...when you don't know?

I try to just be straightforward with the guy that I'm really not sure what's going on, that I'm going to rule out any life or limb threatening causes, treat the pain, and if I can't figure it out, put him in the right direction toward figuring it out with the right type of physician.

Rendar5 said:

I try to just be straightforward with the guy that I'm really not sure what's going on, that I'm going to rule out any life or limb threatening causes, treat the pain, and if I can't figure it out, put him in the right direction toward figuring it out with the right type of physician.

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This post is so full of win. Only thing I usually add is to validate the patient's symptoms, makes them feel like you care about them. Mastering the above approach is the difference between pissed off and satisfied patients.

"Neurocardiogenic syncope" really seems to wow my patients looking for a diagnosis. It's really rare you know.

Rendar5 said:

I try to just be straightforward with the guy that I'm really not sure what's going on, that I'm going to rule out any life or limb threatening causes, treat the pain, and if I can't figure it out, put him in the right direction toward figuring it out with the right type of physician.

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This is ideal

Out of curiousity, did you check a ESR or CRP? That sounds like it could be a vasculitis...

r/o life/limb threats - UE DVT, infection. if you're moonlighting as a resident and you need a 2nd opinion - ie. you're not sure, there might be an emergency condition - call your home ED and run it by an attg. communicate well with the patient, treat any sxs you can, ensure close f/u. document well.

Aside from the ABCs, my emergency medicine mantra boils down to the following when I don't feel like I have a good sense of what's wrong with the patient....

1) Is this patient going to die right in front of me?
--if yes --> back to ABCs and what needs to be done immediately
--if no --> move to step 2

2) is this patient sick enough to stay in the hospital (or be transferred from smaller facility), or well enough to go home?
--if sick enough to stay --> what do I need to do for this patient to initiate appropriate therapeutics, and what do I need to order to identify problem (keeping in mind I know person is sick and isn't going home, and realizing I need something that will meet admission criteria, pique interest of admitting service, etc)

--if well enough to go home --> what are the worst possible things that can be happening to this patient based on complaint, and how do I rule it out so I feel warm and fuzzy about sending them home.

I find that I have a home vs stay decision on my patients before any test result after talking to them, based on how they look, chief complaint, age, vitals, and risk factors about 85% of the time.

And there are plenty of times where you don't know what's wrong or you don't find anything abnormal. If you say to the patient, "there's nothing wrong, go home" they're going to interpret it as you don't care about them and you're not validating their concern. some seem genuinely upset that there's no diagnosis.

instead, when i know the patient doesn't fit into any one box, especially when not sick, i say, "here's the deal. at the end of the day, i may not know what's wrong with you. but i will be able to tell you its not A, B, C, D or anything else life threatening, and its safe to send you home. I absolutely believe you are experiencing symptom X, and I will give you medicine Y to help you at home. It goes over very, very well.

If the patient is genuinely sick and you don't know what to do from a diagnostic standpoint, there are consultants tied into your hospital (in person or by phone) that you can ask for their opinion -- thats what they're there for.

and i agree wholeheartedly with the other poster who said call your home institution, you know them and trust them, and they don't judge.

I reassure the patients that their tests are negative and tell them that sometimes we cant make the diagnosis but I have done my best to rule out life and limb threatening conditions. I give them follow up with the specialist of choice.

I think in any place w/ press ganey the im sure your pain is real thing is key.. makes them feel you dont think they are nuts.

I'd echo everybody else above. I say that I definitely think they have some reason for seeking evaluation and believe their symptoms (even when I sometimes don't believe the severity). From there, I can say that although I don't know exactly what it is, I do know that it's not a variety of life, limb, or eye sight threatening emergencies: blah blah blah, and blah blah blah.

The worst situation is when the 45 yo female with a history of chronic abdominal pain has seen specialists at Hopkins, Mayo and Harvard with a work-up spanning a decade only to have no answers but she comes to your ED on a Friday night because she wants a diagnosis and cure. You know then that she will not be reasoned with.

Great question and one of the most difficult aspects of our field.

One thing that I do frequently is to discuss the concept of a disease process declaring itself. I tell them that everything looked good today and that I expect that whatever they have will be self limiting and I'll write them some medications to try to help until it does. If it continues it's really important for them to follow up with their doctor regularly because it will eventually start to look like something more recognizable, i.e. declare itself, and we want their PMD to be onboard when it does. I've actually found people to be pretty reasonable with that explanation. I also point out that we did a lot of the testing their PMD would have done so when they follow up they already have all the preliminary stuff out of the way. They like that too.

One thing about not knowing stuff is you get more comfortable with it as you get on in years. I don't mean the diagnostic stuff. I'm talking more about the zebras that patients occasionally show up with in the ED. When I was fresh out and a patient showed up with some weird syndrome that they had gone to some other city to get diagnosed and they sneered "You probably don't know anything about it." I'd get sheepish. Now I just say "I've been doing this long enough that I know it doesn't belong in the ED."

docB said:

Now I just say "I've been doing this long enough that I know it doesn't belong in the ED."

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Kris1 said:

The worst situation is when the 45 yo female with a history of chronic abdominal pain has seen specialists at Hopkins, Mayo and Harvard with a work-up spanning a decade only to have no answers but she comes to your ED on a Friday night because she wants a diagnosis and cure. You know then that she will not be reasoned with.

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I ALWAYS start out this visit by managing expectations. I listen to the complaint, then state that it sounds like an ongoing problem that has had many specialists' opinions. I then tell them that my specialty is looking for emergencies and that I will definitely treat their pain in the ED and help them get referrals to other ongoing care if necessary but I will not be likely to be able to give them any new definitive answers in this ED visit or make their ongoing condition totally resolve. Goes SO much better when we get to the time to discharge home...

Kris1 said:

"Neurocardiogenic syncope" really seems to wow my patients looking for a diagnosis. It's really rare you know.

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I don't see this as gaining you anything. It doesn't help the patient by letting them truly know you don't have a cause for their symptom and it doesn't protect you medico-legally. Confusing the patient only does that....and if they get the sense later on that you trick them with big words that mean nothing, it can only stand to hurt you.

EctopicFetus said:

I reassure the patients that their tests are negative and tell them that sometimes we cant make the diagnosis but I have done my best to rule out life and limb threatening conditions. I give them follow up with the specialist of choice.

I think in any place w/ press ganey the im sure your pain is real thing is key.. makes them feel you dont think they are nuts.

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Totally agree. Sometimes when your ED workup is negative, patients think you're telling them that nothing is wrong. I almost always tell them that even though we don't find anything emergent going on, it doesn't mean nothing is going on. I tell them that I agree something is going on and definitely needs follow up by either the PCP or whatever specialist is appropriate. I try to sound encouraging that 'hey at least this isn't life threatening,' which usually makes them somewhat happy.

I'm almost positive this isn't Ebola...

Kris1 said:

The worst situation is when the 45 yo female with a history of chronic abdominal pain has seen specialists at Hopkins, Mayo and Harvard with a work-up spanning a decade only to have no answers but she comes to your ED on a Friday night because she wants a diagnosis and cure. You know then that she will not be reasoned with.

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See my angry patient's thread. Chronic abdominal pain is my nightmare.

anonymousEM said:

I ALWAYS start out this visit by managing expectations. I listen to the complaint, then state that it sounds like an ongoing problem that has had many specialists' opinions. I then tell them that my specialty is looking for emergencies and that I will definitely treat their pain in the ED and help them get referrals to other ongoing care if necessary but I will not be likely to be able to give them any new definitive answers in this ED visit or make their ongoing condition totally resolve. Goes SO much better when we get to the time to discharge home...

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I've learned to recognize when we're not going to get any answers and I try to set the stage for that by being upfront and honest. "We may not find out exactly what's going on, but I'm going to try and make you feel better and get you to your own physician who has the resources to get you a better answer."

I also like DocB's 'declaring itself' method. Right now it doesn't appear to be x, y, or z, but it could be early and you need to come back of a, b or c happy or persist.

Rendar5 said:

I try to just be straightforward with the guy that I'm really not sure what's going on, that I'm going to rule out any life or limb threatening causes, treat the pain, and if I can't figure it out, put him in the right direction toward figuring it out with the right type of physician.

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Exactly!

By the by (since an occasional thread pops up around here about "handling" ED consultants), this type of approach also works beautifully with admitting/consulting specialists.

Just being plain, honest, and straighforward works wonders for communication and camaraderie.