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The Eyes Have It

I was coming to the end of my ER shift and realized that a fairly large list of patients still waiting to be seen. I scanned the chief complaints listed on our white triage board to see if there was a straight forward case that I could handle quickly before I went home. Since it was early in the morning, we had the typical extremes of patients – those who were badly injured (drunk driving is more common in the wee hours) and those who were really weird.

ER nurses are amazingly adept at capturing the seriousness of a complaint with their choice of words. Reading between the lines is a bit of an art form – and part of the natural communication in a busy ED. I understood the art fairly well, though this night I missed a big clue. Here were some of the chief complaints that I could choose from:

1. Crushing substernal chest pain x1hour

2. Butt twitching x3 months

3. Head vs. light post

4. Ear pain x2 days

First of all I made sure that a colleague was with patient #1, which left me a choice between patient #2 – clearly weird and doubtful that I’d be able to resolve his problems any time soon, patient #3 – probably going to take a lot of sutures and more time than is left in my shift, and patient #4 – a fairly innocuous-seeming issue, probably otitis media.

Needless to say, I chose patient #4… though I hadn’t recognized the subtle distinction between “ear pain” and “ear ache.” I was about to figure this out the hard way.

As I drew back the curtain to patient #4′s room, I saw a tall, thin man sitting bolt upright in the chair next to the stretcher. He was polite and respectful – but there was something odd about him. A few minutes into our interview about his ear pain, I finally put my finger on it. The guy never blinked.

After several more minutes of what could only be described as fairly straight forward answers to medical history questions – and a fully negative review of systems – I had this sneaking feeling that Patient #4′s pain wasn’t otitis media.

“I’d like to ask you a question that might seem kind of strange…” I said, peering intently at his face.

“Ok,” said the young man.

“Have you ever thought that your pain is related to a transistor radio of some sort in your ear?”

His eyes grew as large as saucers.

“Yes! How did you know?!”

And there it was – a young man with schizophrenia, experiencing his first psychotic break. It took me a few hours to get him a full work up and a discharge plan to the inpatient psych unit… and I was very late getting home from this shift. So much for a straight forward case…

I wonder what would have happened if I’d chosen patient #2?


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10 Responses to “The Eyes Have It”

  1. avivagabriel says:

    Do you get “overtime” pay? Or are you an exempt salaried ER doc? Or neither of these?

    I ask because I wondered about also choosing by other criteria:

    1. “what am I most interested in, medically,” or
    2. “what do I most want to help resolve for a patient,”

    …as opposed to choosing solely on:

    3. “what can I most probably address effectively in the time I have left in this shift?”

    Just another curious reader…

  2. I love this story. It is reflective of so many things…”quick” does not always mean you get to leave. Things are not as they seem. Gut feelings usually pay off. End of shift usually means you'll get delayed big time. Great post!

  3. valjonesmd says:

    My first priority is always patient safety – if everyone's safe and being taken care of, then the next priority is choosing to help someone in the time I have remaining on my shift. There is no overtime pay… and working overnights is exhausting and you really want to get out on time (I've almost had car accidents trying to get home after an extra long shift). However, if it's early in the shift and there's plenty of time I'm happy to take on complicated and challenging cases, with the most acute people first in line.

  4. avivagabriel says:

    Do you get “overtime” pay? Or are you an exempt salaried ER doc? Or neither of these?

    I ask because I wondered about also choosing by other criteria:

    1. “what am I most interested in, medically,” or
    2. “what do I most want to help resolve for a patient,”

    …as opposed to choosing solely on:

    3. “what can I most probably address effectively in the time I have left in this shift?”

    Just another curious reader…

  5. I love this story. It is reflective of so many things…”quick” does not always mean you get to leave. Things are not as they seem. Gut feelings usually pay off. End of shift usually means you'll get delayed big time. Great post!

  6. valjonesmd says:

    My first priority is always patient safety – if everyone's safe and being taken care of, then the next priority is choosing to help someone in the time I have remaining on my shift. There is no overtime pay… and working overnights is exhausting and you really want to get out on time (I've almost had car accidents trying to get home after an extra long shift). However, if it's early in the shift and there's plenty of time I'm happy to take on complicated and challenging cases, with the most acute people first in line.

  7. avivagabriel says:

    Thanks for your very clear answer; I well understand the costs involved in seriously overdoing one's work. It just doesn't help anyone. The price is too high. It's not a way to live. As you implied in your “almost had car accidents,” it's a way to die!

    And we all know the concerns about residents working long hours, which increases the risk that they'll make a serious medical error, and increases the risk for medical problems of their own in the future (as they abuse their bodies, minds, and spirits).

    Finally, not receiving monetary compensation for overtime makes it that much more expensive to one's own health and quality of life. At least with a little overtime pay, one could spend it on a nice, long spa vacation (maybe) and rehabilitate oneself!

  8. avivagabriel says:

    One last comment: “butt twitching” is pretty vague. Who writes it up like that?

    It could mean “anal itching and twitching,” and involve infection or nerve damage.

    It could mean “colonic spasms,” and be caused by any and all physiological and structural systems in the human body!

    It could mean muscular twitching of the gluteus muscles, and involve…who knows?

    Could be a million causes, from musculoskeletal to psychiatric! I could go on with possible scenarios that are covered under “butt twitching.” But I'll spare you.

    All I really want to say is:

    Do doctors really write “patient complaint descriptions” like that on an intake board or log? Or is this just your language for the purposes of the blog post?

    If the former, I'd be worried (as an ER patient). Doesn't seem like that kind of language would communicate enough information to conduct meaningful triage!

    If the latter, I find the language clever, provocative, and humorous…

  9. valjonesmd says:

    The butt twitching complaint is exactly how it was written. You're right that it's vague, and that's the point. The nurses are subtly saying that the patient is a poor historian, and that this is more likely to be psychogenic than anatomic. It also means that the nurse who triaged the patient does not believe that the person is “high acuity.” Right or wrong, it suggests to the doctor (especially the x 3 months) that this is not an emergency and the patient can be prioritized lower than the others.

  10. avivagabriel says:

    Aha!

    I think we (collectively, as a society) need training courses for patients on how to be better patients.

    I'm mystified: what in the world drove this person to suddenly experience the butt-twitching as urgent, after 3 months? Loneliness? Boredom? Inability to access any other source of medical care? All of the above? Or…?

    I'd be ashamed to go to the ER for a chronic, relatively-painless condition… wouldn't be able to bring myself to walk in there for such a reason… unless I had NO other recourse (and had been “putting up” for quite some time with a condition that was beginning to scare/distress/worry me.

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