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Emergency Medicine News

First Person

How to Keep All the Plates Spinning

Harmon, Stacy MD

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doi: 10.1097/01.EEM.0000672632.23981.e8

    Malcom Gladwell, in his latest book Talking to Strangers, talks about how we humans are so susceptible to being duped or deceived because we have automatically default to truth. That is, we tend to believe people are being truthful with us.

    If you think about it, it has to be that way or our social contract would fall apart and we could never get anything done. Most of the time, it works out fine because most of the time people are truthful. Every once in a while, though, we run into a Bernie Madoff or a Cuban spy who is so believable that he goes unquestioned even when things stop adding up.

    This default inhibits the evidence from sinking in. I thought of myself, of course, but also of my fellow emergency physicians as I was reading this book. We are the opposite of truth defaulters. We don't believe anything patients tell us, and we are often convinced that they are out to get us. I don't necessarily mean consciously, although I could question the integrity of a few folks with only two teeth who had the same toothache for three years and multiple ED visits looking for pain meds.

    You know how the conversation goes: A 90-year-old with foot pain, ESI level 4, is put in the fast track. He has no medical problems. You start with your best open-ended question, “What brings you into the ED today?”

    “An ambulance.”

    “OK, why did you call an ambulance?”

    “I didn't call them.”

    “OK, who called them?”

    “I don't know.”

    “OK, what's bothering you today?”


    “So why are you in the hospital?”

    “I don't know. You're the doctor.”

    (Have you ever been choked by a doctor?)

    “What about your foot? How long have you had pain?”

    “Two years.”

    “What's different about today? Is it always blue?”

    “It's blue?”

    “Yes, is it always blue?”

    “I don't know.”

    “Do you have any medical problems?”


    “What about this bag of medicines?”

    “That's why I take them, so I don't have problems.”

    “Are you short of breath?”

    “No more than usual.”

    “How short of breath are you usually?”

    “Not as bad as today.”

    “Are you still taking your blood thinner?” (I hate that term.)

    “No, they told me to stop before my dental work.”

    “When was that?”

    “Right before my foot turned blue.”

    “When was that, sir?”

    “Ask my daughter.”

    “Is she here?”

    “No, they wouldn't let her ride in the ambulance.”

    I make eye contact with my scribe and give him my let's-cut-our-losses-and-get-out-of-here look. He knows it well. Big workup, here we come.

    There's a scene in the movie “The Fugitive” when Richard Kimble (Harrison Ford) is trapped with his back to a spillway at the top of a dam. The hardened U.S. Marshall Sam Gerard (Tommy Lee Jones) has him at gunpoint. With his hands up, Kimble says, “I didn't kill my wife.”

    Gerard, without missing a beat, says, “I don't care.”

    It's a classic scene. It might be important to know all the ins and outs of the crime, how justice was miscarried, and how the police need to capture the real murderer, but it has nothing to do with his job: bringing in a fugitive. The truth, the whole truth, and nothing but the truth is important in a courtroom, but not 100 feet up at the top of a raging waterfall. It's also not what we're after in the ED.

    I want just enough truth to decide what's next. Sick or not sick, in or out. That's my job. It's not that I don't care (well, sometimes I don't), it's just that it's not helpful. It goes without saying that the biggest difference between what we do in the ED and what most other doctors do is time pressure.

    I told a seventh grade health class once that going to your doctor is like doing the dishes and working in the ED is like spinning plates in the circus. In the office, you can wash one dish, put it in the rack, and then take the next one. If one requires more scrubbing, the others wait. In the ED, all the plates are spinning at the same time, and require us to run from one to the other to keep them going. Give me enough info to start spinning your plate, and then I'm off to spin another. I'll be back when you start to wobble or it's time to stop the spin.

    Even our consultants don't understand our truth. Did you calculate the osmolality, is the CBC back yet, what about the magnesium, who is his primary, when did he eat last, are you sure he can't walk? I just served you up a whole plate of dispo, and you want a full course meal of diagnoses. I get that sometimes we miss things; sometimes the diagnosis does determine a lot, including the dispo. But we rarely miss things that change the dispo or cause harm. Plates wobble, but they rarely crash to the floor because of us. Most of the time we have already prevented the crash before we even call our consultants.

    Funny how that's not satisfying enough for them. One might say that the very word emergency obviously implies that time is of the essence. The truth is that a true emergency is debatable even among us. We know it when we see it, but defining it is something else. Somehow, we have allowed patients to fend for themselves in this arena. They are supposed to know when to come and when not to. They also assume that coming to the hospital is going to provide answers to all their questions and that the technology in that building is so advanced that a scan of some Spock-like quality will be done and the House-like diagnosis will set them free! Therefore, they cram every bit of symptomatic, internet-influenced info they can into the story, never suspecting that you and I are more interested in what they don't have than what they do.

    They count on us not to believe them and even not to listen to them sometimes. We can't have early closure or anchor. They want us to get to the bottom of things and figure out what it is. We are definitely more concerned about what it isn't. It's no wonder that the patient with the blue foot could have a huge, expensive workup and be sent home and later complain that we didn't do anything in the ED.

    Patients trust us completely. In what other context can you check for blood in the stool within five minutes? ...OK, don't answer that. My point is that they trust us not to trust them. They need us not to be truth defaulters because it's dangerous. Two phrases to watch for that none of us was taught in residency are “well...” and “by the way.” When a patient, usually an older one, starts his story with a long breathy “well,” you know you are in for quite the rodeo sorting through this history that starts with how much the turkey weighed last Thanksgiving.

    At the other end is “by the way.” This usually comes at the end of the workup while you are explaining the discharge instructions. “By the way, did I tell you I have cancer?” Put the plate back up, and start spinning.

    After your shift, you have to leave that tendency not to be a truth defaulter at the office. It doesn't translate well back in the real world, particularly at home when your wife or kids want to tell you about their day. When people find out I'm an emergency physician, they say, “Wow, you must have a stressful job.” I usually say it can be, but that it is what I'm trained for and that stress is different for different people. I usually say that it would be stressful if you ask me to sing karaoke. But I think I'll agree with them from now on, and just say yes. In spite of being warned as a kid never to do it, I now make a career out of talking to strangers.

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    • richard.e.alegre9:19:34 AMExcellent article.