DENIAL? IT’S ABOUT HOPE

A patient presents with a scalp hematoma from a remote fall. When you press on it, it feels very soft but is not swollen. You are confused, and order a CT, which shows complete lysis of the bone,. Further workup suggests metastatic renal cell carcinoma. The patient is avoidant on history and keeps explaining away the findings and concerns. Hours later, while he is awaiting a bed upstairs, he reveals that a year ago his doctor suspected renal cell carcinoma but he refused a workup.

 

This patient suffers from denial. Whether that is a perfect term is debatable. In this case it is severe but so often denial seems to overlap with avoidance, perhaps even procrastination. It is at times the unwillingness to address an unpleasant reality. In medicine all too often we judge “denial” as a break with reality but we need to understand it as a human experience. Denial is the way some patients try to grasp onto hope. Go read Arthur Miller’s Death of a Salesman if you want a literary exploration of denial and hope.

 

We shouldn’t always oppose denial. Don’t argue over code status. If they want to be full code don’t gripe about them at the nurse’s station. They are dying. If knowing they will get 30 minutes of CPR in the end gives them comfort then let them have that consolation. If the patient-centered reasons aren’t enough, remember that practicing code situations only makes you better at it.

 

The literature is accumulating articles portraying denial as a positive thing. Denial mitigates terror and allows patients to continue to function. But in the emergency department we sometimes see patients at an earlier stage, where denial gets in the way of potentially curative treatment. So what should we do?

 

Accentuate the positive

Without distorting the truth, emphasize the safety and efficacy of your recommendations.

 

Build a relationship of trust by genuinely connecting as people

Spend some time getting to know them as people. Share anecdotes of those who have had good experiences, which not only illustrates safety but also displays your connection to patients. As emergency physicians we will not get long-term rapport, so build it for your consultants, whose expertise and caring we should commend to the patient (assuming we can do so truthfully).

 

Tools of persuasion – allowing an “out” lowers the cost of an “in”

Finally, point out that they can always choose to stop treatment later. That way they can say yes without feeling stuck. By giving them an “out” you are lowering the cost of going “in.”

 

Ultimately, denial is their choice. We will not be able to convince everyone to face the unpleasant reality but we should use the skills and techniques that best address their frame of feeling.

 

Take Home Points:

-Denial is often a way for the patient to have hope

-Give such patients hope through emphasizing the positives of treatment

-Connect on a genuine, human level

-Remind them they can change their minds later

REAL TIME CHARTING IS REAL TIME THINKING

We speak of physical diagnosis as if the sign and the suggested diagnosis always match. Often they do, for example when we see acromial step off and suspect anterior shoulder dislocation.

 

But more often there is ambiguity. Most bedside information is non-specific. For example, tachycardia can mean a lot of different things. Later when we look at everything at once, there is the chance to “put it all together.”

 

But when will you do that? It is necessary at times to give uninterrupted concentrated thinking to a patient’s symptoms and signs. For example, how about the chronic headache patient who saw the chiropractor for neck pain? When you put it all together you might think of vertebral dissection.

 

Some call this a “cognitive pause,” others just call it medical decision-making, and others focus on the disruptive effect of interruptions.

 

Many ED groups routinely expect charting to be done at the end of the shift, after the patients are gone.

 

But charting is a chance to think critically, to put it all together. And sometimes when we do that early in the visit, it can prompt a “lightbulb” moment where we realize the need to check something else.

 

I advocate real time charting. The act of creating a chart requires thinking. Why not do that while the patient is still in the ED? I think at the end of the visit just before discharge is okay but even better would be right after seeing the patient. The recitation of the symptoms and signs are most accurate at that time and the “cognitive pause” of thinking through the whole presentation then can happen early, when it can change the workup.

 

It is simply impossible to do that on all patients on all shifts. But this is something we should try to do. The bottom line is that most historical and physical findings are ambiguous. There needs to be an explicit stage after information collection, which is information “integration.”

 

Take Home Points

-Complex patients require a “cognitive pause”

-It is hard to do that on a busy shift but real-time charting makes it more possible

 

References:

Check out Mark Jaben EP Monthly April 2013

To Reduce Medical Errors, Take a Cognitive Pause

CRITICAL THINKING REQUIRES SYMPTOMS TO BE SORTED CHRONOLOGICALLY

A patient presents with right arm weakness and sensory loss associated with nausea and headache. This is a stroke, right? The symptoms cleared…okay so its a TIA, right? But he is 15…. But kids can have strokes. Let’s get an MRI… its negative.

Hold on a minute here. We listed symptoms but did not sort them chronologically. Does that matter?

Now let’s sort these symptoms chronologically. First this patient had nausea and visual scintillations, then a few minutes later right facial numbness, then a few minutes later he had right hand weakness and numbness. This was all followed by a unilateral headache. Each symptom was temporary and replaced by something new. Now you wonder and ask – yes, he has a strong family history of migraines. This was a complex migraine doing its “Jacksonian” march across various territories of the brain. The diagnosis seems obvious when presented chronologically.

When you take a medical history, ask open questions, let the patient talk without interruption, and sort out your answers in chronological order. You will probably find that you need to take scratch notes to record all the rich detail you are getting from a patient-centered narrative.

Take Home Points

-Chronology allows you think critically about what may be causing a patient’s symptoms

-Take notes if you find that helps to remember all the symptoms

THE PEDIATRIC EXAMINATION PART 3: LOCALIZATION BY PROXY

In the last 2 posts we discussed techniques for winning rapport and trust with children and for using distraction and play. We discussed a case of a 16 month old with scalp tenderness. In that case none of these techniques worked. So what do you do next?

Parent’s Arms

Most children between the ages of 1 and 3 will become more calm when examined in the arms of their mother or father. The child calms down, and clings to the mother and sometimes that is enough for examination.

Examination By Proxy

If all else fails you can deputize the mother to do the localizing examination. In this case she tries but the child still cries. You decide to leave the room to let her calm down and you ask the mother try to better define the area that is tender. You suggest a gentle scalp massage starting away from any areas of pain.

Come Back Later

Once the limbic system is aroused and heated it takes a few minutes to cool off. Come back later to reassess the child. Of course, treating pain is important for enabling a good examination.

You come back and she thinks it is the left ear. You expect external otitis but see nothing. Then you look at the scalp in that area and see bulging and redness behind the ear. You order a CT scan and find mastoiditis with abscess formation.

Take Home Points:

-Examine the child in the parent’s arms if needed for calmness

-In the uncooperative child, try localization by proxy

THE PEDIATRIC EXAMINATION PART 2: DISTRACTION AND PLAY

In the previous post we talked about using proper greetings and explanation to win rapport and trust. We talked about a 16 month old with scalp pain that could not be localized. Often efforts at rapport and trust do not work. What do you do next?

For straightforward presentations there is nothing wrong with physical restraint and looking in the ears against resistance etc. William Carlos Williams has a short story “The Use of Force” where he makes this into a morally ambiguous act about subduing another person. Nonsense! Tell the child that you help kids feel better and you are going to check for owies. If you see resistance, have the parent hold the kid and proceed.

But sometimes the presentation is not clear and we need skill in winning a child’s compliance.

Distraction

Use objects in the room for distraction but these do not always work. Blowing up a glove into a balloon and drawing a happy face works pretty well. Having the glove talk to them is even better. Smartphone photos are great, the child is usually mesmerized.

Play

You might tell them a story; “there is a mouse on the loose in here, have you seen the mouse?” The mouse story, if it works, is good because the mouse can run to wherever you want to examine. “Let me check your ears for the mouse.”

Other forms of play might be to state your commands in ways that captivate the child’s imagination; “pant like a dog” elicits better compliance for oropharyngeal examination than “say ah.” For the abdominal examination, say “let me check your abdomen and see what you had for lunch.”

Take Home Points:

-Use distraction to help localize tenderness

-Use imaginative play to make the examination more fun

THE PEDIATRIC EXAMINATION PART 1: RESPECT AND EXPLANATION

A 16 month old presented with pain in the scalp. The examiner was not able to localize it further because the child was uncooperative and crying. What now?

To localize pain in a toddler, we need the child’s cooperation. There are three ways to achieve this. The first approach is to win rapport and trust.

Introduction: I start with a proper introduction to the child on eye to eye level. If they are old enough to understand, I might say “I am the guy who fixes owies.” (sometimes followed by a comical search for “owies” well away from the affected area).

Non-clinical touch: The first touch should be non-threatening. I sometimes do a formal handshake for humor, or a pat on the back, or a light touch of the foot as I say hello.

Say his or her name:

Use his or her first name frequently to enhance familiarity.

Anticipatory Guidance

Demonstrate the exam on yourself or on the child’s mother first. This is really important with the otoscope. The best model is a cooperative older sibling.

If this works, great! Sometimes it does not. Read my next post for the second approach, on distraction and play.

Take Home Points:

-Treat kids like little adults: With respect. Introduce yourself, use an age-appropriate physical greeting, and address them by their name.

-Explain things in advance: model the examination on yourself or a family member.

XRAYS VRS EXAM – WINNING THE PATIENT’S TRUST

I hear a lot of clinicians say that they order unnecessary x-rays because patients demand them.  There are probably some situations where that is inevitable.  But before resigning yourself to role of taking your patients “order,” consider whether a more open communication approach might help.

For example, I found the Ottawa ankle rules to be impractical because patients always wanted the x-rays.  But then I started introducing the Ottowa ankle rules to patients before performing them.  The patients could see the logic of this approach and now it is rare for a patient to demand an unnecessary x-ray (though some inevitably do of course).

Patients almost always trust the physical examination, as long as it is explained to them and the physician is able to explain the evidence for it.

Take home points:

If you want patients to trust your physical examination, explain it to them