The Real Question

Let me tell you a small secret about life in the ER.  Mind you this is not some bit of hidden lore that all ER doctors are pinky sworn to keep from the patients.  No, it is something that you just figure out over time, at least if you are paying attention to the right things.  Here it is:

THE CENTRAL QUESTION TO BE ANSWERED IN EACH AND EVERY ER VISIT IS THE SAME:  WHY IS THIS PATIENT HERE AT THIS TIME AND FOR THIS PROBLEM.

Sorry if you were looking for something else.  But this is actually a profound concept.  You want to know why that smiling toddler is in at 3AM with a runny nose?  You want to know why the guy with chest pain waited three days to come in?  You wonder what the real question is when a patient hems and haws and can't quite get to the point?

There are no illogical ER visits.  We just sometimes lack the time and energy to ask the right questions.

Let me give you an example.

The ambulance brings in an elderly woman.  The reported complaint is altered mental status.  She is known to be a cancer patient and to have had a cranial surgery.  The place is hopping, so there was no time to grab the EMTs and try to figure out more.  This looks like a difficult problem, because if a patient really is out of it you do lose some helpful history.  Accept as a given that you have no ready access to patient records and that there is no family to be seen anywhere.

A quick duck into the room shows me a quiet woman in no distress.  Vitals are stable.  The problem is not evident.  When you talk to her she says that she is just having a hard time managing.

The standard ER algorithm here is scan the head, call oncology with the results and just keep marching from room to room.  Keep them doggies rollin' as the old song said.

But I regard this as a wrong answer.  Or to be more precise, an answer to the wrong question.

The sun is up and the clinics are open.  I call over and ask them to walk some notes over regards her history.  I also spend enough time with her to realize that she is lucid and well oriented.  Her speech is a little halting, but not remarkably so for a woman who has had a brain tumor removed.  The oncology notes turn up and indicate that she is known to have persisting disease and that a "cure" is not in the cards for her.

At this point I decided that it was reasonable to check a few basic labs.  She had been on decadron which can send your blood sugars crazy and all cancer patients are at risk for elevated calcium levels and so forth.  All tests were unimpressive.

Now you could do a CT or MRI scan at this point, but you should stop and ask yourself...what would it show that is going to change management in the near term?  Oh, and it appears she is scheduled for a scan next week anyway.

This poor lady sat in my ER for far too long.  But there were other folks more in need of help.  When the anxious parents had been reassured and the broken leg teased back into a straight line and the family of three with trivial problems and persisting requests for pain meds had been dealt with I got back to her.

Cup of coffee in hand I sat on the bed next to her.  She was sitting up, having just finished some soup and crackers.

"How's it been going for you?" I asked.

It was the entry point to a 15 minute chat.  About how she got married at 16 and had five children in six years.  How she and her husband struggled in their marriage and finally divorced.  How they had later met again in a random encounter, started dating all over again and remarried.  How they were so happy until he got Alzheimers.  How she cared for him for six long years.  How she felt as if she had not done all that she could for him.

She talked about her cancer diagnosis.  About how she did not really fear dying but wanted so much to be around when her grand daughter, now 16 herself, graduated from high school.

So why was this patient here at this time and with this problem?  Well the superficial answer turned out to be that in a phone call with a family member she got a little choked up and just couldn't speak of some matters.  Said family member assumed the worst and called the ambulance.

But the real reason?  She was afraid.  Afraid of dying before she could pass along her wisdom, which was considerable, to a grand daughter at the very age she was when wisdom was most needed.

So we just chatted.  I think the chicken soup was a little therapeutic.  I decided she could ditch a few of her medications.  After all, when you have metastatic cancer the importance of keeping your cholesterol down to reduce the odds of a heart attack in the distant future seems hard to fathom.

In fact I told her that I saw no reason she could not have some bacon and chocolate if she wanted to.

And I told her to spend the time she had, be it short or long, on the really significant business at hand.  She did after all have more important places to be than in Room 7. And more important people to talk to than me.