Authors: Jerome Groopman
Perhaps you breathe a sigh of relief when the triage nurse sends you a patient you have seen before. People who repeatedly visit the emergency department are called "frequent flyers." Instead of a single page of a new patient sheet, the frequent flyer has a hefty chart with ample past history and testing that would seem to simplify things. Except, of course, when it complicates them.
Maxine Carlson was a single woman in her early thirties working as an office secretary in Halifax. Two years earlier, she had developed sharp pains in her right lower abdomen. She told her primary care physician that it was different from the pain she had as a child with appendicitis or the postoperative pain of the appendectomy. The doctor examined her but found nothing of concern. Over the next few months, on some days Maxine Carlson was constipated and on other days her bowel movements came with great urgency. Her doctor suggested she eat a more balanced diet, including fiber every day, but this had little effect on the pains. Maxine finally was referred to a gastroenterologist. At first the specialist wondered whether she might have an inflammatory bowel disease, like ulcerative colitis or Crohn's. But the doctor didn't find anything abnormal after an extensive evaluation that included numerous blood tests, x-rays, and both upper and lower endoscopy, which visualized her esophagus, stomach, duodenum, and colon. The gastroenterologist confirmed that she had irritable bowel syndrome and emphasized the importance of a high-fiber diet. A psychiatrist also evaluated her and prescribed antianxiety medications to relieve the stress that can exacerbate irritable bowel syndrome.
A year after the onset of the sharp pains in her right abdomen, Maxine Carlson felt discomfort in her pelvis. At first her primary care physician said it was just her irritable bowel disease, but Maxine insisted it was different, a squeezing, persistent ache rather than the familiar sharp, fleeting pains. She was referred to a gynecologist, who performed an internal examination and then ordered an ultrasound of her uterus and ovaries. He, too, found nothing abnormal.
Maxine's pelvic aches waxed and waned and then eventually disappeared. Then, two weeks before she came to the emergency department, the regular pains in her right abdomen became more intense. It was August and her primary care physician was away, so Maxine went to the hospital. The doctors in the emergency department had the two volumes of her medical records. They examined her, obtained blood tests, and told her that nothing was wrong. It was just a flare-up of her irritable bowel disorder.
Dr. Pat Croskerry was working in the emergency department when Maxine Carlson returned for the third time in seven days. "The triage nurse was rolling her eyes when she told me about the case," Croskerry recalled. "That this was a young woman with no tangible problem, that she had been worked up extensively by her primary care physician, her gastroenterologist, and her gynecologist, and she carried a functional diagnosis." The euphemism "functional" means psychosomatic in clinical medicine. "She is really woolly," the nurse told Croskerry. "And she won't stop coming in."
It was very busy in the emergency department, and Croskerry was caring for several patients with urgent problems. When he finally entered Maxine's room, he saw how agitated and distraught she was. She bitterly complained that the pains just wouldn't go away. He found no new symptoms when he asked Maxine Carl son what prompted her visit that evening. As he examined her, he later told me, he felt "consoled" upon seeing the appendectomy scar, since Maxine's pain was in her right lower abdomen.
"I'm coming up with nothing," Croskerry told the triage nurse. Nonetheless, he said he was sending off blood and urine tests. This was met by considerable resistance. "Why are you doing this?" the nurse asked. "She's already been worked up." Croskerry told me he felt "palpable" pressure because it was hectic in the emergency department and the nurse needed Maxine's bed for another patient. But he insisted. About an hour later, her test results were in hand, all normal. "I reassured her that this seemed to be her irritable bowel acting up," Croskerry said. "I went over again issues about proper diet and stress management. I also emphasized to her not to be reluctant to come back." Croskerry has learned from experience never to discourage patients from seeking follow-up care.
"She broke into tears, crying that no one believed her, that no one was able to come to a diagnosis," he recalled. "She kept saying that the pain was getting worse, that it was much worse than it had been even a week before.
"How can you not be moved by a patient's tears?" Croskerry asked me rhetorically. Still, he sent Maxine home. A short time later, she was rushed by ambulance back to the ER. "She collapsed while walking home," Croskerry said. She was bleeding internally and on the verge of shock. She was rushed to the OR, where a surgeon found that Maxine had a ruptured ectopic pregnancy. "It had been missed three times. I was the third miss," Croskerry told me.
Yes, Maxine Carlson did suffer from irritable bowel syndrome. She had been extensively evaluated by her many doctors. That evaluation had ultimately exhausted the options of her physicians, even the most astute, like Pat Croskerry. During my training, we used a euphemism, "worked up the gazoo," to refer to a patient who had been examined by every conceivable specialist, had had every imaginable blood test, x-ray, and procedure, and there seemed to be nothing left to do for them. In Halifax ER parlance, Maxine Carlson had been worked up the "yin-yang" and then was "out." "The physician tells himself that he can't throw any light on the dark place where a diagnosis might be hiding," Croskerry said. "You go through a checklist of all the avenues that have been explored, and it seems that each was a dead end, and you have no new direction to go in." Croskerry refers to the failure to think of a new direction, because you assume all have been explored, as the "yin-yang out" mistake.
The ec ology of an emergency department includes not only patients, their families, and, of course, nurses, but also other doctors. At Highland Hospital not long ago, Alter was the attending physician when a resident in training evaluated a man in his thirties complaining of a sore throat. "It's an open-and-shut case of strep," the resident told Alter—an "uncomplicated" patient. Alter had the sense that the resident wanted to move quickly to his next patient. Alter asked for details. "He has an exudative pharyngitis, pus near the tonsils, and painful lymph nodes," the resident said. Alter insisted that he wanted to meet the man himself. The resident sighed in frustration.
Alter peered into the patient's throat and saw no signs of pus. He ran his fingers along the sides of the man's neck and felt small, soft lymph nodes that were not tender. Alter pressed more firmly on them. Still no reaction from the patient. The resident had already given him a large dose of an antibiotic and a prescription for more.
Alter led the resident into the corridor and told him that it didn't at all look like strep, that it was most certainly a virus causing the sore throat, and that prescribing antibiotics unnecessarily could have serious consequences. "Our hospital is overrun with MRSA," Alter told the resident, using the acronym for methicillin resistant staphylococcus aureus. This type of staph infection has become the bane of modern medicine; it is the direct result of promiscuous prescribing of penicillin, and extremely difficult to eradicate. "I questioned the resident's automaticity," Alter said, "how he just wanted to dispose of the case, and the easiest way was to label it strep, give a slug of antibiotic, and be done with it."
A short time later, another man came in with a sore throat. "Go to room 23 and start with the patient," Alter instructed the resident. After Alter had sutured the arm of a man with a knife wound, he made his way back to room 23. "He's fine," the resident said curtly. "Another one of your favorite viruses."
Alter didn't just sign off on the resident's assessment. As he interviewed the patient, he saw that he was restless, moving around on the examining table, unable to find a comfortable position to rest his head. When Alter peered into his mouth, he saw nothing abnormal. The man was breathing easily, and there was no stridor, no harsh sounds suggesting an obstruction in the upper airway. But Alter was concerned about the patient's restlessness and his fever of 101° F. He lingered awhile, thinking.
"Like I said, it's a viral pharyngitis, and at Highland Hospital we don't give these people antibiotics," the resident said with dripping sarcasm. Alter ignored the baiting tone. He again moved his fingers down the sides of the man's neck, marching meticulously, this time pressing inch by inch. When he was about halfway down, the man winced in pain.
"I want a CT scan of his neck," Alter told the resident. For a long moment the junior doctor said nothing, but then he left and ordered the scan. The call later from the radiologist did not surprise Alter: the man had an abscess in his neck. "This is the kind of infection that can kill you," Alter said. "If it's not treated quickly with intravenous antibiotics, it can block the upper airway and you'll suffocate."
There were sixteen attending physicians and forty residents working in the Highland Hospital emergency department at the time. Most of them were dedicated, serious, honest, and emotionally balanced. But not all. As Alter explained it to me, the resident's behavior was "payback" for the earlier criticism for prescribing antibiotics when they weren't appropriate. The resident wanted the second patient's diagnosis to be viral pharyngitis so he could needle Alter, and that desire led to an inadequate physical examination. That kind of incomplete care and immature acting out could have resulted in the man's death had Alter not been the kind of attending who double-checks everything the residents say and do. As in every place, ecology is determined in part by atmosphere. Here, the emotional temperature had risen dangerously high.
Most people believe that decisions in the ER must be made instantly, but Alter said that "is a misperception that we doctors in part foster." In order to think well, especially in hectic circumstances, you need to slow things down to avoid making cognitive errors. "We like the image that we can handle whatever comes our way without having to think too hard about it—it's kind of a cowboy thing." As if being swift and decisive saves lives. But as Alter put it, he works with "studied calm," consciously slowing his thinking and his actions with each patient in order not to be distracted or pressed by the hectic and sometimes chaotic atmosphere.
Alter also emphasized that laypeople should realize the limitations of emergency medicine and have realistic expectations. "We are diagnosticians, but not comprehensive diagnosticians. Often whatever is bothering a patient, it's flying below the level of our clinical radar. Like with Nathan, the last thing I want is a patient to leave the ER and say, 'The doctor said there is nothing wrong with me.' What we try to establish to our comfort, and the pa tient's comfort, is that what is bothering them is not going to kill them in the next three days."
An ER doctor's "studied calm" should be apparent to a patient or his family. If the physician is distracted, frequently interrupted by other doctors, nurses, social workers, or the administrative staff as he interviews or examines you, the steady flow of his thinking may be diverted in the wrong direction. There is similar cause for concern if the physician seems rushed or breaks in as you answer a question, so that you feel he is not letting you tell him everything about your symptoms. Being quick and shooting from the hip are indications of anchoring and availability. These are the two most frequent cognitive biases in the emergency department, and often they are all a doctor needs to hit the mark, to make a correct diagnosis and recommend an effective therapy. But they also can veer wide of the mark.
So a fair question to ask an ER physician is: What's the worst thing this can be? That question is not a sign of neurosis or hypochondria; in fact, residents are trained to keep it in mind with each patient they see. But it can easily slip from the forefront of thinking in the intense environment of emergency care. By asking that question, a patient, friend, or family member can slow down the doctor's pace and help him think more broadly. You can prompt him to consider lifting his anchor from the most available harbor. You might also cause the rare doctor who is acting out of pique, like the resident we just saw, to stop in his tracks and revert to a professional form of behavior.
Twice in Pat Croskerry's career he made a dazzling diagnosis in the emergency department. In each instance, a triage nurse had diagnosed a middle-aged man with a kidney stone. It was a fair first assessment. The usual hallmarks were present: the onset of acute pain in the flank, so severe that the patient vomited, followed by blood in the urine. Treatment with painkillers and intra venous fluids until the stone passes is almost always successful. But Croskerry recalled the importance of the worst-case scenario. "I found that it wasn't a kidney stone at all," he told me, "but a dissecting abdominal aortic aneurysm." The aorta, the large vessel that carries blood from the heart through the chest and into the abdomen, had a tear on one side, accounting for the acute pain. Blood was leaking through the vessel into the kidney and being passed in the urine. Croskerry told me he didn't think the diagnosis was brilliant at all, but I felt otherwise. I imagined myself not in relaxed conversation with him but in the midst of evaluating four or five sick people at once under all the stresses of the ER environment.
Another way that laypeople can focus a doctor's attention is to ask: What body parts are near where I am having my symptom? This sounds elementary, but this query can help avoid "yin-yang out" errors. "Yes, I know that I have irritable bowel syndrome," Maxine Carlson might have said, "and that I've been here many times and been told that it's my chronic condition. But if the pain is something new, on top of that long-standing problem, what body part might be causing the symptom?" Enumerating the tissues and organs in the lower abdomen could have steered the discussion to the reproductive tract, and then on to recent intercourse and missed periods.