The Size of the Bite; Managing Stress in Emergencies

‘You never seem to get too stressed out’, one of the nurses at my work recently told me, ‘why is that?’ It got me thinking, why don’t I seem stressed out, what am I doing when I do get stressed out at work? Certainly there are times when I feel stressed, but because I believe that an uncontrolled stress reaction can be detrimental to my ability to do my job I have found ways to turn down the gain when the stress is high.

In the emergency department stress is everywhere, from the critically ill patient in septic shock, to the patient with a sprained ankle. Every patient in the department is having a bad day, and every one of them is stressed out. Some doctors love the stress, the air around them glows as their very nature of being elevates surrounding electrons to higher energy states.

Stress itself can be a useful response, it can hone thinking and actions and when used appropriately can elevate your game. When stress degenerates into panic or frustration however it becomes just another obstacle to be overcome in an already difficult situation. As a physician in a busy emergency department often with single physician coverage I believe stress management is an important part of my job. It would be easy to become overwhelmed and over-focused on any of dozens of things in an individual shift. Emergency physicians working in an environment that is frequently stressful (probably 99% of us) should employ active strategies of stress reduction throughout our shifts. This increases our job satisfaction and it also increases patient care.

By now some of you are thinking ‘This guy lives n the west coast, he probably has a little yoga-meditation room at his hospital and sees 1 patient every 2 hours!’ Nothing could be further from the truth. The type of stress reduction I am talking about happens as you work, and it allows you to work better and faster.

Step 1: When the temperature in the room goes up, my temperature will go down. When the patient, the nurses or other physicians are getting increasingly overwhelmed, agitated, and stressed the situation becomes dangerous. The potential for medical error and misadventure is high at these moments. This group stress response can feel like a tornado and it can be tempting to allow yourself to be sucked into that vortex. Resist. When everyone else is stressed force yourself to speak calmly, slowly, with little intonation. Do not yell, but if you need to you may start out by saying in a firm voice ‘Everyone listen to me, this is how we will begin…’ Set (or reset) the tone of the room, the tone you want to project is calm confidence (even if you do not feel confident).

Step 2: Identify the person in the room who is the most stressed out and give them a task. If this person is a nurse, you need them to go draw up a med or start an IV or do some other useful task. You need to choose something that is simple and tangible and will redirect their focus away from the stress of the situation. If this person is a family member, give them a pen and paper and ask them to write down what they think is important so it will not be forgotten. If this person is the patient place your stethoscope on their chest and tell them you need them to give you 10 slow breaths while you listen to their lungs.

Step 3: When the whole situation is overwhelming break it down into smaller bites. An ambulance arrives unexpectedly and the paramedic runs into your resus room holding a child who has just been run over by a car. The situation is overwhelming, people are screaming, what do you do. This situation is emotionally charged and overwhelming, it would be easy to get caught up in the panic. Really we know nothing about the patient aside from the fact that there is a potentially devastating injury. The totality of the situation is overwhelming from both an emotional as well as a practical perspective. In a situation like this the best strategy is to step away from the totality of the situation for a moment, and take a small very manageable piece to start with. In situations of critical illness these initial first steps are the same regardless of the illness or injury. These initial first steps; put oxygen on the child, immobilize the C-spine, establish IV access, offer an opportunity to reset the tone of the room. Although these first steps take only moments if they are directed with calm confidence they will de-escalate the room and allow the remainder of the resuscitation to proceed calmly. When you personally feel stressed or overwhelmed it is useful to simply think of the next 1 or 2 things that need to be accomplished and then execute these very short term goals. Usually this will reset your internal stress level and allow you to again assert a calm confidence into the situation.

Stress is a useful response and it should not be ignored. Many of us in emergency medicine are here because we enjoy stress, and thrive in a world of high stakes decision making. Stress can be one of our most useful tools in emergency medicine, but for all of us there are moments that threaten to overwhelm our capacity to cope and degenerate into panic. Whether it is a failed airway, an injured child, or a difficult patient encounter using active techniques to manage stress will improve both your situational responses as well as your patient care.

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.

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.

Learning to learn

The best teacher I’ve ever had once told me ‘Accept ignorance, accept that you just don’t know, once you get that into your head you’ll start to learn.’ (Since many have asked me, the person who gave me this advice was Dr. Jim Ducharme…a true master and student of emergency medicine)

Emergency medicine is the broadest of disciplines, we treat all comers for all problems. The field represents a body of knowledge that borders on the un-master-able. Every experienced emergency doctor will tell you how the pride goes before the fall, when everything is clicking just perfectly when you have finally become a master physician prepare to be humbled by your next patient. And yet there is another side to emergency medicine, a side that demands from us a confidence and an arrogance to be the person who steps up when a patients life is on the line and says ‘I am the best person to take care of this incredibly sick patient’.

Unfortunately we have all been through a teaching process as medical students and residents where we were taught that identifying our own ignorance of a problem identified our weakness. As a result most doctors have a tendency to flee from ignorance. When confronted with a situation where our knowledge is inadequate we tell ourselves ‘I mostly knew what to do’ or ‘I figured out what to do’. We don’t want to admit to ourselves the truth, our knowledge was inadequate, because we have been taught that this makes us a bad doctor.

If you doubt that doctors dislike confronting ignorance offer to audit your departments CME for a year. You will see that the best ECG reader in your department is going to more ECG courses and your tox guy is going to more tox courses. This is often more an process of continuous medical affirmation than continuous medical education.

People are worried about admitting that they don’t have all of the answers; ‘If I admit I don’t know something the people I work with will think I’m an idiot.’

Au contraire mon frere. When you admit you don’t know something and are able to rapidly and effectively learn and apply information the people around you, both professionals and patients, will be impressed. We live in a world surrounded by information, the days where information was scarce and had to all be kept in our heads are gone. No one expects us to know everything (half of the patients we see think that we are junior doctors not yet seasoned enough to have our own practice and relegated to the emergency department), and ‘I don’t know but I can find out’ is perfectly acceptable.

The secret to life long learning is simple. Everyday, and every patient ask yourself ‘Could I have done that better?’ Then identify the gaps, with brutal honesty, and fill them in. Then, when someone asks you if you’ve mastered emergency medicine yet you can proudly say ‘No, but I am a better doctor today than I was yesterday’. And that humble doctor, who slowly and relentlessly improves, on every single shift, by admitting their own ignorance, is eventually the doctor everyone on the medical staff wants treating them when they have their own emergency.

Opioid related deaths and emergency room prescribing

Today the United States Centre for Disease Control issued an early release of an article to be published in it’s Morbidity and Mortality Weekly Review (MMWR). The title is Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States 1999 – 2008, and the content is startling. Overdose deaths due to prescription opioid pain relievers are almost as common as deaths due to motor vehicle collision (36,450 vs 39,973 for 2008).

You heard correctly, your cause of death is now equally likely to be from either a motor vehicle collision or an overdose of prescribed narcotics. If you worry about dangerous drivers on the roads, you should also worry about dangerous prescribers in the hospital.

In the emergency room we are faced with a difficult dilema, confronted with acute pain, but uncertain of risk to the patient when we prescribe narcotic pills. This is risky business. My own feeling is that we should be very aggressive about the control of acute pain within our departments. When we send patients home with narcotic pain pills we should send them with a very small supply, and instructions for close follow-up with a provider they know who can follow them along over time.

There are ways to assess the risk to patients when they commence on opioid medications. Dr. Douglas Gourlay’s paper Universal Precautions in Pain Control is a must read for anyone who ever writes for opioid medications. However, with even the best of training and the best of intentions our interactions with patients in the emergency department are fleeting. We have no capacity to follow patients along, to assess their risk and response over time. As prescribers of opioids medications pills that flowed from our pen have killed people. We must be cognizant of this, reduce the risk for our patients and confine our prescribing to agressive relief of acute pain within our department, and short bridging therapy until the patient can be reassessed by their own family physician. To do otherwise exposes our patient to unacceptable risk.