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How to Lose Your Voice
CHANGE OF SHIFT
How to Lose Your Voice Sara Dyer Flora, MD
From the Kentuckiana Emergency Physicians PLLC, Louisville, KY.
0196-0644/$-see front matter Copyright © 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2007.10.016
[Ann Emerg Med. 2008;52;80-81.] Feel a tickle in your throat? Have a cough, maybe some postnasal drainage? Voice getting just a bit hoarse? Congratulations: you are well on your way to losing your voice! Just follow these simple steps, friends, and you, too, can take your pen and pad of paper and proudly write “I have laryngitis!” The steps are simple, friends, but it does take patience and time. And talking. Fortunately, you are an emergency physician, so you are a talker. Grab your first chart out of the rack and let’s get started! Go into Room 5, apologize for their 6-hour wait, and sit. Listen attentively as the family describes how their 82year-old mother’s 5-year slow decline has come to a head at 5 PM on Friday. The major concern currently seems to be that Mom sleeps a lot. Take a detailed history of present illness; review of systems; social, occupational, and family history; and be sure to review the patient’s 30 home medications and 15 allergies. Try as you may, you will not uncover any acute symptoms other than increased sleeping. Speak loudly and repeat yourself often, because your patient doesn’t hear well and can’t understand why her family brought her to the ED in the first place. Order an exhaustive evaluation to “rule out anything bad that could be going on,” and promise to come back in 2 or 3 hours when the tests are back. On your way out of the room, the patient’s middle-aged daughter-in-law will pull you aside and tell you that the family wants Mom hospitalized and then placed in a nursing home immediately. The son and daughterin-law just got into town and really don’t feel that Mom can make it on her own anymore. Express your sympathy with their predicament but discuss the fact that you will have to uncover a medical diagnosis other than sleepiness to justify an admission. Mutter a prayer under your breath that something will show up on your testing, and move on. Grab a cough drop for that tickle in your throat, grab another chart, and let’s go! Your next patient is here to be checked because she is having some pain and someone told her that her ex-boyfriend has “got something.” Make an ironic joke to the charge nurse about running a free all-night STD clinic and head to the room. Your patient is angry about her 3-hour wait, and you will spend the first few minutes of your evaluation discussing ED staffing levels and apologizing for the patient’s inconvenience. The rest of the case is pretty standard, but you will have to return to the room to apologize for the delay in obtaining the pregnancy test results and to negotiate her work 80 Annals of Emergency Medicine
note request down to 1 day off. The patient’s disdainful swagger and bitter-sounding cell phone conversation on her way out the door will leave you convinced that she probably won’t check a “5” on her evaluation. By this time, you have been seeing patients, talking to families, apologizing for waits, and taking test results over the phone for a few hours. Take a short diet-Coke-and-granola-bar break to keep your energy up and tell your nurse friends a few funny stories about your 2-year-old daughter. This is fun and life-affirming, so ham it up a little and reenact the fit your child threw in the grocery store. The nurse who was discharging Bed 3 will want to hear what all the laughter is about, so tell the story again, complete with mock screaming. Your voice has become noticeably hoarse— congratulations! To compensate for this, speak a little louder. Now get back to work! “Code Blue, 4th floor.” Whoops, that’s your cue. Grab the difficult intubation bag and head for the stairs. When you get to the floor, speak up to identify yourself as the ER physician and ask what is going on with the patient. Repeat yourself a couple of times. You will be told that her nurse is on the phone with the primary physician, and she is the only one who knows the patient. An aide will tell you that the patient just had a bath. No one in the room will know the reason for the current hospitalization or what preceded the code. After you intubate and somewhat stabilize the patient, call her physician and give him an update over the phone. Get the chart and briefly review it as you are writing your code note. The house supervisor will ask you to talk to the family. Introduce yourself and sit down to compassionately discuss the end-of-life issues of a patient you have minimal information about. The patient will code again while you are talking to the family. Based on your 5-minute discussion of the pros and cons of continued aggressive care in a 95-year-old with metastatic cancer and pneumonia, the family will be leaning toward less aggressive care. The patient will decide the issue by going into asystole. Give your sincere condolences to the family and update the primary doc. Now head back to the ED; it was hopping when you left! On your way out the door, someone will ask you if you are sick, your voice is so bad. When you get back to the ED, everything is back on your first patient. Unfortunately, every test is totally normal. Return to Room 5, where you find that the son has convinced Mom that she needs admission “for more tests.” In a voice just above a whisper, discuss the comprehensive nature of the ED evaluation Volume , . : July
Flora
Change of Shift
thus far, and the low likelihood of finding a physician to admit a patient for sleepiness. Tactfully suggest that older people sleep more than younger people do. When the family becomes irate, promise to try to get her admitted. Talking will be difficult by now, so scribble a note to the secretary to call the hospitalist and grab another chart. You will decide to conserve what is left of your voice by communicating with the patients in writing. This will last for 3 simple cases, but the next patient will be a woman who just lost her 8-year-old granddaughter and you won’t feel comfortable writing notes to her. Speak in a stage whisper instead. The patient will whisper back to you and you will feel a little foolish. Offer soft condolences for the loss of her grandchild, address her chief complaint, and head back to the nurses’ station to take the hospitalist’s call. The doc on the phone is new to your hospital, and you don’t know her well. She will be taken aback to hear you whispering and you will have to repeat yourself several times to be
understood. She will manage to imply that you are lacking in medical knowledge and ability but will agree to admit the patient. This is a good thing because the son and daughter-inlaw have already left for the airport. Send the nurse in to tell the lady in Room 5 that she is being admitted, because you really can’t talk any more. Your shift is over. Go home and annoy your husband by writing notes about everything. You won’t be able to work your next shift due to total inability to speak, even whisper. Though you will feel silly having your husband call to find you coverage for such a benign illness, you can feel pride in having achieved your goal: you have laryngitis! Reprints not available from the author. Address for correspondence: Sara Dyer Flora, MD, Kentuckiana Emergency Physicians PLLC, 1 Audubon Plaza, Louisville, KY 40217.
CORRECTION NOTICE In the May 2008 issue, in the News & Perspective story (“Emergency Medicine in the VA: The Battleship is Turning”; pages 632-635), Dr. Olszyk’s and Dr. Kessler’s full names and institutions were omitted. They are Mark D. Olszyk, MD, MBA, deputy chief of staff at the VA Maryland Health Care System and chairman of the National VA Advisory Committee for Emergency Medicine; and Chad Kessler, MD, section chief in EM at Jesse Brown VA Hospital in Chicago. We apologize for these omissions.
Volume , . : July
Annals of Emergency Medicine 81
How to Lose Your Voice Sara Dyer Flora, MD
From the Kentuckiana Emergency Physicians PLLC, Louisville, KY.
0196-0644/$-see front matter Copyright © 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2007.10.016
[Ann Emerg Med. 2008;52;80-81.] Feel a tickle in your throat? Have a cough, maybe some postnasal drainage? Voice getting just a bit hoarse? Congratulations: you are well on your way to losing your voice! Just follow these simple steps, friends, and you, too, can take your pen and pad of paper and proudly write “I have laryngitis!” The steps are simple, friends, but it does take patience and time. And talking. Fortunately, you are an emergency physician, so you are a talker. Grab your first chart out of the rack and let’s get started! Go into Room 5, apologize for their 6-hour wait, and sit. Listen attentively as the family describes how their 82year-old mother’s 5-year slow decline has come to a head at 5 PM on Friday. The major concern currently seems to be that Mom sleeps a lot. Take a detailed history of present illness; review of systems; social, occupational, and family history; and be sure to review the patient’s 30 home medications and 15 allergies. Try as you may, you will not uncover any acute symptoms other than increased sleeping. Speak loudly and repeat yourself often, because your patient doesn’t hear well and can’t understand why her family brought her to the ED in the first place. Order an exhaustive evaluation to “rule out anything bad that could be going on,” and promise to come back in 2 or 3 hours when the tests are back. On your way out of the room, the patient’s middle-aged daughter-in-law will pull you aside and tell you that the family wants Mom hospitalized and then placed in a nursing home immediately. The son and daughterin-law just got into town and really don’t feel that Mom can make it on her own anymore. Express your sympathy with their predicament but discuss the fact that you will have to uncover a medical diagnosis other than sleepiness to justify an admission. Mutter a prayer under your breath that something will show up on your testing, and move on. Grab a cough drop for that tickle in your throat, grab another chart, and let’s go! Your next patient is here to be checked because she is having some pain and someone told her that her ex-boyfriend has “got something.” Make an ironic joke to the charge nurse about running a free all-night STD clinic and head to the room. Your patient is angry about her 3-hour wait, and you will spend the first few minutes of your evaluation discussing ED staffing levels and apologizing for the patient’s inconvenience. The rest of the case is pretty standard, but you will have to return to the room to apologize for the delay in obtaining the pregnancy test results and to negotiate her work 80 Annals of Emergency Medicine
note request down to 1 day off. The patient’s disdainful swagger and bitter-sounding cell phone conversation on her way out the door will leave you convinced that she probably won’t check a “5” on her evaluation. By this time, you have been seeing patients, talking to families, apologizing for waits, and taking test results over the phone for a few hours. Take a short diet-Coke-and-granola-bar break to keep your energy up and tell your nurse friends a few funny stories about your 2-year-old daughter. This is fun and life-affirming, so ham it up a little and reenact the fit your child threw in the grocery store. The nurse who was discharging Bed 3 will want to hear what all the laughter is about, so tell the story again, complete with mock screaming. Your voice has become noticeably hoarse— congratulations! To compensate for this, speak a little louder. Now get back to work! “Code Blue, 4th floor.” Whoops, that’s your cue. Grab the difficult intubation bag and head for the stairs. When you get to the floor, speak up to identify yourself as the ER physician and ask what is going on with the patient. Repeat yourself a couple of times. You will be told that her nurse is on the phone with the primary physician, and she is the only one who knows the patient. An aide will tell you that the patient just had a bath. No one in the room will know the reason for the current hospitalization or what preceded the code. After you intubate and somewhat stabilize the patient, call her physician and give him an update over the phone. Get the chart and briefly review it as you are writing your code note. The house supervisor will ask you to talk to the family. Introduce yourself and sit down to compassionately discuss the end-of-life issues of a patient you have minimal information about. The patient will code again while you are talking to the family. Based on your 5-minute discussion of the pros and cons of continued aggressive care in a 95-year-old with metastatic cancer and pneumonia, the family will be leaning toward less aggressive care. The patient will decide the issue by going into asystole. Give your sincere condolences to the family and update the primary doc. Now head back to the ED; it was hopping when you left! On your way out the door, someone will ask you if you are sick, your voice is so bad. When you get back to the ED, everything is back on your first patient. Unfortunately, every test is totally normal. Return to Room 5, where you find that the son has convinced Mom that she needs admission “for more tests.” In a voice just above a whisper, discuss the comprehensive nature of the ED evaluation Volume , . : July
Flora
Change of Shift
thus far, and the low likelihood of finding a physician to admit a patient for sleepiness. Tactfully suggest that older people sleep more than younger people do. When the family becomes irate, promise to try to get her admitted. Talking will be difficult by now, so scribble a note to the secretary to call the hospitalist and grab another chart. You will decide to conserve what is left of your voice by communicating with the patients in writing. This will last for 3 simple cases, but the next patient will be a woman who just lost her 8-year-old granddaughter and you won’t feel comfortable writing notes to her. Speak in a stage whisper instead. The patient will whisper back to you and you will feel a little foolish. Offer soft condolences for the loss of her grandchild, address her chief complaint, and head back to the nurses’ station to take the hospitalist’s call. The doc on the phone is new to your hospital, and you don’t know her well. She will be taken aback to hear you whispering and you will have to repeat yourself several times to be
understood. She will manage to imply that you are lacking in medical knowledge and ability but will agree to admit the patient. This is a good thing because the son and daughter-inlaw have already left for the airport. Send the nurse in to tell the lady in Room 5 that she is being admitted, because you really can’t talk any more. Your shift is over. Go home and annoy your husband by writing notes about everything. You won’t be able to work your next shift due to total inability to speak, even whisper. Though you will feel silly having your husband call to find you coverage for such a benign illness, you can feel pride in having achieved your goal: you have laryngitis! Reprints not available from the author. Address for correspondence: Sara Dyer Flora, MD, Kentuckiana Emergency Physicians PLLC, 1 Audubon Plaza, Louisville, KY 40217.
CORRECTION NOTICE In the May 2008 issue, in the News & Perspective story (“Emergency Medicine in the VA: The Battleship is Turning”; pages 632-635), Dr. Olszyk’s and Dr. Kessler’s full names and institutions were omitted. They are Mark D. Olszyk, MD, MBA, deputy chief of staff at the VA Maryland Health Care System and chairman of the National VA Advisory Committee for Emergency Medicine; and Chad Kessler, MD, section chief in EM at Jesse Brown VA Hospital in Chicago. We apologize for these omissions.
Volume , . : July
Annals of Emergency Medicine 81