Every emergency medicine shift teaches something

Tonight a 17 year-old boy came to the emergency room complaining of headache. As I entered his room, in my usual hurry to do an assessment as expeditiously as possible, so as to get on to the next case and attempt to avoid the inevitable backup of patients so common in our ER, I was struck by the vulnerable demeanor of the patient before me. The triage nurse’s report assured me that the temperature and other vital signs were normal (unlikely to be the dreaded meningitis, I thought) and that no trauma has prompted this visit.

At the youth’s bedside sat his mother, a woman of about forty years. She waited quietly with a soft, though concerned and vigilant look on her pretty face. Early on in the encounter she informed me that her son had been having occasional headaches for two years but that the symptoms had worsened in frequency and intensity over the past couple of months. Not only were the headaches worse, but the boy also wanted to sleep a lot and was “difficult to wake up.” My thoughts immediately turned to a possible diagnosis of some sort of brain lesion, namely a tumor, though rare in this age group, nevertheless consistent with the presenting symptoms. While conducting the physical exam, with special attention to the neurological system, I asked the mother if her son had ever had a CT scan during the time he has been suffering from these headaches. She remarked that indeed he had undergone such a test two weeks earlier, when one of my colleagues had evaluated him in our ER and that the scan had been normal.

This news gave me some measure of comfort, though MRI is a more sensitive method for ruling out a brain tumor. I now headed down the migraine pathway as the route most likely to lead me to the correct diagnosis. Certainly there was a migraine history in the family and this young man was a likely candidate for such an affliction. Dear God, let it be migraine, I silently prayed, so I can treat it and get on to the next patient. I could see that the ER was getting busier and I, the sole physician on duty, would pay the price of keeping other patients waiting.

I quickly reviewed in my mind the facts of the case, but the most remarkable feature was the mother’s insatiable need for reassurance that her son had no life-threatening condition.

Initially, the young man would not respond to my inquiries as to the nature of his headache, such as when it started, where exactly it was located, whether he felt nauseated or had any visual disturbance, ie, the usual questions asked of every patient presenting to the ER with pain in the head. I began to appreciate his mother’s concern that he just wanted to sleep and was difficult to wake up. Finally, suspecting that he really could hear and understand me, I took the assertive maternal approach and told the boy to sit up and cooperate with the exam. Much to my relief he responded in an appropriate manner, a clear sign that his level of consciousness was not impaired, an important thing for me to know.

Yet, he looked so sullen.

By the third time his mother asked if I was sure he was all right and I was beginning to wonder what on earth was causing her so much worry, when I had, I thought, in my usual caring and compassionate manner, done everything I could think of to allay her fears, she remarked, ”I’ve already lost one son, I couldn’t bear to lose another.”

Suddenly any hope of getting out of that room quickly and on to the next patient was seriously compromised. I was now compelled to ask the inevitable question of what had happened to her other son. Thoughts of a dreaded, rare, familial disease that presented with headaches and took the lives of children, and which I could not remember from my medical school days, raced through my mind. I glanced at this pathetic-looking woman, whose desperation I could feel in my own heart, and, as gently as I could, asked the awful question.

“He was murdered two months ago,” she said, with what must have been more courage than I could only imagine a mother could muster up. Her words stung me. Suddenly the whole case took on a different light and as I looked again at my young patient I now saw the obvious face of grief and depression.

Often in a busy ER doctors and nurses alike, because of a myriad of stresses inherent in the work, become impatient with and, at times, intolerant of some of the members of society who “bother” us with seemingly minor complaints, especially if they are repeat visitors to our hospital. Everyone knows that teenagers tend to be moody, uncooperative individuals who often don’t want to get out of bed. But how many of us have ever had to endure what this young lad had experienced? His older brother, his idol, has been killed, shot by two men who hijacked his car and left the young man and his companion dead in a Florida orange grove. Why would anyone want to get out of bed again after that?

Emergency medicine is a challenge, to say the least. Each 12-hour shift teaches something. Patients come and go. Life hangs in the balance.Sometimes the pace is frenetic and survival (my own) is questionable. Many people come to our doors and we may never know what pains lie hidden in their hearts. Usually the diagnosis is easy, the physical problem obvious and treatable. Though life-threatening events happen every day in the ER, in most cases we can make a positive difference, occasionally even saving a life.

The problems of the heart (not in a cardiac sense) are often the most difficult to treat.

I am reminded each day that life is precious, that today might be my last on this earth, that I am honored and privileged to be an ER doctor and to be entrusted with the health and lives of the many patients who seek sanctuary inside our doors.

But every once in a while I stop to reflect and savor the moment and one such time was tonight when, after having a heart-to-heart talk with a wounded mother and her son, a 17-year old boy gave me a hug as he left my ER.

Marlene Buckler is an emergency physician 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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