I love a great story.
There is truly no substitute for the way a woven web of words can play to your sensibilities. If you think about an incredible movie, the CGI is what makes it come alive in front of your eyes; however, without a great story line, it all falls flat as smoke and mirrors. Medicine is no different. As we come to love and embrace the sexiness that is advanced scan techniques, ultrasound, robotics, it is easy to lose the more human element of the people that stand before us.
“We need a little help down here.”
The emergency department called with a 40 year old male, diagnosed with bilateral pneumonia, who they were having difficulty oxygenating. The report that they received from the flight crew was that he had been sick for approximately two weeks. Had seen his PCP 4 days ago, been prescribed antibiotics, no real improvement. Progressive dyspnea today and his wife called EMS.
On my arrival, his 02sat was 79%. Violent coughing, froth to the OETT, normotensive, tachycardic at 135, significant JVD.
Patient was more heavily sedated, decreased tidal volumes, increased PEEP and achieved a sat of 91. I took a quick look at his CXR while someone retrieved his wife.
“So he’s been sick for about two weeks?”
She immediately gave me that look that my dog gives me when I try to discuss the intricate details of this week’s episode of “The Walking Dead” with her.
Okay, we have no matches thus far, neither clinically or historically.
“So why don’t you tell me what happened tonight?”
She states that they were watching TV in bed, he had been very tired all day. She drank all of his Coke and he had gone to the kitchen for a refill. After about 5 minutes, she heard him call out. He was clutching his chest in the kitchen floor, complaining of severe chest pain and “foaming at the mouth.”
His father died at 46 of an MI. He has pain in his legs when walking more than a few minutes. When asked how much he smokes, “A lot.”
“How much is that?”
“Like, a lot-a lot.”
I have come to understand that “he’s really cut back” means a half a pack, “a good bit” is a pack, “a lot” is two packs. Based on that progression I can only assume that “a lot-a lot” means around three packs a day.
His repeat EKG revealed subtle V2-V4 ST elevation and a troponin of 4.
He coded prior to cath lab arrival, 8 mins to ROSC. LAD occlusion that was successfully stented and he was released one week later.
Our repeat clinical assessment and testing, as expected, told us everything we need to make a correct diagnosis. However, his wife’s story, made a far clearer impression. If transmitted effectively, her words would have guided our investigation more effectively.
Unknown altered mental status.
“A real bad headache and an ear infection that was so bad the shoulder of her shirt was wet.”
“Stole a ‘teener’ of meth from friends at the lake and shot all of it up before falling into the water.”
High dose methamphetamine abuse.
MI with subsequent ischemic CVA
“She went shopping last week and brought home a beautiful new dress. She said it was for her funeral.”
Trust no one
Medical transfers can play out like a playground game of telephone. No one is at fault, but the convoluted path of the patient can change a history. I always lead off with family by saying, “I know you have rehashed this several times with different providers. I have been updated, but I want to make sure I’m not missing anything. Do you care to go back over things again with me?” It reassures family that the team is in communication but allows you to hear the story first-hand and probe more deeply into the things that catch your attention in particular. Although exhausting, people always appreciate being heard and feeling like an important part of the medical team.
Not only do have the opportunity to glean details that are important to you, the time you take to simply sit with a family and listen builds an incredible rapport. When people feel heard they become a part of the team.
This is the fun part
Not only is a history integral to the care of the patient and involving for the family, it can be sublime for the provider. This investigation makes the group of body systems in front of you human. It will give you insight, empathy and on occasion, a good laugh.
“I will tell you something about stories
They aren’t just entertainment.
Don’t be fooled.
They are all we have, you see,
all we have to fight off
illness and death.
You don’t have anything
if you don’t have the stories.”
Leslie Marmon Silko’s Ceremony