The hysterical patient during a busy ER shift

by VeronicaB, MD

We’ve all had that hysterical patient.  The one that comes in during a busy shift.  Grabbing at their head, their chest, their abdomen.  Yelling out that they are in pain.

You know the one.  They makes the nurses’ eyes roll.  They add to an already chaotic scene.  Other patients stop to watch as the gurney rolls by.

You debate how long you’re going to wait to go into the room when the triage nurse hands you the chart and tells you the patient is so agitated that they can’t give her a history.  The EMS crew tells you the call came out as a chest pain, a headache, an abdominal pain.

This is the patient where you go in the room and try to patiently get a history.  You count under your breath as the patient continues to cry and “carry on.”  Finally, frustrated you tell the patient you can’t give them anything until they talk to you and tell you what’s going on.  Even then you might not get some useful information other than their presenting complaint.

You walk out of the room.  The nurse asks, “So what are we going to do with this one?”  You shake your head in exasperation.  ”I don’t know.  Let’s start with…”

You jot a quick note.  Go to tend to the other demands of the department.  A while later the EKG or chest x-ray or flat plate or lab result comes back, and you think, “Oh crap!”  You rush back to the room.  Suddenly that crying, wailing patient is the STEMI, the widened mediastinum, the free air in the abdomen.

You look at your watch.  How much time has passed?  What needs to be done?  You start to mobilize your team.  You get the nurse to run extra labs.  You order the CAT scan.  You call your consultants.

You go back in that room with a different view on the patient and start to explain what is going on, try to reassure them, ask them what you can do for them.  You get consents, place lines, make phone calls to families.

The patient is rushed off to the Cath lab, the OR, the ICU.  Then you wait.  You’re seeing your other patients in the E.D. but your mind is on that patient.  What did you miss?  What could you have done sooner?

You get some information.  The patient had a 100% lesion in the LAD, a ruptured AAA, necrotic bowel.  They’re going to Tele, the ICU, or they died on the table in surgery.

You stop and think.  Was I professional?  Did I make them comfortable?  Was I even nice?

Then the next patient comes in the door yelling and screaming that the only thing that’s going to help their pain is “something that starts with a D.. dill… doll…”  You take the chart, go in the room, and start again.

“VeronicaB” is an emergency medicine resident who blogs at The Central Line, the blog of the American College of Emergency Physicians.  Reprinted with permission from the ACEP.

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  • anonymous

    Yes, the “positive review of systems” patient does make things hard. You never stop second guessing yourself when something goes wrong.

    • also anon

      Is it always the patient who makes things hard?

      Some diseases and combinations of diseases lead to a “positive review of systems”.

  • Maria

    Wow. When somebody is dying in front of you, do you really sit down to ask them about vaccinations, childhood illnesses, and surgeries? Does it even matter what their last blood pressure readings were, when they are now having a heart attack?

    I must say, I would also panic if I know I’m in danger of irreversible health damage or death, and precious minutes or even hours are wasted on protocols. And then, obviously, my family and I would be labeled “hysterical” and punished with extra slow and disinterested care.

  • http://www.thenerdynurse.com The Nerdy Nurse

    This is why it is so vital to attempt to remember that people interpret pain subjectively and react accordingly.
    Also, different cultures react very differently to what they interpret as pain as well. We have to do our very best as healthcare providers to attempt to remain as objective as possible and treat them based upon what they say, not how you feel, unless of course they are slurring so bad they can’t get their words out because they’ve already received 2mg of IV dilaudid, they may very well need some more to calm their pain.
    Every situation we encounter as healthcare providers is a new experience and unique to itself. We must not forget that.

  • sandra bereza

    Having been on the “patient” end of this, I can assure you that as a patient with a history of necrotic gut, chron’s, and a-fib, I will never go into another ER complaining of abdominal pain again. I will always arrive by ambulance and tell the intake that I have severe chest pain.. I waited 3 hours after triage and then went into a coma in the ER. 7 hours of surgery found major blood clots in my 1 working kidney and more necrotic gut. All this after being told it was all in my head. NO — it was in my gut.

  • kullervo

    When my father went into the ER one day at noon with abdominal pain, he was medicated, given a CT and an ultrasound, and parked overnight with a diagnosis of cholecystitis. He was taken into surgery twenty-four hours later. Luckily the surgeon had a look around with the laparoscope and found the thrombus in the inferior mesenteric vein and the jejeunal volvulus. My father did great after surgery. His surgeon looked a little pale.

  • http://sickmomma.blogspot.com SickMomma

    So what I’d like to know is does having a patient like that, who was easy to write off initially but turned out to be seriously ill change the way you look (and treat) other patients? And if so, for how long before you get cynical again that everyone is a drug seeker and/or making a mountain out of a mole hill?

    • L.

      So – I’m hoping some of the ED docs will reply. My VERY subjective view of this – based on reading too many medblogs and their attendant comments from practicing physicians – is NO it doesn’t change their behavior.

      They will play the odds. Odds are that the patient is a drug seeker, or hysterical (and always female) and attention-seeking, or exaggerating their symptoms – so if a few “real” patients die due to their mission of keeping pain meds out of the hands of those unworthy souls and wasting time on the others – then so be it. They die. That’s the price of vigilance. Some of them may feel bad about it for a while.

      There are dozens of Emergency doctor blogs around. Most have a recurring theme of frustration of having to deal with the dregs of society. It seems they become very cynical very quickly. it can’t be an easy job.

  • jsmith

    I recently had a crazy young Korean woman come into my office moaning and crying and carrying on about the pain in her upper abdomen. I’ll be danged if she didn’t have appendicitis!
    My nurse practitioner just had another crazy young woman who kept coming back into the clinic complaining of dyspepsia. Danged if she didn’t have acute cholecystitis!

  • Lola

    If a patient that you’ve never met before is getting under your skin, the least you owe them is to act professionally. What do you possibly expect a hysterical, sick, vulnerable patient to do when you up the ante by blowing them off.

  • Dr. J

    As an ED doc I can tell you that most hysterical ED patients are hysterical, and they are having severe mental anguish about something that you will likely never find out about. I can also tell you that severe anxiety is a hallmark of some serious and terrible pathology. Vascular emergencies in particular, aortic disection, carotid disection, pulmonary embolus and mesenteric ischemia all seem to have an overlay of anxiety that seems disproportionate to initial physical exam.

    The nervous patient makes me nervous. At the very least it makes history gathering more difficult, and it widens the confidence interval I have in any particular diagnosis.

  • Anon

    If you never find out the cause of the severe mental anguish, how do you know it’s mental? Along with your examples, what about undiagnosed endocrine and neurological diseases?

    Many of those may be better handled outside the ED , but how is the patient supposed to know that prior to getting a diagnosis?

    Nervous doctors make nervous patients even more nervous. Politeness always helps.

    • Dr. J

      I think you are misunderstanding my comments. I am in no way being impolite to patients, and I never appear nervous at work, I am saying that the highly anxious patient raises my barometer for badness (ie. makes me nervous). My job in part is to be the coolest cat in the room regardless of the situation, my calmness is a tool that I use to calm everyone down so we can get things done in terrible situations.

      Sometimes (often) over the course of hours, the mental anguish a patient is suffering becomes apparent, though it’s root cause may remain elusive, that is reality, most people with severe anxiety are not in fact dying, and it is important to recognize that so that they too can receive appropriate care targeted towards their symptoms. The patient is not supposed to know this before being evaluated. It is totally appropriate for these patients to come to the emergency room. If I identify a problem that needs out patient management I will refer them to this.

      Finally although lots of medical conditions can cause anxiety (from the neurological to the dermatological) the conditions that cause well appearing patients to come in looking well but severely anxious and then suddenly die tend to be vascular catastrophes. I have no idea why tearing through the intima of an large artery sometimes causes a feeling of dread instead of pain or any other expected symptom but it does. Any emergency doctor can tell you this. When someone with no physical exam findings is pale, sweaty, breathing fast and asks me if they are dying vascular emergency is at the top of my list of diagnoses to exclude.

      Dr. J

      • Anon

        Hey, thank you very much for clarifying, and I’m sorry I misunderstood you. I interpreted your response through the filter of my own bad experience, which was of a serious (in a long-term way) but not immediately life-threatening nature. I don’t know anything about vascular emergencies, so I should be thankful it’s not something like that.

        I have been that nervous patient, a couple of times in the ED, but mostly in various doctor’s offices. After many years of trying to get a diagnosis, I ended up very recently finding out that I have a rare, chronic, progressive disease with an uncertain, but usually bad, prognosis. This may lead to emergencies down the road, and I’m afraid of being blown off again.

        Having so many doctors thinking I was (only) anxious, at best, or faking, at worst, just had a snowball effect on my discomfort with doctors. I got to where I could pick up on – or at least I thought I could – doctors’ raised “barometer for badness” as you put it. Based on the fluctuation of my disease, sometimes my nervousness was more physiological, and sometimes it was more emotional, based on trepidation at how my symptoms/history would be received.

        I just wanted to point out that gray area of “not dying right now but still quite sick and undiagnosed”. You sound like a great doctor and a nice person.

      • Anon

        I think I still misunderstood what you meant by “barometer for badness”. You meant the disease is bad, not the patient?

        I’ve had the opposite experience in the ED and in doctor’s offices. Eye-rolling, etc. I appreciate now that you meant something different.

  • http://www.myheartsisters.org Carolyn Thomas

    Here’s a news bulletin for ED staff: people in pain inevitably exhibit anxiety, much of it pretty severe.

    When I suffer my next MI, please remind me to just stay very very quiet and not act like that “crazy” Korean woman. Remind me to paste on my happiest happy face so the “mental anguish” of having another heart attack won’t “seem disproportionate to my initial physical exam”. Remind me not to say or do anything that might make the nurses “roll their eyes” if I’m not behaving in a pleasant and likeable fashion.

    • Anon

      Can’t be too pleasant or happy either. That could be taken for “la belle indifference”.

      There’s an extremely narrow range of acceptable behavior for a patient reporting symptoms, and each doctor is a little different in terms of what’s acceptable to him/her. Good luck navigating that when you’re ill.

      • JustADoc

        Yeah, forbid that a doctor might learn typical ranges of behavior/presentations/exams/etc after seeing literally thousands of patients.

        • Anon

          Sure, but you still need to be polite and try your best with patients who present atypically.

  • http://www.wjhb.de William

    I wish I were still amazed at the number of people capable of waving the moralistic baseball bat in response to stories like this. But sadly I am not surprised in the slightest. That last reply is a good example. “Sure, but you still need to be polite and try your best with patients who present atypically.” There is no decent response to this sort of comment. The article is a report of an experience on the job not an invitation to preach.

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