Stories from the Stethoscope: August 2020

It was the fall of 2003. My new role as the Medical Director of Developmental Disabilities Institute had just begun a few months before. I can still recall, that Tuesday evening, which exam I was in, when I first met Jacob. He was in his early 20’s. Jacob was nonverbal and lived in supportive housing with twenty-four-hour staffing. I was asked to see him regarding ear pain. The encounter started without any deviation from my then-normal, as a physician. Looking directly at Jacob, I stated, “Hi Jacob.  I’m Dr. Powell. I understand you have some ear pain. Let me take a look.”

I walked over to the otoscope on the wall, placed the metal object in the center of my hand, and I approached my patient. As I was about to place the otoscope in his ear, Jacob, with intense fear in his eyes, reached back and struck me on the side of my head with all his might. I stumbled back as I began to lose my footing and was almost knocked down. I was hunched over – staring at my feet, before I slowly stood up to regain my composure. During my attempt at composure, my eyes were drawn to the big, shiny, and pointy, metal object in my hand. The “ah-ha” moment that followed was more powerful, than the original blow to my head.

Instantly, I realized that – Jacob did the right thing! Let’s think about this for a moment as I had…If I had severe ear pain and I could not communicate that to anyone, what would I do if someone wanted to jam a big, shiny, and pointy metal object into my ear? 

When I finished the appointment, I thanked Jacob for helping me, even though it was really  my job to help him. I instantly began to replay the session in my head, over and over. What could I have done differently?  How could I prevent this from happening again? Was my medical training wrong? Can I modify what I have learned and improve upon the service which I am supposed to provide?

Years ago, many providers were trained to start their exam at the head and work their way down, as they examine a patient. I decided that no matter what type of patient or whatever the reason for the visit, I will try to take both of their hands and greet them with warmth; Then move up their arms,  to their head.  I have also decided that any instrument or device that I plan on using, needs a demonstration, especially if there is concern about communication. I have learned that now, I turn on the light of the otoscope and give a quick show and tell demonstration first. I have also found over the years, that if you allow patients to hold your stethoscope or otoscope with you, our success rate is much higher. For those patients who may have difficulty with an ear exam, we often prescribe Debrox drops, to use at home for a short period of time. This way, they may get used to objects placed in the ear which may desensitize them for future appointments. 

I am often asked by patient and/or fellow staff members, “Can you give a flu shot if a patient is afraid to receive one?” I will tell you that it is often difficult to predict how any patient may react the first time we approach them with a needle, especially individuals with Intellectual and Developmental Disabilities. My method  begins as we clean their shoulder with the alcohol pad. You can often get a sense of their potential response, if fearful, at such moment. If I believe that if the response may be “difficult”, I will ask the staff member with me to slowly help take the patient’s  shirt off. The key is to stop once the shirt covers the eyes and pause for a second while the arm is exposed. The window to give a flu shot may be very small. Speed during these sessions is extremely important. This process often creates great success with our vaccine administration. The most important part of any encounter is for the provider and patient to feel comfortable. My goal is to provide as thorough an exam as possible. I do not get upset if this does not happen. As an internist, my goal is creating life-long relationships. An incomplete exam or a bad experience does not mean that you will not be successful in the future. I have examined patients on the floor, in bathrooms, hallways, minivans, and their homes. A growth mindset allows you to grow, learn, and share – there is no ONE WAY of accomplishing things. There is nothing more powerful than the connection you can make with a person if you’re willing to look past the obstacles and continue to search for solutions. Thank you Jacob, for providing me the opportunity to create continuous growth in my mind, my methods, and subsequently, my relationships with my patients. The bond we eventually created will never be forgotten.

 I walked over to the otoscope on the wall, placed the metal object in the center of my hand, and I approached my patient.  As I was about to place the otoscope in his ear, Jacob, with intense fear in his eyes, reached back and struck me on the side of my head with all his might.  I stumbled back as I began to lose my footing and was almost knocked down.  I was hunched over – staring at my feet, before I slowly stood up to regain my composure.  During my attempt at composure,  my eyes were drawn to the big, shiny, and pointy, metal object in my hand.  The “ah-ha” moment that followed was more powerful, than the original blow to my head.

 Instantly, I realized that  – Jacob did the right thing! Let’s think on this for a moment as I had…  If I had severe ear pain and I could not communicate that to anyone, what would I do if someone wanted to jam a big, shiny, and pointy metal object into my ear? 

 When I finished the appointment, I thanked Jacob for helping me, even though it was really  my job to help him.  I instantly began to replay the session in my head, over and over.  What could I have done differently?  How could I prevent this from happening again?   Was my medical training wrong? Can I modify what I have learned and improve upon the service which I am supposed to provide?

 Years ago, many providers were trained to start their exam at the head and work their way down, as they examine a patient.  I decided that no matter what type of patient or whatever the reason for the visit, I will try to take both of their hands and greet them with warmth;  Then move up their arms,  to their head.  I have also decided that any instrument or device that I plan on using, needs a demonstration, especially if there is concern about communication. I have learned that now, I turn on the light of the otoscope and give a quick show and tell demonstration first.  I have also found over the years, that if you allow patients to hold your stethoscope or otoscope with you, our success rate is much higher.  For those patients who may have difficulty with an ear exam, we often prescribe Debrox drops, to use at home for a short period of time.  This way, they may get used to objects placed in the ear which may desensitize them for future appointments.

I am often asked by patient and/or fellow staff members, “Can you give a flu shot if a patient is afraid to receive one?”  I will tell you that it is often difficult to predict how any patient may react the first time we approach them with a needle, especially individuals with Intellectual and Developmental Disabilities.  My method  begins as we clean their shoulder with the alcohol pad. You can often get a sense of their potential response, if fearful, at such moment.  If I believe that if the response may be “difficult”, I will ask the staff member with me to slowly help take the patient’s  shirt off.  The key is to stop once the shirt covers the eyes and pause for a second while the arm is exposed.  The window to give a flu shot may be very small.  Speed during these sessions is extremely important.  This process often creates great success with our vaccine administration.  The most important part of any encounter is for the provider and patient to feel comfortable.  My goal is to provide as thorough an exam as possible.  I do not get upset if this does not happen.  As an internist, my goal is creating life-long relationships.  An incomplete exam or a bad experience does not mean that you will not be successful in the future.  I have examined patients on the floor, in bathrooms, hallways, minivans, and their homes.  A growth mindset allows you to grow, learn, and share – there is no ONE WAY of accomplishing things.  There is nothing more powerful than the connection you can make with a person if you’re willing to look past the obstacles and continue to search for solutions.  Thank you Jacob, for providing me the opportunity to create continuous growth in my mind, my methods, and subsequently, my relationships with my patients.  The bond we eventually created will never be forgotten.