When patients come to the ED, there is almost always some level of fear or anxiety that plays a role in their presenting symptoms and their response to treatment. Recognition of this overlaying factor is often just as important as distinguishing the underlying illness or injury; and of course sometimes fear or anxiety is the sole or predominant underlying ‘illness’ responsible for the somatic disturbance that brings the patient to the ED. Surprisingly, unlike pain management, fear and anxiety in the ED is not a subject that I have ever seen offered at continuing education programs for emergency physicians. Perhaps it is assumed that EPs have such frequent encounters with these matters that educators believe competence in the recognition and management of fear and anxiety in the ED is instilled within the first months of practice simply by virtue of substantial exposure. There are undoubtedly some young EPs who are inherently attuned to their patient’s emotional and somatic reactions right from the get-go, but I think many of us have had to experience chasing one inexplicable merry-go-round of symptom complexes after another over several years before we develop the nuanced antennae that allows us to redirect our attention to the etiologic role of fear and anxiety underlying many of our patients’ health care issues. Even more experience is often required to be able to manage these issues, in all their varied presentations, in just the right way.
One of the problems with the identification and management of fear and anxiety in the ED is the time constraints inherent in this practice. I often struggled with the impulse to ‘cut to the chase’ when getting a history from patients: listening was never my strong suit. Yet I did come to realize that the time spent allowing patients to work their way around to the real issues that led them to the ED was actually the most efficient way to manage the glut of patients in the Department. Yes, there are all sorts of tell-tale indicators of fear and anxiety that you can pick up on the minute you enter the exam room: tremor, tachypnea, facial cues, agitation, restlessness, and the like; but all of these indicators can point to a host of pathologic derangements, and of themselves can also evoke anxiety and fear. The clinical history, as more than a few educators have advised me early in my career, is where the real action is. Nothing beats acknowledging anxiety and asking a patient about their concerns as a first therapeutic step in dealing with these feelings. I feel EPs and other physicians sometimes shy away from such questions for fear of getting caught up in long, involved discussions that distract from the diagnostic/therapeutic objective. In the ED, getting to the fact that the patient IS anxious is often as important and useful as finding out why. Ordering unnecessary tests and treatments is usually a lot less efficient, overall, than taking a few minutes to deal with these underlying emotional issues.
Anxiety is typically described as ‘a diffuse, unpleasant, vague sense of apprehension…often a response to an imprecise or unknown threat’, as distinguished from fear as ‘an emotional response to a known or definite threat’. Obsessing about something is one of the key facilitators of anxiety, especially in association with depression, and breaking the cycle of rumination with meds, relaxation techniques, mindfulness exercises, or other approaches may really help patients in the ED deal with their anxiety, at least temporarily. I have often used meds like IV versed or even Ativan in titrated doses to help patients cope with fears and anxieties in the ED. EPs tend to be a bit reluctant to offer anxiolytics to patients in the ED, perhaps because of concerns about: adverse reactions or disinhibition; disruption of discharge plans; impaired mentation; drug dependence; and the like. However, I have seen many patients whose mentation has actually improved with short-acting anxiolytic management, and whose underlying illness is more readily identified.
Dealing with fear and anxiety in the ED isn’t just about psycho-somatic illness, it is also about moderating concerns about painful procedures, the angst of air-hunger, hearing bad news, coping with an unknown and uncertain prognosis, or a new and unexpected disability. Empathy is certainly important, gathering support from friends and family, a calm and unrushed demeanor, attention to alleviating pain, even a quiet room can all be helpful to allay the symptoms of anxiety and fear that many, IF NOT MOST, patients in the ED experience to some extent during their visit. How many times have you seen patients panic at the sight of an IV needle, predicated on a previous painful experience? Once they have been pre-medicated with a sub-cutaneous Lidocaine wheel before the catheter is inserted, not only will they never want to go back, but they will no longer freak out at the prospect of another stick. Addressing anxiety and fear in the ED, especially in kids, can have an impact well beyond the incipient visit.
I would really like to see a presentation or two from health educators who have diligently worked to understand and study fear and anxiety in the ED. It is a topic that probably deserves almost as much attention as pain management.