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True Detectives: The ED Files

2023; Lippincott Williams & Wilkins; Volume: 45; Issue: 10 Linguagem: Inglês

10.1097/01.eem.0000990144.88729.3f

1552-3624

Robert Brandt,

Data-Driven Disease Surveillance

Figure: EPs, detectives, mysteries, DKA, Scooby-Doo, Sherlock Holmes, emergency department, clues, physicians, diabetic ketoacidosis, decubitus ulcer, dementia, heart rate, UTIFigureWe often find ourselves assuming the role of detectives in the chaotic world of the emergency department, piecing together clues and unraveling the mysteries presented by our patients. We wish for the insight of Sherlock Holmes or the cunning insight of Batman and his gadgetry, but the reality sometimes more resembles an episode of Scooby-Doo. The answers in the ED may only come after all the tests return. Then, like the end of a Scooby-Doo episode, we can exclaim, “OK, gang, let's see who the villain really is. Why, it's old man sepsis from the abandoned sawmill!” The DKA Dilemma My first patient one day came in priority one with diabetic ketoacidosis. I checked some labs and then started aggressively treating him, and he began improving. I thought my detective work was complete, and the patient was all set. Sometimes, however, as any investigator knows, there is more to the story. A thorough examination revealed an infected decubitus ulcer hiding behind the mask of DKA, and I had almost missed it. That could have been devastating to the patient. It reminded me of a Confucius quote that nowadays is attributed to Batman: Our greatest glory is not in never falling but in rising every time we fall. The Box of Birds A patient with dementia arrived complaining of lightheadedness. He was charming and seemed spry, energetic, and humorous, though possibly the world's worst historian. He informed me that he “felt like a box of birds” when I inquired about his health. My detective skills clicked into action. I initially thought this was the dementia speaking, but I later learned this was a local colloquialism for “feeling fantastic.” Then I looked at the monitor and saw the patient's heart rate read 232. I could feel my inner Watson springing into action as I looked at that number. “Confound it, Holmes. This number is utterly preposterous! Surely that must be the cause of his ailment!” Something seemed off, mainly the fact that I have never seen an elderly patient with a heart rate that fast. Completely cocooned inside his blankets, the patient vehemently resisted our evaluations. Every time we tried to examine him, he tightened his grip on the layers of blankets. “I'm cold! No! I'm cold!” he repeatedly informed us. For new residents reading this, have caution treating older people with dementia; they often have the power of a sledgehammer. I evaluated him as best as I could. His heart rate did not sound that fast when I listened to his chest. I then peeked at his hands and discovered the solution. “Elementary, my dear Watson. He has Parkinson's, and his hand is tremoring at 232 oscillations per minute.” He also had a UTI. The Embarrassed Patient A 72-year-old woman with a sharp wit refused to tell anyone what happened. She said she had fallen and wanted to be checked out, though she refused to give more information. I evaluated her, did a thorough physical exam, and ordered some tests. I also chatted with her a bit more, and she felt comfortable enough to give me the rest of her story. She actually started laughing before she could even get it out. She explained she was supposed to use a cane to walk. She had been told always to use her cane or she might fall. But she never used it. She had always felt fine without it. Today, she explained, just to mix things up, she decided to use her cane, and she fell trying to get it. Zoinks! We embody the spirit of true detectives in the ED. We may resemble Batman, Sherlock Holmes, or sometimes Shaggy, but our ability to embrace the uncertainty and unravel the unknown sets us apart. There will always be more mysteries awaiting us in the ED, so stay committed and vigilant. DR. BRANDT is an emergency physician currently working in New Zealand (after 12 years in Michigan). Read his blog and other articles at http://brandtwriting.com, follow him on Twitter @brandtwriting, and listen to his humorous ED podcast, EpineFriends, which can be found at http://apple.co/3d9Nco2. Read his past EMN columns at http://bit.ly/EMN-BrandtsRants. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].