There is something unique about being an emergency physician. There are a few other specialties who also see large breadths of pathology and some undifferentiated patients, but probably no other specialty has quite the same patient relationships we have. The quick two- to five-minute interactions we have are sometimes incredibly gratifying, and at other times, unbearably painful. Sometimes we love these relationships, but others, well… they’re more love-hate. Either way, these day-to-day interactions are what define our specialty and form the basis for our fondness for emergency medicine. Every shift is a reminder.
“Doctor, I have abdominal pain. I took a pregnancy test earlier today and it said I was pregnant,” says a young lady as she holds her abdomen and grimaces in pain. “You are pregnant,” I confirm. “However, your pregnancy is not in the uterus. You have a pregnancy growing in your fallopian tube, which has ruptured, and blood is now pooling in your abdomen.” “Oh,” she replies, looking unsure of how to react. I continue, “Your blood count is low, and your heart rate is high. You are showing early signs of shock and you need to have an emergency operation.” “Wow,” she replies, only able to speak in single syllables. “Good luck. I hope I never see you in the emergency department again,” I say, and we both chuckle.
“I went to my primary care doctor today and they told me to come right in,” says the well-dressed, middle-aged woman sitting upright in bed. “What’s been going on?” I ask. “It says here you have been having diarrhea for three weeks.” She nods, “Yeah, about four times per day I’ve been having diarrhea. My daughter also had it for a week. We probably ate something strange.” She then pauses, reluctantly adding, “This damn diarrhea is also causing me to lose a lot of weight. I think it’s because I’m not hungry and everything is going right through me.” With the gravity of the situation weighing on me, I meet her eyes through a furrowed brow. “You were sent here by your primary care doctor because your liver enzymes were high….” “Well then what does my CT scan show?” she asks. “That’s what I came to talk to you about,” I respond. “You have cancer in your pancreas, which has spread to your liver and your lungs, and it is blocking your biliary system, causing bile to back up into your blood.” She looks at me and sardonically quips, “Well, thanks for that; I hope I never see you in the emergency department ever again,” and we both chuckle a little uneasily.
The next one looks like a dragon, huffing furiously, steam coming out of an oxygen mask turned up full blast, as she futilely struggles to get air into her lungs. I listen with my stethoscope, but despite her maximal effort there is no air movement. “What hurts?” I ask. “Nothing,” she says. “Are you feeling short of breath?” She rolls her eyes and cracks a wry smile at my questioning the obvious. She responds slowly, “I’ve been feeling… crummy all week… and nothing I do… seems to help. I was reading the… newspaper this morning… and started gasping… for air. I couldn’t eat… my breakfast. And I do… love my eggs.” It takes her nearly a minute to speak these few lines, a few haltering words at a time, punctuated by gasps for breath. These turned out to be the last sentences she would ever speak. Within minutes, she was intubated, loaded into a helicopter, and emergently flown for a higher level of care. I learned later that she was dead by that evening. I was the only witness to her last words, and I will never see her in the emergency department again.
“I hate you, you piece of shit!” — the first words to greet me as I enter the room of a not-so-pleasantly intoxicated young lady who had just face-planted onto the sidewalk. Ignoring her introductory epithet, I ask, “How are you feeling?” in my usual manner. She snarls in response, “I don’t know. Just get me out of here!” “Well, you are very intoxicated and you need to stay here so we can assess you,” is my metered response. “Fine,” she snorts in reply. She begins walking heel-to-toe across the room and moving her finger from her nose to random points in space, perhaps assessing her own coordination, but more likely showing me a defiant satire of her clinical sobriety. Following her lead, I proceed to perform the neurological exam, asking her to push against my hands. Instead, she shoves her hands into my chest, forcing me against the wall. This unexpected assault leaves me winded, the breath knocked out of lungs. She grits her teeth, and I wonder if I’m about to be bitten. “Not tonight,” I quickly resolve, and swiftly exit the room to find a more peaceful locale. This was not the first time I have been assaulted in the ED and it probably won’t be the last. After meeting her medical needs, I discharge her to the detox facility and say, “I hope I never see you in the emergency department again.” This time I really mean it.
“Doctor, I am pretty nauseated. I have been feeling this way for quite some time,” states a young woman resting comfortably, but looking somewhat anxious. “Well,” I respond, “you are pregnant.” “Oh my God! We have been trying for so long. This is the best day of my life! Thank you, thank you, thank you!” she states, unable to conceal her joy. “Congratulations,” I say with a weary smile. This interaction I needed; it’s been one of those days…. As she leaves the department, I think, “It would be nice to see her again, just not in the emergency department.”
This is the blessing, the curse, the fascination, and the frustration of life working in the ED. Whether it’s a broken arm, an ingrown toenail, or a traumatic spinal cord injury, the experience of each patient is but a part of a kaleidoscope of images, sounds, and experiences for me as an emergency physician. From the vigorous first cry of a newborn baby, to the whispered last words of a dying patient, the ED is an emotional roller coaster. Walking under the EMERGENCY sign on my way to a shift, I never know what kind of ride I am in for. However, I am sure I will make a difference for my patients, and that they will make one for me.
We all have different interests within emergency medicine, but these shifts are common to us all, and in a way bind us together as a unified body unlike any other in medicine. EM Resident encourages you to write in and tell us about your shifts and your patient interactions, both difficult and sublime. We are made stronger by sharing our stories — NM.