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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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