I don't believe patients' pain - help me reframe?

[mxns]

I'm an M4 (who isn't going into EM) on my EM rotation. I'm not sure what it is, but somehow hanging out in the ED made me realize that I don't usually believe my patient's discomfort. Syncope in a young woman? Vasovagal. Shoulder pain? Patient should have stayed home and just iced it. The overwhelming majority of headaches are nothing. Sometimes I just think, "ARGH people need to chill out, develop higher pain tolerance, suck it up, and then maybe... just maybe... call their PCP." I almost find myself getting annoyed with the patient who comes in "for nothing," even though I cognitively understand that their anxiety, if not pain, is real to them. It's draining to see how resource-intensive the ED can be for these patients with pretty benign complaints and in most cases don't need emergent care. I understand that the mindset of EM is to rule out the worst-case scenario for such patients, and that 1 out of every several thousand presentations will end up actually being a PE... but I am confused and a little angry at the sheer number of CTs I've ordered on patients who seem and end up being FINE. That said, I did have one patient who kept coming in for pain-- she had a drug history and I think that worked against her-- and on her fourth visit we ended up finding out that she had something really serious.

Obviously emergency medicine plays a vital role in our nations' healthcare, and not all patients come in for frivolous and sundry reasons. Since y'all on this forum are interested in or practicing in EM-- can you help me process and possibly reframe these thoughts? Thanks!

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[GandalfTheWhite]

I'm an M4 (who isn't going into EM) on my EM rotation. I'm not sure what it is, but somehow hanging out in the ED made me realize that I don't usually believe my patient's discomfort. Syncope in a young woman? Vasovagal. Shoulder pain? Patient should have stayed home and just iced it. The overwhelming majority of headaches are nothing. Sometimes I just think, "ARGH people need to chill out, develop higher pain tolerance, suck it up, and then maybe... just maybe... call their PCP." I almost find myself getting annoyed with the patient who comes in "for nothing," even though I cognitively understand that their anxiety, if not pain, is real to them. It's draining to see how resource-intensive the ED can be for these patients with pretty benign complaints and in most cases don't need emergent care. I understand that the mindset of EM is to rule out the worst-case scenario for such patients, and that 1 out of every several thousand presentations will end up actually being a PE... but I am confused and a little angry at the sheer number of CTs I've ordered on patients who seem and end up being FINE. That said, I did have one patient who kept coming in for pain-- she had a drug history and I think that worked against her-- and on her fourth visit we ended up finding out that she had something really serious.

Obviously emergency medicine plays a vital role in our nations' healthcare, and not all patients come in for frivolous and sundry reasons. Since y'all on this forum are interested in or practicing in EM-- can you help me process and possibly reframe these thoughts? Thanks!

How do you know these things without doing an H&P, labs, and imaging? The answer is you dont. You may miss the HCM or brain tumor in the young woman. You will miss the brain tumors, ICH, IIH, SDH, & migraines in a patient because you think the overwhelming majority of them are nothing.

You are right that most people in the ED dont need emergent care, but that is an issue regarding the lack of FP and lack of affordable healthcare... call your congressman.

IDK where you got the statistic of 1/1000 being a PE. Even assuming its true, do you ever want to take a 1/1000 chance of risking your license? Ill answer for you... No. Then you shouldn't be taking that risk with someone's life.

Ive seen all of the above in a single day, and if most of them stayed home or waited to see their PCP, they'd be dead.

 

[CliveStaples]

I think you may be best served thinking in terms of pre-test and post-test probabilities for emergent conditions.

Syncope in a young woman? An emergency doc thinks ruptured ectopic pregnancy. Your history and physical quickly puts a pre-test probability of disease to the patient. In this case, we have tests are are non-invasive and inexpensive (UPT and ultrasound) which can quickly rule out the disease, so we do them almost every time, even when pre-test probability is low (the tests are just that good).

Headache. An emergency doc thinks of things like SAH, meningitis, epidural abscess, etc. A history and physical establishes a pre-test probability of disease. Now the tests available to us are more expensive/invasive (CT, LP) so we start doing some risk stratification using clinical gestalt and decision tools which help us quantify the probability of disease. Look into decision tools for various disease states and tests; you may begin to appreciate the numbers behind the probability of that headache you just scanned being a brain bleed. As clinicians we work in a world of n=1 and it can feel like we are pissing scans into the wind looking for nothing, but I think it's important to try and avoid using our anecdotal experiences when we have decision tools available to us.

Thinking this way has really helped me to appreciate why we do what we do. What would you want if the patient were a loved on of yours?

 

[alpinism]

EM in the United States is essentially a business that functions to make money off the worried well including those too lazy to see their primary care physician.

Why do you think EDs post their waiting times and offer online appointments?

 

[jd989898]

Is there a field out there that deals with more real emergencies (ie immediately life threatening pathology) than EM? I would think trauma surgery, thoracic surgery, CCM and maybe neurosurgery and interventional cardiology/vascular surg are the only ones that come close?

I ask as an MS2 interested in the real emergency part of EM.

 

[dadaddadaBATMAN]

Is there a field out there that deals with more real emergencies (ie immediately life threatening pathology) than EM? I would think trauma surgery, thoracic surgery, CCM and maybe neurosurgery and interventional cardiology/vascular surg are the only ones that come close?

I ask as an MS2 interested in the real emergency part of EM.

It depends where you work for all of the above. Ed in middle of nowhere has a big difference in acuity from Detroit receiving

 

[throwaway33]

Is there a field out there that deals with more real emergencies (ie immediately life threatening pathology) than EM? I would think trauma surgery, thoracic surgery, CCM and maybe neurosurgery and interventional cardiology/vascular surg are the only ones that come close?

I ask as an MS2 interested in the real emergency part of EM.

Where do you think all those patients get their diagnosis? The ED. While EM physicians don't perform the definitive surgery, they are the ones who have to determine if this is an emergency that requires one of those specialties or is something benign. Now the average patient of a neurosurgeon is more critical than the average ED patient, but in many places, the EM physician is their first point of contact for the neuro patient (in addition to many less critical patients in the rest of the department).

 

[Vandalia]

How do you know these things without doing an H&P, labs, and imaging? The answer is you dont. You may miss the HCM or brain tumor in the young woman. You will miss the brain tumors, ICH, IIH, SDH, & migraines in a patient because you think the overwhelming majority of them are nothing.

Medicine is one of the three learned professions, along with law and ministry (i.e., clergy). Today, most people don't understand what that means, they think it means you go to school for a long time. However, it actually means that these professions are learned through experience, not through classroom instruction.

This is one of the primary issues with mid-level providers; it you haven't actually seen some disorder, you are very unlikely to diagnose it. Once you see a simple case of stomach flu turn into a bleeding cerebral aneurysm, or elbow pain turn into an MI, or whatever, you never look at those simple cases the same way again. There is a technical name for this, the Dunning-Kruger effect. Or perhaps more commonly known as "a little knowledge is a dangerous thing." That is why residencies exist.

 

[Janders]

(1) Some of the "mundane" complaints will be real emergencies. I'd say a needle in the haystack, but more common than that-- I had 4 patients come in the past 4 days just saying "I just feel kinda weak all over doc". two were old, so unsurprisingly one of those was a new renal failure with BUN 140, Cr 8, etc... the other was a chronic dig poisoning with a HR of 35. The two young ones were a sodium of 120! (interesting case) and a HCT of 20, both with normal vitals. Those aren't even good examples, I've seen an actual tooth ache (like a tooth that a root canal was done on the day before) turn into an inferior STEMI... left elbow pain be a ruptured spleen (mono)... etc.

(2) Still, after you've done this a while mundane things are a bit boring. Heck, emergencies can be a bit boring. I had a couple patients seize in front of me yesterday. I yawned. You need to like this job not JUST for adrenaline but also for other reasons.

(3) As above, a LOT of these mundane complaints are just worried well. But you need to take the perspective that these are nice, normal people who have a specific concern about their health to the point they came to an ER and waited to see YOU, an expert, to help them. Sit with them for 5 minutes, talk to them, teach them, they will be very thankful. And it pays the bills. You don't HAVE to test all of them with the CT-donut-of-truth. But you do need to do a reasonable H&P.

(4) And yeah, some of the mundane stuff will be the young person with chronic belly pain NOS who never follows up with specialists, smokes 18gm MJ a day, has a percocet habit, is rude to your nurses, complains of 20/10 pain, and comes in roughly 5x a week. All jobs have their difficulties

 

[namethatsmell]

I've seen an actual tooth ache (like a tooth that a root canal was done on the day before) turn into an inferior STEMI.

What else tipped you off to this one?

 

[GeneralVeers]

What else tipped you off to this one?

Yeah I would miss that every day of the week, especially with dental procedure recently.

 

[surgonc2017]

Probably the ekg almost every ED patient gets


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[littlejuan]

My tooth hurts. Oh and I have crushing chest pain.

 

[dadaddadaBATMAN]

My tooth hurts. Oh and I have crushing chest pain.

Theres no way that could come up during a history of tooth pain unless the discharge order had already been placed and the words "oh by the way" preceded it

 

[Pisiform]

You just need to remember your ABCs - airway breathing and CT

The patient population that annoys me most are:
- homeless peeps
- alcoholic drunks, guys on bath salts
- pain Med seeker
- those that need a letter for missed day at work so they thought why not
- those that came 3 times in last 2 weeks in the ED and didn't f/u with PCP as told
- fibromyalgia
- URI sx started last night doc
- hypertension.. my bp was 160/95... it's never that high doctor

And the labs are pretty much from the selected pool of CBC BMP BNP LA UA CThead CTspine CTabd CXR KUB EKG LFT XRay Ultrasound BloodCx rapid strep flu etc

ER is hard work but patient population 80% of the time sucks


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[deleted77919]

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[littlejuan]

Theres no way that could come up during a history of tooth pain unless the discharge order had already been placed and the words "oh by the way" preceded it

I dunno. Where I am at patients come in with multiple complaints like that. It burns when I pee and I have the worst headache of my life. I am out of my blood pressure meds and my left leg is 3x more swollen than my right.

 

[The White Coat Investor]

Most of your patients have weird symptoms attributable to no diagnosable disease process. Your job is to find the few with disease that will kill or disable them soon. The fact that there are so many worried well not only makes that job more difficult, but also makes it pay so well. Just the nature of the beast. If it took you 11 years of education, ten years of experience, a history and physical, three hours of observation, 25 lab tests, a CXR, two EKGs, and a stress test to determine that their chest pain wasn't serious, what makes you think they would be able to do it at home by themselves on the couch?

And for every 10 anxious chest painers, there's one guy who sat on his couch at home with a STEMI because "it's probably just indigestion, I'll call my PCP tomorrow."

 

[The White Coat Investor]

Maybe you need to find a higher acuity shop to work in. Our admission rate is about 30% and most of those patients are quite ill. In other words we are not admitting low risk chest pain.

I'll have a central line and intubation nearly every shift. Chest tube once every couple of shifts. The closest I get to worried well are ankle sprains that could reasonably have been fractures. We have a stringent pain management policy that has pretty well weeded out drug seekers. The one area of frustration is that we do have a fair amount of psych patients who are probably malingering - but the psychiatrists still place most of those patients.

It is not the patient's job to prove to you they are sick. It is your job to prove they are not. The presumption should be anyone who presents to the ED has an emergency medical condition and through your history, physical, and testing (if necessary) bring your probability low enough for you to sleep at night.

WTH? Do you live in the PTX capital of the world? A chest tube every other shift? Let's assume it's really high acuity so you're not seeing all that many a shift. Let's say 2 an hour. So in an 8 hour shift, 16 patients. So in two shifts, 32 patients. That means you're putting a chest tube in to 1/32 patients, or about 3% of your patients. Forgive me for my disbelief.

And you have psychiatrists that come to the ER? What kind of a weird place is this?

 

[dadaddadaBATMAN]

I dunno. Where I am at patients come in with multiple complaints like that. It burns when I pee and I have the worst headache of my life. I am out of my blood pressure meds and my left leg is 3x more swollen than my right.

I agree, I was joking. Admittedly it wasn't that great of a joke

 

[TorMed]

I will bend the rules as an MS3 and reply as a patient. I've done an ED rotation. But I could easily end up in the ED as a patient for mofo pain from ankylosing spondylitis. Periodically it just explodes and you can't sleep, can't eat, and I just get really quiet. I can see someone OP brushing me off as a drug seeker or as a low chronic back pain sufferer.
The pain needs to be addressed and is real but there is nothing visibly wrong.
It won't kill me but it is a crisis.
I have never gone to the ED for it but I can see doing it when it's bad.
By the way, the blood work for AS often doesn't show any inflammatory markers especially early in a flare.


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[littlejuan]

I agree, I was joking. Admittedly it wasn't that great of a joke

Ah. I was sleep deprived when I read it. Haha. And it's hard to read sarcasm sometimes.

 

[The Knife & Gun Club]

Maybe you need to find a higher acuity shop to work in. Our admission rate is about 30% and most of those patients are quite ill. In other words we are not admitting low risk chest pain.

I'll have a central line and intubation nearly every shift. Chest tube once every couple of shifts. The closest I get to worried well are ankle sprains that could reasonably have been fractures. We have a stringent pain management policy that has pretty well weeded out drug seekers. The one area of frustration is that we do have a fair amount of psych patients who are probably malingering - but the psychiatrists still place most of those patients.

It is not the patient's job to prove to you they are sick. It is your job to prove they are not. The presumption should be anyone who presents to the ED has an emergency medical condition and through your history, physical, and testing (if necessary) bring your probability low enough for you to sleep at night.

Can I ask what kind of EDs get this level of acuity? Mostly inner city/county hospital type situations? Or places that just have a gigantic catchment area?

(Or something that my pea sized med student brain is missing entirely)

 

[CanadianEM]

I want to work wherever the heck it is that you work. Jeeze. I might be lucky to tube someone once a month, though admittedly I work mostly at an academic centre.

Maybe you need to find a higher acuity shop to work in. Our admission rate is about 30% and most of those patients are quite ill. In other words we are not admitting low risk chest pain.

I'll have a central line and intubation nearly every shift. Chest tube once every couple of shifts. The closest I get to worried well are ankle sprains that could reasonably have been fractures. We have a stringent pain management policy that has pretty well weeded out drug seekers. The one area of frustration is that we do have a fair amount of psych patients who are probably malingering - but the psychiatrists still place most of those patients.

It is not the patient's job to prove to you they are sick. It is your job to prove they are not. The presumption should be anyone who presents to the ED has an emergency medical condition and through your history, physical, and testing (if necessary) bring your probability low enough for you to sleep at night.

 

[deleted77919]

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[deleted77919]

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[Janders]

What else tipped you off to this one?

Yeah I would miss that every day of the week, especially with dental procedure recently.

Probably the ekg almost every ED patient gets

My tooth hurts. Oh and I have crushing chest pain.

Theres no way that could come up during a history of tooth pain unless the discharge order had already been placed and the words "oh by the way" preceded it

Ladies and Gentlemen, I missed this one.

My PA saw the patient. Nice mid-aged "healthy" lady, had tooth pain for a week-or-two, got real bad mostly right lower jaw. So she saw a dentist. He did a root canal (day prior to ED visit) but said it was so big/bad/whatever that she needed to take the penicillin he was prescribing and come back in 2 days for more root canal action. The next day the tooth was just killing her, she'd taken her 1gm APAP, her 800mg motrin and her penicillin and it was just killing her and it was 5pm so she came to the ED. Denies all other symptoms, normal vitals, denies medical history.
PA checked the state Rx database-- nothing. PA checks, dentist exists, patient has a card for him, appointment written for the next day. PA looks at the tooth-- yeah looks like some fresh action there. Comes over to me, tells me about the patient, says she wants to give her a few Vicodin to get her through 'til tomorrow... basically that she buys the story, lady seems to be normal and checks out vis-a-vis being a seeker.
I walk over to shake her hand and discharge her, confirm the fact her tooth hurts, told her vicodin are poison but for a day or two perhaps they are reasonable, and warn her to come back if she gets a fever to 102 or her face explodes.

Now at this point, I have to add, the ED is packed, every hall space is full, the WR is exploding, ambulances are queued up to drop people off, its a total craptacular day.

So the RN runs in with the discharge paperwork. And the patient winces in pain while she's signing all the papers. The (young, excellent) RN asks if she's ok. She notices the patient has beads of sweat on her forehead. The patient says "yea, sometimes the toothache.. it just comes in a wave... and my whole head feels like it will explode... and it hurts so much i get woozy for a second and then it like hurts all the way down the front of my chest and my entire body hurts".

The RN thinks to herself that the lady is a bit too dramatic and rolls her eyes. But something about the diaphoresis looks bad to her, so she decides to just put her on the monitor and grab a 12-lead. Just a little angel on your shoulder moment. She almost stopped herself because she felt silly, but something made her do it.

Fast forward 10 seconds later she is chasing me down the hall with a beautiful 12-lead of inferior tombstones.

99% RCA is what the interventionist called and told me. Then he was chuckling we almost missed a "jaw pain"-- he'd read our chart. I told him to look her her mouth himself. He did, and he ended up calling OMFS to treat her jaw abscess in house. So she did have a bum tooth. And a bum coronary.

And that, my friends, is why I love my nurses.

 

[The White Coat Investor]

Maybe every fourth shift. The intubation and central line numbers are accurate. Academic Level 1 trauma center. I'm including pigtails which we have moved to for a lot of our patients. On one shift I can have 16 beds, 4 hallways beds, a first and third year resident. I'm counting procedures I have to supervise. When I was hired 1/3 of patients were only seen by attendings but that number has probably dropped some as we have expanded the residency.

We have a lot of cardiac arrest patients or patients who are peri-arrest. EMS probably only has 50% of them intubated prior to arrival.

We don't actually have psychiatrists come down. We have social workers who eval the patient's after they are medically cleared. They will get an order from the local magistrate to hold patients and present the cases to psychiatrists at inpatient facilities. Was just short handing through that to make the point most of our patients still get placed.

Okay, now we're getting into believable territory. So every fourth shift and while supervising two trainees. So maybe one out of every 200 patients. That I can believe. Especially now that we know there aren't any psychiatrists in your ED either.

 

[alpinism]

NOLA is a great program...

We see similar numbers in Detroit and average at least one intubation or central line per shift.

The point is though that even with those numbers we're only seeing 1-2 sick patients out of 10-20 patients per shift.

 

[DocEspana]

Our center is a hiccups center of excellence.

We've diagnosed two (!!) MIs, an empyema, and at least one big ass PE.

We honestly get other facilities sending their hiccup patients here (not a joke) because of our success at treating hiccups seriously.

 

[Psai]

Our center is a hiccups center of excellence.

We've diagnosed two (!!) MIs, an empyema, and at least one big ass PE.

We honestly get other facilities sending their hiccup patients here (not a joke) because of our success at treating hiccups seriously.

I've always wondered how many hiccups were cancer

 

[docdragon]

This is fundamentally an issue of compassion overload, emotional burnout, and mental discipline.

Our job has nothing to do with *feeling* bad for the patient. The patient is usually doing a very thorough job of feeling bad for themselves, and family members usually help with the whole empathy. Sure, your job has something to do with projecting some mix of professionalism and empathy, and the better you project that, the more likely your patient will choose to follow your ultimate recommendations. What matters is maintaining the mental discipline to Do The Right Thing anyway, even though the Right Thing is extremely risk-averse for missed diagnosis and almost risk-seeking for excessive testing in this society.

People come to the ED because they hurt or are worried, anxious, afraid, etc. Ignore the drug seekers. You somehow have to survive despite their negative influence on your cognitive biases. Most people come because they think they need to see a doctor within about 6-24 hours, and usually this is a reasonable assessment based on their chief complaint. Again, ignore that patient 6 months ago who skipped his/her PMD appointment because the patient was IN THE BATH and decided it would be easier to go the ED instead. Really, you won't forget him/her ever, but you somehow have to ignore the instinctive memory.

Instead, your ED colleagues' job is to think "worst first", establish a plan of care, and stratify the pain with the patient's suspected diagnoses, apparent pain tolerance, and medical history to make a smart decision about optimal pain management.

Whatever you go into, fer cryin' out loud, train yourself to avoid habitually maligning a patient's reported pain. Because you know what? If you don't treat your patient for post-operative pain, guess where they'll end up? My ED. If you don't treat them empirically for shingles pain, guess where...? And quite frankly, if you don't treat the sober heroin addict for his diverticulitis, guess where...?

Does that help?