In this episode, Mitchell Zekhtser, MD and Christopher Doty, MD FAAEM discuss how to provide better care for the most vulnerable patients. Dr. Zekhtser, is an Emergency Medicine Resident at Albany Medical Center, as well as a past AAEM/RSA Medical Student Council Western Regional Representative, and a past AAEM/RSA Vice Chair of the Education Committee, and Dr. Doty, is the Residency Director of the Department of Emergency Medicine at the University of Kentucky, as well as a member of the AAEM Education Committee.
Follow Dr. Christopher Doty on twitter at @PoppasPearls
There are three things that are essential in medicine and if you have not been able to discharge the patient you have not done one of these three things.
As Dr. Doty said, say to the patient “Thanks for coming in today. I know you are concerned and I am too, but we are going to look at a few things and you will feel better soon.” This is hope and compassion. You provide them with compassion by affirming their concerns and you give them hope that they will be feeling better soon. Which generally is true. People feel better when they know someone cares for them regardless if you do any interventions. The final point is providing medical magic. Medical magic is listening to their heart and lungs or looking in their mouth or their ears. This may not be essential and won’t change your disposition, but the patient may feel that they came to the emergency department and someone truly evaluated them. Lastly, this is something that works well for me. Patients can feel silly for coming into the emergency department. However, I always respond with, “It is not your job to know what an emergency is. It is my job.” It is especially useful when you don’t have an exact diagnosis on why they came to the ED today, but you at least provided them with peace of mind that it is not a life-threatening diagnosis.
Case 1. The imaginary twins:
Early 20s female who is 28 weeks pregnant presenting with bleeding and contractions. Generally in Dr. Doty’s shop, those patients are sent to obstetrics triage when they are beyond 20 weeks pregnant. OB runs a pregnancy test and it says she’s not pregnant. So the patient comes back to the ED where a serum pregnancy test is run, again it was negative. This patient was absolutely sure she was pregnant. Pelvic exam shows a non-palpable uterus. It became more apparent that she was delusional, but the patient was convinced that she was pregnant with twins. The rest of the case has a good twist, so I won’t ruin it here.
The teaching point is the medicine for the psych patients is not complex. The most complicated thing they may have is malnutrition or alcoholic ketoacidosis or clotting disorders or liver disease. We need to know how to manage the social issues. We feed them, give them hydration, and discharge. However, we didn’t fix them. We should try to get the social aspects addressed with to the best of our abilities and resources.
Case 2. The case where the patient has nowhere to go:
Veteran who served overseas. When he came back, he didn’t get the welcome he needed. No job, homeless, PTSD, anxiety, honorable discharge from army and served his country. Living on the streets of Lexington, was robbed. Forearm fracture of radius/ulna. Patient’s arm was reduced and splinted. Patient can’t follow-up with ortho because he can’t pay. Despite wanting to pay for the hospital bill. Now he has to be in pain, in a splint. Fortunately he could follow-up with the VA.
The teaching point is that sometimes an unsafe discharge can be considered an admittable diagnosis. However, this may require finesse because it is difficult to get reimbursed for this.
The three factors of Joiner’s theory on suicide
Our outlook on our jobs.
Sometimes we feel that is not our job to fix the drug addict or the alcoholic. We are there for the variceal bleed, the trauma, the diabetic ketoacidosis.
Maybe we are.
We are there to heal and to take care of people. At times we may lose touch with this thought. Everyone needs taken care of. Everyone who comes in perceives they have a problem and they are asking for help. As Dr. Daniel Moore from University of Kentucky says, “I am in the business of saving lives and helping people.” We must take these people seriously every single time!
Let’s not judge patients for a single mistake that may have led them to this current life they are in. Let us reframe the this interaction with the drug addict, reframe the interaction with people seeking pain meds. We can either let us drive us crazy or we can see this as an opportunity to have an impact in people’s lives. That is why we do it. This is an opportunity to heal people. The way we add resiliency to see this an opportunity to help. Maybe today is the day when the patient thinks, “This is the first time I went to the ED and someone treated me like a person and maybe I need to get my stuff together.”
Choosing compassion for our patients.
We are in the business of saving lives and we are in the business of providing compassion to our patients. When a patient loses their clothes in a trauma or in another unfortunate situation, let us consider providing them with something other than paper scrubs to go home in. Consider getting a clothing bank.