Catchphrases in Emergency Medicine: Part 1, by Mike Heller, MD.

Mike Heller, MD

Let’s face it: we’re in a repetitive business. We face the same problems over and over again. Not surprisingly, some of these situations are difficult but the good news is that they are (almost) never unique. The sagacious and/or experienced ED doc will have learned a number of   phrases that can help in such situations. I hereby share some of these with the bloggership with the proviso that you send in your favorites.

 1)    The sticky situation where the family member has been brought in unconscious or gravely impaired and the CT has just shown a large intracerebral bleed. You know it’s “over” but the patient could actually live a long time with intubation etc. Here’s what you say to the family who asks what’s going to happen: 

1)    The sticky situation where the family member has been brought in unconscious or gravely impaired and the CT has just shown a large intracerebral bleed. You know it’s “over” but the patient could actually live a long time with intubation etc. Here’s what you say to the family who asks what’s going to happen:

                                                    Her meaningful life is over.

In addition to being true, this has the added advantage that you are not required to make a declaration regarding “how much longer does she have?”  It allows the unprepared family to decline a respirator or to allow you to remove the tube and “disconnect the machine” if it has already been initiated.

2)    The frequent situation where the patient-usually young- presents yet again with chest pain (or abdominal pain etc.)  that is clearly nothing, often with many negative caths, CT’s etc. in the past. You explain it is not serious and then he/she asks yet again, “But what is causing it?”  You look them in the eye and reply:

It’s just like headaches; doctors have no idea what causes most of them but we do make sure it’s nothing serious or dangerous and we’re sure of that in your case.

Again, you have told the absolute truth and reassured these patients- often of an artistic temperament- that the pains are nothing to worry about. You then immediately say that you will, of course, treat their pain (see previous blogs regarding Darvocet, Levsin, etc.).

3)    She is 6-10 weeks pregnant and has had cramping and bleeding. The bedside ultrasound shows an intrauterine pregnancy but it’s not right. The g-sac is eccentric, there’s not a great double decidual sign and there’s something in the sac but it doesn’t have a clear heartbeat and/or it is not at all right for the dates (which you can be especially sure of if she’s had a positive pregnancy test or ultrasound some weeks prior.) You make eye contact and speak gently:

The reason it’s taking so long is that we want to be extra careful. There is a pregnancy and it is in the uterus but it really doesn’t look right. I would expect at this stage to see a good, strong heartbeat and other parts and there’s nothing like that. I’m afraid you’re probably going to go on and have a miscarriage. There’s nothing you could have done to cause it and nothing to prevent you from having a baby in the future

Although not every word of this is necessarily true (maybe she did do something to “cause” it and maybe she will have trouble having a baby in the future). It honestly transmits bad news, gives a fair idea what will happen in the next few days, and lays out an optimistic scenario for the future.

I’ll have more in upcoming months but I’d like to hear yours, first. 

Comments

[Graham Walker]

I posted several similar thoughts over on The Central Line. I like yours too! One Liners to Convince Patients

[Neal Little]

I have one I frequently use- e.g chest pain with a negative workup for MI or PE, or abdominal pain where whatever you have done excludes acute emergencies. When i'm giving the "good news- no findings" and they ask, so what is it, I respond that the way we approach some things in the Er seems backward to patients. They come in with a series of complaints, and want to know "What is it?" and i want to know "what it isn't". And then tell them that we've gotten to that point, and their doc can "pick up the ball" ( sports analogies are always good) from here. And, it is actually how we approach many complaints.