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19 November 2008

The Boy and Girl Who Cried "Wolf"

There are some patients that drive you crazy. Usually, they are the ones that come into the emergency department with a "I've had chest pain/cough/stomach pain/leg pain/back pain, etc for the last 6 weeks/months/etc. and I thought I should have it checked out." When you ask if they've ever talked to their primary physicians about the problem, they say "I forgot," "He's looked into it and hasn't found anything yet," or "No, I was going to mention it on my next visit, but I thought I should get it checked out today."

It's hard not to discount those patients. Not to be mean, but seriously, like we always ask, "And, what about today made it so bad you had to come to the Emergency Department to be seen?" Two patients that I saw during my last shifts at Suburban are good examples of how even the simplest cases can surprise you.

We'll call the first patient Frank. Frank is around 72 and has dementia. He also had a heart attack about 10 years ago, underwent bypass surgery, and since then has complained on a regular basis about having chest pain. He was brought into the ED in the morning after having been found on the floor of his board and care facility lying in front of the elevator. He told paramedics that he didn't feel well and needed to lie down.

His daughter was called, and he complained to her about the chest pain. She told him that they would "go out to lunch" which she later told me was her way of "distracting him" from his usual rant about having chest pain. She explained that he had been evaluated time and time again for complaint about chest pain, and that all of the tests had been negative so far.

Still, he insisted on coming to the ED, and since EMS had already been called, they brought him in. So, we did our thing, evaluating him for the "chest pain" we assumed he didn't have, and expecting to discharge him after talking to his primary care physician. The first EKG didn't look very suspicious but still had some changes that made it just enough dissimilar to a prior EKG that we were more concerned than previously thought.

You can guess what was happening... his next EKG showed a major heart attack, and an EKG taken about 15 minutes later was worse still. We immediately contacted cardiology, and the patient was transported to another hospital to get angiography.
When I called later that same day, a colleague told me that the patient was in the cardiac care unit. I'll find out tomorrow how he did. Needless to say, the daughter felt guilty, we felt guilty, and the patient almost suffered because of it.

The next patient we'll call Thelma. I saw Thelma on my last morning at Suburban. She is a sweet 80 year old lady who came into the "non-urgent" part of the E.D. that I picked up because I wanted an easy last day. Her complaint "chest pain" was classified a "green" not urgent because in triage she related her chest pain to her reflux disease and not as a cardiac issue.

When I talked to her, she was telling me that she'd had the pain for years, that her primary care physician had done multiple tests for it, and that this morning it didn't hurt any more or less than usual, but that she just thought she should "have it checked out." I asked when she'd last seen her doctor, Thelma told me she'd just seen him a few weeks earlier. When I asked if she had told him about her "chest pain" she said that she'd forgotten, but that he had been treating her for her reflux for years.

I went to my attending and told him that I didn't think she really had anything wrong with her. He asked what I wanted to do. I told him, that I really didn't want to do anything, but that we probably should just get a chest X-ray, EKG, and give her something for her reflux. It was an easy morning so far, so he said, "OK."

The EKG was not very exciting. I probably spent about another hour running around seeing other people before I had a chance to look at her chest X-ray. I took a look at it and quickly called my attending over. We both looked at it, and I went over to the computer to see if there was another X-ray to compare it to. Her last one had been in 2001, and there was nothing on the film viewer. All I had was the report. It was negative.

Her chest X-ray now showed a large mass in her lung. My attending and I shook our heads and both immediately agreed that she needed a CT scan of her chest. I told her we had seen a spot on her X-ray and just wanted to evaluate it better. She smiled and said, "OK." Very polite and pleasant.

The CT scan showed about 9 different nodules and some enlarged mediastinal (middle of her chest) lymph nodes. This wasn't infection, this is most likely metastatic cancer. I went back to her room after talking to the radiologist to confirm my suspicians. I asked if she had ever smoked or worked in a factory. By this time, her daughter had arrived, and they both said, "No." But, then they admitted that Thelma's late husband had smoked all his life, and that all of the kids and in-laws smoked.

I explained that there were masses in her lungs, and that the mediastinal nodes could have been pushing on her esophagus causing the reflux-like symptoms and chest pain. I said I couldn't call it "cancer" because that's a tissue diagnosis, but that the nodules were suspicious for cancer. I told them I would be calling her doctor and making a plan.

After talking to him, and he was majorly surprised, I went back into the room and had to explain everything all over again to the son-in-law. He and her daughter both looked somewhat guilty when we talked about the possibility of second-hand smoke having caused her nodules. We sent them off with a referral to Roswell Park Cancer Center. Unfortunately, they're not connected to our system, so I don't know how I will be able to follow up, but I am sure I should be able to find some info.

Again, something so simple... and, I ended up giving this family some of the worst news you can share with a family. I hope they do well. They seem close. I certainly hope they are.


erarein63 said...

I hate those! We had a 17yr old come in c/o sudden onset of severe crushing cp while playing basketball. The kid was very obese so we just blew it off to being out of shape but because he was soooo symptomatic upon arrival we did a complete workup. The kid was sob and diaphoretic and clutching his chest. Would you believe he had a huuuuuge mass in his left kidney and had a PE? Good golly! We transferred him over to children's but didn't think he was going to make it because the PE was enormous as well. Would you believe I just triaged him about a month ago for some minor fast track complaint? I was like .... "I know you!" And he was like "yeah, you were my nurse". Miracles everyday. Just goes to show you those wolves in sheep clothing do exist huh? De ;)

Julie said...

My infarct patient today was a rude little lady with no pain and I was sure she would be neg. Very fussy. Last set of amies bumped and her EKG showed a MI. Never would have guessed.

Claudia's thoughts said...

I guess the patient and their MO's are the same all over the country. What is interesting is you got somewhat of a response to the second hand smoke. I think most people are in denial that their smoking caused a problem. I have seen people who smoked 2ppd and then they are really so surprised that they have lung cancer. "I never thought it would happen to me...." That is denial and perhaps fantasy thinking at its best.