Hinge! Hinge!

"Hinge! Hinge!"

I am, damn it.

But I wasn't. I was arching my back. I was dropping my shoulders. My poor form made me felt I was already hinging, as my chest was already hitting my knee.

But no. Straighten up the back. Open up the shoulders. Then hinge. Now I'm really hinging. Plunging the paddle deeper into the water. Rotating more fully. Then kick. Pull back. Snap.

Sometimes, we all need someone on the outside looking in, to tell us to do better what we thought we were already doing okay in.

Or in some instances, tell us how we had it completely wrong, and we didn't even know it.

We all have room to grow, things to improve on. Often I get a lot of positive feedbacks from people. While they are encouraging, they do not make me grow. Sometimes, they even act to reinforce my misconceptions, or in more extreme cases, masks my shortcomings.

But the observant soul. The outspoken one. The one who calls me out.

Makes me grow. Makes me be better.

And I shall try to listen more. 

On the other side of the table.

Yesterday I went for a little medical procedure. Nothing much, just a little test. And thankfully everything was alright. But every time I was on the receiving end of medical care (and thankfully, it hasn't been too many), it's always a reminder of what it feels like when you're the vulnerable patient, at the liberty of the health care professionals looking after you.

A colleague used to say, "remember what it feels like when you're sick, cause that's how you build empathy".

Very true. Even as I lie there on the stretcher, waiting for my test, looking around the room surveying the faces or other patients coming in. Some where scared. Some looked lost. Some recovering and still groggy. I waited, patiently, remembering to smile when my nurse comes to me. She look stressed. Overworked again, I bet. She came to start an IV. Would it hurt? I thought. I hate needles. I don't mind giving them, but I hate needles.

She was very good. Popped and it went in. Thank you, I smiled. How was your day? She didn't answer. She was distracted by another patient who just rolled in to the recovery room.

Then my doctor came. I've met him once already before. Super nice guy. Warm smile. Kind manner. I notices he pushes his own patients into the procedure room. Chatting with them as he goes. That's a good approach. Do a little bit of your "dirty" work. It shows that you're not just some big shot waiting for others to do everything for you. It makes you kinder, more personable. I should remember that.

The whole thing went very well. He was polite and attentive again in the end, although I don't really remember much of it.

It's funny, but I always thought consultants are often arrogant jerks who have lost all their kindness through their grueling years of training and over-extended schedules. And in my position I have every reason to think so. Most phone calls I make in the ER to consults are min-battles. They would almost universally frown when I identify myself. "Hi, this is Keith Tang from ER, sorry to bother you, but I have a patient I need to ask you to see..." Growl.

Usually, I would just ignore it and continue to pitch my case. Consultants who I work with usually know I go as far as I should before I call them. I seldom deliver them crap cases. One even went as far as to say that I think like an internist (well, I started my training as one) and would put them out of their job if I keep doing all their work for them. I know they are busy. So I try to run with the ball as far as I should. But we all have other priorities, and mine is to keep my department humming along without much delay. But to them, every phone call usually means more work for them, just another name to add to the bottom of the list of their never ending on-call day.


But these mini-battles add up. And soon I start to forget, they they are doctors too, and they do it because they care, and very often, they are actually very, very nice. And they care about their work, a lot.

There was one doctor who really stood out on this point. He was an ENT consultant at one of my hospitals. Frankly, he is almost universally disliked among my peers. When we are on shift, we frown when we see his name listed as the on-call staff for the day. Phone calls with him are never pleasant. One time he told me he was at a wedding and needed me to hurry with with my call as the bride was about to walk down the aisle. He's on call, for god's sake. Then finally, one day, I met this doctor. In person, he was every bit as condescending, blunt, and arrogant. However, everything changed when I watched him interact with a patient. He was kind, and gentle, and showed great care. I don't believe it was an act. I think he genuinely cared. Yes his bedside manner was polished, but one has to be a decent person to whip that out on the spot like that.

In the medical arena, it is easy to build up animosity towards your colleagues. When all you see is their name on a chart or on a call list, and in the context of meaning more work and headache for you, their name never seems to shine in that light. But more often, doctors are nice people, and they genuinely work hard for their patients and is almost always thoughtful for them.

It is a good reminder, however, that this is likely how others see me as well. As much as I think I put my heart into this, I'm sure on paper I would often come off as equally stupid, incompetent, and annoying to those who have to pick up the chart from me. So the lesson here is to always be kind, and to hopefully document accordingly with thoughtfulness. And to give others the benefit of the doubts. Most doctors put in a good effort, and sometimes we just don't see that when we feel they left us with more work. Every time I have the benefit of actually observing my colleagues at work, I am always impressed by their knowledge, professionalism, and manners. I experienced that first hand today, from someone whom I was used to using as a a consultant and receiving consultation reports on. I'll never look at his name in that negative light again. But the same should probably go for all the other consultants I work with. 

Cute things.

Cute things happens in the ER. Sometimes.

Little boy. I think he was 7. Let's say 7 year old boy.

Chief complaint: Smelly discharge from nose.

Thought to myself, gotta be kidding me. This to the ER? (Of course, classic case).

Resident I was working with picked up the chart. Sure, go check it out. Let me know if you're worried about anything.

Resident came back. "The kid's just got a booger up his nose. I'm going to remove it".

Great. Done. That was easy.

Wait, that's too easy. Can't be. Let me take a look.

Resident showed me the booger. That was tiny. Can't be it.

Kid looks cute. Giggling. Shy. Brave.

Where's the nasal kit? (Resident didn't have the right tools to examine the nose).

Ah, there it is. (Taking out the kit that has the nasal speculum and bayonet forceps).

Kid freaked out, just a little. But then he braved up again. Showed me his nose.

Peek in. Something funny going on in there.

Ah. I see it. Let me go grab it.

Sticker pulled out from the left nare. Pretty big thing rolled up into his tiny nose. Cute but gross. It was a Captain America sticker, I think.

Showed it to mom (mom was hiding behind the curtain).

"Do you want to keep it?". Come on. Definite scrapbook material, I thought.

Shook her head. Guess not.

Sometimes the most silly cases still require a little digging. Reminder. No sane person (or parent) would willingly sit through hours of ER wait if it's not something they've sat on already for hours at home contemplating if they should come in (I could be wrong, I can actually think of quite a few too many who shouldn't have been here). Anyhow, if they're here, they usually get the full meal deal. Plus, this is probably as textbook as it gets when it comes to cute kiddies and nasal foreign bodies. It was a cute way for my resident (and me) to remember not to take things too lightly sometimes, even if they come in cute and giggly small packages.

Preaching tolerance

Recently, my department head forwarded me a letter sent in by a patient thanking me and my staff for their care. I looked up her case. I sort of remember her but honestly didn't feel I treated her any differently than the rest. I guess I was lucky she saw me in a good mood.

My department head said good job. My reply was much more melancholy. Thanks, I said. You win some, you lose some, I added.

For every patient who felt inclined to thank us, I'm sure there are many others who would much rather complaint about us.

In light of all the recent negative media portrayals of ER congestion and care in Fraser Health (many of which unfairly reported, I must say), frustrations and negative sediments against Emergency Rooms are at an all time high.

The down stream affect? Everyone is on edge, as if they are not on edge enough already simply by doing this job. In Abbortsford, where after an unfortunate outcome involving a pediatric patient early last month, a colleague told me the pediatric unit admission rates went sky high. That is hardly good medicine. Unnecessarily hospitalization lead to a whole host of potential adverse events and tremendous inconvenience for the families involved, not to mention a much higher financial burden on our already taxed medical system and draining of essential resources that would otherwise be serving patients who really need them. But that's what the situation is becoming. Medical practice not from sound judgement, but driven by fear or missing something.

This is a thankless job. We know this going in. We are happy to be doing it. We also know it's a field filled with landmines and it's all about mitigating and managing the risk we work with.

In fact, if there is one term that summarizes Emergency Medicine, it is essentially effective Risk Management.

Much of the Emergency Medicine scientific literature is about this. How to evaluate risk of a specific condition when a patient comes to the emergency room. How to calculate and perceive such risk. How to balance this risk with costly and sometimes invasive investigations that has its own downfalls. How to weight to risk of false positive or false negative results. What is an "acceptable" risk to miss a potentially dangerous condition? It can never be zero. Nothing in life is that definitely. In medicine, if your assessment tells you that the chance of missing something bad is down to about 1-2% or less, usually that is enough evidence to say stop.

But things are not always this easily calculated. And despite best sound judgement and evidence application, we don't work in a mathematical model, and things are just not that precise.

Clinical judgement, or gestalt, as we like to call it, counts a whole lot. Sometimes we do have to trust our gut.

But very often, I find that patients don't understand that. Patients like to (or hope to) think of medicine as black or white. Doc, do I have this? Will I get better if I do this? Are you certain this is not my heart? Is this cancer?

No, sir. I can't say anything like that. Our tests and technology cannot tell us that with absolute certainty. But I can say that having heard your story and after my examination and tests, I feel really good about you. I highly doubt this is this or that. But there's always a chance I can be wrong. Or perhaps this is too early in the illness and I'm not seeing all that I need to make a more informed decision. So, let's do this. But please, come back if things get worse.

Please, come back if things get worse.

That is perhaps the most important statement of all. And people need to realize that. Just because you are fine now, we cannot guarantee nothing bad can happen or develop. Of course, we don't want to send you home with doubts and uncertainty, and I think we can do our best to mitigate that fear. But, just in case, if things don't get better or get worse, please come back to us.

We live in a world of grey. Not back and white. Patients need to appreciate that. Emergency Medicine is MEANT to miss stuff. It is DESIGNED to miss a certain percentage of bad outcomes. That's just a fact of the limitation of the world we live in. We try our best, but you have to be your own advocate here.

I've certainly been humbled by a few cases when all my clinical judgement tells me there's nothing, but the patient asked one last question that made me change my mind, and added a test, and discovered something. These things do happen. And I'm humbled by them, and every time I told the patient thank you for advocating for themselves, and that working TOGETHER, we did something worthwhile.

But the key here is TOGETHER. Sometimes when I come across a difficult patient, I remind them. Hey, time out, let's work TOGETHER on this. We want the best for you, but you have to help me on this, so here's what I think, what do you think, let's reach a reasonable approach that we are both happy with, and go from there.

Advocating for yourself doesn't mean stomping the ground and demanding every single test to be done to "check everything", as many patients like to ask (I have no idea what that means to "check everything"). It doesn't mean demanding a CT head for every little head bump especially for your little ones. It doesn't mean antibiotics for every cold or flu. It doesn't mean admission for every elderly who is sick but can totally recover better at home. It does NOT mean projecting all your expectations and fears in an unreasonable fashion onto the medical staff until you get your way.

But it does mean you are entitled to speak up, politely, about your fears and let's work through them. And if your gut tells you something really isn't right, I usually trust that instinct, and I do promise to chase after it to the best of my ability.

We all need better tolerance and understanding at this time when our Emergency Rooms are in a perpetual state of crisis. (Having perspectives is important, however, and I do understand that wait times in a lot of departments across the country are far worse than what we have here in BC). We need patients to be aware of what we can and cannot do for them, and to look out for themselves, to advocate when it is appropriate, but most of all, to understand the importance of serial medical visits and examination. That is sound medical care, not negligence.

So please. Work with us. So that we can all do better for you. Which is why we go to work in the first place.