Telling A Patient "I Don't Know" Takes Years of Practice.

Telling A Patient "I Don't Know" Takes Years of Practice.

by The Happy Hospitalist

Physicians don't know everything. You may or may not have been raised to believe that physicians will always have the answers to all your questions.  They don't.  Not even the subspecialists whom patients believe are supposed to know everything. They don't. 

For many physicians, one of the hardest things to learn is how to tell the patient "I don't know". Medical school and residency offers no curriculum  that teaches your doctor how to tell you "I don't know".  For many doctors, admitting failure to the patient is a form of torture.

Telling patients "I don't know" takes practice.   Actually, it takes a lot of practice. You wouldn't think so, but for many new physicians, admitting their lack of knowledge about the science of your disease process is not easy.

I remember how hard it was to get through complete history and physical examinations during my early years as a third year medical student and then having to tell the patient I didn't know what was going on.  Telling a patient you don't know is hard.  Some doctors will never get comfortable with saying it.

As a resident, physicians are expected to engage in a greater sense involvement with their patient's care plan.  They are also expected to know more and more as the years progress. But rarely does one show up in morning report with the right answer being "I don't know".  Not knowing is never an acceptable answer during the grueling physician training process.  And many physicians train to accept that as the truth once they leave their academic training centers and enter the real world. 

I remember fielding hundreds of "That's the first time anyone has ever asked me that" type questions in my resident clinic.  I always seemed to have an answer  even if it wasn't the right answer.  I remember how hard it was to sit there, face to face, with a patient asking what may or may not have seemed at the time to be simple, easy and straight forward questions.   I remember thinking to myself that I should know this, but I don't. 

After seven years as a hospitalist and thousands of patients later, I find telling patients "I don't know" to be one of the easiest parts of my job as a physician.  If I don't know an answer, I don't hesitate.  I just tell the patient up front that I don't know.  And when I don't have an answer, often times the reason is because there is no answer, at least not the answer the patient is looking for.  In my clinical practice one of the most common indications I have found for telling patients "I don't know" comes in patients with chronic pain of unexplainable etiology that only responds to that drug that starts with a D.

Happy:  Ma'am, I understand you're having 12/10 abdominal pain,  I have concerns about pursuing further evaluation given the dangers of CT scan radiation exposure we are learning more and more about every day.  I think I am comforted by the fact you have had twelve CT scans, four ultrasounds, an exploratory surgery and hundreds of esoteric labs drawn in the last year,  all of which have been normal.  I am also comforted by your ability to keep down the Big Mac your boyfriend brought you an hour ago.  I see you have previously been referred to the outpatient pain clinic but refused to take the Elavil they recommended.  I have  previously discussed my concerns with you regarding your body's evidence of tolerance and dependence to narcotics, but you declined further evalutaion of this care modality.  I don't know why you're having abdominal pain for the last three years that only responds to dilaudid, but I have nothing further to offer you in your hospital care. I'm going to discharge you to home today.

Patient:  I can't go.  I'm having too much pain.

Happy:  I'm sorry ma'am.  I don't know what's going on, but I have nothing further to offer you in the hospital.  I'll fill out your paperwork for dismissal. 

Patient:  You're going to fill my dee-luu-ded aren't you?

Happy:  No ma'am.  I have a personal policy of not prescribing narcotics for unexplained chronic pain that only responds to dilaudid.   You'll have to talk to your primary care physician about long term management. 

Patient:  F**k you.

Happy:  I don't know what to say to that.

See how easy it is?  It gets easier every year.  Do you find it hard to tell a patient, "I don't know?"

Trick of the trade: Single digital block

Trick of the trade: Single digital block

by Stella Yiu

Your next ED chart: Finger injury

The finger needs to be anesthetized.

Patient: "I have had this freezing before. The needles really hurt! Is there anything else less painful? "
Trick of the Trade: 
A single, subcutaneous, volar-approach digital block

The traditional ring block involves two injections at the base of the finger (and a third injection if anesthetizing the thumbs and toes). A recent article adds to the literature on a non-traditional approach to the digital block - thesingle subcutaneous method.

Where do we inject?

Midpoint of the crease where the finger joins the palm, on the volar side.
How deep is the injection?
Subcutaneously. The anesthetic will deposit on top of the tendon sheath and infiltrate to where the digital nerves are.
How much volume?
About 2-3 cc.

Study results

How effective is this volar subcutaneous approach?
It is just as good as the traditional multiple-stick, dorsal approach. In this study at 5 minutes, 76% (28/37) patients in the single injection group were adequately anesthetised compared to 65% (22/34) patients in the traditional block (p=0.436, no statistically significant difference).

Also there were no differences in anesthesia at 10 minutes.
Is this less painful?
The self reported pain score was less, but again the difference was NOT statistically significant.
Do clinicians like this better?
Yes, the difference in Clinician Satisfaction score WAS statistically significant. In fact, many study clinicians adopted the single injection method, making recruitment of the trial subjects difficult.
What is my experience?
I really like this method since patients seem to tolerate this better. However, it does not work as well for the thumb, probably due to the dorsal branches of its digital nerves.

Other techniques described involve infiltrating the area 1-2 cm proximal to the digital-palmar crease similarly. I find they all work well for me.
What are others' experiences?
Converts swear by this. Some even use this to anesthetise toes!
Bottom line:
A single volar subcutaneous injection is efficacious and may be less painful for finger anesthesia.
Reference:
Cannon B, Chan L, Rowlinson JS, Baker M, Clancy M (2010). Digital anaesthesia: one injection or two?Emergency medicine journal: EMJ, 27 (7), 533-6 PMID: 20360491

You Know You Work for an A&E When

You Know You Work for an A&E When

You Know You Work for an A&E When:

1. You find yourself regularly asking people “Now, what part of this complaint fits into the Accident part or the Emergency part of A and E? Because, sorry, I really do need it to fit into one of those categories to let you see a Doctor…”

2. You see any person with a welfare card as your “employer”

3.You and all your friends work for an emergency service or a hospital

4.You marry an Ambo, Nurse or Doctor (sometimes if you want to step outside of this routine you may marry a Cop)

5.It drives you absolutely nuts when someone asks you if you ever think about going to university so that you can make medical decisions on your own.

6.You know that when a kid has been injured the person who will take up most of your time managing at the scene will be the parent, regardless of how sick or injured the child is

7.When a patient arrive at your ED and your first impression is, Umm why have you come here?

8.You thrive on serious trauma (and no, a paper cut doesn’t count a serious trauma people!)

9.You know that Full Moon = Insanity.

10.When you’re always checking out peoples’ veins for IV access.

11.Unconscious = cooperative.

12.You’re up at 2:00 am on Facebook, all in a day’s work.

13.Random phones and buzzers send your heart into VF

14.You get back pain just looking at really fat people!

15.Your dinner conversations often migrate toward that really messy trauma or explosive diarrhea call and you won’t lose your appetite.

16.If you’ve ever conducted a practical joke using oxygen tubing.

17.If you have use lignocaine gel on people’s phones, car handles or any door handle

18.If you find skipping with an oxygen tubing a good form of exercise

19.When your home first-aid kit consists of OP airways, maternity kits and bag and masks!

20.When your quick remedies kit for a hangover includes: 1L of Hartmann’s and a Maxalon

21.When you’ve wanted to hold a seminar on ’Suicide – How to Get It Right The FIRST Time.”

22.When you have come to the conclusion that you are sicker than 3/4 of the people in the emergency department

23.When you wash your hands before using the bathroom.

24.When you are watching TV and get annoyed and point out all the inconsistencies of the TV medics.

25.All your “funniest” stories are considered vulgar and disgusting

26.You tell the best story ever, and you’re the only one who can see the humor in it

27.“LOL” doesn’t mean “laughing out loud” but rather it means “little old lady.”

28.You have at least one “things up people’s butts” story.

29.You often finish a story with “and then he died”

30.When you think you did a great job… even though the patient still ended up dead

31.You’re covered in some bodily fluid or another more often than not and it doesn’t bother you.

32.You’re tempted to use “oxygen therapy” on all annoying people, not just patients: an O2 tank over the head fixes everything (especially in combative patients).

33.You want to throw something at the TV when they shock assystole on some TV show.

34.When a patient arrive in your ED and a relative says that you will need a chair because the patient can’t walk – umm… I will make that decision!

35.When you come home in a clean uniform after a shift and your spouse automatically becomes suspicious of your whereabouts.

36.You remember every patient by their injury or disease and not their name.

37.You describe a hospital gown as a “nice backless number”

38.You know every party illicit drug ever invented and what the “popular” ones are this week

39.You believe that most occupants of an MVA don’t have a spinal injury

40.Believe all patients lie

41.Although, unable to speak any other language, are adeptly fluent in all hand languages to signify that if the patient can walk into the Emergency Department, they can walk to the see the Doctor!

42.You know that its easier and more accurate to check a patient’s medications than to ask them what previous medical illnesses they have.

43.Have been caught out at some stage by suggesting that you will decide if a patient can walk or not, only to find that they have a broken leg.

44.You class CPR as one of your weekly exercise workouts

45You’ve described a patient who has suddenly died as having made “a good innings”

46You’ve made jokes, which you have honestly thought were funny, about a funny way in which a patient has died

The Differences Between Lucky and Unlucky People

The Differences Between Lucky and Unlucky People

by noreply@blogger.com (Lockup Doc)

by Lockup Doc

What separates the lucky from the unlucky in the world? Do people have control over their “luck,” or is luck an entirely random phenomenon?

I’ve often wondered about these questions. I have heard many successful people mention that an element of luck was one important ingredient in their success, but what exactly does this mean?

A couple of years ago I discovered a book called The Luck Factor. It was written by a British psychologist, Dr. Richard Wiseman. He carried out various research studies in order to better understand luck.

Here are some of his findings:

1. “Lucky people create, notice, and act upon the chance opportunities in their lives.” 

The way that lucky people think and behave makes them more likely to experience good fortune.  They expect positive results.

a. “Lucky people build and maintain a strong ‘network of luck.’” Generally speaking, lucky people are more social and more extroverted than unlucky people. They smile more; tend to like people and strike up conversations with strangers. They naturally develop networks of people. In turn, they increase their odds of coming across chance opportunities that more introverted persons might not.  This makes perfect sense to me. While I believe people should be able to happily exist as introverts or extroverts, this point presents a great argument for why introverts might want force themselves out of their comfort zones occasionally and learn to network with others.

b. “Lucky people have a relaxed attitude toward life.” Dr. Wiseman found that people who tended to be uptight and therefore too focused on a particular task at hand were less likely to see opportunities that those with more laid-back approaches to life. He cited several specific examples to illustrate this point. Interesting!

c. “Lucky people are open to new experiences in their lives.” Those who crave predictability and sameness are less likely to come across new opportunities than those who like variety and unpredictability. Again, there’s nothing inherently wrong with existing with either mindset, but those who fear change might find new opportunities if they shake the humdrum routine up a bit.

2. “Lucky people make successful decisions by using their intuition and gut feelings.”

a. "Lucky people listen to their gut feelings and hunches.” A larger percentage of lucky than unlucky people used their intuition; their gut feeling of whether something was right or wrong; in financial decisions, career choices, business, decisions, and personal relationships. Of course lucky people use more than just intuition in making most decisions, but this was one important aspect.

b. “Lucky people take steps to boost their intuition.” Lucky people were more likely than unlikely people to use strategies such as meditation, returning to a problem later, clearing their minds, or finding a quiet place.

3. “Lucky people’s expectations about the future help them fulfill their dreams and ambitions.”

a. “Lucky people expect their good luck to continue in the future.”  I think this is one of the most important points to emphasize from this book. Lucky people have lucky expectations. On questionnaires about their expectations of positive things manifesting and negative events not occurring, positive people expect the positive and do not expect the negative. The converse was true for the unlucky. I truly believe that what we put our attention on is what expands in our lives. I spend half of my professional time treating inmates, and every day that I work with them I encounter many who have such low expectations for their own lives that it’s no surprise that they fail to achieve what they say they want.

b. “Lucky people attempt to achieve their goals, even if their chances of success seem slim, and persevere in the face of failure.” Along these lines, both lucky and unlucky people create self-fulfilling prophecies. In other words, because of their positive or negative beliefs, they behave in ways that significantly increase the odds of the expected positive or negative outcome to occur. Although the author did not specifically mention that the positive and negative groups define failure differently, I suspect that they do. I personally believe that lucky people are more likely to see failure as nothing more than a negative judgment about a result that has been produced. It’s what one does with that result that matters. I suspect that many unlucky people are more likely to see the failure to produce a desired result as a personal failure.

c. “Lucky people expect their interactions with others to be lucky and successful.” This expectation often becomes another self-fulfilling prophecy: Lucky people behave in a manner that results in others responding to them positively.

4. “Lucky people are able to transform their bad luck into good fortune.”  

It’s not that lucky people never experience misfortune. However, when they do, they tend to approach it very differently than do those with an unlucky mindset.

a. “Lucky people see the positive side of their bad luck.” I think we all know that the concept of luck is relative. Whether or not we consider ourselves lucky in a particular situation really comes down to how we frame it. When involved in unfortunate circumstances, lucky people were far more likely than unlucky people to appreciate how much worse their circumstances could have been. Conversely, unlucky people tended to dwell on the negative any time that something happened that they didn’t like. For me personally, this point was the one I found most useful. While I generally have a ‘lucky’ mindset and expect good fortune, I realized that this was the one point on which I could most improve. 

b. “Lucky people are convinced that any ill fortune in their lives will, in the long run, work out for the best.” Often when something happens that we didn’t expect and don’t like, we assume it is a negative. But in the bigger picture, we really don’t know—events that appear negative at the time often become blessings in disguise. Regardless of apparent adversity, lucky people hold on to their belief that in the end, everything will work out for the better.

c. “Lucky people do not dwell on their ill fortune.”  This is an important point in our victim culture where people are often encouraged to bond to their wounds, forming an emotionally unhealthy identity tied to their misfortune.

d. “Lucky people take constructive steps to prevent more bad luck in the future.”  When things don’t work out, unlucky people are more likely to give up and feel defeated whereas lucky people are more likely to persist and to try to learn from their mistakes.

This book was a fun and at times enlightening read. If you’re expecting a book filled with rigorous objective scientific tests, this isn’t it. But if you want to learn about some of the practical differences between those who are more successful and less successful in life, then I believe the book has some valid points. Personally I found it useful.

What do you think about this?

Photo by Greencolander

Rules of EMS, Part One

Rules of EMS, Part One

Posted by kellyg in Genera
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1. Skin signs tell all.
2. Sick people don’t bitch.
3. Air goes in and out, blood goes round and round, any variation on this is a bad thing.
4. About 70% of the battery patients more than likely deserved it.
5. The more equipment you see on a EMT’s belt, the newer they are.
6. When dealing with patients, supervisors, or citizens, if it felt good saying it, it was the wrong thing to say.
7. All bleeding stops… eventually.
8. If the child is quiet, be scared.
9. EMS is extended periods of intense boredom, interrupted by occasional moments of sheer terror.
10. Always follow the rules, but be wise enough to leave them sometimes.
11. If the patient vomits, try to hold the head to the side of the bus with the least difficult-to-clean equipment.
12. If someone dies by chemical hazards, electrical shocks or other on-scene dangers it should be the patient, not you. (Also known as rule 1313)
13. Any EMT, FF, LEO and/or scene chief who is more drunk than the patient is the realproblem.
14. There will be problems.
15. The severity of the injury(s) is directly proportional to the difficulty in accessing, as well as the weight, of the patient.
16. Make sure the rookie EMT knows that a med patch is a radio term, and not a medicated bandage.
17. Paramedics save lives; EMTs save Paramedics.
18. If the patient looks sick, than the patient is sick.
19. If the patient is sitting up and talking to you, then the patient is not in V-Fib, no matter what the monitor says.
20. It is that bad.
21. Full spinal precautions were custom made for obnoxious drunks. So were NPAs.
22. If you absolutely must vomit, than it is probably best to turn your head away from the patient.
23. It is generally bad to use the words “holy s***” on scene, in reference to the patient’s condition.
24. Patients that crash in separate vehicles should be transported in separate vehicles.
25. Just because someone is fully immobilized doesn’t mean they can’t be violent.
26. If I’m up, EVERYONE is up!
27. Better them (another unit) than me.
28. I saved the patient… from the fire department.
29. When responding to a call, always remember that your ambulance was built by the lowest bidder.
30. Never get into the front of the ambulance with someone that is braver than you are.
31. When in doubt, use industrial strength therapy.
32. If it’s stupid, but it works… then it ain’t stupid.
33. Algorithms never survive the first thirty seconds of patient contact.
34. Always honor a threat.
35. Always know WHEN to get out of Dodge.  Always know HOW to get out of Dodge. Don’t go INTO Dodge without the marshal.
36. The important things are always simple.
37. The simple things are always hard.
38. If the patient is going to vomit (especially projectile) be sure to aim towards any bystanders that would NOT clear the scene. (This also works for OIC’s)
39. Sometimes it’s easier to beg forgiveness than get permission.
40. You can’t please any of the people any of the time.
41. They said, “Smile, things could be worse.” So we smiled and sure enough, things got worse!
42. Always answer a newbie’s questions. You once asked them, too.
43. Always trust bad feelings
44. Touch no one’s genitalia but your own.
45. The number of drugs a patient has on board is directly proportional to the number of knuckles tattooed. If the patient has every knuckle tattooed, the drug screen will simply say, “YES.”
46. PVC’s can be eliminated by sending a strip to the hospital.
47. The likelihood of a lethal arrhythmia increases with the distance of the paramedic from the “SHOCK” button on the monitor.
48. The ultimate QA program in EMS is an autopsy.
49. Best time to work a code: overtime.
50. Pain never killed anyone.
51. All fevers eventually fall to room temperature.
52. A patient’s weight is directly proportional to the chances the elevator will be non-functioning.
53. Here is a simple ETOH test: Hold your hands about 6 inches apart with thumbs and forefingers touching and ask the patient what color string you are holding. If he indicates a color, it is a positive test.
54. A tourniquet around the neck solves all problems.
55. If you drop the baby, pick it up.
56. Oxygen is good, blue is bad.
57. Never trust an ER doc with anything sharper than a tongue depressor.
58. GCS less than 8, intubate.
59. Asystole is a very stable rhythm.
60. A patient’s weight is in direct proportion to their altitude in the building.
61. A patient’s weight is directly related to the number of stair flights between him/her and the bus.
62. “When in trouble, when in doubt, run in circles, scream and shout”.
63. EMS RULE OF THREES (as it relates to codes) 300 pounds; <30 minutes to shift change; 3 stories up in the building.
64. Whoops: 1) the monitor just fell down the stairs, 2) the cold and flu patient just coded; 3) the wrong house. (Hint: the one with the Lab probably didn’t call 911)
65. Rules: 1) Don’t get dirty, 2) Don’t run, you may violate rule #1, 3) If it looks like you might get dirty doing something, let the new guy do it.
66. For every ALS skill we learn, we forget a BLS one.
67. The fire tetrahedron consists of the following: heat, oxygen, fuel, chief officer. Take any of them away and the fire goes out.
68. “Compassion kills.” Don’t dive into incidents.
69. If there is little to be gained, there is little to be lost. If there is a lot to gain, there is a lot to be lost.
70. If you lift an inch, crib an inch.
71. What do you call a medical student who finishes last in their class? Doctor.
72. If you think the cost of education is expensive, check out the cost of ignorance.
73. If it’s wet and sticky and not yours, leave it alone.
74. Death is a stabilization of the patient’s condition.
75. Every emergency has three phases; PANIC, FEAR, REMORSE.
76. You are bound to get a call either during dinner, while you are on the can, or at 02:00 in the middle of a great dream.
77. Training is learning the rules, experience is learning the exceptions.
78. Good judgment comes from experience, and experience comes from bad judgment.
79. Rocket scientists that get into stupid car crashes are the first ones to complain how bumpy the ambulance ride is.
80. “Poke & Hope” = blind sticking
81. Why do fire chiefs where white helmets? So you know where the Preparation H goes.
82. Never trust your bus, drug box, or airway bag to be fully stocked, in spite of the assurances of the off going crew.
83. If you don’t have it, don’t give up. Adapt, improvise, overcome. And if that doesn’t work, call for a second unit.
84. There is no such thing as a “textbook case.” Patients don’t read the textbook.
85. Newbies always look for large things in the smallest compartments, and vice versa.
86. There is no such thing as a bad call, only calls that didn’t go the way you planned.
87. Just because someone’s EMT or Paramedic original license date is before yours, does not mean they know what they are doing.
88. There are very few paramedics with 20 years of experience. There are thousands of paramedics with 1 year of experience, repeated 20 times.
89. Truckies are people who are over 6 feet tall and their hands drag the ground while walking upright.
90. Newbies have their own way of doing things.
91. When it comes to needles, ’tis better to give than to receive.
92. Listening to some EMTs talk on the radio makes you wonder why they don’t become professional auctioneers.
93. For every 25 calls you run, only 1 will be exciting.
94. Take comfort in the fact that most of your patients survive, no matter what you do to them.
95. The old EMS constant; no matter how bad the politics get, the doors go up and the trucks go out.
96. ALS really stands for “absolute loss of sense.”
97. Many of your patients will be healthier than you are.
98. Being in emergency services means you get to celebrate your holidays with all your friends, while on-duty.
99. Being an EMT means you get to expose yourself to rare, exotic and exciting new diseases.
100. EMS does not save lives; EMS is to care for people. It is 95% of what we do.