Trusting the Patient (Part 1)


Emergency medicine is an all-senses sport and then some. See, hear, smell, touch, (hopefully not) taste, body language, psychological clues, bullshit detector. We have to figure out which complaint is the chief, which are contributory, and which are noise that our patients use to make our jobs more difficult. Our patients were strangers to us only moments before we introduced ourselves; they often don’t speak our language (medical or otherwise), come from different cultures who interpret or experience pain or discomfort in other ways, or lack the education to understand what we’re asking or telling them. (But if it were easy, we probably wouldn’t have been drawn into the field in the first place, would we?)

We don’t always have much to go on. A history from the paramedic, from the home attendant, from the son: a medical game of telephone. Sometimes patients lie — for their own gain or from their own shame. Sometimes we miss the elephant in the room. Sometimes our patients are confused. Or aphasic. Or angry. Or drunk. (And sometimes all of the above.)

In medical school, we’re always told “listen to the patient,” that the patient and his or her history will very frequently lead to the diagnosis. And frequently it does. But get any number of patients we see every day with 4 or more complaints and a grossly positive review of systems, and you simply can’t address them all, or unify them all into one little nice diagnosis.

And with our handicap of not knowing the patient plus the patient often not knowing his or her own history, the patient often has magic words that force our hand. We lack the luxury of being the primary care physician who knows the patient, has evaluated the patient on multiple occasions for her “chest pain” or “abdominal pain” with negative workups. For us, however, say the magic words, and you’ve bought yourself an admission, if you want.

“Chest pain?” EKG, troponins, chest x-ray.
Intoxicated and “I hit my head?” CT brain.
“Weakness?” As big or little a workup as the physician wants.

Often we can’t tease out what made the patient decide to come in today, no matter how many times we ask, or how many ways we phrase it. Often the answer ends up being “I just got tired of it not going away,” like my patient last week told me for the reason he finally came in after being blind in both eyes for 6 days. Ugh.

On other occasions, we have to take the gist of what the patient is saying — the overlying theme, if you will — but ignore the context. Last month, a patient came in because, as he explained it, “The pain I always have whenever I get stressed just didn’t go away.” 3 hours and a CT scan later, voila, perforated appendicitis.

The history often leads us to our diagnosis, but sometimes through a very circuitous route. Sometimes hunches, guesses, or stabs in the dark lead to the answer. Often the textbooks are wrong and the patient is right.

A lot of this whole “becoming a doctor” thing is refining our filter — getting more comfortable with disease presentations, and teasing out the subtleties that lead to the answer. It’s why the “chief complaint” is supposed to be in the patient’s own words, but the rest of the history and physical is described by the physician. You take the patient’s history, and turn it into your own story to deduce what’s going on.

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  1. #1 by bostonian in ny - September 16th, 2009 at 14:30

    I had a patient last month that came in for “When I pee I have to move my bowels.” Nocturia, frequency…better get a UA. I was thinking BPH and was lining up some primary care follow-up when i noticed he was discharged the week before with a sugar of 350…UA had 3+ glucose

    So I rechecked his sugar (in the 400’s) and it sort of pushed me in the direction of diabetes. His BP was poorly controlled, and on further history he was having polydypsia, polyphagia and polyuria…all from the vaguest of chief complaints

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