A Broken Soul
Many people think that Emergency Physicians only treat emergencies such as gunshots, stabbings, heart attacks, and strokes. Well, that’s not always the case. For people who are hurting not from a gaping wound but rather mental anguish, who have no other place to turn; the Emergency Department is their haven. Everyday we meet people who are running on empty, who are just about to lose it and throw in the towel. It is our job to help them see another round.
A couple days ago a man in his 20’s presented to the ED, escorted by his mother. I glanced at his chart. The chief complaint read, “I’m vomiting.” No big deal, I thought, this could wait – since I am caring for 5 other patients who are much sicker than this young man with a few episodes of vomiting. About thirty minutes later, the nurse approaches me and asks if I spoke with the patient in room 13? “No, not yet,” I answer. “Could you please,” says the nurse. When a nurse tells me to go see a patient, I do it. It’s rare that this happens, but when it does, there is usually something wrong with the patient. So, I finish up a few things and walk over to bed 13.
As I approach the room, I see a young man with light brown hair down to his shoulders, sitting in bed, tears rolling down his cheeks, hyperventilating and vomiting clear to yellowish emesis. His mom is at his side, holding up his hair. He is rocking back and forth in the stretcher. I introduce myself to mom and she replies, “Hi, I’m Pauline, Steven’s mother, I’m a nurse.” OK, I say to myself what’s going on, this young guy, who looks miserable is here with his mom, a nurse. My first thought is that this guy has meningitis, an infection of the brain that causes young people to look very ill. I’m waiting for her to tell me about his high fevers and stiff neck, classic for meningitis. “Steven’s brother died a few months ago and he’s never been the same,” is the first thing she tells me. “His uncle died two days later,” she continues. “And his father, a cop, died in 9/11, Steven was also in the building before it collapsed.” How do I handle this? I am at a loss for words. What can I do to help this family? Who am I? “I’m very sorry, it sounds like you have been through more than most people can handle,” I say. I don’t believe that society appreciates the effects of psychological stressors. I often see these stressors cause people to have physical symptoms; probably the cause of Steven’s vomiting. “We’ve been to 3 different hospitals over the last month, but Steven keeps throwing-up, can’t keep any food down. He’s been x-ray’d, CT scanned, even had an endoscopy, nobody can figure out a reason why he is vomiting,” says Pauline. I push on Steve’s belly, it’s soft, no areas of tenderness, then listen to his lungs and heart, look in the white’s of his eyes for icterus or yellowish discoloring seen in gallbladder disease. Everything appears normal. Steven says, “My hands are so numb, and my mouth is tingling.” I watch him breath, too fast, about 30 breaths a minute, double the normal respiratory rate. I tell the nurse to administer fluids and order a milligram of lorazepam, an anti-anxiety medication.
Five-minutes after he receives the medication I walk back over to him, and already I can see a difference. The tears subside. “How is the tingling in your fingers,” I ask. “Much better,” says Steven. I see calmness in his body; his breathing slows down, the vomiting stops. “I think your symptoms are due to the enormous psychological burden you carry in your mind; its psychological symptoms manifesting as physical symptoms, that is why all of your x-rays and CT scans are normal.” “There is nothing wrong with your organs,” I tell him. Steven sits in bed, staring straight ahead. “I can barely get the energy to go on living, everyday is a struggle,” he says. “I can’t imagine what you’ve been through, but I’m sure you are doing your best, I say. Steven replies, “I am trying, but failing.”
When things go bad in emergency medicine, it is usually not the patient who tells you. It is usually a vital sign, ECG, or lab result that is dangerously abnormal. Today, my patient is telling me that his health is critical. I call the psychiatrist and relay a brief history. “I’ll be right over,” says the consult, “Sounds like this guy is sick.”
The most critical patients aren’t always those who are hypotensive. Sometimes, our most critical patients have a completely normal physical examination with normal vital signs. But if you look deeper, you’ll see their illness – a broken spirit. It is our job to start the healing process in these patients. To find these patients the proper care. Steven presented to our Emergency Department broken. After two weeks in the in-patient psychiatry ward, he left with a sense of hope. Putting his shattered life back together, one piece at a time.
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