by Chew Keng Sheng
Although a medical student has always been taught to take a comprehensive history and a complete physical examination from head-to-toe, she may find this methodical approach a challenge in the emergency department (ED). Many of the patients who come to the ED are often first-time patients, unfamiliar with procedures, and have diverse complaints ranging from a manipulative attempt to obtain a sick leave certificate to a complex, life-threatening situation. This challenge is further compounded by the fact that many patients in the ED are suffering from acute illnesses or injuries that compromise their cognitive capacity to comprehend and respond.
The Emergency Medicine Approach
Although some studies have shown that history-taking alone can determine the diagnosis in up to 75-80% of the cases (Hampton 1975, Peterson 1992) obtaining such a comprehensive history in the ED can be an extremely daunting task especially if the patient is extremely ill.
In such a situation, the linear clinical approach – history first, followed by physical examination and investigation – may not be feasible. Rather, data gathering from the patient’s history, physical examination, and investigation may need to be performed concurrently. The most important element in the approach to the patient in emergency medicine is to establish the composite initial impression of the patient. This is based on data gathering from multi-sources including the history, physical findings, and bedside investigations. Of particular importance is answering the vital question: is there any life or limb threat in this patient? And once a life or limb threat is identified, immediate measures must be initiated to reverse the insult before moving on in the data gathering process.
- Watch a video podcast on General Approach to the Emergency Department Patient.
- What are the strengths and limitations you see in this emergency medicine approach model where all processes of data gathering (history-taking, physical examination, and investigation) may have to occur simultaneously as compared to the traditional linear clinical approach?
As tough as it may seem, a doctor working in the ED must still establish a good communication rapport with the patient, as much as possible. To attain this, one must utilize open-ended questions.
Ask the 5-Ws and 1-H questions: “What?” “Why?” “Who?” “When?” “Where?” and “How?”
Pay particular attention to any symptom developed acutely. Acute onset of a headache, for example, suggests a vascular origin. If a patient has had a chronic, persistent or recurrent condition, the important question to ask is “Is there any difference between the symptom before and the symptom now?” A patient with a migraine headache, for example, can present with a sudden “worst ever headache” suggestive of subarachnoid hemorrhage rather than a chronic migraine. If we do not ask for the symptom pattern changes, the patient may not volunteer this information.
- What is the message that the patient is trying to convey to me through the words he does and does NOT use? Observe the non-verbal communication cues that he is trying to convey, e.g., a sense of nervousness, fidgety movements, etc. Often, patients are prone to conceal sensitive information such as sexual history as well as psychiatric/psychological complaints that may only be detected through non-verbal cues.
- Examples: Why does the patient choose to come in the middle of the night? Why does the patient choose this form of treatment and not another? Why does the patient think that his or her illness is not serious?
- Examples: Who is/are taking care of the patient at home? Whom does the patient seek advice from when he/she is sick? Who else knows about the patient’s illness? Who is/are the eyewitnesses of the accident or the trauma that the patient was involved in? Who is the patient’s next of kin? Who can be a legitimate surrogate decision maker for the acutely ill patient?
- Examples: When does the pain occur? When does the patient first notice the swelling, the discoloration, etc.? A sudden onset of symptoms is a warning sign and may suggest a vascular event.
- Examples: Where did the accident happen? Where does the patient come from? How far from the hospital?
- Examples: How did the accident happen? Did the patient lose his/her consciousness before or after the event?
Be attentive to the patient’s non-verbal cues as well, not just the verbal contents of his visit. Albert Mehrabian, a professor of psychology, developed the classic 7-38-55 rule. This rule consists of the following: while 7% of what the patient communicates comes from the actual words used (the content), 38% of the message comes from the way it is said (the tone), but 55% of the message comes from the non-verbal cues including but not limited to the facial expression, eye contact, etc.
Does the patient appears fearful and defensive? Aggressive? Angry? Disinterested? Click here to watch a video on Mehrabian’s study.
This is especially so when the patient is trying to communicate across sensitive information such as his sexual history or psychological symptoms. Unfortunately, it was found that only between 20 – 40% of doctors responded positively to the patient’s verbal and non-verbal cues (Beckman 1984).
Allow the patient to describe his/her concerns using his own words without interruptions. It has been found that a doctor interrupts his patients as early as 18 seconds into the conversation, even though it takes at least 150 seconds for the patients to tell his stories (Beckman 1984).
- Watch this short video: Presenting your patient to your attending in Emergency Medicine by Dr. David Pierce
- Reflect: In the video, Dr. Pierce admonishes his residents not to miss anything important by thinking of 5 other differential diagnoses. Why is it especially important to adopt a broad-based approach in diagnoses formulation in the ED?
- Watch this video: Approach to the ED Patient.
- Discuss/reflect on the following questions:
- In his talk, the speaker stated that “most patients do not take going to the ED casually.” How does knowing that most patients do not take going to the ED casually affect the way you view your patients, especially in the middle of the night?
- The second thing that the speaker said is that fear and anxiety are routine emotions experienced by ED patients. Do you agree with this statement? If yes, why do you think this is so, and how would this affect your data gathering process? In your ED rotation or posting, observe whether it is indeed true that fear and anxiety are routine emotions experienced by the patients you see. Do you think the doctors have done enough to alleviate these emotions of fear and anxiety in their clinical encounters?
- The speaker also talked about the long waiting time in the ED. How does the long waiting time affect your data gathering process?
References and Further Reading
- Hampton JR, Harrison MJ, Mitchell JR, et al. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J 1975;2(5969):486-9.
- Peterson MC, Holbrook JH, Von Hales D, et al. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med 1992;156(2):163-5.
- Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101(5):692-6.
- General Approach to the Emergency Department Patient.
- Mehrabian’s study: https://www.youtube.com/watch?v=_emfl7u2FsI
- Presenting your patient to your attending in Emergency Medicine by Dr. David Pierce URL: https://www.youtube.com/watch?v=EGNe_lzCDUA
- Approach to the ED Patient. URL: https://www.youtube.com/watch?v=h-5lXC0wNg0.