Friday, July 9, 2010

Reflection on a Friday: Say What?

(*names, details, etc. changed. . .you know what's up)

(A big-a, red-a sock)

"Why don't you say what you say when you say what you said anymore?"

- from Jermaine Jackson's "Do What You Do"
I often wonder what's the best approach to teaching about patients at the bedside on rounds--in front of the actual patient. I struggle with vacillating between medical language and living room language, feeling like I'm some bilingual person that is neglecting to fully interpret everything to the monolingual bystander. Because of this, I try to pay attention to how I talk to patients, and also about them. And usually, I will offer a disclaimer before I speak in our "other language."

It turns out that some of the terms used in every day English mean something different in Med-lish. And, like I said, usually I'll remember that when I'm talking. . . .that is until I run across an unexpectedly exciting medical encounter. Here's an experience I had where all my medical manners went out the door (all secondary to my clinician-educator nerdiness.)

This one time, on the Grady wards. . . .

"Hmmm. . . . impressive," I said on rounds one day while looking at our patient's leg with my team. "Really impressive." The interns, student and resident gazed at the limb-in-question, doing their very best to take mental note of what qualifies as "impressive" by an attending. I quickly turned my attention to Mr. Banks, our patient, who was anxiously following our discussion. I offered him an easy smile which seemed to relax him a bit. "Sir, we're just shop-talking for a few moments. We promise to explain everything we're saying to you in a few moments, okay?" He nodded, but still watched us intently.

"He said that this started two days ago as a little bit of erythema, but then it just evolved into this confluent, angry eruption," spoke the senior resident."The good news is that his blood cultures are negative and his temperature has already come down nicely with this antibiotic regimen."

I followed the redness down his calf to the top of his foot. It looked like a shiny, red boot made of skin. "Wow, this is angry." I reached down and touched his skin gently with my gloved hand. He winced and I stopped abruptly. "Sorry, sir," I apologized. He nodded again and smiled bravely. "Mr. Banks, has anything like this ever happened to you before?"

"Naw, not really. I mean this one time, I had the cellulite on my foot after a sore got infected, but they didn't even keep me in the hospital for that. I just took some pills and it got better. This time? Shoot, it's waaay worse."

"Hmmm," I murmured while still studying his leg. Now that it was clear that he was clinically responding, I allowed my inner clinician-educator-nerd to be unleashed. OMG, erysipelas! I haven't seen or talked about erysipelas in forever! Cool, man. This is a really cool case. I could feel myself getting ready to foam at the mouth from excitement about this upcoming teachable moment.

Why, you ask? It's what nerdy clinician-educators do. I mean. . . .imagine running across your most favorite episode of Good Times or What's Happenin' that you haven't seen in like, forever and ever, but that you loved and remembered every punchline to. (Whoops--just realized that not everyone reading this is an African-American raised in the 70's. . .uh. .my bad. . . so. . .make that, errr. . .Buffy the Vampire Slayer. . .errr. . . .or Dawson's Creek, maybe? Look, you get the picture.)

"Mr. Banks, sir?" I queried. Mr. Banks looked up at me with raised eyebrows. "I'm going to chat with the team a bit, okay?"

"That's cool, Miss Manning," he answered while reaching for his cell phone amidst the heap of sheets on his hospital bed. I redirected my attention to the medical student standing next to me. This is so cool, I thought. Hmm. . .how will I even begin?

"Ronald, what is St. Anthony's fire?"

He looked startled, and then cocked his head and pursed his lips. "Beg pardon?"

I smiled and cleared my throat. "St. Anthony's fire," I repeated. "Have you ever heard of St. Anthony's fire?" The interns looked at each other nervously, knowing how predictably such Socratic questioning moves up the food chain. They both immediately stared at the floor when Ronald shook his head no. "Phone a friend, Ronald. Who's your consult?"

"Errr," he glanced at the two interns quickly, "errr. . . .Sharon." He shrugged his shoulders and offered her an apologetic grin. I moved the spotlight to Sharon, one of the interns.

"Is it, like, some kind of . . . .uh. . . . medical thing?" she stammered.

"Yes. It actually is a term used to describe two different things, but since we're in the United States, I'm referring to only one of them. Do you know what condition is referred to as 'St. Anthony's Fire?'"

Foster, the other intern, piped in before he could get placed on the hot seat. "Is it used to describe cellulitis?"

I delicately pulled the cover back from Mr. Banks' leg to fully expose the skin above the knee, using care to respect his privacy. "Look how angry this skin is," I pointed out. "Now notice how the skin is intensely red and raised but then how right here all the angry area abruptly stops. This sharp border here is called a leading edge. Mr. Banks has more than just a cellulitis." The team nodded intently.

"I coulda told you that!"remarked Mr. Banks. "When I had the cellulite, it was red, yes, but naw, it didn't have nothin' on this here."

"Right, Mr. Banks," I acknowledged, "You are absolutely right, sir." Everyone looked at Jenny, my senior resident. She was last on the food chain. "Okay then, boss, what would you call this?" I offered her a half-smile.

She squinted her eyes and took an exaggerated breath. "Erysipelas, Dr. M? I've only read about it, but would you call this erysipelas?" (I love it when learners answer my questions with questions.) I gave her a congratulatory nod. "St. Anthony's Fire?" she added. "I don't know that part, though." In other words, Don't even go there, Manning.

(Erysipelas, courtesy of ADAM online health photos)

"Yep. That's what they used to call erysipelas back in the day. St. Anthony spent most of his life in the desert, and honestly, that's about as much as I know about him," I told them. "In some countries, they call ergotism, or any overdose on ergot derived medications, St. Anthony's fire. Here in the states, if you hear that term, it's most likely erysipelas." No one said anything so I went on, still enjoying every second of the subject. "Erysipelas is almost always caused by invasive streptococci. What really distinguishes it is the extreme confluent erythema and induration with blistering, see? And that classic leading edge. Folks used to draw cultures by aspirating a bit of fluid into a saline-filled syringe right from the leading edge." I still had a captive audience. Now I was in my rabid teach mode; a very dangerous zone for lazy learners, which fortunately, this team did not have. "In the pre-antibiotic era, this was a tremendously feared and deadly infection--especially in babies."

"Babies?" gasped Sharon.

"Yep, babies." I continued. "The majority of cases used to be on the face, but the extremities, especially the legs are also well described affected areas. Some of the worse cases you can see are on the face."

"Damn!" exclaimed Mr. Banks causing all of us to startle. "I'm glad this ain't on my face!" We all collectively smiled, wholeheartedly agreeing with our patient. He seemed to like the attention. "Miss Manning, I learned a whole lot just now. When my old lady come up here, I'm gonna tell her I got the St. Elmo's Fire!" This time I couldn't help but laugh out loud.

I reached for the clear bag of antibiotics hanging from his IV pole, turned it over, and read the label. "Mr. Banks, this medicine is already attacking the germ that's causing this problem. I'm hoping this will get a lot better while you're here."

The resident explained the rest of our plan to Mr. Banks and we prepared to continue our rounds. This is good medicine, I thought feeling proud of our interaction with Mr. Banks. Our team is practicing good medicine. I punctuated the encounter with my standard question of all patients every morning, "What questions do you have for us, sir?"

Mr. Banks winced and gingerly place his leg on top of a pillow. Then, he snapped his finger and said, "You know what? I do got some questions, doc." I raised my eyebrows in anticipation. "First, why you first said my leg was 'impressive? really impressive?' Then what is 'confluent ery-deema?' Y'all said that twice. Oh, yeah, and why you kept calling my leg 'angry?'" The whole team laughed. But Mr. Banks didn't.

I felt my face growing a little hot with embarrassment. I couldn't believe I'd done that. The residents all know how much I emphasize avoiding too much medical jargon at the bedside of patients. How could I have gotten so caught up in this "cool case" that I'd forgotten to follow my own ground rule: "Listen to yourself and your team speak, and autocorrect as you go." Uggh!

"Um, Mr. Banks? Uhh. . .I think I owe you an apology." The team looked intrigued. "Sir, I haven't seen any one with. . .well 'The St. Anthony's Fire' in quite some time. I got so wrapped up in talking about you that I forgot about how I was talking to you and about you." I let out a sigh and started to answer his questions. "First, I shouldn't have said 'impressive.' It was really me saying that I hadn't seen skin this. . . .well. . . .angry in a while. When I say angry, I'm talking about how red and warm your skin is. . . ."

"Kinda like how somebody look right before they 'bout to kick somebody's ass?" laughed Mr. Banks amusing himself with the metaphor. I was glad he was being a good sport.

"Yes, sir," I replied while pointing my index finger at him for emphasis, "Exactly like that. And the 'confluent erythema' is just a term we use to describe when. . . all the red, angry parts start running together."

"Like a big-ass, red-ass, hot-ass sock on my leg, huh, Miss Manning?" We all laughed again. This time, Mr. Banks laughed, too.

Lesson learned from Mr. Banks:

Sometimes the patients are better interpreters of our medical language than we are.

1 comment:

  1. You know...a big challenge in my first year has been learning to explain things to people in ways they will understand but also in ways that down make them feel like I am being condescending. I would love to do rounds with you, haha it sounds like fun (and also a great learning experience).


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