The Parallel Visit

“DS, 80 y.o. Fe, abdominal pain, room 37” flashed onto my pickup screen on my first shift of the month in the emergency department (ED). I assigned myself to her care and quickly ventured into Delta 2. I entered her room to find a frail-appearing black female lying on the bed comfortably, with two younger companions close to her bedside. I discovered that they were her daughters because, upon entering the room, I always introduce myself to all the players, and daughters of an elder parent are major players. They accompanied their mother, someone they obviously cared for a great deal, and they wanted answers as to the reason she had not been feeling well. Like many family members in the ED, they were more than willing to supplement the patient’s history. It turns out “abdominal pain” on the tracking board meant left lower quadrant (LLQ) pain for 2–3 weeks and some intermittent diarrhea, but little else to the history. The patient may not have come to the ED if not for her daughters. My exam revealed LLQ tenderness, focal, with no peritoneal signs. “Diverticulitis?” I questioned. No clinical diagnosis was possible on my exam. “We’ll get a CT scan to see what is going on,” I told DS and her daughters. I asked if there were any further concerns or questions and, when the entire family was satisfied with the plan, I left the room to see another patient. “Dr. Caudle, Delta 2 for radiology.” “Hey, this is Matt Caudle,” I answered. “Yes, are you taking care of DS?” the radiologist replied. “Yes,” I replied. “She’s got cancer. Left sigmoid, pretty large mass.” “Really? . . . Wow,” I said. “Thanks for the read,” I said finally and hung up the phone. I reentered DS’s room and attempted to shut out the noise by closing the room’s glass door. I pulled the curtains that inadequately separate rooms 36, 37, and 38 and hit the blue light indicating that no one was to enter the room. I sat down, lower than eye level, and let DS and her daughters know that she had colon cancer. I was silent after “cancer.” There was not the emotional outburst I might have expected, but a silence of devastation, of a ruined day, month, year, of knowing that things were no longer right. I sat silent for what seemed like minutes. I answered (or failed to answer) questions regarding the next step in workup, the prognosis, and the chances that Mom would survive. I reassured them that I would get her into the hospital and that workup and treatment would be started right away. The encounter with DS and subsequent emotionally charged encounters with patients and families has made me realize that a “parallel visit” exists with every encounter in the ED. The medical history; physical exam; laboratory, X-ray, and medical diagnostics; and treatment are the framework upon which an ED visit is built. It is the visit reflected in the permanent medical record. Accompanying this framework of pure medicine is the parallel visit. The parallel visit is not contained in the medical record, but lies in the human connections you make with patients and families. It incorporates the professional introduction made to a patient and his/her family and friends. It includes identifying all the important players in the room, including family members that you will have to satisfy as much as the patient. It is the instillation of confidence in your medical abilities in all involved, even when knowledge gaps exist within. A successful parallel visit requires the patient to know that you are an advocate for him or her, an educator, and perhaps most importantly, that you allow yourself to share in the intense emotional experiences that often characterize an ED visit. Through the rest of the month, I diagnosed three new pregnancies in unexpectant mothers, one of them a twin gestation. I showed each mother the miniscule flicker of early fetal cardiac activity on ultrasound. I saw a shaken family of four from ages 8 months to 36 years involved in a rear-end motor vehicle collision. I regretfully explained a complication of subclavian central venous catheters and the necessity of placing a chest tube after collapsing a mother’s lung. I took a mother and father’s 6-year-old daughter off of a backboard and out of a cervical collar. I educated and reassured two emotionally-distressed mothers whose children had experienced simple febrile seizures. These encounters are the essence of emergency medicine. In a given ED visit, your total time with a patient and family may total 15–20 minutes, but they will never forget the services provided. Interestingly, you will most likely be judged by the quality of your parallel visit more than the medical visit. Dr. Greg Henry says medicine is “show business for ugly people.” In a way, he is right. Emergency physicians establish certain rehearsed explanations, speeches, and behaviors to cope with common emotionally-charged patient visits, but just as you cannot be prepared for every medical emergency that rolls through the door, you cannot prepare to comfortably handle every joy, heartbreak, or pain that is associated with time in your ED. That is where the demonstration of empathy, regardless of situation, protects the parallel visit. In my short experience, I am more fulfilled in focusing on both the medical and the parallel visit, and I know patients are more satisfied with their visit. Because the parallel visit will exist in each patient encounter of my career, I hope to always provide it the attention, time, and effort it deserves.