Listening.
It seems like such a simple thing, but we're all so busy.
I had a patient the other day -- an old man who has been losing weight and growing weak. He had his esophagus removed 10 years ago and has had problems ever since -- diarrhea, loss of appetite. Now almost ninety, he is frail and spiritless.
He meets us at the door of his room in the assited living retirement community, all dressed up with his buttoned and pressed shirt and pants, a cowboy hat in his hand. He is annoyed when I tell him I have to take off his shirt and undershirt and put him in a hospital johnny. He says the nurse shouldn't have told him to get all dressed up if he was just going to have to get undressed again. Then he sees the scrape on his elbow that he got when he banged it against the dresser, and he is annoyed that the nurse didn't put a band-aid on it. I tell him not to worry, I will dress it for him.
He slowly takes off his shirt, refusing my help and then we put the johnny on him. He stands there for a minute, just a few feet from the stretcher that is in the low position with a clean sheet spread out on it. Finally he stakes a few small steps over and with my help now, sits down.
I put a 4 X 4 on his elbow and wrap a little kling around it. I read the W-10 and see the words, malnutrition, depression. His skin is very dry, but his vitals are all normal and the only pain he has is in his abdomen -- pain he says he has had every day for ten years. All the way to the hospital, he looks uncomfortable, a sour look on his face. The hospitals have stopped taking our bloods so I am less inclined to put in an IV as a matter of course. The man, who needs to be hydrated, can wait for it at the hospital. I sense he will be bothered if I tell him I need to put in an IV. I think I have taken him in before -- he seems familiar to me. We don't make much conversation. Its a long trip to the hospital -- not the closest one, but the closest one to where his daughter lives. He's not happy about it, but that's where she wanted him to go.
I call the hospital and give the basic story -- elderly man losing weight in recent weeks, no appetite, stable vitals.
I spend the rest of the time writing up my form. I could be conversing with the man, but he seems rather miserable, and I want to get my form written, front and back, because its the last day of my shift and I want my paperwork done by my shift's end so I can get out on time.
When we come through the door, the nurse gives us a room number, and then comes in after we've moved him over to the bed. I start to give my report, but she is already interrupting me, asking the patient and me questions. I try to tell her that he had his esophagus out twelve years ago, but she starts asking him about esophagitis. She sees the bandage on his elbow and says, "You fell? Did he fall? Were you dizzy or did you trip?" She says "We need an EKG in here." She is going 100 miles a hour -- this is not the first time I have dealt with her. I just say, "I'll finish writing up my report and you can read it when I'm done." I leave the room. She'll get the story eventually. I'm tired of dealing with her. The only time I ever interrupt her and tell her to stop and listen is when I feel the patient needs immediate intervention in which case I usually just go find the doctor. Its like she has attention deficit disorder compounded by ten cups of coffee.
A couple weeks ago I brought an elderly patient with an open ankle fracture to a hospital only to find no triage nurse. At the same time two critical patients came in. The triage nurse came running to the front then and was trying to triage all three patients at once. She asked me what I had. I said a severe ankle fracture, but the patient was stable and medicated. I probably should have said an open fracture instead of a severe fracture. She triaged the other two patients -- a stroke and a semi-responsive OD, and then went back to me. She was looking at her computer screen and typing as I started my report, and she cut me off almost right away. I told her it was a severe fracture with an open laceration and that I had given 7 mg of morphine. We took the patient down to the room and I waited there for about ten minutes until the PA came in and I gave the report, telling him how badly fractured the ankle was, but that the patient was now pain-free. I later heard the triage nurse was pissed at me because the patient met their internal guidelines for a trauma room activation and she hadn't triaged it to the trauma room.
Hey, she was busy, looking at her screen, not listening to me, and for my part, I could have been more demonstrative about the injury, could have used different buzz words. We both could have used a do-over.
EMS is a hectic world -- both prehospital and in the ED. Listening is a rare skill. It's hard to block everything out. We make decisions based on "pattern recognition." Its easy to make a mistake or go down a wrong track. Most of the times it doesn't affect a patient's treatment. The old man will get hydrated in the end and hopefully also have his depression addressed, and the old woman will get her ankle fixed.
I read an article in the New York Times :
Study Says Chatty Doctors Forget Patients
It set me thinking. We are with patients longer than their doctors are. Now I know at times I am mostly interested in getting the info I need: an assessment, history, do the skills I have to -- IV, ECG, maybe 02, occasionally give meds, and get the demographics and patient signature to make my reports written and verbal, but that still leaves a good amount of time to talk to the patient -- more time it seems than the doctor or nurses can afford at the busy ERs.
I want to try to make the most use of that time I can -- I want to try to use that time to really find out what is going on with the patient -- and not just use the extra time as silence -- a time to wander in my own thoughts. A famous medical saying is that "if you listen, the patient will tell you what is wrong."
I should master my own listening skills before I get too upset at others for the lack of their own listening skills.
I'm going to try to do better.
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Here's a post I wrote a few weeks ago that talks about listening and pattern recognition.
How Doctors Think
