Last night around 6:00, I picked up my last patient of the night. I wasn’t supposed to pick up any patients, but I had about an hour before the end of my shift and not much to do. I told the PA working another “team” (there are several colors, and you only pick up your team’s patients) that I would start the workup on one of his.
The patient was an older gentleman, here with complaints of “dizziness” for the last few days. Now, many of us in emergency medicine hate the chief complaint of dizziness. It can mean so many different things. Think of all the ways you (likely a young, healthy person) have been “dizzy” - there’s the room spinning, there’s that feeling like you are about to pass out, and then there’s that feeling like you can’t quite walk upright (like when you’ve had a few drinks). Each one has its own meaning and workup. However, this gentleman was not a native English speaker and had trouble conveying what he meant. I was trying to get a translator on the phone, but hadn’t had any luck. As such, we communicated through his wife and hand signals. I came out of the room after a careful history and physical feeling incredibly unsatisfied with my work and a nagging concern that I couldn’t pinpoint.
I sat down to write it up and discuss with the supervising physician. Knowing that there’s value in keeping your workup to a minimum (when possible) and keeping patient flow through the Emergency Department (henceforth ED) I was tempted to suggest some basic labs, IV fluids and a reevaluation. In speaking with Dr. M, though, I suggested all that and said, “I think I want to bite the bullet and get a head CT and a neurology consult.” He agreed - whether out of agreement with my plan or willingness to go along with my plan to further my education I’ll never know. I finished up my shift and passed the information back to the PA. I called neurology to see the patient and was put through the wringer by the neurology resident who answered. I didn’t know how to explain that this guy’s story just didn’t fit, and I felt he should be seen by an expert in the field. I hung up the phone at the end, realizing that frustration was palpable on both ends of the phone call - on his there was resentment at even more work to do, on mine there was frustration that he didn’t want to do work.
When my classmates arrived to relieve me, I joked with them for a few minutes and then got ready to go home. Although it’s ideal for me, as an emergency medicine intern, to look at my own films I will openly admit that I rarely do secondary to time constraints. Something inside me made me want to look at his film, though. I pulled it up and scrolled through the images. I’m not sure WHAT I expected to see, as the only thing I can REALLY identify on one of those is blood where it shouldn’t be. These films, however, were grossly ABnormal. I grabbed my supervising physician and we went over to the radiology reading room and asked the supervising radiologist there to pull up the film. He did, and a few frames into the series was alread on the phone to neuroradiology (the specialists) asking for their opinion.
I’m not sure what the final results were (the thought was some sort of cancer vs. some sort of chronic infection) and we may never know as the couple was from out of town, but what struck me was how close I could have come to blowing this off. I had no concrete evidence that made me think he needed the CT scan. I could have easily been talked out of it, as I couldn’t verbalize WHY I thought he needed it. I’m not even sure that deep down I thought he needed it, I might have been feeling a little overly cautious. However, it was one of the first times in the last 26 days that I felt like I was able to make a potentially critical difference in someone’s life. I didn’t just relieve pain (which is wonderful, but often temporary) or send someone who was a painfully obvious admission where they were going to go anyways (to be admitted). I caught something before a patient was really handicapped by it, and depending on what it is I may have made a big difference. It’s for patients like these that I became a doctor.