Good Question

[Ann Emerg Med. 2008;52:168-169.]

“Dr. V, your patient in room 4 has a question,” the nurse informed me, yet again interrupting my train of thought. The last interruption was 2 minutes ago when the daughter of the patient in room 6 refused Tylenol for her mother's fever because “she has kidney stones and isn't Tylenol bad for your liver or kidney or something…?” If not for the room 4 inquiry, I would've decided what to do next with the comatose man in room 2. His hemorrhaging brain was squeezing through his foramen magnum like toothpaste, propelled by the blood pressure of 250/150, while his EKG showed atrial fibrillation and ST elevations. The neurosurgeon, whose operative patients must all be not too sick and not too well, had recommended “medical management.” Until “Room 2” got an ICU bed, he promised to be an “interesting challenge” while I also dealt with the aortic dissection in 1, prolonged QT in 3, possibly ruptured spleen in 5, unstable angina in 8, GI bleed in 9, and bilobar pneumonia, PCP pneumonia, nursing home pneumonia with impending septic shock, and chronic ventilator pneumonia (or was it CHF or aspiration?) in rooms 6, 7, 10, and 11.

Amid all this, patients wish to see me while waiting for their tests and dispositions to ask burning questions that simply cannot wait. The ED is designed for efficiency, not entertainment, and patients' information needs are high due to a combination of fear, confusion, and boredom. So what are these questions that must be answered right now? Often, they are negotiations. After agreeing to a laboratory test and CT combo during our initial discussion, the patient sometimes concludes that the workup is not “drive through” enough and he is going to miss his favorite evening TV shows. After all, his mother-in-law had a pain last year in her left big toe similar to the one he currently has in his abdomen, so it too must be “just a nerve thing.”

Usually, the conversation is informationally light. Patients need to feel heard. I listen. They complain. I agree. They ask if everything being done is necessary. I think: God may know what's necessary but I can only aim for “based on what I see and know right now, it is more likely than not a good idea unless some of the 17 variables change.” But patients don't want to hear their emergency physician hedging and wavering. Everything down here feels like a big deal, and big-deal decisions need to stand on solid ground. I say, “I think it is important to do this, to treat A and rule out B.” I help the patient progress through all 5 stages of what I call “workup grief”1:

Addressing workup grief satisfies the patient but almost never makes a difference in his diagnosis or treatment and takes time away from truly ill patients who need me more. Unlike the television physicians who seem to have all the time in the world for their patients, I referee competing interests and ration limited resources (myself included) among a dozen people. Becoming my priority implies a high risk of dying. Few patients appreciate the fortune of being ignored while the neighbor's hypotensive V-tach gets undivided attention. My efforts to set realistic expectations about wait times and delays are discredited by yesterday's medical show du jour where the main character's entire evaluation, diagnosis, treatment, miraculous recovery, and teary wedding fit into a 1-hour season finale minus the commercials. I, too, would gripe if someone said “the specialist is not available, your CT scan should be done in 4 to 6 hours, and then it may take until midnight to find you a hospital bed.”

With these demands and challenges, complete focus on each patient is essential to provide the highest quality of care in the shortest amount of time under unpredictably adverse conditions. Minimizing interruptions prevents dangerous errors and not wasting time translates into lifesaving and limb-saving decisions. Yet my patient in room 4 still had a question that would eat up at least 200 seconds I felt I should probably invest elsewhere.

“How can I help you?” I asked, wondering which stage of workup grief I was about to hear. His response was surprising. He did not argue with my decisions or negotiate for a “lighter sentence.”

“What did I say that made you decide on this treatment?” he asked.

“What kind of work do you do?” I asked in return, taken aback by his insight.

“I program computers,” he answered. “And the first thing you learn is ‘garbage in, garbage out.' If I wasn't precise enough in my story, you would not play with a full deck of cards.”

A close review of his symptoms proved that he was correct. The initial history-taking missed several red flags, and the timeline suggested pulmonary embolism more likely than angina. A CT angiogram confirmed the clot, and the heparin prevented the next one which could've been fatal. His question was essential.

The job never runs out of stories and surprises, and patients continue to humble me with their insight and wisdom. I always come for the questions. I look forward to the good ones.