Discharge Instructions

It’s 1AM, you’re a third of the way through your night shift. You finish at 7:30 but that seems a long way away. You’ve just seen a 25 year old male patient with some vague abdominal pain, nothing specific, and a normal examination. You don’t think it’s an appendicitis and you’re getting ready to discharge him.

At most hospitals you now have the option of creating a discharge information package for this fellow. It’s a document written by the hospitals medical staff and lawyers, usually many pages long, detailing every imaginable thing that could happen or go wrong. Usually it prints from the computer system and you fill in the blanks. It’s written in plain language, easy to understand as long as the patient has at least a pre-med degree.

Pre-printed discharge instructions are mostly useless. Most emergency departments place a waste container near the exit to handle these instructions as patients leave the building. Patients with wood-stoves or fireplaces may keep them to use as kindling, but they serve little other purpose. They are too long, too complicated, and too impersonal.

When you are discharging a patient, especially a patient with an uncertain diagnosis, do it yourself. Take a moment and sit at the bedside. Tell the patient that it is still uncertain what exactly is causing their problem. Tell them that you don’t think it is anything serious or life threatening or you would be keeping them in the hospital.

When you explanation is complete tell the patient; ‘There are a few things I want you to do.’ Then take out your prescription pad and write down a maximum of three discharge instructions. Three, that’s the number that most patients are going to be able to handle. If you need 15 instructions to get the patient home, the patient should probably not be going home, so you only get three.

Instruction number 1 is about time and place specific follow-up. ‘See your GP tomorrow morning.’ ‘See the orthopaedic surgeon next Tuesday.’ ‘See me, in the ER in 6 hours for a recheck.’ The person is specified, and the time is specified with no room for ambiguity.

Instruction number 2 gives situation specific cues for the patient to return to the emergency room immediately. Usually these are simple, if your pain is worse, if you have any weakness, if you are vomiting. This instruction always lists the place of follow-up as the emergency department.

Instruction number 3 always gives the same simple message; If you are worried, or if you think something is wrong, come back to the emergency department right away. We would be happy to see you again, anytime.

These instructions are simple and understandable. They minimize your medico-legal risk by minimizing the patients risk. They are personal, the patient knows that you created the instructions just for them, and just for this situation. Finally they are written on a prescription pad, a quarter sized piece of paper that only important things are written on.

Our patient has abdominal pain, maybe he has gas, maybe he has early appendicitis, the reality is that we just don’t know. So that’s what we tell him, and then we write a set of discharge instructions that list:

  1. Time and person specific follow-up
  2. Cues to return to the emergency department immediately
  3. An open invitation to return at any time if the patient thinks something is wrong or has any concerns

Sample discharge instructions

The chances are that our patient will be all better in the morning and go to work, instead of coming back for his re-check. But, for the occasional time that this patient will come back with appendicitis a good set of discharge instructions changes everything; instead of being the doctor who missed appendicitis, you will be the doctor who knew it might be appendicitis and arranged follow-up.

Factoid: Causes of Acute Vision Loss

A patient arrives in your ED with acute loss of vision. How many potential causes of acute vision loss spring to mind?

  1. Globe rupture
  2. Optic neuritis
  3. Iritis
  4. Uveitis
  5. Endopthalmitis
  6. Glaucoma
  7. Corneal ulceration
  8. Ocular migraine
  9. Ischemic optic neuropathy
  10. Traumatic lens dislocation
  11. Arterial dissection (aortic, carotid or vertebral)

  1. Hyphema
  2. Vitreous haemorrhage
  3. Macular haemorrhage
  4. Retinal detachment
  5. Retinal artery occlusion CRAO
  6. Retinal vein occlusion CRVO
  7. Occipital/PCA cerebrovascular event
  8. Pre-eclampsia
  9. Functional visual loss
  10. Idiopathic intracranial hypertension (could also be painful with headache)

Minimizing pain with local anesthesia

‘Wow doc! That freezing hurt more than the cut did in the first place!”

It’s common knowledge among our patients that the ‘freezing’ we give them as we prepare a wound for closure is often worse than the initial injury. We tell our patients that it will only hurt for a second, or that the momentary discomfort is for good reason. ‘Ouch!!’ they still yell as we inject the lidocaine and get ready to suture ‘That stuff hurts!’

Are our patients just wimps? Should they just suck it up and deal with the pain?

If you think the answer to these questions is yes then here’s a little experiment for you. Go get some 1% lidocaine and a 22 gauge needle. Now inject 1 ml into yourself, it doesn’t matter where really but for the sake of the experiment choose somewhere sensitive like your volar forearm. Okay, how did that go?  Yes, it hurts, but don’t worry we did the experiment for a good reason.

How can we minimize our patients discomfort during administration of local anesthesia? Most of us already know how to do this, but we aren’t. Perhaps we are desensitized to pain issues, but more likely we worry it will take too much time. In reality there is very minimal time requirement, and patients will be grateful. In fact, if they have had ‘freezing’ before and you do this well they will automatically think you are an amazing doctor!

  1. Minimize your patients anxiety. Tell them in a reassuring voice that you are going to minimize their pain.
  2. Consider alternatives to injected local anesthetic. Will topical anesthetic work? Should the patient have procedural sedation?
  3. Choose 2% lidocaine. High volume injections are more painful, so choose to inject a smaller volume of more concentrated lidocaine. 1% solutions are best used for large wounds where we need to get good anesthesia but are constrained by maximum doses, so need more dilute solution.
  4. Put your anesthetic somewhere warm. Warm anesthetic hurts less. I like to put a few ampules of 2% lidocaine in my scrubs pocket, or under the desk light at a work station.
  5. Buffer your lidocaine. Lidocaine has a pH of 7.4, and injection hurst less when it is buffered. Use a ratio of about 10 parts lidocaine to 1 part sodium bicarb.  I usually draw up 0.5ml of 8.4% sodium bicarb from an amp then fill the rest of a 5ml syringe with lidocaine, invert several times to mix and voila!
  6. Provide a distracting counter-sensation prior to injection. Rub the patients skin proximal to the injection site.
  7. Use a small gauge needle.
  8. Infiltrate directly into the wound rather than through intact skin.
  9. Inject the anesthetic slowly.
  10. Allow time for the anesthetic to work. Lidocaine works fast, but you need to allow a minute or two for it to take full effect.

Once we decide that providing a maximally pain free experience for our patients is important the rest is easy. These steps will become second nature to you, and patients will think you’re the best doctor ever, because ‘It didn’t hurt a bit!’

A scan to be sure…

Both doctors and patients like the idea of certainty. We want to be sure that a patient with chest pain isn’t having a heart attack, and that the patient who seems to have a kidney stone doesn’t actually have an aortic aneurysm. We are trained to think ‘worst first’ and to consider uncommon presentations of common diseases. Most of time this serves us well, but sometimes it can lead us down the rabbit’s hole into a world of testing as a surrogate for certainty. We will go to great lengths to prove something is or isn’t happening, but there’s a dirty little secret in medicine; we’re never 100% sure.

Even in our most certain moments, the chest pain patient with a ECG showing STEMI, the abdominal pain patient with CT proven appendicitis there lives uncertainty. Every test and examination we do in medicine has a sensitivity and specificity (though sometimes the s/s is un-studied and unknown). In emergency medicine we live in a world of uncertainty, and it can be difficult to communicate this with our patients.

“Doctor, how do you know it’s not my appendix?” asks the patient who vomited and has abdominal pain, but a completely reassuring examination “Shouldn’t I have a scan to be sure?”.

In some medical systems, driven by fear of litigation, the answer seems to be yes, the patient should be scanned in order to be sure. But, we should be clear, many of these definitive tests offer only the illusion of certainty, along with the reality of risk. For many of the tests we think of as offering certainty (imaging, angiography, etc) the risks of complications and of false positives of any sort are amplified when the test is applied to patients at very low (but not zero) risk of the disease. Some resource limited systems err in the oposite direction, encouraging clinicians to be overly certain of the lack of pathology in low risk patients.

Do we need to go down the rabbit’s hole of testing every-time? Should we simply tell the patient they don’t have the illness, when there is still a tiny bit of uncertainty? Is there a better way to communicate risk to the patient we think that the risk of disease is low? I think there is, and the path to get there is through better communication. When we see patients at low (but not zero) risk for a condition what we need is usually not more, or better tests, rather better communication. In any doctor-patient interaction there are 2 crucial questions that must be answered, the question of the disease entity the doctor is worried about, and the question of the disease entity the patient is worried about. The first is almost always answered, the second is surprisingly often both unknown and unanswered.

I find it useful to ask patients ‘What’s the thing you were most worried about today?” Sometimes it lines up with what I’m worried about and sometimes not, regardless that question is the reason the patient came to the emergency and the patient deserves to have that question answered and explained. Then I say to the patient; ‘When I first hear a story like yours I am worried about X. Today, when we really flesh the story out, and did a good exam I can tell you that I think you are at low risk for X and here’s why…”  Then I disclose to the patient medicine’s dirty little secret, we are never 100% sure, and I try to give a risk estimation to the patient. Then I try to gauge the patients personal risk tolerance and reconcile with the actual risk level, sometimes there are tests we should consider in particularly risk averse patients. Finally I give the patient a brief summary  of the cues that will bring them back to my care.

In summary:

  • Answer the concern that prompted the patient to come to the emergency department
  • Answer the concerns you had when you heard the patients story
  • Disclose the risk level as accurately as possible to the patient
  • Try to reconcile the risk level and the patients risk tolerance
  • Give the patient a brief summary of cues to return to the emergency department

There is always resistance to this approach, doctors believe it will take too much time or that patients won’t like this approach. In fact it probably saves time rather than placating patients with potentially un-needed tests, and it is definitely an approach most patients appreciate.

So the next time a patient with abdominal pain and a normal exam asks you if they shouldn’t have a scan, just to be sure, try taking the couple of minutes to have a discussion about shared risk. I think you will be surprised how effective this strategy actually is.

Factoid: Causes of an elevated troponin

  • Myocardial infarction
  • Myocarditis
  • Congestive heart failure
  • Pulmonary embolism
  • Aortic dissection
  •  Sepsis/Shock
  • Arrhythmia
  • Cardiac contusion
  • Intracranial haemorrhage
  • Chronic Renal Failure
  • Takasubo cardiomyopathy
  • Prolonged exercise (marathon running)