Thoughts from the ER

I don’t live in Charlottesville anymore, and this is my last rotation here.  I’m staying with friends who live nowhere near campus.  To get to the hospital, I have a half hour drive, a hunt for a parking space, and then a 15 minute walk.  I arrive breathless (pregnancy seems to be using all my blood elsewhere) and stand by the door of the ER for a minute, catching my breath and waiting for the sweat on my forehead to dry.  I did a triathlon less than six months ago.  I backpacked from the north rim to the south rim of the Grand Canyon.  Now the sloped driveway to the ambulance bay gets me huffing and puffing. 

I’m not the only one.  My first patient is a 66 year old man with shortness of breath. 

Working in the ER, my resident gives me four pieces of information about each patient before instructing me to go to see them: age, sex, chief complaint, room number.  I scan the computer for the fifth piece: the patient’s name.

“Hi Mr. Hiles,” I say, sticking out my hand, “I’m Mali, the medical student on your team.  What brings you in today?”

Mr. Hiles is skinny and tan, he looks younger than 66, he has long stringy hair under a dirty baseball cap.  He sits cross-legged on the gurney in bay 50.  He is not wearing oxygen, which is standard for people with shortness of breath.   “Well, I’ve had this knot on my leg for a while now.” 

Don’t you hate it when you only know five things about someone and one of them is wrong?

“I’ve had this knot in my leg and it gets to hurtin’ real bad and the pain goes up the leg and spreads across my whole body and I feel dizzy and uncoordinated and it is hard to breathe.”

“How long has this been going on?”

“I’ve had the knot in my leg for six months, but the rest of it has come up in the last eight weeks or so.”

I’m having trouble making this fit into any particular pathologic process.  When I hear leg pain and shortness of breath, I worry about pulmonary embolism, but the time table isn’t right.  Asthma, COPD, heart failure, and heart attack are all also still on my differential, but he looks very healthy and comfortable, and none of them really address the leg pain.  “This sounds like it has been troubling you for a while.  What made you come to the ER today?” I ask.

“I tried not to come in, I made an appointment with my regular doctor for this afternoon.  But this morning I felt like I was fixin’ to die.   I didn’t think I would make it to 3:30.”

This gets my attention.  A feeling of impending doom can be associated with pulmonary embolism or a heart attack.

“I got worried I was having a blood clot somewhere.”  Way to steal my thunder, Mr. Hiles.

I continue his history.  He has no chronic medical conditions, does not smoke, has no reason to have blood that coagulates too easily.  He does have severe anxiety that occasionally keeps him from working or going out in public.  He has never seen a psychiatrist or therapist or taken any medication for this.  He has never discussed it with his primary care doctor or anyone else. 

I choose my words carefully.  “Thanks for telling me about that,” I say, “in the ER today we want to make sure you aren’t having something life-threatening like a heart attack or blood clot in your lungs, but you should definitely talk with your primary care doctor about the anxiety.  Some people feel like it isn’t a real problem, but it can make you feel really terrible.  It sounds like your anxiety is pretty serious, since it is keeping you from working or going out.”

Mr. Hiles nods at me.  “Maybe I will keep that appointment this afternoon and talk to him about it.”

I pray silently that Mr. Hiles’ primary care doctor will not let us down on this one, won’t act like he doesn’t want to hear about it or doesn’t have time to deal with it or try to refer him to some expensive psychiatrist right off the bat. I hope he’s one of the good guys, and that he’s having a good day.

“Good,” I say, taking out my stethoscope, “can I take a listen to your heart and lungs?”

I love the quiet moment of listening to a patient’s heart, hearing that reassuring lub-dub, lub-dub, getting to steal a few seconds to organize my thoughts, concentrating solely on being with that person.  Mr. Hiles’ heart and lungs sound beautifully normal.  His vital signs are all normal.  His left calf is not swollen or red or warm to the touch.  The knot seems to be some scar tissue from a construction injury. 

I tell him we are going to run a few tests, but that I am very reassured by his physical exam.  I don’t think he has a blood clot.  He is visibly relieved, and I am surprised that the words of a lowly medical student are enough to reassure him.

I describe his symptoms to the resident, who cuts me off midway through my second sentence, “Is this guy sick or not sick?” he asks.

“Not sick, but I want to check and EKG just to be sure, then I think we will both be reassured enough to send him home to follow up with his PCP about his anxiety.”

The resident rolls his eyes about the anxiety.  “If you are thinking PE, does he need D-dimers, CT Angio?”

“No,” I tell him, feeling like the only person in the ER concerned with medical costs.

Mr. Hiles EKG prints out and I stare at it.  I am still at the stage where I follow the outline in my pocket medicine guide to look at EKGs.  For good measure I google the EKG signs in pulmonary embolism, but no matter how I look at it, this EKG is normal. 

Mr. Hiles is thrilled, feels much better, and promises that he will talk to his doctor about getting some therapy and medicine for anxiety.  The resident signs his discharge papers.

To the Emergency Medicine resident, this was not an exciting patient, just another example of people using the ER when they don’t actually have an emergency.  But to me, this was one of my favorite patients.  I prefer my patients to not have anything serious wrong with them (in part because I lack confidence in my medical abilities, but mostly because I want people to be healthy and well).  Mr. Hiles needed help, and I was able to help him, so I consider it a job well done.  Also, I am hopeful that he will get long-term help for his anxiety, and long-term solutions are few and far between in the ER.