Exclamation Points And Exhalations

I’ll be honest; I groaned when I heard the ping of my pager. I pulled out my phone and opened the paging app. My pager had been quiet for a miraculous 10 minute stretch and I thought I could take the opportunity to run through my to-do list. I’d finished one out of five outstanding tasks before the alert—hence the groan.  

The page read: The parents of 843 have a few questions about the labs that just came back.  

Another groan. This groan was inspired by the time (5:00 AM) and the fact that I still had a number of tasks to complete before morning sign out in two hours. One was reviewing all morning studies. I serially opened the charts for the children on the unit and ended with room 843. I called back the nurse who paged as I reviewed the complete blood counts, chemistries, and liver panel.  

“Hey, it’s Aji,” I started as I crossed review labs off the list. “Sorry that I’m just getting back to you. I’m a little confused, these labs look totally fine. What are the parents worried about?”  

“Honestly, I’m not sure,” the bedside nurse said. “I thought things looked fine too, but the parents kept pushing for me to call you to chat with them.”  

“Ok, I’ll head that way. I want to finish a couple of other more urgent tasks before I come by to chat. Can you let the family know?”  

“I’ll tell them now. Thanks for coming.”  

I crossed off another two quick tasks and leaned over the desk to look once more at the results. There were a few red exclamation points, the indication on the electronic medical record that something was outside the normal range, but nothing that I considered actionable. I logged out of the computer and walked to room 843. I exchanged nods with the bedside nurse, who was charting outside the room, before knocking and opening the door.  

I found the patient asleep, his mother weeping, and his father comforting her. I was surprised by the emotion. The boy was just two days post his bone marrow transplant and doing remarkably well. My sign-out was “NTD,” or in other terms, “nothing to do.” I connected with the Arabic translator via video. What unfolded was a surprising conversation. It started with review of his morning laboratory studies; they wanted to know if any of the exclamation points meant that the transplant did not take. They worried that the bump in liver enzymes was a sign of veno-occlusive disease that had been mentioned during the transplant consent process.  

At the core of the conversation was this: would our team inform them if something was wrong? Could they trust us to bring them into the fold? Would we be honest? If they slept, would they miss it: something, anything, everything?  

I thanked the interpreter for her help. The patient’s parents had carried the weight of the world into the bone marrow transplant unit. They’d arranged a rotational sleep schedule so that at least one parent was awake at all times. They’d worried themselves sick. They feared that information would be withheld. And if withheld, they may not have the information they needed to escalate concern. So they opted for hyper-vigilance.  

I thanked them for their transparency and their dedication to their son. I reminded them that it was our duty to keep them informed. I promised them honesty. Relief washed over their faces and the exhaled audibly. I hugged each of the parents in room 843 before I closed the door behind me.  

That night, I learned that there is an art to providing reassurance for normal or almost-normal laboratory studies. This art is invaluable and warrants practice and refinement. Reassurance without context is a series of empty words. That overnight shift taught me a number of lessons:  

1. Create space and time for discussion.  

A conversation regarding normal or almost-normal laboratory studies may not be short. Sit with the patient and their caregivers and create an environment for conversation. It’s imperative that you don’t give the impression that this conversation must be rushed or that the conversation isn’t very important.  

2. Come prepared.  

If asked to discuss a recent set of lab studies, review the most recent trend of results beforehand. It’s rarely appropriate to interpret labs in isolation and most often, patients and caregivers are curious about a change from prior studies.  

3. Gently uncover the root of patient and caregiver concerns and fears.

The lab results can be a jumping off point for bigger or more important concerns. If you find that your reassurance doesn’t seem to be effective in assuaging worries, it’s worth exploring the root of the concern. My favorite open-ended question to explore additional concerns is “What worries you?” 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.