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Emergentology: Tell Your Patients ‘I'm Not Going to Fix You’

Walker, Graham MD

doi: 10.1097/01.EEM.0000455720.77008.f0
Emergentology

Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him @grahamwalker, and read his past columns athttp://bit.ly/WalkerEmergentology.

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By the third fender-bender bounceback I'd seen with bilateral, non-midline muscular neck pain, I started to realize: Whiplash just hurts more the next day. The patient falls asleep, the muscles spasm and tighten (along with a lack of ice, heat, and NSAIDs during sleep), and they are stiff the next morning.

I've started warning my patients: “The good news is your x-rays are fine; I don't see anything broken. The bad news, however, is that you're probably going to be in more pain tomorrow. And that's completely normal.”

Magically, patients stopped coming back for worsening pain after whiplash. Ta da! Expectation-setting in the ED.

A colleague recently had a patient with classic acute gastroenteritis who returned with persistent vomiting. The patient had tolerated liquids in the ED, but decided the first thing she was going to ingest after leaving was a carnitas burrito. (This wasn't healthy Chipotle fare. I live in San Francisco, home of the best and unhealthiest burritos in the country.) Perhaps some explicit anticipatory guidance for the patient might have prevented her recurrent vomiting: “Start with small sips of clear liquids every 15 minutes, then move on to more frequent clear liquids, then broth, crackers, and solid foods over the next 24 hours. The key is to go slowly.”

Anyone who has seen a mother hand her child Cheetos right after the kid started to tolerate fluids knows that patients often don't understand what to us seems like common sense.

I wonder if we shouldn't be doing more of this expectation-setting and anticipatory guidance for our patients. I've certainly started to, and I like to think it's led to fewer bouncebacks and unnecessary clinic visits, better-educated and more proactive patients, and patients who are more confident in their ability to manage their recovery at home. We have a wonderfully international and mobile society now, but it often comes at the expense of passing on simple home remedies and home treatments for common ailments that now bring patients to the ED. I bet new parents would never come to the ED at 3 a.m. if a grandmother lived with them.

I used to think that my job was to cure patients in the ED. Now, I think my job is to help them. I used to feel I had done something wrong when my back pain patients weren't tap-dancing out the door after pain meds, but now I can set more reasonable expectations. “I'm going to give you some pain medicine that will hopefully take the edge off, but nothing is going to make the pain go away significantly besides time. We'll watch you here to make sure you're improving, and I'll send you home with some medicine to take over the next few days. But you'll likely have pain no matter what for at least a day or two. Take it easy over the next few days and be careful: no heavy lifting, no going crazy at the gym. Do your best to do your basic activities around the house to prevent your muscles from tightening up even further.”

This expectation of pain even works well with the under-promise-over-deliver mantra that I've discussed before: if the pain meds work perfectly, great! If not, it's expected.

It also works well for setting expectations about waiting in the ED and for a number of low-acuity issues:

  • An adult with a bad ankle sprain is going to have several weeks of slowly improving pain, and should follow-up with physical therapy once the pain improves.
  • People's bowels don't return to normal for a good week or two after a bout of minor diarrhea. Tell them to expect bloating, cramping, gurgling, and even constipation as their gut tries to find a steady state.
  • Patients with concussions often have symptoms for several days after injury (occasionally several weeks or even months). It's now recommended to rest for several days, get adequate sleep, take time off from studying or work, and follow return-to-play guidelines for sports.
  • Bronchiolitis symptoms can last much longer than we typically tell parents. One study that asked parents when their child's symptoms resolved found the average was 12 days, but 18 percent had symptoms 21 days after initial diagnosis.

We rarely provide a cure for patients, and often we are beginning a process of recovery, either speeding things along or moving them in the right direction. I like to think that this is not fatalistic but realistic. When we provide education and guidance for home care, warning signs of when to return to the ED, and how to follow-up with primary care, we help them find their own magic pill: part of that is time; part is taking care of themselves.

© 2014 by Lippincott Williams & Wilkins