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Emergentology

When a Clean Bill of Health Isn't Enough

Walker, Graham MD

Emergency Medicine News: May 2015 - Volume 37 - Issue 5 - p 30
doi: 10.1097/01.EEM.0000465709.72358.5e
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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Among the aphorisms you'll hear during a painfully, overwhelmingly busy emergency department shift, a few always seem to be the most popular: “Only two more hours,” “At least we have job security,” and “Alcohol keeps us in business.” But increasingly, it seems that another should be thrown into the mix: “Anxiety keeps us in business.”

Perhaps this is a mantra unique to San Francisco or relatively healthy cities or tech-friendly cities (more on that in a minute), but I don't think so. It often seems that a large percentage of our crowding woes are from people who just don't need to be in the ED because they seem to lack common sense or they cannot perform a trial of observation at home.

I'm obviously not talking about patients who have a particular chief complaint and end up having a negative workup, like unexplained chest pain or the tender belly with negative labs and imaging whose pain just seems to go away. And I'm not trying to be the highly educated doctor jerk and ignore my knowledge bias. I realize that a patient with throat pain does not know that his throat pain is viral and not a peritonsillar abscess. I'm referring to the patient with completely resolved minor symptoms or the middle-aged person with cold symptoms.

I'm referring to the patient whose “friend's sister's next-door neighbor had the same thing, and it was actually a brain tumor, so I'm here at 3 in the morning even though it's been going on for five months intermittently, but, no, I have no complaints at all right now, but it was like really bad four days ago” or the patient who says, “I didn't get to the second page of the article on chest pain, but the first thing it said is, ‘If you have unexplained chest pain, the only way to confirm its cause is to have a doctor evaluate you.’” (WebMD)

I have to assume a lot of this is anxiety, but I guess it's possible that this is actually a lack of common sense in the population (or what I as a physician assume to be common sense). It's common sense that it's going to hurt if you drop a picture frame on your toe whether it's broken or not, right? It's common sense that if your first child was seen by the doctor and diagnosed with a cold, and then your second child gets a runny nose — or you do — that you probably caught a cold from the first child, right? It does not appear to be common sense that, no, your nose will not stop bleeding if you hold pressure for 30 seconds, check to see if it's stopped bleeding, and then jab a tissue up your nostril.

As I've said before, a lot of this is related to the mobile family unit. When Grandma lives 10 states away, she's not there to tell worried parents how long a kid's fever usually lasts, which home remedies work well for the stomach bug, how many sleepless nights she had with her child with a persistent dry cough, or how many times her child fell down and ran into things with her head and lived to tell the tale. (Adult parents also can't tell their adult children that, yes, joints just start hurting around a certain age or all the men in our family lose their hair by 40.)

I actually did some Googling on a part of the Internet I don't think I've visited since medical school — the patient-search-term Internet. I typed in things like, “broken toe vs stubbed toe,” “why do I have chest pain,” “signs of a heart attack,” and “blood in my poop,” just to see what my worried-well patients are reading. And I have to admit, a lot of it sounded a lot more reasonable than I had expected (when read in full, of course). Most of it was not as medico-legally “cover your ass” as I'd expected, but all of it certainly focused on life-threatening diagnoses on page one, not common diagnoses.

WebMD's page about chest pain, for example, states, “Some of these conditions are serious and life-threatening. Others are not,” but it doesn't mention GERD until the third page or musculoskeletal pain or anxiety until the fourth page. You have to wade through two pages about myocardial infarction, myocarditis, pericarditis, hypertrophic cardiomyopathy and — wow, are they thorough — coronary artery dissection to get to those pages. These are clearly written by physicians, and end up giving would-be patients way more information than they need. Do patients really need a differential diagnosis of the causes of cardiac chest pain? Is that what they're looking for when they're searching? Of course not. They're searching to see if their chest pain could be something life-threatening because they've heard chest pain is a concerning symptom, and they're trying to see if they should see a doctor about it. (Or drop $250 for a co-pay to go to the ED for it.)

A history and physical exam often seem to be enough in the clinic, but I think there's an expectation of some testing in the ED, that my clinical judgment and experience isn't enough. Maybe it's me or the fact that the patients don't know me or that most people in the ED do get some testing, but I'd say the vast number of patients that I deem to be “fine” and don't have anything life-threatening or even at all concerning (“My hand was numb for 10 seconds six hours ago”) just aren't satisfied with a clean bill of health. Where's all this anxiety coming from? Next time in Emergentology.

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