Emergency Medicine Clerkship

The chief complaint box was filled with quick scribble that simply read "headache." The nurses had already warned me that my patient was "well known to the emergency staff," a statement with ominous implications. Entering the room, I found a dark room and a 50's-something woman who wore the hard years on her face. She was obviously in distress, physically and emotionally. After introducing myself I inquired as to her reason for reporting to the emergency department. "I have a headache," she said, her hand over her face shielding the light from her eyes.

I asked her to describe her symptoms to me, whether it hurt more on one side or another, to rate her pain on a scale of 1-10, if anything made it better or worse, if the pain radiated anywhere beside her head, if she had experienced any trouble speaking or walking, trouble with double or blurry vision. I quizzed her regarding her past history, family medical history, profession, allergies, current medications, and past surgeries. I discovered a woman who often visited the ER complaining of a headache. She rarely followed up with primary care physicians or specialists who might be better able to follow and monitor her progress at not just treating headaches, but preventing them. Still, something concerned me about her demeanor. She remained at the edge of tears throughout our interaction. Finally I asked, "Is there anything else going on?"Tears ran down her lined checks. "My daughter died a year ago, and I would do anything to trade spots with her." She told me about her two grandchildren, her son-in-law, and husband and how her daughter had succumbed to breast cancer just a year earlier. The headaches she had always suffered through somehow seemed worse, and she couldn't fathom that anyone including her family and own grandchildren could hurt as much as she did about her own daughter's death. She felt like everyone else could move on, but that she was just emotionally stuck. We talked for an hour, and I shared encouragement and Bible verses after she told me her faith was important to her.

The patient was taking antidepressant medications, but only worked with a psychologist once. Her habit of arriving in the emergency room had become a disturbing one. While reviewing her medical records I found that she had become increasingly demanding with her care, listing allergies to common non-narcotic medications used for pain relief. Our patient had even left several times against the medical advice of physicians who insisted on treating her pain with anything besides narcotics. She seemed to be treating her profound condition with prescription pain killers. Therein lies the quandary, the patient is in real pain both organic and psychiatric in nature. Inappropriate use of the emergency department and drug-seeking behavior has lead to distrust from many healthcare providers; yet this woman needs help. I did my best to listen and encourage. I insisted she find some counseling and a primary care physician for long-term follow-up. I explained that her loss was a terrible one, so bad that I could not understand. I urged her to embrace not only her daughter's death but also her daughter's life. She claimed she'd find a psychologist and family doctor. I'm sure I didn't say anything she hadn't heard already, but I hoped something I said might stick with her.

That's the challenge and excitement of the emergency room (ER). Anyone and everyone who arrives in the ER is evaluated by a physician regardless of their insurance, profession, gender, race, age, class, sobriety, or ability to pay. Healthcare for all is accomplished in the ER. "I was minding my own business and all of the sudden…" is a phrase I've grown accustomed to during my month-long clerkship in a local emergency department. Unfortunately, finding the truth behind the incident and treating the patients' medical conditions may be at odds with one another. Patients may withhold the entire truth for a myriad of reasons, including fear and anxiety. Despite these challenges, the emergency room (ER) is an interesting place where nothing and pure chaos can happen at seemingly the same time.Somehow I feel strangely at home in the chaos. The team atmosphere and unpredictability of practicing emergency medicine appeal to me. After a year of wondering if I'd be a family physician, internist, surgeon, or psychiatrist, I think I've found the career that best suits my skills and interests. I must say I breathed a sigh of relief now that I know how to answer the question, "What will you be when you grow up?"

"An ER doc," I answer.

Andrew Jacques ('05)