“Your EKG doesn’t look so good,” the tired night shift ER doc tells his patient in the age old ER doc cocktail story.
“Doc, am I going to die?” the frightened patient asks.
“Not on my shift,” the doctor replies checking his wristwatch.
The fact is that reassuring patients in times of stress is the stock and trade of ER docs. Whether the question is “Am I going to die?” or “Do I have cancer?” or a heart attack or whatever, it is often our job to make sense of the limited amount of information that we are able to glean from the patient and the lab and to come to some reassuring statement as a conclusion. Many times we are working on limited, and often inconclusive, data. How we handle that situation is truly part of the art of being a good emergency physician.
Give the wrong patient volumes of data, probabilities and potential contrary outcomes and they will be paralyzed and do nothing, panic and try a raft of unproven and often detrimental remedies, or be so stressed that the messenger has just added another problem to their already long problem list. Give a different patient a sunny general summary of all the best outcomes of their problem and they might not trust you and go off looking for more information with alternatives. Whatever your specific patient needs and wants to know, there is one thing we all have to be able to handle and that is reassurance in the face of limited knowledge.
It’s an age old axiom to ‘Know what you know, and know what you don’t know.’ But that sort of begs the question, how well do we know what we think we know? And what part of that doubt do we convey to our patients? I teach a seminar to midshipmen at the US Naval Academy that bears on this very subject. How do leaders know what we know? And how do they convey confidence in their conclusions to those whom they are leading?
In a typical scenario to illustrate this dilemma: a new 2nd Lieutenant in the Marines is leading a rifle company on patrol when they come under mortar fire. The initial rounds miss, but subsequent rounds start to come closer. It is evident that someone, somewhere is acting as a spotter for the mortar team and is directing their fire.
Everyone in the rifle team starts scanning the horizon to find the spotter. Someone sees a man in the far distance who appears to be watching the action. He has a drink in hand and a child is nearby. Is he the spotter or an innocent bystander? The sniper sets up for the shot as the rounds get closer and closer. At some point the young officer must make a decision that will possibly end that man’s life. Indecision or mistake could cost all of his team their lives. Only after he gives the order will he know if it was the right decision.
As in this situation, we too have to make all sorts of decisions based on limited knowledge. Sometimes we have the benefit of waiting to see what develops, but often not. Take the fine line we walk when deciding to use a thrombolytic in a case with marginal stroke symptoms near the end of the therapeutic window. Do you advise its use while reassuring the family that everything will turn out all right? Do you inform and advise the family of the risk of complication so that if there is a bad outcome there will be shared sense of guilt? Or do you make the decision yourself based on your understanding of the risks versus your understanding of the benefits to the patient?
Patients look to us to make the best decisions in a given circumstance, but that is only the beginning of leadership. How we communicate our decisions can be just as important. It’s no secret that this would eventually get around to our present circumstance of our response to the corona virus pandemic. Testing the patient with a fever and cough who just got off a cruise ship after visiting Asia is the easy decision.
But what do you tell the patient who has a cough only who wants to be tested because they are worried about getting their elderly parents sick? Do you take the 20 minutes necessary to explain the rationale for testing various risk groups or do you just say “You don’t meet criterion for testing…at this time. Quarantine yourself and come back if you develop a fever.” And even if you have the luxury of testing any and all comers do you smile and say, “You know that even if you are negative this week, you might be positive next week?”
Moreover, this is not just an academic question that affects others. What about yourself? How are you reassuring yourself that you are not going to be the next victim? After all at this writing there are at least two ER docs who have contracted Coronavirus. Does that give you pause for thought? If you are young and healthy you may still be living under the delusion of invincibility. But what about those of us who may be starting to dip a toe into the ‘high risk’ age group or carry a few of life’s scars like lung disease, heart disease or borderline immunocompetence?
Do we just whistle past the graveyard like nothing is happening, or take an unplanned vacation and dump your shifts on the younger guys, or do we double down on the PPE and just accept the risk? It’s not all gloom and doom though. I have to say that the first time my wife met me at the front door after a shift and told me to strip naked so she could wash my scrubs I thought this whole pandemic thing wasn’t so bad after all.
Even when we develop a rigid criterion for testing and admission of patients when we are at work in the ER, there are questions. I don’t know about you, but my friends and neighbors are bombarding me for my ‘expert’ opinion of the situation. Of course, we know what to do.
Social distancing is mandatory. Call your doctor to arrange testing if you have a fever and cough. Don’t go to the ER unless you are seriously short of breath. We all know what to tell people to do. But my friends and neighbors trust me and want to be reassured that there is not going to be a mass die-off of our elderly.
That’s when it is important for all of us to be able to look people in the eye and say calmly, “I’m not sure where this is going. But one thing I am sure of is that the doctors, nurses and other healthcare providers in this country are the best in the world. And we are going to do the absolute best we can to make sure we get the best outcomes.” If you see a look of relief after that it’s because your neighbors, your family or your patients trust you even when you don’t have exhaustive knowledge. Isn’t that the old axiom, ‘People don’t care what you know until they know that you care.’