Always Ask the Question: Navigating Delicate Patient Encounters
The Scenario
The call initially went out as “14-month-old boy with difficulty breathing” so the sound of tones ringing through the station were followed immediately by running boots. Two of our units, a BLS unit staffed by two EMTs and an ALS unit with an EMT and a medic, drove the six minutes to the address. We piled out of our ambulances with a suction unit, oxygen tank, pediatric airway bag, monitor, and code kit. We entered the house with purpose to find a pink, upright and annoyed-looking baby in the arms of his strikingly yellow father.
This kid passed his pediatric assessment triangle with flying colors. His skin tone was excellent, he wasn’t working to breathe at all and he worked desperately to evade the pulse oximeter. His capillary refill was brisk in all extremities and the sounds over his lungs and throat were like a gentle breeze going through a quiet forest: perfectly clear. His oxygen saturation was in the high 90s, and his pulse was an age-appropriate 134.
I spoke with the father, who grew noticeably less alarmed as, one at a time, the posture of the entire crew relaxed. He talked about the event that had concerned him: his son had made some “odd noises” while breathing. No, he hadn’t been eating anything. No, he’d been in his father’s arms at the time, unable to reach any small objects to cram into his mouth. No, he had not gone limp, blue, or unconscious in any way. No, he had no medical history of interest.
This man had undergone a very contentious breakup with the mother of his child, and this past hour was the longest stretch of time he’d ever spent with a baby. Finally, I asked him to please do his best to imitate the sounds his son had made that had upset him.
It sounded like hiccups.
I made the same offer with the same explanation I always provide: We would be happy to take his son to the hospital. It’s just not possible to truly conduct a complete assessment ruling out life threats outside of an ER. That ultimately, he had been there during the event and I had not. That there is something called a Brief Resolved Unexplained Event (BRUE) observed in children in this age group that could, sometimes, portend very serious problems.
He said that he would call back if anything else odd happened, but he felt good about his choice to remain at home. He wanted to spend time bonding with his son, not sitting in an ER waiting room. I felt this man had not only heard my explanations but listened to them.
Which left the matter of the unusual appearance of the reporting party — the father. He was the most jaundiced person I had ever encountered. His corneas were the shade of a sunflower petal and his skin, though it was muted through his tan, was also unmistakable yellow. Anyone who walked within 200 feet of this man would describe him by that color alone.
I considered my options for a few minutes while we took another set of the vitals on the baby and tried to get an end tidal reading, just in case. I was 97% sure that he was fully aware that one of his vital organs was failing, that he was in treatment, possibly even on a transplant list.
It would be rude and prying and was entirely unrelated to the situation I was summoned to the scene to handle. But taking action hundreds of times in a row to no effect in exchange for the single time it actually pays off is the true, beating heart of prehospital medicine.
Tough Questions
An excellent patient history and the social rules that allow humans to successfully exist in large groups are directly at odds with each other. It can’t be denied that an excellent thorough patient history involves an escalating series of highly personal questions that would be very inappropriate to approach at your family Thanksgiving.
It’s best to make these inquiries with the same tone you’d make any others. Let’s say you’re presented with a tachypnic, tachycardic and febrile adult man. His blood pressure is fine but his end tidal is low at 20.
There are a lot of questions you need to ask him, both as part of every patient assessment and to try and discern the source of his likely sepsis. It’s best practice to escalate from the least to the most personal inquiries. In this example, it might go something like: What are your medication allergies? Have you had a surgery recently? What about a productive cough with yellow sputum? And then, continue to the equally essential questions without changing your tone at all. Any pain on urination? Any wounds, sores, or abscesses, particularly on areas of your body I’m not able to see? Any unusual discharge from your penis?
Part of being a healthcare provider is perfecting the art of asking prying questions while conveying only a mild and business-like interest in the answer. In summary: If you ask it like a normal question, the patient will answer it like a normal question. Remember that you are the professional and you are asking because you need to know.
Be Uncomfortable
In this case, of the jaundiced man with the perfectly healthy baby, I chose a slightly modified technique. If you take this option, you openly admit that you are breaking social norms a bit. We were packing up our kits, and I teetered on the edge of a decision. I looked again at just how profound the depth of color in his skin was.
“Sir, I know this is absolutely none of my business.” He looked up at me from where he’d been bouncing his son on his lap and made eye contact. “But who’s treating you for your liver failure?”
“My what?”
I immediately apologized for my lack of delicacy in approaching the matter. I explained that his skin tone was almost always associated with a failing liver. I asked him how long he had had been that color.
“I don’t know.” He finally managed.
“You’re telling me this is brand new?” I confirmed.
“Well, the mother of my child this morning said I didn’t look well. But no, I looked totally normal in the bathroom mirror yesterday.”
He expressed concern about the cost of treatment, stating that his health insurance didn’t kick in until the next month. I told him that sounded like a very stressful circumstance but that he didn’t have another month. He may not have another day. I also tried to explain that the longer this went untreated, the worse and more expensive it would become. I offered to give him and his son a ride to the emergency room right now, since in my district residents don’t pay transport fees.
“You’re telling me to go to the emergency room?"
“Today. Yes, that is what I am telling you.”
The Moral
Always ask the question, every time, with both patients and other providers (for example: we already took a blood sugar, right?) Endure as many socially awkward circumstances as necessary to arrive at the one person whose life you can change.
I never heard back from that man, but I also wasn’t summoned to attend to him in a coma. I hope that he looked at himself in the mirror and appreciated why his physical appearance so disconcerted me. I hope he immediately sought definitive care. But as is so common in emergency medicine, all I could provide for him was a chance at getting to raise his son to adulthood, to guide him through decades of his life. And there is plenty of pride to take in that.
