of guilt either. By pointing out all the criteria that led you to believe that the quality of life has been poor — Foley, feeding tube, decubiti, multiple morbidities — it is the right thing to do to suggest that providing all means of pain relief and comfort for their loved one at this point in his life (or death) is more humane than days or weeks of probably painful and surely uncomfortable invasive measures that may prolong the process but not the outcome.
- A few moments spent celebrating the good that the recently deceased has meant to the gathered family is time better spent than medical detail.
- There are two things every family needs to hear during that painful conversation. I want every family to believe that everything reasonable was done to save their loved one. I also want no family member to be left with guilt over his actions prior to the death. I see no productive reason that any family member should be blaming himself or others for the rest of their lives for not calling 911 sooner, for not going to a different doctor and hospital, or for not following their doctor's advice. I consider it a victimless crime to reassure families that nothing better could have been done prior to the death. “It was just too massive, too advanced a disease, or too something for any other outcome. It is nature's law, God's will, or an end to suffering that has occurred.” If this is lying, then guilty as charged.