On Back Pain and the Discipline of Empathy

Samuel Locoh-Donou is an IUEM PGY-2 resident and part of the IUEM Avocacy Track.

“Let ME tell you how to do this dance, doc. First, I want an American doctor who speaks good English and who knows what he is doing. Second, I want my brother to get an MRI today, instead of a goddamned rectal exam. Nobody is getting a rectal exam! I have a slipped disk, so I know how you guys operate. Always trying to line your pockets by billing for unnecessary procedures!”

How did we get here? I recall vividly an angry man standing in front of me, eyes blazing, with his index finger pointed in my face. He must have been in his late 50’s, and had tobacco stains in his beard and moustache, and a hunting cap screwed on his head. His brother, who actually was my patient, was resting on the ER room’s bed, in his mechanic dark blue overalls, looking very uncomfortable with the unexpected turn of events.

I was in shock. Over the course of my clinical training, I had yet had to encounter this level of disrespectful and prejudiced speech. In the space of two seconds, this family member had made allusions to my ethnicity, my accent, and my treatment plan in a way that made my blood instantly boil. This was new for me. My experience as a healthcare practitioner in this country has always been a very positive one. My French accent and a bit formal English vocabulary (conditioned by my schooling in the British system) was generally welcomed with an initial wide-eyed curious surprise on behalf of my patients, quickly replaced by a smile and a heartfelt, mindful conversation on what brought them to the hospital.

My 55-year old male patient had actually come in for back pain, like one of the thousand others who walk into our emergency room every day with the same complaint. He worked as a mechanic, and had developed instant back pain 3 days ago when bending over the hood of a truck he had been working on. His symptoms included lumbar pain so severe that he could not sleep at night, as well as shooting pains radiating from his lumbar area into his L. calf. He had no history of recent back trauma, IV drug abuse, cancer, or chronic steroid usage. When I asked about cauda equina symptoms, he denied saddle anesthesia, but endorsed 3 recent episodes of urinary incontinence and 2 episodes of weakness in his bilateral lower extremities that had caused his legs to buckle at the knees. The patient was unable to tell if his legs gave away because of pain or because of pure weakness. His past medical history was positive for hypertension and hyperlipidemia. He had undergone hernia repair surgery in the past, and smoked 1.5 pack of cigarettes a day.

My patient was clearly uncomfortable, but pleasant and calm during the interview. As I proceeded to the clinical examination, his brother walked into the room and sat silently on a chair in the furthest corner, watching us warily. Since it is my habit to acknowledge every person in the room, I greeted the family member, and earned a grunt for a response. As I focused back on my clinical examination, it struck me that my patient was very tender to palpation in the paraspinal lumbar areas, and had difficulty with proximal and distal bilateral lower extremity strength testing. When I asked why he was weak, he said he was actually too in pain to move. His lower extremity sensation and reflexes were normal. Given his story of urinary incontinence and the findings of weakness (possibly due to pain), I decided to check for a rectal tone for my own peace of mind. I explained to the patient what I wanted to do, and the reasoning behind a thorough physical exam for the type of symptoms he was having. The patient flat out refused, and the brother erupted from his corner with his index finger pointed to me.

I maintained an attitude as professional as possible, attempted to explain the indications for an emergency MRI and the required physical exam components to precede the actual MRI, but every single word I calmly uttered only further aggravated the family member. He screamed that he wanted a different doctor for his brother, so I excused myself and stepped out of the room. I closed the door with shaking hands as I tried to quell the anger storming inside. My female staff ended the visit after walking in the room alone and getting a better history of the episodes of urinary incontinence (more related to inability to get to the bathroom in time) and lower extremity weakness more related to pain than actual weakness. The patient was discharged with pain control, return precautions, and a physical therapy referral.

As I reflected on this incident in the following days, I realized that the outburst directed at me by the angry family member was actually rooted in the love the man had for his brother, and a fear that his brother would have to suffer unnecessarily because of perceived inadequate care. Since no man is perfect, the family member’s emotions could not be detached from his personal socio-cultural canvas, and his perception of a different skin tone and accent in a healthcare provider only heightened a sense of unfamiliarity and insecurity already ignited by a loved one’s suffering. I came to terms with my initial feelings of anger and indignation, by applying to my patient’s brother the same principles of empathy I apply with all my difficult patients.

According to a 2007 study, the development of clinical empathy by physicians is key in managing difficult patient-physician encounters, and clinical empathy was defined as the ability for physicians to be emotionally engaged during conflicts with patients. In a nutshell:

– Physicians should accurately acknowledge their feelings and negative emotions as they occurred;
– Physicians should take the time to consider the meaning of their negative feelings and how they may relate to the patients’ feelings;
– Physicians should attempt to discern the emotional issues that underlie the patients’ negative reactions;
– Physicians should be sensitive to the patients’ body language, as the patients’ nonverbal cues will require the provider to adjust their own nonverbal signals accordingly;
– Finally physicians should accept patients’ criticism and negative feedback without falling in the trap of getting defensive.

I believe that the disciplined application of these key principles to not only patients, but patients’ families as well, is a healthy technique for healthcare providers to engage in a conflictual conversation with emotional intelligence and without compromising themselves. The discipline of clinical empathy goes beyond the simple doctor-patient relationship, as a provider is also engaged in some type of therapeutic communication with a patient’s loved ones. And this is the challenging beauty of the art of medicine.

J. Halpern, “Empathy and Patient–Physician Conflicts,” Society of General Internal Medicine 22 (2007): 696–700

Rachael’s First Week

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Thanks to everyone who participated in Rachael’s First Week today! We hope that our experiences we shared with you will help you in this exciting time starting college. We’re always here to help. If you have any questions at any time please feel free to contact us through the form below. You can be sure they will stay private.

These will be some of the best years of your life. Enjoy them and remember to watch out for each other.

Carl’s Story

Terez Malka is a 5th year EM/Peds resident at Indiana University School of Medicine. She will be a faculty member at Carolinas Medical Center, working in both the pediatric and adult emergency departments, starting in July. Check out Terez’s fantastic, previous post, The Challenges of Foster Care.

“Carl,” is a 10 year old boy diagnosed with autism at 18 months, and recently discharged from an inpatient psychiatric stay after a three week history of escalating violent behavior towards himself, schoolmates, and his parents and siblings. His parents are at their breaking point as they describe how he screams and hits himself, or anyone who comes near him, for hours at a time. He has not been able to attend school for weeks due to his violence towards classmates. He seemed to have some improvement during his brief hospitalization, but his behavior became unmanageable shortly after discharge home. They apologize for bringing him to the Emergency Department. “We just didn’t know where else to go.”

The following is directly paraphrased from “Carl’s” admission note:
“Father called [facility 1] and asked “what do we do?” and was told that they could not provide any assistance as patient was not followed in their outpatient program. Father states that he was told that patient was not a candidate for the outpatient program at the time of discharge. Father then called patient’s pediatrician, who advised them to call their behavioral pediatrician. At that number, they received a recorded message advising to contact the crisis center. At the crisis center, they were told that no providers were available who specialized in autism. At that point, family was afraid of patient’s behavior and had nowhere else to go, so presented to the Emergency Department.”

Most physicians who have cared for patients with psychiatric illness are well aware of the limitations and difficulties in obtaining timely and comprehensive care for our patients in crisis. Recent national events of violence perpetrated by those suffering from psychiatric illness highlight the devastating results when we are unable to provide them support, monitoring, and crisis respite they require. In my area of the country, pediatric patients requiring psychiatric admission can wait up to 72 or more hours in a general medical unit awaiting placement. These children may require phsyical or chemical restraint during that time period as the hospital floor is not fully equipped to support an agitated child, or one at risk of harming themselves or others. While the topic is widely discussed and lamented, no viable solutions seem to have come to light.

In our ED, Carl quickly requires physical restraint and then sedative medication in order to complete his exam and assessment. We are fortunate enough to have an in-house psychiatrist, who agrees that Carl represents an immediate threat to himself and others and requires inpatient psychiatric care. She sets off to secure an appropriate placement for Carl. But even after arriving at a large tertiary care pediatrics center, securing care for Carl is not seamless.
Below are direct quotes from the psychiatry resident’s phone notes:

“Facility 1: Discussed this patient with a social worker who stated that he will accept the patient. Received a call back and was told that the case was staffed with a non-physician, their administrator. Patient will be declined as he “reached maximum potential” from previous hospitalization that happened two weeks ago. I asked for definition of maximum potential, and was unable to get an answer.

Facility 2: Stated that all of their beds were full

Facility 3: Initially stated that they would accept the patient, then updated that they could not open up any new beds. Tomorrow there may be a bed if others are discharged.

Facility 4: Stated might take minimum 4 hours to staff, never heard back from them.

Facility 5: Physician declined patient as the patient would not be appropriate to their milieu.”

Right now, Carl is admitted on our general pediatric ward, restrained in a netted bed, with scheduled antipsychotic medications, awaiting placement. It has been 24 hours…

2014 IUEM Bike Safety Fair

With mother nature giving us sunshine recently, May 1 was a perfect day for the Bike Safety Fair! The IUEM Advocacy group, with support from Women for Riley, Riley and Methodist Trauma Services, I-EMSC, Free Wheelin’ Community Bikes and Indy Cog, were able to help protect the noggins of 1300 kids! Check out how much fun we had in the process:

Indiana Emergency Medicine Day and the Annual Legislative Assembly

DSC_0382January 14th, 2014 was officially named Indiana Emergency Medicine Day in honor of the men and women who are committed to providing 24/7/365 care for the state. This was announced at the annual INACEP and IUEM Legislative Assembly Day. Residents, faculty and community physicians congregated at the State House to present key issues to local state leaders. It was overwhelmingly successful with eight legislators present and active discussion between the politicians and physicians.

State Representative, Dr. Tim Brown, provided the residents an inside look into life in the State House and the feasibility of a career in medicine as well as politics. This was followed by presentations by doctors Sarah Hemming-Meyer, Kyle Yoder, Emily McIsaac and Emily Fitz on mental health, opioids, the value of emergency medicine and the Lifeline Law. The legislators were very receptive to the requests by the residents and asked for their experience to help improve legislation specifically in mental health and opioid abuse.

IUEM would like to thank all the residents and faculty who attended. A special thank you to Dr. Lindsey Weaver who organized the day and mentored the residents on their presentations. This is a five-year IUEM tradition that not only makes a huge impact for our patients on the state level, but also provides exposure for residents to healthcare politics and leadership opportunities.
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Community Resource Spotlight

Kyra Reed, MD – PGY-2 EM/Peds

The Community Resource Spotlight is a recurring submission intended to highlight community organizations that advocate for vulnerable populations and to also increase awareness about these remarkable local resources.

February Spotlight: CIRCLES® OF SUPPORT

“Family”… “strength”…“ hope for the future”… These were just a few examples of the uplifting rhetoric shared by the members of Circles to describe what the group meant to them. At the weekly meeting, the group was seated in a large circle, of which was a recurrent theme echoed in the vision of this innovative group. There were no socioeconomic barriers in this circle – they had melted long ago into a unifying movement during the process of developing new, long-standing relationships that may not have otherwise come into fruition. As each person shared their reflections on the impact that Circles has had on their lives, it was apparent that I was witnessing the metamorphosis of not only the individuals who had sought a way out of poverty, called “Circle Leaders”, but also that of the “Allies”, volunteers who were paired with Circle Leaders as a pillar of support and guidance. Individuals from different “circles”, or walks of life, were now engaged in candid conversations regarding poverty, violence, and daily life struggles. This inspiring group of individuals are indeed the boots on the ground in the campaign against poverty – and it is working. Watch: Success Story Video

It all starts with dinner. After loading up a plate of a warm, delicious cooking, everyone gathers around the multiple tables for a family style dining experience. This aspect of the meeting is arguably one of the most important pieces – everyone is family, and you sit by someone new every week. Dinner is filled with discussions about one another’s past weekly events, where they are coming from, hilarious stories, and children doodling in their spaghetti sauce. Certainly, this is a family gathering. Following dinner, children are shuttled to the playroom, where volunteers lead interactive games. The volunteers, guests, Allies, and Circle Leaders all bring their children to play together during the meeting –yet another wonderful layer to the Circles’ theme. At the meeting’s conclusion, everyone shares positive, new experiences. There were many victories to be applauded, including job interviews, improved school grades, and graduating from the program. My positive experience that day was being able to learn about this tremendous organization and its truly exceptional members.

The Nuts and Bolts of Circles

Circles is a local and nationwide campaign against poverty using a unique and thoughtful solution – a 16 week course for “Circle Leaders” (underserved individuals from the community) that focuses on self-reflection, employment, finances, and the skills needed to thrive in the community. After completion of the course, Circle Leaders are paired with “Allies”. Allies are volunteers that act as a support system in the transition out of poverty – encompassing the emotional, psychological, and financial aspects of what it means to be impoverished. The result is self-sufficiency, long lasting solutions/relationships, and ultimately breaking the cycle of poverty. How Circles Works

We care for underserved and impoverished individuals in the ED every day.

This is therefore a valuable opportunity to educate ourselves about the lives of our patient population. As advocates for our patients, we have the responsibility to directly engage in our communities and discover the very real cultural, societal, and financial barriers that affect health care. Understanding our patients from this perspective would ultimately lead to improved, thoughtful solutions and subsequently, a higher quality of care. Why not get out there and make a difference in a new and inspiring way?

How can you help?
– Sponsor a poverty simulation for your group: Poverty Sim
Become an Ally
– Volunteer at the weekly meetings: childcare, plan meals and meetings
Provide a meal for one of the weekly meetings
– Donate to Circles

Want to attend a weekly meeting?
– Julian Center Circles: Marie Weise at mwiese@juliancenter.org, or 317-941-2200
– Circles – Back on My Feet: Brian Meyer 317-250-4133

More information:
http://www.circlesindy.org/
http://www.circlesusa.org/
http://www.juliancenter.org/Get-Involved/Circles-of-Support.aspx

Special thanks to the Julian Center and Circles of Support.

Childhood Obesity: An Epidemic Growing By The Mouthful

Bethany Beard, MD

I’ll be the first to admit, chubby babies with mushy Michelin thighs are very cute and fun to squeeze on. I see these kiddos frequently for well child checks and I actually applaud the mother on her job well done to grow and nourish her baby. There is no other time in life when wrist and ankle rolls are cute, so when does this ideal end and become a health concern? At what age is fat no longer preferred? The human body’s future metabolic “programming” can actually be modified by diet and nutrition in early infancy, so maybe that chubby infant shouldn’t be so admired.

America’s children are fat and quite frankly, it’s not cute. This epidemic is spreading through the United States each year. Childhood obesity has more than tripled in the past three decades and statistics from the CDC indicate that obesity in children age 6-11 has increased from 6.5% in 1980 to 19.8% in 2008, and that obesity among adolescents age 12-19 years increased from 5% to 18.1% respectively.

Interest in this topic began during my undergraduate study of nutrition. I learned all about flavonoids, phytochemicals, biochemical nutrient metabolism, blah, and blah; however, nutrition’s real life importance did not come to fruition until later in my career. At a nearby table in the Riley cafeteria sat a morbidly obese toddler, roughly three years old. The child was accompanied by what appeared to be some sort of health coach. I observed the “coach” help the child count green beans, carrots, and apples as if to re-program her mind about healthy foods and appropriate portion sizes. I assumed she worked at Riley’s POWER clinic, which was established for overweight and obese children. Shortly thereafter, before the food was gone, the woman took everything away and said “ok, that’s all for now. Let’s go”.  I put my cheeseburger down. My emotion was initially sadness, then it was later followed by motivation to learn more about childhood obesity and it’s harms on today’s youth.  

So what’s the big deal with childhood obesity and what impact are we seeing across the country? Childhood obesity results in multiple health related illnesses including hypertension and hyperlipidemia, diabetes, worse asthma control, sleep apnea, and mental health disorders such as depression and body image issues. As emergency physician’s we are seeing these children present more commonly with lower extremity injuries, commonly knee pain and sprains, compared to their normal weight for age peers. Obese children perform worse academically and miss approximately 4x more school days than their classmates. They also sleep worse. Probably the most startling statistic is from a study in 2005 which shows that if obesity continues at the current rate, children of today’s generation will have a shorter life expectancy than their parents for the first time in over 100 years! In addition, these children present challenges in the health care setting. Obese children are more difficult to obtain IV access and intubation, their belly rolls limit the sensitivity of ultrasound, and there are dosing difficulties for both medication and defibrillation during resuscitation. Aside from numerous co-morbidities, the heath care system also feels the impact of childhood obesity, as these children are 3x more expensive compared to the cost of normal weight children.

Obesity results from a combination of a little genetic and mostly multifactorial environmental influence. Some influences include a lack of education on what’s healthy and what’s not, limited access to healthy food, and sedentary lifestyles as technology and television viewing increases. Another challenge is that our nation’s schools have limited resources. School lunches lack fresh fruits and vegetables and due to budget cuts, physical education was reduced leaving the majority of elementary schools without daily gym classes. The biggest contributor to childhood obesity, in my opinion and that of expert researchers, is the parents of these children. As a mom, I realize that it is both cheaper and easier to warm up prepackaged chicken nuggets, hotdogs, cookies, etc. I get it; especially when parents are busy and on a budget. However, the quality and quantity of food a child receives is controlled by the parents and directly impacts a child’s weight.

The chance that an obese child will grow into an obese adult is 70%; therefore, it is our job as physicians to identify these children early. One study suggested targeting obesity at six months of age as these infants were most likely to remain obese at their two-year visit. Although there is no strict age cut off, most pediatricians and researchers believe that obesity should not be diagnosed before two years of age. The first step is to simply target those children at risk. This can be achieved by calculating a BMI on all children who present to a primary care clinic or the emergency department. With electronic medical records, this should already be calculated when both height and weight are submitted. The next step is to identify those with BMI 80-94% which will classify the child as overweight. Those with a BMI >95% are obese.

The consensus of obesity experts in the National Association of Children’s Hospitals and Related Institutions (NACHRI) Obesity Focus Group recommends that identification of obesity and treatment should occur in all inpatient and outpatient settings in a children’s hospital. Promotion of healthy behaviors at the hospital is also encouraged. Change is currently underway at Riley Hospital, as McDonalds will soon be replaced with healthy food options and Andrew Luck’s ‘Change the Play’ campaign was established to promote the importance of physical activity and wellbeing.

Cornerstones of obesity treatment are focused on promoting a healthy diet and increasing physical activity, along with parental involvement and support. Emergency department visits are an opportunity to have discussions with patients and families about weight loss and encourage regular follow-up with their primary care physician for monitoring. Exciting initiatives are also supported nationally. In 2010, three events occurred: Michelle Obama’s “Let’s Move” campaign, the Patient Protection and Affordable Care Act, and the White House Task Force on Childhood Obesity report. Together as physicians and advocates for children’s health, we can combat the childhood obesity epidemic, make a positive impact on their adult health, and hope for change in generations that follow. 

Resources:

-Arpilleda, Joyce C. “Managing Childhood Obesity in the Emergency Department”. Pediatric Emergency Medicine Practice: 9 (2012), 1-15.

-Golan, Moria. “Targeting Parents Exclusively in the Treatment of Childhood Obesity: Long-Term Results” Obesity Research. 12 (2004) 357-361

-Pomerantz, Wendy J. “Injury Patterns in Obese Versus Nonobese Children Presenting to a Pediatric Emergency Department”. Pediatrics. 125 (2010) 681-85

-Prendergast, Heather M. “On the Frontline: Pediatric Obesity in the Emergency Department”. J Natl Med Assoc. 103 (2011). 922-25

-Scheff, Sue. (2011, Mar 1). 10 Frightening facts about childhood obesity. Retrieved Jan 10, 2013 from http://www.examiner.com

-Vaughn, Lisa M. “Obesity Screening in the Pediatric Emergency Department”. Pediatr Emer Care. 28 (2012). 548-552