As an emergency medicine physician, we’ve all had that hysterical patient. The one that comes in during a busy shift grabbing at their head, their chest, their abdomen. Yelling out that they are in pain as they roll by.
You know the one. They make the nurses’ eyes roll. They add to an already chaotic scene. Other patients stop to watch as the gurney passes.
You debate how long you’re going to wait to go into the room when the triage nurse hands you the chart and tells you the patient is so agitated that they can’t get a history. The EMS crew tells you the call came out as a chest pain, a headache, an abdominal pain, and they weren’t able to get much more information after that. Maybe they’ve been called out to that patient’s house before and they acted similarly. Maybe you’ve seen them in your own ED before and think, “What do you want this time?”
This is the patient where you go into the room and try to, um, patiently get a history. You count under your breath as the patient continues to cry and “carry on.” Finally, frustrated you tell the patient you can’t give them anything until they talk to you and tell you what’s going on. Even then you might not get some useful information other than their presenting complaint and they need something for it right now!
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You walk out of the room. The nurse asks, “So what are we going to do with this one?” You shake your head in exasperation. “I don’t know. Let’s start with something.”
You jot a quick note. Go to tend to the other demands of the department. A while later the EKG or chest X-ray or flat plate or lab result comes back, and you think, “Oh crap!” You rush back to the room. Suddenly that crying, wailing patient is the STEMI, the widened mediastinum, the free air in the abdomen.
You look at your watch. How much time has passed? What needs to be done? You start to mobilize your team. You write for medications like heparin, a nitro drip, antibiotics. You get the nurse to run extra labs. You order the CAT scan and call and tell the tech that this patient is next on the table. You call your consultants.
You go back into that room with a different view on the patient and start to explain what is going on, try to reassure them, get medications started and try again to get a better history. You get consents, place lines, make phone calls to families.
The patient is rushed off to the cath lab, the OR, the ICU. Then you wait. You’re seeing your other patients in the ED but your mind is on that patient. What did you miss? What could you have done sooner?
You get some information. The patient had a 100 percent lesion in the LAD, a ruptured AAA, necrotic bowel. They’re going to tele, the ICU, or they died on the table in surgery.
You stop and think. Was I professional? Did I make them comfortable? Was I even nice?
Then the next patient comes in the door yelling and screaming that the only thing that’s going to help their pain is “something that starts with a D, dill, doll.” You take the chart, take a deep breath, go in the room, and try again.
Veronica Bonales is an emergency physician.
