The James Bond Opening
Introduction
You’ve arrived at the cinema, paid a ridiculous amount of money for a bucket of something fizzy and taken your seat. The adverts have finished and the anticipation is palpable. The next two hours depends on those first few scenes. Will it suck you in and have you on the edge of your seat, or wondering at which point you are able to leave to check your Instagram.
If you’ve ever watched James Bond movie you’ll know that those first few minutes are always some of the most exciting, with the largest stunts and a cliff-hanger that makes you long for the rest of the film.
This is how all your presentations should start. A James Bond Opening…
SBAR
Hopefully you have already come across SBAR as a useful tool for communication
- S- Situation – Identify yourself, your patient and why you are calling- “Hi, This is Iain Beardsell one of the ED Doctors and I want to refer a 39 year called Jane Smith who I believe has appendicitis.”
- B – Background – Give some more details about the patient- “She has had 24 hours of worsening right illiac fossa pain, with nausea, anorexia and three episodes of vomiting. She is previously fit and well and has no other relevant history.”
- A – Assessment – Outline your assessment- “On examination she is tender in the right illiac fossa. Her urine dipstick is negative and her blood tests are awaited.”
- R – Recommendations – Say what you believe needs to happen next- “I would be most grateful if you could review her and assess whether she needs further observation or a operation. I have requested a bed on the surgical ward.”
The James Bond Opening
Often when I hear medical students (and doctors) present cases it often seems to start with a long preamble, including ‘a past history of….’
As an Emergency Doctor I have an incredibly short attention span and I need you to grab my attention. When you present a case, it’s not an Agatha Christie novel where the reveal the murderer in the last chapter. Frame the conversation with a succint ‘S’
An Example Case (simple)
History
You’ve just seen a 30 year old male patient with abdominal pain. They’ve had it for a day, accompanied with some episodes of vomiting. He’s not hungry and didn’t fancy his dinner. He feels a little feverish. He had his tonsils out aged 8. He has no allergies and takes no medication. He lives at home with his wife and 2 year old son and works as an accountant. On examination he has tenderness in his right illiac fossa. His vital signs are normal. You think he may have appendicitis.
So how would you start the conversation here? Think about it before you open the answer below…
Now, I know you think this is too simple, but it completely frames the conversation and helps the person you are talking to focus on the problem. Let’s try another…
An Example Case (complex)
History
You’ve just seen a 67 year old male patient with chest pain. It came on suddenly at about 9am and seemed to get worse throughout the morning. It made her short of breath and anxious. The pain radiated to both arms and into her jaw. She has a past medical history of COPD (on inhalers), a NSTEMI two years ago and recently returned from a trip to see her daughter in the USA. She gave up smoking two years ago after having a mini stroke. She lives at home with her partner for whom she is the main carer. On clinical she has a respiratory rate of 25/min, but it is othewise unremarkable.
Again, you can make a complex situation more digestible. You’ll give more information in the BAR of your SBAR, but at least the person you are talking to has a graps of the main issues.
Conclusion
Presenting cases is arguably harder than the actual medicine and requires practice. Try to think how you can summarise what is happening with the patient in one or two sentences and then stick to the SBAR format.