- Email: [email protected]
The Advocate
CHANGE OF SHIFT
The Advocate Lawrence A. Kassman, MD
From the MaineGeneral Hospital Medical Center, Emergency Services, Waterville, ME.
0196-0644/$-see front matter Copyright ª 2005 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2005.04.013
[Ann Emerg Med. 2005;46:556-557.] As a volunteer working in a small emergency department on the island of St Lucia in the Caribbean, I heard a commotion at the door. A 36-year-old man staggered into the unit, clutching his abdomen. Supporting him was an anxious-appearing woman, his ‘‘girlfriend’’ and mother of his 6 children. Normally, as in other EDs, patients wait to be called into the treatment area, but this woman would not hear of waiting. ‘‘Where is the doctor?’’ she demanded, emphasis on the word ‘‘doctor.’’ The nurse, the only one on duty because the other had called in sick, was obviously irritated that this couple had barged into the unit to add to the confusion of the day. After working as a volunteer for a week, I still did not understand the system of patient flow. By the words being exchanged in harsh tones between the nurse and woman, punctuated by the groans of the man, I could tell however that this intrusion was not usual accepted procedure. ‘‘OK, come lie down!’’ the nurse finally exclaimed. ‘‘Come!’’ she repeated, pointing to a stretcher in the back of the ED usually reserved for suturing and procedures. The sheet, changed only prn, was wrinkled but had only a few dried bloodstains from a previous laceration repair. The man flopped onto the stretcher, fully dressed, and was then ignored by the nurse who returned to her charting. I got up from my corner of the desk where I was filling out laboratory requisitions for another patient. One for CBC, another for chemistries, another for urinalysis, another for blood culture, a last for chest x-ray. This paperwork was the physician’s job, a disincentive to ordering tests in a country where there is no health insurance and patients must pay cash at time of service. Ordinarily, I consider myself fairly conservative when it comes to ordering tests, but I had just examined an 87-year-old man with a temperature of 39.5 C who was undoubtedly going to be admitted. I walked to the last stretcher to check the man who had just come in. ‘‘He is in pain!’’ yelled the woman, as if I might not have appreciated this fact. The stern look on her face I had seen many times before in the past week. Often parents would adopt this approach with their terrified children in an attempt to make them cooperate for an examination. This actually did not upset me as much as the mother who, in trying a gentler approach, told her 3-year-old, ‘‘The doctor is not 556 Annals of Emergency Medicine
going to beat you.’’ I did not want to know how the 3-year-old would know what a beating was. Often, the nurses would use this same stern, confrontational approach with patients who defied their authority. Our nurse obviously sensed that she had met her match today and was having nothing to do with the assertive woman advocating for her man. ‘‘I’m Dr. Kassman. What can I do for you?’’ I asked, trying to melt the icy stare of the woman with an attempt at compassion. It did not work. ‘‘He is in pain, doctor!’’ she again stated, as if I were an idiot unable to grasp the seriousness of the situation. Again, the word ‘‘doctor’’ was emphasized as if the woman felt she had to remind me of my role. The next few minutes went relatively well because my full attention was focused on the patient, performing a history and physical examination. The man was complaining of abdominal pain of a few hours’ duration. Whether because of his discomfort or previous habit, he deferred to his lady friend to answer most of my questions. The history was not enlightening, nor was his examination, which was completely benign. I had become used to examining patients fully dressed because gowns were not part of the usual ED supplies. ‘‘What is wrong, doctor?’’ demanded the woman, as I finished my examination. ‘‘I’m not sure, but I don’t find anything that appears serious,’’ was my incorrect reply. ‘‘But he is in pain!’’ she angrily responded, and the glare in her eyes became even more intense. ‘‘I know,’’ I said. ‘‘I will give him something for the pain while we do some tests.’’ ‘‘You will admit him?’’ she continued, half question, half order. ‘‘That will depend on the results of the tests and how he feels,’’ was my answer. I ordered an injection of morphine while I went to fill out more requisitions. The woman seemed temporarily appeased. The nurse was visibly disappointed in my weakness. Patients were in pain all the time. Morphine was in short supply and should be reserved. For what, I was not sure. In the hours that passed while the man had an ECG, abdominal films, and waited endlessly for results of his blood work, he did improve considerably. In between seeing other patients, I would check on him from time to time. As his pain improved, so did the attitude of his lady friend. She did, however, look at me in a doubting, suspicious way each time I reported a test that had come back normal. Volume 46, no. 6 : December 2005
Change of Shift Finally, everything was back. Everything was normal. The patient, having had his morphine almost 4 hours earlier, was still comfortable. A reexamination again revealed no suspicion of a surgical or serious problem. ‘‘Then what is wrong with him, doctor?’’ the woman questioned, this time politely with a tone suggestive of concern rather than anger. ‘‘Nothing serious shows up on our tests,’’ I replied. ‘‘Is there something in particular you are worried about?’’ If she said ‘‘cancer,’’ I would explain that cancer symptoms do not come on suddenly. If she was worried about appendicitis, I could point out his soft abdomen and normal CBC. If she said ‘‘heart attack,’’ I could refer to the normal ECG. I would not try to explain that any of these conditions were still possible, but I was confident that the findings did not suggest them. The woman’s reply to my question surprised me, not only by what she said, but also in the way she said it. ‘‘Is he going to die, doctor?’’ she asked softly. I thought I saw a small tear in the corner of her eye. Now I realized why she had acted so aggressively. She had been afraid. In some parts of the world, people become ill and die, and their relatives never understand why. Medical care is not easy to access. Testing is limited. An explanation or
Volume 46, no. 6 : December 2005
diagnosis may not have been given because it may not have been known. Any illness is potentially like the one that killed a relative or friend. This is why parents rush their child to the ED if they vomit once or have had a fever for an hour. My patient had gotten off the stretcher. ‘‘I feel better,’’ he announced. His lady friend stood by his side, still looking at me for the answer to her question. I felt that in the past 4 hours we had finally brought down the wall of suspicion and distrust that had prevented useful communication. Although there are no absolutes in medicine, I had spent enough time with this patient to be confident of my answer. I looked her in the eye and smiled. ‘‘No, he will not die,’’ I answered. The woman smiled back. She put her arm around her man. ‘‘Thank you, doctor,’’ she replied. This time, the emphasis was on the words ‘‘Thank you.’’ Publication dates: Available online July 12, 2005. Reprints not available from the author. Address for correspondence: Lawrence A. Kassman, MD, Maine-General Hospital Medical Center, Emergency Services, 149 North Street, Waterville, ME 04901; 207-872-1307, fax 207-872-1302; E-mail: [email protected]
Annals of Emergency Medicine 557
The Advocate Lawrence A. Kassman, MD
From the MaineGeneral Hospital Medical Center, Emergency Services, Waterville, ME.
0196-0644/$-see front matter Copyright ª 2005 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2005.04.013
[Ann Emerg Med. 2005;46:556-557.] As a volunteer working in a small emergency department on the island of St Lucia in the Caribbean, I heard a commotion at the door. A 36-year-old man staggered into the unit, clutching his abdomen. Supporting him was an anxious-appearing woman, his ‘‘girlfriend’’ and mother of his 6 children. Normally, as in other EDs, patients wait to be called into the treatment area, but this woman would not hear of waiting. ‘‘Where is the doctor?’’ she demanded, emphasis on the word ‘‘doctor.’’ The nurse, the only one on duty because the other had called in sick, was obviously irritated that this couple had barged into the unit to add to the confusion of the day. After working as a volunteer for a week, I still did not understand the system of patient flow. By the words being exchanged in harsh tones between the nurse and woman, punctuated by the groans of the man, I could tell however that this intrusion was not usual accepted procedure. ‘‘OK, come lie down!’’ the nurse finally exclaimed. ‘‘Come!’’ she repeated, pointing to a stretcher in the back of the ED usually reserved for suturing and procedures. The sheet, changed only prn, was wrinkled but had only a few dried bloodstains from a previous laceration repair. The man flopped onto the stretcher, fully dressed, and was then ignored by the nurse who returned to her charting. I got up from my corner of the desk where I was filling out laboratory requisitions for another patient. One for CBC, another for chemistries, another for urinalysis, another for blood culture, a last for chest x-ray. This paperwork was the physician’s job, a disincentive to ordering tests in a country where there is no health insurance and patients must pay cash at time of service. Ordinarily, I consider myself fairly conservative when it comes to ordering tests, but I had just examined an 87-year-old man with a temperature of 39.5 C who was undoubtedly going to be admitted. I walked to the last stretcher to check the man who had just come in. ‘‘He is in pain!’’ yelled the woman, as if I might not have appreciated this fact. The stern look on her face I had seen many times before in the past week. Often parents would adopt this approach with their terrified children in an attempt to make them cooperate for an examination. This actually did not upset me as much as the mother who, in trying a gentler approach, told her 3-year-old, ‘‘The doctor is not 556 Annals of Emergency Medicine
going to beat you.’’ I did not want to know how the 3-year-old would know what a beating was. Often, the nurses would use this same stern, confrontational approach with patients who defied their authority. Our nurse obviously sensed that she had met her match today and was having nothing to do with the assertive woman advocating for her man. ‘‘I’m Dr. Kassman. What can I do for you?’’ I asked, trying to melt the icy stare of the woman with an attempt at compassion. It did not work. ‘‘He is in pain, doctor!’’ she again stated, as if I were an idiot unable to grasp the seriousness of the situation. Again, the word ‘‘doctor’’ was emphasized as if the woman felt she had to remind me of my role. The next few minutes went relatively well because my full attention was focused on the patient, performing a history and physical examination. The man was complaining of abdominal pain of a few hours’ duration. Whether because of his discomfort or previous habit, he deferred to his lady friend to answer most of my questions. The history was not enlightening, nor was his examination, which was completely benign. I had become used to examining patients fully dressed because gowns were not part of the usual ED supplies. ‘‘What is wrong, doctor?’’ demanded the woman, as I finished my examination. ‘‘I’m not sure, but I don’t find anything that appears serious,’’ was my incorrect reply. ‘‘But he is in pain!’’ she angrily responded, and the glare in her eyes became even more intense. ‘‘I know,’’ I said. ‘‘I will give him something for the pain while we do some tests.’’ ‘‘You will admit him?’’ she continued, half question, half order. ‘‘That will depend on the results of the tests and how he feels,’’ was my answer. I ordered an injection of morphine while I went to fill out more requisitions. The woman seemed temporarily appeased. The nurse was visibly disappointed in my weakness. Patients were in pain all the time. Morphine was in short supply and should be reserved. For what, I was not sure. In the hours that passed while the man had an ECG, abdominal films, and waited endlessly for results of his blood work, he did improve considerably. In between seeing other patients, I would check on him from time to time. As his pain improved, so did the attitude of his lady friend. She did, however, look at me in a doubting, suspicious way each time I reported a test that had come back normal. Volume 46, no. 6 : December 2005
Change of Shift Finally, everything was back. Everything was normal. The patient, having had his morphine almost 4 hours earlier, was still comfortable. A reexamination again revealed no suspicion of a surgical or serious problem. ‘‘Then what is wrong with him, doctor?’’ the woman questioned, this time politely with a tone suggestive of concern rather than anger. ‘‘Nothing serious shows up on our tests,’’ I replied. ‘‘Is there something in particular you are worried about?’’ If she said ‘‘cancer,’’ I would explain that cancer symptoms do not come on suddenly. If she was worried about appendicitis, I could point out his soft abdomen and normal CBC. If she said ‘‘heart attack,’’ I could refer to the normal ECG. I would not try to explain that any of these conditions were still possible, but I was confident that the findings did not suggest them. The woman’s reply to my question surprised me, not only by what she said, but also in the way she said it. ‘‘Is he going to die, doctor?’’ she asked softly. I thought I saw a small tear in the corner of her eye. Now I realized why she had acted so aggressively. She had been afraid. In some parts of the world, people become ill and die, and their relatives never understand why. Medical care is not easy to access. Testing is limited. An explanation or
Volume 46, no. 6 : December 2005
diagnosis may not have been given because it may not have been known. Any illness is potentially like the one that killed a relative or friend. This is why parents rush their child to the ED if they vomit once or have had a fever for an hour. My patient had gotten off the stretcher. ‘‘I feel better,’’ he announced. His lady friend stood by his side, still looking at me for the answer to her question. I felt that in the past 4 hours we had finally brought down the wall of suspicion and distrust that had prevented useful communication. Although there are no absolutes in medicine, I had spent enough time with this patient to be confident of my answer. I looked her in the eye and smiled. ‘‘No, he will not die,’’ I answered. The woman smiled back. She put her arm around her man. ‘‘Thank you, doctor,’’ she replied. This time, the emphasis was on the words ‘‘Thank you.’’ Publication dates: Available online July 12, 2005. Reprints not available from the author. Address for correspondence: Lawrence A. Kassman, MD, Maine-General Hospital Medical Center, Emergency Services, 149 North Street, Waterville, ME 04901; 207-872-1307, fax 207-872-1302; E-mail: [email protected]
Annals of Emergency Medicine 557