Night Shift: Sick or Not Sick

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“I just poked my head into Room 21 to see someone that I didn’t think was sick, but I think he has really questionable lesion.  So I set him up for CT.  And they have been really slow today.  I hate to ask you, but can you follow up on this?” my partner asked plaintively.

He was a great doc and a good friend, not the kind of guy who dumps bad cases on you at check out.  So I knew he had tried to do me a favor by clearing the board of the simple cases, but this one had backfired on him.  But the end result was that after the CT came back I was going to get to be the guy who says, “Hi, I’m Doctor Plaster.  You have cancer.”

“It turns out, he’s been losing weight…”

“It’s OK,” I interrupted.  “Get out of here.  It’s late.  I’ve got this.”  I didn’t relish the conversation.  But it wasn’t the first time I had had to break that kind of news to someone who came in with what they thought was a simple complaint.

But the next morning as I related this story to my wife over our own morning check out, she reacted with her usual compassion.  “That’s terrible.  I’m so sorry for him…and you.  I’m sorry that you have to deliver that kind of news to people.”

“Well, the crazy thing is that,” I broke back in, “the radiologist read the CT as negative.”

“That’s great,” she said with relief breaking up the clouds that had come over her face.

“You would think,” I went on.  “I walked into the room, introduced myself and explained that I was following up for the doctor from evening shift and said that I had good news.  I explained that the radiologist had read the scan as being consistent with a benign process.  I expected everyone in the room to be either relieved or wondering what the big fuss was about.”

“They weren’t?” she said, confused.

“No.  The wife said, ‘Is that what you think too?  Have you looked at it?’”  I didn’t tell my wife this, but she really had me on my heels with her question.  I had seen the reading and I thought I would be delivering the good news, discharging the patient and quickly moving on to the long list on the board of truly sick patients.  I had not taken the time to examine the patient for myself.  So I really didn’t have an opinion.

“Well, I told the wife that I have to defer to the experts on reading the CT scans, but she wasn’t buying it.”

“What did you think of the man’s lesion?” my wife said.  I love my wife.  She thinks I’m the smartest guy in the world, even when she has to tell me how to drive to places I’ve been a zillion times.

“That’s the crazy part. When I looked at the lesion myself, it looked for all the world like a cancer,” I said.

“So?”

“It was really awkward.  I told her I understood why she was worried.  But that we weren’t going to get to the bottom of this at midnight on a weekend.  I told her to follow up with the specialist on the home going instructions to get a third opinion and possibly a biopsy.  But I tried to reassure them that the radiologist thought it was benign.”

“That’s weird,” she said.  “You come home with some of the craziest stories.”

“I know,” I said, shaking my head in disbelief.  “Everyone thinks that ER docs run from fixing one crisis to the next all night long.  But many times the biggest job I have is to answer the question whether the patient is sick or not sick.  And sometimes I can’t even do that.”

“It’s not that they’re not sick,” she said.

“You know what I mean,” I said while crunching on my cereal.

“Don’t talk with your mouth full.  You’ll choke,” she said as if talking to one of our five- year-old grandchildren.

“Well, OK.  But I mean sick like there is anything I can do about it.  Or should do about it.  Do you know how many mom’s bring their kids into the ER when all they have is a fever?”

“A baby with a fever is sick,” she scolded.

“I know. A baby with a fever is sick.  But I’m talking about toddlers and older kids.  They get fevers all the time.  And they don’t even look sick.  I come in and they are sitting there munching on chips watching the TV.  Hey, I’m happy that they bring them in.  That’s job security.  But many times there is nothing I can or should do other than give them my fever lecture.”

“That’s something,” she responded with a shrug.

“You know how many middle aged executives I see who come in with a cough and want a chest X-ray and an antibiotic.  These are guys who are supposed to be smart.  Smart enough to run big companies.  And they can’t figure out that they are going to get better no matter what I do.  I could wave my hands over them and do a dance and they would have the same results as the $1,500 workup.  Maybe I’ll try that some time,” I said returning to my cereal.

“Talk about smart not smart,” she said with an eye roll.  “Do not try that.  We still have a mortgage to pay.”  She just sat there staring at me for a minute with her funny little ‘what am I going to do with you?’ grin.  “I know you.  You always listen to everyone.  Answer their questions.  And even if they don’t have anything serious, they go home feeling better because you took their problem seriously.”

Like I said, I love my wife.  But she’s a real buzz kill when I’m in full rant mode.  It’s like I’m standing on the ledge shouting to the world how bad my life is and she hands me a cloth and tells me to clean the windows while I’m out there.

“Hey, Juliet is complaining about her ear hurting,” she said returning to the present.

“She’s in the pool all day every day.  What do you expect?” I said reflexively.  “Does she have any cold symptoms, running nose, cough?  Has she been trying to get the water out of her ears using a Q-tip?  Does it hurt when you pull on her ear lobe or is the pain coming from inside the ear?”  Has she used any ear drops on taken anything for pain?”  It was as if someone had turned on a recording inside my head.

“The patient is a four-year-old white female weighing 22 kilos with the complaint of right ear pain.  She takes swim lessons and is just learning to dunk her head.  The vital signs are normal with no fever.  The past medical history is unremarkable as is the family history except for raging ADD and mild mental retardation in the paternal grandfather.  She’ll be napping in bedroom 1 when you wake up from sleeping…Doctor.”

“You missed one part of the history,” I said with my best arrogant smirk.  “Her paternal grandmother suffers from angina gluteus maximus.”

“And what is that?” my wife asked with a challenging squint.

“Go Google it.  I’m going to bed.”  Hopefully she’ll have cooled off by the time I wake up.

 

ABOUT THE AUTHOR

FOUNDER / EXECUTIVE EDITOR Dr. Plaster has been an emergency physician for more than thirty years, working exclusively night shifts for the past twenty years in emergency departments across the country. During that period he joined the U.S. Navy and served two tours in Iraq. Dr. Plaster is the founder and executive editor of Emergency Physicians Monthly and the founder of Plaster Publishing.

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