In the extreme sport called emergency medicine, the patient and physician in the emergency room are locked in a crucial relationship that requires clear and fast communication. In the most severe events, just how well the patient-physician interaction works within the chaotic hospital environment plays a major part in the quality of care delivered to patients.
In the 1990s the ER was renamed the Emergency Department (ED) to acknowledge the reality that emergency services are provided by a full department consisting of many providers - physicians, nurses, radiologists, blood and urine labs and referral services.
Gail Coover, a faculty member and researcher at the Center for the Study of Cultural Diversity in Healthcare at UW-Madison School of Medicine and Public Health, explained both patients and physicians in the ED face similar challenges, but don't often realize it.
By the time a patient is finally seen by the physician, they are both experiencing the stress and chaos of the environment,"" Coover said.
In the high-stress ED environment, mistakes can easily occur during the transition between work shifts. Debbie Stamps, the Director of Nursing at Rochester General Hospital in New York, said miscommunication regarding medication instructions, and elopements (patients walking out before being discharged) typically increase during the transition period between work shifts.
The ED must also deal with the growing problem of patients using the department for their primary care - patients range from those lacking insurance to the insured who seek specialized care they erroneously think an ED doctor can provide.
So, how can patients best manage their expectations of the ED, and how can ED physicians clearly communicate they care and will effectively use their skills to treat patients?
A recent visit to the UW Health ED during two shifts revealed the ups and downs of patient-physician communication, and opened the door for further exploration into how these interactions can be made easier and clearer.
*Chest pressure*
On a quiet morning in the ED, a middle-aged man came in complaining of chest pressure. He was apologetic because his symptoms had subsided once UW Health Medical Resident Paul Turley arrived at his bedside. To rule out the possibility the patient was experiencing a heart attack, Turley completed a full blood work-up.
Turley then explained that as part of the work-up, he would be checking the patient's troponin - an enzyme whose presence in blood might indicate damaged heart tissue.
""[Troponin] are enzymes that leak into the blood, like little machines,"" said Turley.
From the patient's reaction it seemed he appreciated Turley's attempts to make sense of complex terms with colorful descriptions.
Seconds later, Turley began a battery of follow-up questions.
""Do you have a history of COPD? CHF?"" Turley asked.
What was a brief moment of clarity for the patient appeared to be lost, as he made a hand gesture as if to say, ""That's way over my head.""
When asked if he felt the patient understood what COPD (chronic obstructive pulmonary disease) was, Turley responded, ""You explain what you can. Generally, if they've never heard of it, they've probably never had it.""
But, according to Coover, a patient hearing such jargon may respond to the fast pace of the interaction and hurry the visit along - in other words, ""that sounds complicated, so I'll just shrug it off.""
Although the communication between Turley and his patient in the ED was a mixed bag, Turley exhibited the kind of authentic behavior that Coover said is crucial to a more relationship-centered exchange between patient and physician where the experience of each person counts equally to the success of the visit.
""Physicians must always work on themselves and the assumptions they bring to each situation to make the exchange as genuine as possible,"" Coover said. As it turned out, Turley's patient's blood work and stress test were negative. Since he described himself as having ""woman problems,"" he may have been suffering from a broken heart more than anything else.
*Abdominal pain*
During a busy overnight shift, a prisoner from the Wisconsin Correctional System was brought in complaining of abdominal pain. He was a strong man who writhed about so much from the pain that the EKG technician couldn't get a proper reading of his heart rhythm. UW Health Medical Resident Lindsay Krall and the nurse easily took control over the situation, which had the potential to go badly because the patient was not lucid. The nurse later confessed that she thought his problems might have been drug-related.
His blood work and a toxicology screen were negative, and a first read of his CT scan seemed normal. By the time UW Health attending physician Azita Hamedani observed him for the first time, she discovered that instead of writhing in pain, he was sitting up in bed, watching TV; his condition seemed resolved. There was a huge disconnection between what Krall and the nurse observed initially, and how the patient appeared later to all three of them. The patient, however, still complained of a dull ache.
Despite mounting pressure to discharge the man, Hamedani trusted the consistent reports of Krall and the nurse, and tried to reconcile the ""before"" and ""after"" picture of this patient. She requested a more refined reading of the CT scan. The new reading revealed a volvulus, a section of intestine that had looped upon itself. This condition is painful, but can resolve if the knot loosens or shifts. Left untreated, however, a volvulus can become life-threatening.
Stamps applauded Hamedani's tenacity, observing that this was a classic case where a physician not concerned with providing individualized care might write the patient off based on personal prejudices (for example, the patient is ""drug-seeking"") and discharge him.
For Hamedani, this was what she referred to as a ""near miss."" If another physician had not appreciated the extent of the patient's distress as Krall did, Hamedani may not have pursued it, especially since the laboratory and radiology reports were clean.
Later that day, Hamdeni's patient was admitted with a high likelihood of surgery.
The two separate physician-patient interactions observed at UW Health ED serve as reminders that communication between patients and physicians can always be improved.
""There's a lot of mistrust of the healthcare system,"" Coover said. To overcome this perception, Coover suggested patients help themselves by understanding the power and the limitations of the ED, and physicians by listening and being true to themselves.
