play by play

Monday, January 1, 2018

Can you do play-by-play? Can you be Vin Scully or Mike Emrick, telling stories so that your audience can understand through your words, what your eyes are seeing? Every family has a great storyteller, but in the real world, it’s tough to explain complicated situations in just a few words. Imagine if your health depended upon that skill. Now, imagine 12 seconds.

You get 12 seconds to tell your story. If you’re lucky you get 18.  That’s the average time before your doctor will interrupt you as you tell the story of why you’re visiting. In that time, you have to describe your situation, frame what’s going on and explain your worries and fears. And while you’re doing your play-by-play, the doctor could be planning what happens for the rest of your life. Miscommunication may lead to confusion, inappropriate tests and errors in diagnosis and treatment. How good are you at play-by-play?

Imagine falling and being brought by ambulance to the ER. You would think that the nurses and doctors would know why you’re there, but they ask anyway. Everybody in the room, patient, family, nurse and doctor knows that you fell.

The story lines

  • The patient wants to tell you that they hurt their hip and can’t walk because of pain.
  • The family wants you to make the family member comfortable.
  • The nurse has numerous responsibilities including asking whether the patient feels safe at home.
  • The doctor may want to know why the fall happened.

Consider a couple of stories. It’s one consideration if the patient tripped on a loose mat in the bathroom and fell. It’s a totally different situation, if the patient passed out and then fell. Instead of an isolated hip injury, the focus switches to why a person would lose consciousness. Was it a stroke? How about a heart rhythm disturbance? If they were diabetic, was their blood sugar too low?

And perhaps the patient hit their head and can’t remember what happened. It’s all detective work. Then medication lists matter. If they are on a blood thinner, the big worry is bleeding within the skull brain, and a neurologic exam checking out the brain might be the priority.

“But I hurt my hip, not my brain!” It’s difficult when patient/family priorities and expectations are different than those of the doctor. And sometimes, the original reason for the visit can get lost. Ideally, the patient also gets to interrupt the doctor to make certain their both on the same page. There is somewhat of a power imbalance and patients may not like making that interruption.

Years ago, Dr. Jonathan Gilbert, a professor of medicine at the University of Alberta, would gently, and sometimes not so gently, remind his students that history was the key to diagnosis. His philosophy was that if the diagnosis couldn’t be made after talking to the patient, then the physical exam, lab tests and x-rays would be less than helpful. Dr. Gilbert was able to ask just the right questions and listened intently to the answers. The patient would lead him to the diagnosis, the physical exam would add to his suspicions and any tests would confirm the final answer.

That was a generation ago. His world was not ruled by 12 seconds and patient visits lasted more than the average of today’s 11 minutes. Allowing the patient to speak unfettered doesn’t fit into that time frame and interruptions are a technique used to direct the conversation to the specific questions that the doctor wants answered. Hopefully, those questions will be the same as the patient’s.

Planning

Play-by-play is hard. It takes hours of preparation and study to learn about the players on each team, their coaching philosophies and what to expect as the game starts. People need to plan for their doctor appointments as well as announcers plan for their game.

  • Why are you seeing the doctor?
  • What one or two problems do you specifically want addressed?
  • If the office has the capability, email ahead of time and let them know your needs.

Even a routine visit to recheck a chronic problem might be derailed if the patient brings up a concern that wasn’t expected. Unless an urgent intervention is needed, the doctor has two options. One is to deal with any and all concerns, knowing that the time spent will be taken from another patient, or the second is to ask the patient to schedule another appointment to deal with the unexpected concern.

Emergency visits are tougher because one usually doesn’t routinely plan for emergencies. Don’t expect your medical record to be always available. Even with electronic health records, systems can be down for maintenance, computers can crash and different electronic record systems don’t talk to each other. The medical world still depends on photocopying and faxing. But be prepared and carry these things, all the time.

Medical information list

  • Know your medical history.
  • Make a list of your diagnoses and previous operations
  • Have a list of your current medications
  • If you’ve had an EKG, keep a copy of the most recent tracing.Know the contact numbers for your doctor’s office and your hospital.

It’s the new year. Learn a new skill. The best play-by-play announcers have lots of notes and refer to them routinely. They can paint pictures with their words so that their audiences understand what’s going on. Become the next Vin Scully or Mike Emrick.

 

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it’s just noise

Monday, May 13, 2013

How hushed the world becomes at a golf tournament or tennis match. The extreme quiet is needed for the athlete to mesh concentration with physical dexterity to maximize the athletic performance and succeed on the playing field. The crowd can roar in approval once the ball is struck or the point over, but heaven help the poor spectator who has the audacity to snap a photo or cough at the critical moment of play. And how dare Tiger Woods rummage for a golf club while Sergio Garcia stood contemplating his next shot. Sergio was unhappy; his errant shot muct have been due to the interruption. How rude…and how silly.

It’s not often that I use to talk about my world in the ER, but just a little noise would be a wonderful environment, since a lot of noise is the norm. It’s not just the conversations of dozens of people that echo in my workspace, but it’s the monitors beeping, the IV pumps alarming, the ambulance radio going off and we can’t forget the crying children, the sobbing elderly and the extra loud alcoholics. Noise is the norm and we have to deal with it. Numerous studies, in many countries, confirm that the ER noise level can interfere with communication between nurses and doctors and can affect patient wellbeing.

Noise is measured in decibels and a 10dB increase in sound intensity subjectively doubles how loud the sound is perceived. A library averages 20dB and is a pretty quiet place. Normal conversation measures at about 50dB while at 10 yards, a large truck comes in at 90db. The sound levels in an ER wax and wane depending upon what’s going on but in one study averaged 63 dB and spiked higher than 70dB. And that’s just the background noise that inundates the workplace. It can get much noisier at the bedside.

Imagine the scene at a trauma center as a victim rolls in. Surrounding the gurney, there are two physicians, two nurses, a paramedic, a respiratory therapist, a lab and x-ray tech. Each has their role and every finding needs to be communicated loud enough to be documented by the scribe. Now, try to listen to the patient’s chest and decide if there is decrease air entry in one lung compared to the other. A chest x-ray can confirm a collapsed lung, but if the patient is in shock and crashing, clinical skills may be required to decide if a tube needs to be inserted through the chest wall to re-expand that lung collapse. Choose wisely, because putting the chest tube in on the wrong side might be deadly.

Perhaps the next patient has stopped breathing and requires intubation. A tube needs to be placed into the trachea and hooked up to a ventilator. For the emergency physician, this is a skill learned in residency training but there are a myriad of training courses available to teach intubation in the difficult airway patient. It’s a stressful time. The patient isn’t breathing and the potential for death is real. The other disaster complication is taking too long to establish the airway. Not returning oxygen to the body quickly will damage the brain. There are no Sergio Garcia moments when one can hear a pin drop.

As it turns out, noise isn’t the only distraction in the ER. Research has found that the ER doctor has to be able to cope with distraction and interruptions every few minutes. The ability to multi-task is a skill in the physician toolbox. In a busy emergency department, the physician will care for 3-4 patients an hour, will be interrupted to review tests, answer the ambulance radio or take a call regarding a patient, 10 times an hour and will have to break away from performing a task about 7 times an hour. It’s plenty of information for a brain to juggle and a noisy environment adds to the difficulty. By the way, the brain can keep about seven tasks in short term memory.

The calmest time for me is suturing. I have one-on-one time with the patient while I sew up a laceration.  While there are technical challenges and skills, the best results are achieved if one takes the time to be meticulous with cleaning to prevent infection and aligning the skin edges to give end up with the best looking scar. The time to sew is also the time to think about the other patients in the department, organizing what test to consider, what treatment to suggest and deciding who needs to get admitted to the hospital and who gets to go home.

The etiquette of golf and tennis are a world away from my reality in the ER. Noise is everywhere and interruptions are expected. The ability to concentrate and perform is independent of the environment. I can appreciate how Tiger Woods, Phil Mickelson, Raphael Nadal and Roger Federer need quiet to hit a ball. I can’t imagine it requires more than putting a needle into an artery or a tube into a chest. But if I had some quiet, perhaps my job would be easier.

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