CHAPEL HILL — Dr. Nikki Waller treats most of her patients in the emergency room with a common treatment: a rub to the shoulder, and often, a smile.

“For emergency department doctors, it’s hard to connect with your patients. By definition you’ve never seen them before; there’s no existing doctor-patient relationship,” she said. “It’s very important to gain your patient’s trust, and we have to do that very quickly.”

Waller, who is trained in emergency medicine, treats patients and teaches resident physicians as the assistant director of the UNC Hospitals Emergency Medicine residency program. She serves as an example for her residents. But when asked about why she rubs her patients’ shoulders, she laughed. “Did I do that?”

For some patients, most of the doctor’s job is diagnosis and simply ruling things out – it’s frequent that an emergency doctor can’t name the ailment.

“Trust is important to let them know you did your best, even if you might not know the answer,” Waller said.

She supervises at least one resident physician each shift, but sometimes up to four. Residents normally visit the patients solo and report back to her for approval.

Waller can act as a glue – if the residents forget something, she fills in the gap. She can take the time to inform every family member.

And she decides what transferred patients the hospital admits. Because UNC Hospitals is so large, it has several specialists and a lot of resources that area hospitals don’t. Rarely does the emergency department turn someone away, Waller said, unless it is completely full.

Providing a chair

On a recent Tuesday evening, the department wasn’t full, so a team of more than a dozen people, from X-ray technicians to doctors to the chaplain, arranged themselves to prepare for a patient’s arrival.

The woman was in her 60s and had a rare form of Parkinson’s called progressive supranuclear palsy – a brain disorder characterized by loss of eye muscle control. She had just taken a particularly bad fall, with her eye hitting her walker, and she hasn’t been able to see out of it since, she told doctors.

After first going to WakeMed Cary Hospital, she was transferred to UNC when doctors realized she’d need a specialized eye surgeon.

Waller made the call to the ophthalmic surgery unit, then spoke to the woman’s husband. She brought him a chair after he said he didn’t need one. You’ll be holding her hand a while, so you need a chair, Waller told him.

After listening to him talk about his wife’s two previous falls, Waller stepped outside to make a call – why isn’t the eye surgeon here yet?

“Seriously, I can’t wait for like, two hours,” Waller said under her breath. It’s the only time she’s been visibly flustered all day.

After about 30 minutes, the surgeon arrived and performed an unusual surgery – the patient’s eye is far out of the head and under pressure because the woman had been bleeding so much. She’d been taking aspirin and Plavix, a blood thinner, after she had stroke-like symptoms, her husband explained.

Bonding over toenails

As surgeons cut above and below the eye to get some of the blood out, Waller spoke to the patient’s husband, telling him about herself. She’s originally from St. Louis, but went to UNC-Chapel Hill for her undergraduate degree and just couldn’t leave, she told him, so she came back for medical school.

Waller looked over at the patient’s feet sticking out of her sheets and smiled – the woman’s toenails were painted purple. “My toes are light blue right now,” she told the patient’s husband.

After the surgery, Waller is all smiles with the patient’s husband. He told her about his grandchildren, who are now students at UNC, and his face lit up with a smile.

Such people skills – such as the ability to listen to patients – are key things to look for in hiring for the emergency room, said Dr. Judith Tintinalli, an emergency room doctor and former chair of the UNC Emergency Department.

It’s also part of the residents’ training, Tintinalli said. Faculty members instruct them to, whenever possible, sit down when discussing a patient’s condition – it makes the doctor more relatable.

“When people come in to the ER, regardless of the severity of the problem, they’re vulnerable. They’re coming here because they don’t know where else to go, or they don’t have access to other sources of care,” said Tintinalli, who has worked in emergency rooms for about 35 years. “They’re pretty vulnerable and you have to be able to assure them the things you’re doing to investigate the problem are the best that you can do in this environment, with this condition, et cetera.”

Dr. Alyssa Ratzlaff, a first-year emergency medicine resident at UNC, said patients often come in flustered – they often don’t know what is relevant to a doctor. So they might have symptoms they don’t think are worth mentioning.

“All patients come in and there’s multiple things that are happening, and we don’t necessarily know which of those things are connected,” Ratzlaff said. “That’s part of the art: getting their story so it makes sense for them and for us.”

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