Yesterday, I received a little piece of paper from my residency director informing me that I was the primary provider for some four hundred patients this year during my internship year. This lands me right around an average of one patient seen per hour while working in the emergency department.
Data like these are a coarse brush. Under the headline of my first half kilo-patient as an MD is the smaller text that some fifteen percent of these patients returned to an emergency department within 72 hours of seeing me. Sure, many of those individuals were asked to return for a recheck of their cellulitis or abscess or animal bite or sutures, or, more commonly, are my community’s daily drinkers and intoxicant users refusing rehab. But, buried in these scores of patients are errors in patient assessment and clinical judgement.
Emergency medicine is about risk tolerance. TV shows and, to some extent, even medical student rotations, tell us that the emergency department is about the resuscitation of the critically ill, but the majority of emergency care now appears to me to be about patients experiencing some form of discomfort from which they want relief. Something in their bodies doesn’t feel quite right, is twinging or burning or stabbing or numb. “I just wanted to get checked out,” is a common explanation. The causes of these sensations rarely are namable, at least by me, so the question becomes: how much risk to the patient can I and the patient in front of me tolerate.
Risk is shifted with medical testing. Take, for example, a tall, thin young person with chest pain sent in by their primary care doctor after hours. After good history and physical exam, we’ve arrived at a healthy person with no significant cardiac risk factors, normal vital signs, and pain that is reproducible on palpation. This individual is low risk for acute coronary syndrome or arrhythmia or even pulmonary embolism. Now what? An electrocardiogram is low risk and can give us a sense of underlying arrhythmogenicity. A chest x-ray is a darn reasonable way to look for a pneumothorax and is about the radiation of three coast-to-coast flights. A bedside echocardiogram would be pretty revealing for left ventricular hypertrophy or even aortic root dissection. Oh, this patient is on oral contraceptives or is mildly tachycardic? What about a D-dimer for PE risk stratification? We can escalate diagnostics, but in doing so we escalate exposures, false positive rates, time, and cost.
By the depths of this past winter, I felt like I had begun to really understand our rule-out algorithms – panels of diagnostic tests intended to take the scariest of our diagnoses of low or moderate probability and drop them to some marginal figure. That said, as spring has turned into summer, I have begun to rediscover a new, beautiful tool in managing risk – shared decision making.
You had a low speed motor vehicle accident and your forearm hurts, “Do you think its broken? An X-ray takes about an hour, would you like to wait for that?” Your grandfather come in from the nursing home a bit more confused than normal – “We often do a lot of testing in these situations, but we know that our odds of finding a real urinary tract infection, or bloodwork abnormality, or intervenable issue on head CT scan are low, would you like to talk about the options?” You have had nausea and vomiting for 36 hours, no risk factors, and normal bloodwork – “We can bring you in for observation, but there is no silver bullet for how you feel. Do you think you’d like to come in to be watched or do you have someone at home who can help you through the next 24 hours? It will likely cost over a thousand dollars.”
I get it now, to err is human. There are a few big diagnoses I’ve missed among my half-kilopatients, but most of those folks are the ones in the hospital already with other thoughtful providers at their bedsides. The ones I wonder about are the people I send home, back into that world of uncertainty. Looking around the emergency department, it’s amazing to think about the burden of disease in our world, about what people live with every day. For some of these people, the hospital pipeline of battery testing and medicine titration may be life altering, but for many, the functional benefit will be low. More and more, I find myself wanting patients to be able to go home, to help them understand up and downsides of time spent in our hospital systems.
To err is residency. I’ve made mistakes and I will make more. Now I need to figure out what sorts of mistakes still allow me and my patients sleep at night.