Within the emergency departments where I spent my 40-year career, we do have a higher proportion of patients with problems requiring urgent intervention. However, even in the ED, self-limited illness and minor injury can account for close to half of our patients. The challenge here, of course, is determining which half you are currently encountering.
The following case example will help illustrate some of these issues. In a memorable case that I still find unsettling more than ten years later, I was seeing a 37-year-old gentleman (let’s call him Thomas, not his actual name) who had what sounded like a number of minor complaints when he registered. At triage, his chief complaint was listed as “fever/nausea/postnasal drip” with vital signs showing no fever and just minimally elevated blood pressure and pulse. I picked up his chart at the very end of my shift with just 20 minutes remaining, thinking that this sounded fairly benign. I did this so that I could “try to see just one more patient at the end of your shift,” as my ED administrator had been haranguing me about, while implying that keeping my job depended upon it. My own take was/is that healthcare administrators’ excessive focus on the ‘unholy three P's’ of productivity, performance, and patient satisfaction have put us all at risk for dollar-driven, time-pressured, compromised decision-making.
Present in the triage notes was the notation that Thomas was a hemophiliac, so I was aware of that but didn’t see its relevance to any of his listed complaints. He went on to tell me that he had not been feeling well for the past four days, but at the moment he looked quite well other than talking rapidly and somewhat circuitously. As I was trying to efficiently elucidate his symptoms, he reported to me that he had taken his temperature just once and got a reading of 98 degrees, and in terms of the nausea he reported vomiting just once two days ago and again a second time that day, but without any blood in it or accompanying abdominal pain.
He then reported that his postnasal drip was due to chronic sinus congestion, which he thought was “slightly thicker” than usual for him. He denied any other complaints on a complete review of systems. All in all, not very revealing or alarming and making me wonder why he had even bothered to come to the ED just then. Given that he was a hemophiliac I asked about any bleeding complications, recent falls or head injuries or any significant headache. He reported that his right ear felt “a little uncomfortable,” but not anything else relevant. He did go on to anxiously and in great detail describe a left lower molar tooth extraction he had undergone at a somewhat nearby major metropolitan hospital several months back, and the fact that he had chewed food in that region recently, which he had been advised not to do after being cautioned that “the bone there is tissue-paper thin.”
I was feeling very frustrated interviewing him because he was so vague and was jumping topics frequently. I was having great trouble relegating him to one of the more common categories we see in the ED, such as ‘wanted antibiotics,’ ‘wanted pain medicines,’ ‘wanted an out-of-work note,’ or ‘too anxious to know what he wanted.’ Then in reviewing his upper respiratory tract infection complaints of fever and postnasal drip, I asked about coughing and shortness of breath. To this he answered, “I feel like my body just doesn’t want to breathe.” That meant exactly nothing to me and had in fact just used up my last ounce of patience with him. In my frustration, I chose to turn on my heel and leave the room with a decision to prescribe him some Tylenol with codeine for his described minor right ear discomfort and minor coughing.
Thank God, or the stars, or whatever you want to invoke, right by the door to his room was a wheeled stool which, in my dissatisfaction with ‘the feel’ of that resolution (in EM we often refer to this as our ‘spidey sense tingling’), I sat down on and turned to ask just one more question, “Gee, Thomas, you seem to have a lot of things on your mind today, what is the thing that is most worrying you?” To which he responds, “You know what it is Doc. I’m a hemophiliac and I’m worried that I’m bleeding in my head.” To this, my competing thoughts were, “You’ve got to be kidding me, get out of here!” and “Oh good, we have a test for that.”
Fortunately, whatever it was that made me sit down also made me go with the “Oh good, we have a test for that” thought. After reconfirming the absence of any head injuries, significant headache, prior episodes of bleeding in his head, or other recent abnormal bleeding, I did briefly explain to him that a head CT scan was an expensive test which involved a moderate degree of radiation exposure and didn’t seem to be pertinent to his symptoms. But I decided to order it anyway, mostly to address his main concern and bring our interaction to a conclusion.
So now I’m still trying to grease my exit from the emergency department by the end of my shift, so I simultaneously ordered a head CT scan and wrote up a discharge plan with a prescription for Tylenol with codeine. As I’m handing this to his nurse to discharge him, I’m saying that he absolutely can’t be let go until the relief physician, whom I will sign out and describe my patient and thoughts to momentarily, has confirmed that his head CT scan is indeed negative, as I’m sure it will be. Then I’m sighing with relief as I see the CT technician already guiding him back into his room. The techs are terrifically good and usually come right to us to report any abnormal findings, even before the formal radiologist reading. As I am sighing my relief though, the tech spins around and makes a beeline right to me saying, “This guy has blood all over the entire right hemisphere of his brain!”
‘Working in a minefield with clown shoes’ is how my emergency medicine colleagues and I refer to this process of trying to take only the correct steps in identifying dangerous disease states and living with the knowledge of being at the constant risk of making a misstep. Then, having solved, or more accurately stumbled onto, the diagnostic riddle solution, I now had to address the multiple treatment decisions. I had never treated a hemophiliac before, though I knew from my training that he needed an immediate transfusion of the appropriate hemophilia factor. I quickly learned that option was not available in our hospital, so he would require transfer some 30 miles to the major urban hospital, where he had received his hemophilia-related treatment in the past. I internally debated whether ground transport by ambulance or medical helicopter was best. Airflight would be faster, but the flight paramedics usually insist that the patient already be intubated in case respiratory failure or other significant deterioration intervenes, as they can’t readily intubate in such tight quarters (there’s no pulling off to the side of the road option). The formal radiologist report was that he had acute (very recent) on top of subacute (relatively recent as opposed to chronic) blood, which was compatible with a start of the bleeding corresponding to his first feeling ill four days previously, and his now feeling worse as the bleeding resumed or the accumulation gradually enlarged. However, that could not clarify how fast he was currently bleeding, or what was most likely to happen next.
I ultimately chose to send him by ground transport, thus avoiding the risks of possible complications from the intubation procedure and the associated sedation and paralytic medications that I would have had to give him had I decided to do so in my ED. This would also leave him alert enough to converse with the specialist physicians upon arrival, and they could more easily clinically evaluate his progress. I cringed at the very real risk, though, that this was a wrong choice, with him potentially rapidly deteriorating and possibly even dying en route. I reasoned that the ground ambulance crew with a paramedic on board could easily pull to the side of the road and intubate him if needed. But I also knew that I would be second-guessed if complications ensued (for example, “if you had only flown him here, we might have been able to intervene to stop the bleeding sooner and save his life”).
Thomas and I did both survive that experience, though each of us a little worse for wear. Despite the fact that a lack of productivity kept putting my job at risk, I continued to work at the pace that I thought circumstances required. At my next annual review with my ED administrator, when he predictably pointed out that my productivity could be increased, I related this case and commented to him that ‘I work to my own standards,’ such that ‘fast things are fast while slow things are slow.’ I don’t think he really appreciated my comments, but at least I wasn’t reprimanded further.
Here in Thomas’ case, he had the underlying chronic disease condition of hemophilia, along with an acute disease complication of uncontrolled intracranial bleeding. In this setting, he presented with a vague illness characterized by a host of minor physical symptoms, which appeared entirely unrelated to either the acute bleeding complication or the chronic disease process, except perhaps the “little uncomfortable” right ear and nausea. Those symptoms, by all rights, should have been a debilitating right-sided headache and unrelenting nausea and vomiting. In retrospect, the only thing that might have been related to his acute disease process was that he was having trouble organizing his thoughts, possibly as a side effect of the blood oozing all over the right hemisphere of his brain. However, one cannot be reflexively ordering CT scans of the brain on everybody who has problems organizing their thoughts or relating their concerns in a linear fashion, because that is a shortcoming characteristic of many people when feeling ill, and even some of us when we are not feeling ill.
Ordering a head CT scan on someone who has what we term ‘altered mental status’ is standard medical practice. However, this patient did not seem to be truly altered, just mildly odd and “unfocused. I strongly suspect, though, that if this gentleman had seen his own physician somewhere in the course of the four days of his illness, that physician in knowing him well would have recognized that this was likely a distinct personality change for him and, therefore, would have suspected something more ominous than I was able to readily recognize in not having ever met Thomas before. I ended up ordering the right test on this patient, but for the wrong reason. To this day, I remain disappointed in myself for having allowed my personal wish to leave work on time after a long shift, as well as administrative pressures, to influence my decision-making, which should have only been influenced by consideration of Thomas’ welfare.
Even now I shudder at the thought of his being found cold and dead in his bed the next morning with the bottle of Tylenol with codeine prescribed by me on his bedside table!
New Jersey native and New Hampshire resident, Dr. Drew Remignanti, MD, MPH, author of The Healing Connection: A Partnership for Your Health writes from the dual perspective of a 40 year career emergency physician and of a 50 year career chronic autoimmune disease patient. He considers himself well educated by Dartmouth College, Rutgers Medical School, the Medical College of Wisconsin, as well as 15 hospitalizations, seven abdominal surgeries, and a major disabling stroke in 1992 at age 38. He wrote his book for the benefit of those of us who are involuntarily enduring medical suffering, as well as those who are voluntarily attempting to alleviate medical suffering in its myriad manifestations. https://drewremignanti.pubsitepro.com/
