Portal de Periódicos da CAPES

The Odd, the Mysterious, the Inexplicable

2002; Lippincott Williams & Wilkins; Volume: 24; Issue: 6 Linguagem: Inglês

10.1097/01.eem.0000334136.02689.a4

1552-3624

Edwin Leap,

I was all poised to write something elevating this month. Something personal and touching that would help my brothers and sisters practice with more compassion and care. I spent a few nights pounding the keys trying to divine meaning from a family experience involving health care. But then a strange thing happened. I worked a run of weekend nights, and I decided it would make more sense to poke a little good-natured fun of patients. So compassion, care, hope, and meaning will have to wait. Besides, that other article needs to ferment a bit. Sarcasm, irony, and venom I have in excess. The thing is, nights in general are a time of weirdness. They can be times of wonder and fascination. They can be times when we save lives and make obscure diagnoses. But mainly, in the emergency department, nights are times of the bizarre and the inexplicable. I realize that some patients who use the ED at night are actually quite ill or they wouldn't be there. For some, however, it's just the opposite. They wouldn't come out in the day if you offered them free lottery tickets and a carton of Marlboros. As a physician who works a lot of nights, I have remarked before that these people who populate my workplace from 2300 to 0700 are “my people.” And it's true. I have developed an ability to work with them and understand them. I expect to smell alcohol, to be asked if it's OK to go smoke before admission to the ICU, and to sew up lacerations induced by various blunt and sharp objects. I'm OK with that. In fact, when I work days or evenings and everyone is sober, I feel out of my element. Because of this, I feel my people owe me a little something. And because money doesn't seem to be one of those things, they owe me material for writing. They owe me their stories, happy or tragic. And they owe me their humor, or whatever humor I can develop from the events and complaints that bring them to see me when I would much rather be lounging in my recliner watching “The O'Reilly Factor.” So, this month I have compiled a short list of night-shift mysteries. I've always loved the odd, the paranormal, the sort of thing I used to watch Leonard Nimoy talk about on the show “In Search Of.” Today, I am in search of “mysteries of the emergency department.” And there are a bunch. These can be divided into three general subcategories: medical, social and reality disorders. Beginning in the medical category, ask any patient at night what they were doing when their symptoms began. You ask this for any symptom, mind you, from chest pain to vaginal discharge. The answer? Watching TV. I used to puzzle over this. But it makes perfect sense. Either TV is profoundly unhealthy, which I suspect is true having watched the networks recently, or people watch so much of it that whatever happens is statistically most likely to occur while the tube is glowing in their pale faces. Next, why does everyone have a relative who had a similar illness or complaint and who died a death so horrible and bizarre the story should have appeared on 60 Minutes? “Well, sure, you say it ain't my appendix, but my cousin Jimbo, his appendix up and exploded — his wife heard it — and he died like a dog. Only thing he had was a runny nose.” Or this perennial favorite: “I know little Bobby is only six years old, but when he said his chest was hurting, I realized that his great-grandfather died of a heart attack. I thought it was better safe than sorry, and brought him down to get him checked out.” Family history, it appears, is much more critical than we ever realized. This weekend I had a run of abdominal pain patients. The mystery was this: How can so many people suddenly have abdominal pain at exactly the same time, and with symptoms so similar that I can't tell any of the 10 of them apart? Did the Abdominal Pain Angel pass over? Fortunately, after finding virtually nothing objective on any of them, I settled back into the reality of ambiguity. This is a skill learned after many years, critical for working nights, that enables me to say with perfect comfort, “I have absolutely no idea what's wrong with you, sir. But I feel quite certain you won't die from it. At least not tonight.” Now, what marketing genius decided that every octogenarian needed to have a blood pressure cuff at home? There's a mystery worth solving. “Doc, I was watching TV (see?), and felt kind of funny. My blood pressure was 130/80. But I took it again and it was 150/90. And I got worried and took it again and it was 180/100, so I just called 9-1-1!” I should be able to call a representative of the company that manufactured the home cuff and congratulate him each time on the flawless operation of the device. Medical mysteries are obviously difficult. But in the emergency department, we face hopeless mazes of social problems. In fact, much that is medical begins as social. Social mysteries abound. Like this one: Why are people who live their lives jobless on Medicaid and welfare so frequently and frighteningly obese? More simply, where else in the world are poor people consuming dangerous amounts of food? Images of famine and poverty in remote Africa seldom feature entire villages waddling about in search of “all-you-can-eat” restaurants and oversized spandex pants. Maybe lions eat them because they're slow. Lions. There's an idea for the obesity epidemic. Of course, some social mysteries are not so mysterious. They're simply deception. For example, why does the chronic back pain patient on disability and hourly narcotics need a work excuse for the next day when his chart says “unemployed?” I have a friend who investigates disability fraud. I think he's a patriot. Back to the young patient population. Why is it that every drunk female college student with vomit for hair gel has a mouthy friend who says, “I think someone slipped her a pill. She drinks all the time, and she's never like this! Are you going to check her for drugs? My dad is a doctor, and he said you should check her!” Stunned, I stare at her, and say, “Let's wait till we see what her blood alcohol is.” I love going back to tell them that little Cassie has an alcohol level of 250 being processed through her 105-pound body. Drugs? Not so much. Of course, this type of encounter crosses the boundary into the next category, the disorder of reality perception. This occurs when patients and other health care workers can't grasp reality. I love this exchange: “So, Miss Hall, could you be pregnant?” “Absolutely not.” “Are you sexually active?” “Yes.” “With a man?” “Yes.” “Do you use birth control of any sort?” “No.” “So you could be pregnant.” “No, I couldn't.” “Do you have ovaries, a uterus, and monthly cycles?” “Of course.” “Has your sexual partner had a vasectomy or tragic accident?” “No.” “Then, miss, you could be pregnant.” “No, I couldn't”. Be careful. This sort of exchange could cause you to be sucked into the black hole of ignorance forever. Another conundrum I experienced this weekend is this: “I woke up at 2 a.m. all weak and tired.” And? Whenever I wake up in the middle of the night, I feel week and tired. I feel weak and tired when people tell me they're weak and tired. That's called fatigue. It is most properly treated with an experimental drug called sleep. A similar mystery. Why is it that nursing home staff members feel compelled to send 95-year-old men and women to the emergency department by ambulance for weakness. These are people whose aerobic workout consists of watching someone else work a puzzle. They have Alzheimer's. They have no more muscle mass than a KFC drumstick. Of course, they're weak. If I live to be old and infirm, I'll probably be weak, too. Heck, I feel weak right now. And what list of mysteries, especially those of reality perception, would be complete without the “no one was driving the car” story. Six people, all ejected, all intoxicated, but apparently being driven down the road by the ghost of Elvis Presley. More macabre than mysterious, really. I realize that my patients are more complex than I can ever imagine. I also realize that some of the things I think are crazy are probably real problems that come in under my radar. But most of them aren't. They're just a function of the weirdness that is third shift in the emergency department. I know that this is a partial list. It's so partial, in fact, that I plan to continue compiling these oddities and write periodic updates. It should be easy unless I mysteriously hit the lottery and stop seeing mysterious patients altogether.