I’m on nights in the ED, and last night was an intense shift.
My first patient of the evening was a woman who was sent to the ED by her PCP for an indicentally-discovered WBC count of over 200, with 8% blasts (immature cells). That, non-medblrs, is very high, and she came in the door already understanding that she almost certainly had leukemia. I sat down with her and explained the next steps, and gave her The Talk that I have started to routinely give to people with new, serious diagnoses. The Talk goes roughly like this:
“A lot of things are about to happen in a pretty short amount of time. There will be a lot of people helping to take care of you. It might feel invasive and overwhelming, but I want you to know that you are the driver. If you are confused, ask questions. If something is happening that you don’t like, you can tell us to stop. This is your body and you always get to decide what happens to it. As doctors we sometimes get swept up in treating your disease, and I apologize in advance if you ever feel like we’ve forgotten about the rest of you, but please feel free to remind us. We are experts in medicine, but you are the expert on you.”
I then placed her first IV. It felt like I was firing the starting pistol at a race that this woman really didn’t want to have to run.
Unfortunately, she wasn’t the last person to get The Talk last night. The second person came in with abdominal pain, something we see often in the ED. While this patient wasn’t feeling all that sick, his story worried me, and on exam he had a large palpable mass in his abdomen. As soon as my hands touched the mass I could envision his CT scan in my mind. We ordered the test, and the actual scan looked worse than what I had imagined. There was really nothing that could look like this except for a widely metastatic cancer.
It was a very busy night, and my (awesome) attending was running all over the place. I offered to go tell the patient the bad news, imagining that she would probably want to be there for that conversation. But she just thanked me, and off I went.
I’ve had serious conversations with patients and families, sometimes unsupervised. I had not, however, actually delivered this kind of news before. Of course it was somewhat hedged; cancer is diagnosed by biopsy, not by imaging. But it would have been impossibly dishonest not to tell them that all of the testing we were about to recommend was a cancer workup.
They were fairly stoic about it, which probably made it easier on me, though it made me worry at first that I wasn’t being clear. They asked good questions. They wanted to see the CT scan, so I went over it with them. I gave them The Talk, and they seemed to appreciate it. We wanted to admit him, but they decided to go home and plan further diagnostics as an outpatient, and I felt like The Talk had worked. He wanted to go home, so he did.
I spent the rest of the night sewing and splinting, which is the beauty of emergency medicine: the heavy shit is mixed in with easy, fun, satisfying fixes. But I honestly really love the hard stuff. I love the type of healing that starts – and often ends – with words.
This is an amazing Talk and I’m going to have to steal it for future use.
Thank you. This is the talk I give as well, only with roller coaster analogies and putting your hand up to say STOP, I have a question/want off/don’t believe you, etc.
Putting your patients in the driver’s seat means everything – to their outcome, to their well being, to their families. You, @futuredoctorweirdo, you get this. It is likely because of your non-traditional back ground and I seriously wish I could hug you.
Giving the talk more than once a week is emotionally exhausting. Doing it twice in one day even more so. I want to check in on your well being. Are you making sure you are rebooting at the end of the day? Caring for your soul, your mind, and your body? Are you talking about these folks with someone who cares as much about you as you do about your patients? You are a shiny person, as you know, and I don’t want that shine to tarnish. If we are going to make medicine the healthy culture I know it can be, we all need you at your best.
reblogging for the bolded text. An important reminder
This is wonderful. All of medicine should be like this.
ESPECIALLY psychiatric medicine/mental health, which RARELY is, esp. at the point of Crisis. (also read as “ER mode/the point where you’d be getting The Talk if it was a physical issue”) But in psych medicine when you’re in Crisis, it’s often assumed that you’re not well enough to make hardly ANY decisions, esp. the big ones. (Because otherwise you wouldn’t be there.) Or they’ll say you can say no, but then they’ll take advantage of your weakened state & need to trust and emotionally manipulate you into rescinding that no. (This has actually happened to me.) (Coercion != consent!)
But, yes, this is very important. Glad to see this is happening.
the talk
Published
Mooncustafer 