Learning happens in between cases in the ER. Be it a well-managed case by your colleague or a particular procedure you could have done differently. You learn something after each encounter. At times, learning happens when most unanticipated. Like when you are about to snuggle into your warm bed after a tiring day at the ER. My night was supposed to be calm, maybe punctuated by some calls by a concerned parent of minor flu ridden child, but calm nevertheless. You would not have completed rehearsing your thank you message that you are going to say the day after to the scheduler and the telephone rings. You pick it up because that is literally the only job description for tonight. Answer health queries that people might have. No wonder I was brave enough to feel cozy on the bed in the telemedicine room. It was a call from a 37-year-old female who lived in a village almost 3 hours from Patan Hospital, where I was.
At Patan Hospital, a telephone-based telemedicine service is provided 24/7 via doctors and interns working in the ED. Telephone encounter with a patient has its own challenges. For one, you don’t get to see the patient and hence won’t be able to tell the degree of discomfort. All your Sherlock Holmes like sharp power of observation that you have built through years of practice can only use one of the multiple senses. Listening becomes not only the most crucial skill but the only available tool you have.
Fear to land in the wrong place
Sometimes, you hear that one word that triggers the fast-acting, decisive and flight or fight-mode-run emergency physician in you. That forces you out of habit to think parallel while taking history. A boon and a curse in its own might, differential diagnosis starts popping up and canceling themselves. The goal is either 1) providing the patient reassurance that nothing serious is going on and she can visit a primary care in convenience or 2) urging them to visit the nearest ER because something sinister might be going on. The division seems very black and white but the near distance between the two divisions is so big that you fear to land in the wrong place without a return ticket.
Differentiating headaches
For a starting practitioner that I was, differentiating primary headaches was easier in a precisely articulated MCQ but rather difficult in a real patient scenario.
Temporally jumbled case history, intersecting symptomatology, and vital clues to the diagnosis buried underneath a mist of unrelated information constitute a patient history. To dissect through that mist and reach a sensible differential is an art that comes with practice. As I am sure I will reiterate in years to follow, I hadn’t honed the art form to the degree I have now. I present to you a telephone conversation between an intern on duty at telemedicine and a patient with a headache.
Telephone encounter
Patient
Hello! I have a bad headache.
Me
Hi, I am sorry you have a headache. Let’s talk for a bit; I will try to quickly characterize your headache and advise you on what to do next. Does that sound like a good plan?
Patient
mm hmm. I haven’t had this bad headache ever.
‘First or worst headache’ - this sounds like SAH.
Me
On a scale of 1 to 10, how bad is it?
Patient
I would say 8!
Me
When did it start?
Patient
Around 2 hours ago.
Me
Have you had comparable headaches or headaches on a regular basis?
Patient
Sometimes. I don’t remember.
Me
Do you remember how your headache started? Have you hurt your head?
Trying to rule out the obvious causes like trauma.
Patient
No, I came back from work. At first, I felt nauseous. Then the head gradually started throbbing. It felt like a drum was beating in my head.
At that point, I decided to open up UptoDate and look through the causes of thunderclap headache. SAH, cerebral infections, HTN crisis, Ischemic stroke, cerebral venous thrombosis – the list continued. (1)
Me
Apart from nausea, do you have any other symptoms?
Patient
I am finding it difficult to stay in bright light.
Photophobia! Could this be meningitis or migraine?
Me
Do you feel feverish?
Patient
No
Me
Any rash?
Patient
None that I see.
CNS infection checked off. I feared that I was asking too many questions. Had she presented to the ER, I would have managed her pain first, ruled out my differentials with history taking and sent her for appropriate investigations. The inability to accurately assess the degree of pain further adds to the limits of telephone medicine – you have to trust what you hear without having the opportunity to manage in real-time. History is essential to a proper recommendation, especially when that is the only tool you have – I thought to myself.
Me
Do you have any trouble seeing or walking?
Patient
No
She has been answering well, so no difficulty in speech - her neurological status seems intact.
Me
Do you have any other medical problems? Are you under any medication?
Patient
No. I just took paracetamol but it was of no use.
Me
Do you have nasal congestion or discharge?
Patient
Not now, but I had the flu a week back.
Acute sinusitis is another common cause of headache. (2) Having ruled out serious threatening causes of headache. I was relieved – this sounded like a case of the primary cause of headache, a common presentation in every ER. I needed to remember the differences between different primary headaches – a quick UpToDate search away. Maybe, telemedicine does have some pros – like searching up the internet might not have been very appropriate while talking to your patient.
Me
Where is your pain? Does the pain seem to spread to any other area?
Patient
It’s just in front of my head.
Me
Did you feel anything abnormal before the headache started?
Trying to rule out any aura
Patient
No
Me
Do you feel the urge to isolate yourself and not hear loud noises.
Patient
No. Not really.
Me
From my evaluation, you seem to be having a tension headache. It is not a serious condition and is the most common cause of people presenting with headaches. (3) But I would suggest you visit your nearby health center to ensure you get the right diagnosis nonetheless.
Learning is the summation of moments
Learning is the summation of moments we really understand something, those aha moments, ones that feel like an epiphany. I always knew photophobia and phonophobia occur in migraine and not in tension headache. I may even have read before that day that one of those can happen in tension headache as well. But never had I ever imagined that one day I would reassure a patient that she has a tension headache because she doesn’t have both. The nature of medicine is such that we really learn something after each encounter.
References
- Schwedt TJ. Overview of thunderclap headache. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/overview-of-thunderclap-headache
- Dodick D. Headache as a symptom of ominous disease. What are the warning signals?. Postgrad Med. 1997;101(5):46–50,55–6,62–4.
- Jensen RH. Tension-Type Headache – The Normal and Most Prevalent Headache. Headache 2018; 58:339.
Further Reading
- Cutrer FM, Wippold FJ, Edlow JA. Evaluation of the adult with nontraumatic headache in the emergency department. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/evaluation-of-the-adult-with-nontraumatic-headache-in-the-emergency-department
