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One must always begin with the presenting complaint, then take a history of the presenting complaint. Soon after the presenting complaint, one must pay attention to the patient's past medical history, medications and allergies. One should always ask for the patient's family history to determine if there are underlying genetic diseases. Never forget to ask about smoking and alcohol consumption. Also, have an appreciation of the patient's baseline function, their finances and also what they do for a living to understand the impact their illness may have on their lives. The physical examination of relevant organ systems is then performed guided by the history. Based on the findings and provisional hypotheses, one would order investigations that will allow for appropriate management and definitive, evidence-based care.
In the Emergency Department however, things are quite different. Patients are not often in a position to answer dozens of questions related to their illness. Therefore, the order of the Physician's assessment is distorted. The "shoot first, ask questions later" approach is the mainstay of Emergency Department care, where clinicians are often providing management for patients and occasionally squeezing in a question or two in the process.
On our first day in ED, the six of us sat down with the staff specialist and he asked us a question: A 68-year-old lady comes with chest pain. What are you going to do?
Medical students above all else are taught to be safe clinicians. "If you don't know what the fuck is going on, start with the basics. That might stall you long enough to get to the right answer, or in fact, you may have actually answered the question." We answered the staff specialist's question in the traditional Physician's model.
"We should assess her general appearance."
"I would like to know more about the chest pain."
"Has this ever happened before or is this the first time she's had this pain?"
"I think we should examine her cardiovascular system."
The staff specialist listened patiently until all our eyes were fixed on him for the correct answer, even though one could argue that all of our responses were correct.
The first and foremost step in the assessment of any patient with chest pain is an ECG.
In this patient's presentation, which is a common one, the first and foremost knee-jerk response is an investigation rather than a history or physical examination. If one peers into the literature behind this, it's definitely the most appropriate thing to do. It's just so different not practicing the Physician's methodology of taking a history and performing an examination.
The sole purpose of any Emergency Department is to ensure patients are not critically ill, and if they are: resuscitate them. If they are not, either discharge them with GP follow-up or request intervention from the relevant specialist teams.
Mr. CE is an 82-year-old man who presented to the ED with the complaint: "my heart is missing a beat." At that point, I was attached to the hip of Jackie, an experienced ED resident, and we were seeing patients together. She pulled out his ECG and gave it to me. What do you think?
As I tried to make sense of Mr. CE's myocardial electrical activity, I didn't think his presenting complaint was very critical (in terms of life-threatening causes).
"It looks normal, but I would definitely get a pair of experienced eyes to make sure."
Ok. Well, here's his ECG from 2010 when he presented with a similar concern.
I had a look at the previous ECG and it didn't seem all that different.
Yes, he's had multiple presentations to our department with similar complaints. Although it's less likely to be critical, we should still see him to ensure everything's all right.
The nurse brought the patient into one of the Acute Care observation rooms for patients who are relatively well (i.e. alert and oriented as opposed to moribund).
Immediately, Mr. CE's eyes lit up when we walked into the room and introduced ourselves. He was telling us about why he came in, but often deviated to talk about his past days as an automotive engineer and spoke about his ex-wife's bipolar disorder. The missing beats usually occurred in the morning during breakfast, when he also noticed his temperature rise but not enough to cause a fever. He denied chest pain and any other significant cardiac symptoms. So in the eyes of Jackie, Mr. CE was good to go. The only problem was actually getting out of the conversation, as Mr. CE was so keen to talk to us about whatever he could. At one point I thought he might have been delirious, perhaps even have some flight of ideas (i.e. jumping from one topic to another with no rational transition).
Given that Jackie is a resident, she had to check with the staff specialist, who thought everything was fine but wanted to see Mr. CE herself. So I tagged along and we listened patiently to Mr. CE propel the conversation and the staff specialist was doing whatever she could not to offend him, as she had other patients who required more immediate attention. I think that is one of the rarest qualities of a good doctor: seeming as though they have all the time in the world to listen to a patient's story.
Mr. E, we're confident that this issue is not life-threatening and would be better looked after by your GP. However, I would like to have a look at your urine to ensure there is no underlying infection.
She was worried about an underlying urinary tract infection, which could be making Mr. CE delirious.
Jackie was writing up some notes. She looked up to see whether the staff specialist's impression had changed from her case presentation.
I think the diagnosis is loneliness.
There it was. It made perfect sense. The poor man had multiple presentations to ED throughout the last couple of years and looking through the previous admission notes, it was clear that he was as talkative as he was on the day we saw him. He wanted affection, attention and respect; the basic things everybody should have in their lives on a daily basis.
In my mind, that's how pathetic our society has become. Neighbours don't look out for one another let alone know each other's names. There's a very high incidence of divorce and separation, suggesting that even the deepest connections between people may be flawed and or we lack the language, effort or love to talk them through. Let's not forget about the horrendous stories of people being found dead in their apartments not because they were visited frequently, but from the odour their remains had left to the other tenants going about their business. Even then, it's about "make the smell go away" rather than the "there's something seriously wrong."
All three of us just stood there in silence, remembering that an important but tragic differential to any non life-threatening presentation may just in fact be a lack of human physical contact, just to start all over again with another person willing to listen.
The saddest part about all this was we couldn't give him the attention he craves. In the principles and practices of emergency medicine, Mr. CE is ready for discharge, never mind his solitude.
Unfortunately, it's a unique environment where the patient's needs may not necessarily be addressed and the care maybe misinterpreted as distant, objective medical practice... and the catch is: it's not a misinterpretation.
It's exactly that.
