My Worst Case as an Emergency Physician.

One night in the ER…

A 42 year old lady came in with severe abdominal pain and nausea. She wasn’t vomiting. No other symptoms or problems, except for multiple prior visits to the ER with the same problem.

Many doctors had tried and failed to diagnose and treat her. She had been to all the specialists at all the regional Universities. The famed Cleveland Clinic even took a crack at her.

All the tests were negative including blood work, poop samples, X-rays, scopes in both ends, the camera pill (a camera that the patient swallows, it takes pictures as it traverses the gut), and various scans.

She had CT scans, MRIs and various nuclear scans. There were scans with and without IV contrast and oral contrast. There were scans of her arteries, and scans of her gallbladder.

Her gallbladder was a little weak, so a weak surgeon jerked it out without any benefit.

She had every blood test for cancer known to man. Multiple biopsies were always negative. I thank God that no tired pathologist ever imagined any cancer cells under the microscope. This lady already suffered so much at the hands of her healers.

X-rays were done many times with and without Barium. Some of the X-rays were done as videos. She might have had enough radiation to kill any tumor!

And the scopes! Multiple scopes down the throat and into the stomach and duodenum. Another scope down the throat through which a catheter is passed into the bile duct and pancreas to inject contrast that highlights the ducts for more X-rays. A urologist even scoped her bladder!

She saw stomach specialists, liver specialists, gastrointestinal surgeons, kidney specialists, urologists, neurologists, etc..

There’s an old saying in Medicine, if the only tool you have is a hammer, then everything looks like a nail. This poor lady had been beaten with every specialist’s hammer in 3 states!

When they couldn’t diagnose her, they just skipped straight to the cure. She failed multiple curative procedures and dozens of medications.

There were medications to neutralize acid, coat the stomach, decrease acid production, anti-spasmodics, anxiolytics, antidepressants, antibiotics, anti seizure, antifunguals, and plain old pain medications.

She learned to refuse the pain medications, because she was smart enough to realize that she would be written off as an addict, that doctors stop trying if they think you just want opioids.

She has been put on every dietary restriction, and treated with every fiber supplement. She knew it all because she had tried it all!

The first night I saw her, I just told her that she had already seen many doctors much smarter than myself, working in a low level ER. But I did what I always do in these difficult cases.

I sit down and shut up and listen. I talk about weather, sports, hobbies and family; anything but medicine. But mostly I listen and observe. I try to get the patient talking more than myself. It’s an attempt to make a brain-to-brain connection for a two-way flow of truth. It is engaging the patient’s mind as the powerful problem-solving machine that it is.

Two minds together are more than 1+1=2. It’s more like 1+1=4. And it doesn’t really matter much that the other mind has limited medical knowledge. In fact, this process can sometimes work better if at least one of the minds is unspoiled by medical dogma.

So there we were, in the middle of a hectic ER night with several people trying to die. I talked with her for a few minutes until a nurse convinced me that another patient was closer to the next world than this one.

I grabbed the patient’s hand and begged her to be patient. I promised her that if she would wait for me, that I would give her my best shot. She was obviously in pain, but she attempted a smile and closed her eyes as I left to find something easier to do, like make a room look like an axe murderer walked in on a meeting of hemophiliacs anonymous, by saving a trauma victim.

That night was one of those nights that leaves me feeling a bit PTSD. I just wanted to crawl into my hut for a couple days. Yes, I have an actual stick-and-grass hut in the woods for this purpose.

But I have a soft spot for kids. The nurses all say that kids like me, and I am a pediatrician. I hate to leave a kid at the end of my shift, knowing that the next doctor may not feel as comfortable with kids.

I picked up the last chart in the rack (this was years ago), and saw that it was a 3 year old girl with abdominal pain. She was on the other side of the curtain from my 42 year old patient whom I had completely forgotten, or I would have spent the end of my shift with her as promised.

I took a deep breath and switched my brain from high pressure ER doc mode to easy and relaxed pediatrician mode. I walked into the room and quickly recognized a familiar problem.

I explained to the worried mother that it was a simple stomach virus, that young children can’t tell the difference between pain and nausea.

I explained that I was going to treat her pain with a tablet for nausea that dissolves in the mouth called “zofran.” I told her that I would be back in a few minutes and I left to give my order to a nurse.

By this time it was well after the end of my shift. The nurse I found said, “There you are! We thought you left! Did you forget about the 42 year old woman with abdominal pain? She’s been laying in there for hours!”

Of course I had totally forgotten her, but I remembered fast and said, “No! Of course not! I promised to spend some time with her if she would wait until the end of my shift!”

At that the nurse winked and nodded her head knowingly. I said, “No! Not like that! Look, can you give this little girl 2 mg of Zofran?” And I turned back to see my forgotten patient.

She was still in obvious discomfort but was waiting patiently. I walked over and placed my hand on her shoulder. Before I could say a word, she said, “That was great!” I didn’t know what she meant until she said, “You’re so good with kids, you should have been a pediatrician.”

She did not seem surprised when I said, “Well, as a matter of fact, I am!”

She joked, “No wonder I’m no better, my doctor is a pediatrician!”

I laughed. She tried to laugh. I poked my head around the curtain and asked the mother if it was okay to open the curtain? This violates protocols and is probably illegal, but I was too tired to care. I was simply trying to create an atmosphere to promote dialogue. A pleasant mother-baby dyad seemed the perfect antidote to the chaotic night this lady witnessed.

So now we had 3 minds working together. We talked to the little girl. She was smiling and feeling better already and asking for food. We talked about little girl things like toys, birthdays and sisters.

The mother thanked me. The zofran trick worked wonderfully, despite her doubts. Then she looked at my patient and said, “He’s a wonderful doctor, listen to whatever he says.”

I asked her for permission to share her case and then I explained to the mother with a smile how that she had no idea, that this poor lady has some incurable ailment that has stumped all the specialists at all the Universities.

And then my patient and the mother began to talk about her case. As soon as the mother realized that it was a case of chronic abdominal pain and nausea, she drew an analogy to her daughter’s simple acute stomach virus.

I shook my head at the absurdity of it and was about to interrupt this conversation that was quickly getting off track. And then I remembered my rule for difficult cases (shut up and listen!).

My patient said, “Believe me, I have tried every stomach medication and even some herbs. Zofran does nothing for me.”

But my mind was zipping through all my experiences with chronic pediatric abdominal pain. I thought of the episodic nature of my patient’s condition. I asked her weird questions l usually reserve for pediatric cases like, “What part of the world did your ancestors come from? Any children in your family with health problems? How old is your house? Do either of your parents get migraines?”

She said, “Nobody has ever asked that question. My mother and father have both had migraine headaches their whole life. My brother gets them, too!”

And then I knew the diagnosis, even though I had assumed it was impossible and had never heard of an adult case. There is a condition called “abdominal migraine” that affects young children. There is usually at least one parent with migraine headaches, but most of these kids will get better by age 12. Their abdominal pain just stops. A certain portion will develop migraine headaches about the same time their abdominal pain goes away.

But I had my doubts. Pediatric abdominal migraine is easy to treat with simple medications that had failed to help this lady. But what if I gave her a common adult migraine treatment such as a vasoconstrictor?

The pain of migraine is caused by too much blood flow to the head. Medicines that constrict blood vessels can be curative.

These medications work best if given very early in an episode. My patient was hours into this episode. As expected, the first dose in the ER that night did not relieve her pain, but it did do something much better, it gave her hope.

I gave her a prescription and sent her home, still in pain. But she was so grateful and she thanked me profusely. I felt a little anxious that maybe I was giving her false hope, for surely it could not be this simple? Surely the specialists thought of this?

Several months later she was in the ER with a sick family member. She was beaming and radiant. When she saw me she said, “That’s him! He’s the one who cured me!”

Tears were rolling down both our faces that night.

Source: Quora Writer and Contributor

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