Monday, April 30, 2012

The Cell Phone Sign

The Gist:  An easy way to gauge the seriousness of a patient's illness - determine the patient's texting (or engagement in Facebook, Angry Birds, or Draw Something).  The cell phone sign - the triage equivalent of the "Hamburger Sign" in appendicitis?

I suggest that medical students beginning their clerkships read a short, humorous piece in this month's Annals of Emergency Medicine entitled "It's This Texting Thing."  The author codifies the observations we make regarding a patient's interactiveness into an easy rubric, scaled from 1-5, to assess the severity of an emergency department (ED) patient's ailment based on the patient's texting.  For example, a patient who texts during the examination without looking up is awarded a 1 whereas a patient who is not texting at all gets a 5 (and very likely a body bag as the patient is probably actively exsanguinating or pulseless).  A patient with a score of 3 is probably suffering a ailment of the following severity:  cerebrovascular accident, diverticulitis, or perhaps a fracture.  Sure, the article was probably partially written out of the frustration of extracting a history out of a patient glued to their device of choice and is placed in the journal for entertainment value .  Funny.  Simple.  And, in my experience, fairly accurate.

Anecdotally, I can corroborate this rubric's predictive value, although I came to this conclusion in a more roundabout fashion.  As a zealous medical student, I spent an "off day" during my first month of third year clerkships in the ED.  I entered a patient's room in the ED and began with my routine introduction and history taking.  The patient's "worst headache of her life" brought her to the ED.  I took a stellar history and completed a thorough physical exam, although it was rather difficult at times, as she was engrossed in her Droid, playing Angry Birds or updating her Facebook status.  I eagerly went to present to my attending.  Before I began, my attending asked the crucial questions in the ED, "Well, is she sick or not sick?  Is she staying or going home?"  My attending then shared with me one of the keys to patient assessment in the ED.  "Generally," she said, "you can figure that out within the first 30 seconds you see the patient."  So true.

In the hundreds of patient encounters since that time, I've slowly developed skills in rapidly ascertaining a patient's overall status.  Hopefully this will eventually translate into the sought-after clinical "gestalt."  Generally, one only needs marginal common sense and observational skills - how eager they are for a sandwich, whether they are watching tv or fiddling with a phone, or the difference in pain perception when one is overtly palpating versus palpating through a stethoscope.  Conversely, the absence of these types of behaviors in "tough guy" (or gal) patients have acted as clues that these patients were sicker than they let on.  Regardless, observation of patient's non-verbal cues is an important part of patient assessment (and can be both frustrating and supremely entertaining).

Svesko V.  It's This Texting Thing.  Annals of Emergency Medicine Volume 59, Issue 5 , Pages 438-439, May 2012

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