It’s 2215, nearing the end of the shift. Your chart has been sitting there waiting for a little while, not too long by most emergency department (ED) standards, but long enough. As the medical student, it would have been easy to just ignore your chart, wait until 2300 rolled around, and just finish cleaning up my already sizeable list of patients. However, I still had just enough energy left in me to at least take a look at the chart. I pick it up, and see a chief complaint of back pain ongoing for 2 months. Not exactly the kind of chief complaint that you want to see in your last hour on shift.
Nevertheless, I take your chart and feel like I should see you. I continue on past the triage note. Past medical history: Polycystic Ovarian Syndrome, chronic pain, HTN, dyslipidemia. All of these reinforce that you might not have the simplest disposition. It would have been easy to put your chart back, for no one saw me pick it up. The night guy arrives at 2300, and he could see you.
I walk over to your bed, and see you there waiting expectantly with your husband. From the foot of the bed, I can tell that something is going on; something about you tells me that this was not just the run of the mill, low-back pain that we see every day. As I speak to you, taking your history, you are clearly uncomfortable on the bed. As you tell me your story, I can hear the distress in your voice. You are describing your pain, which has been gradually worsening, and you came in tonight because you had two falls today.
You’re only in your forties, you shouldn’t be falling. I get to the part of our conversation where I ask you about red flags of back pain. We always ask them and really never expect to find anyone who has any or all of them. Rightly or wrongly, we don’t expect you to be so sick when you come in, although we always worry about worst case scenarios. You tell me that you’ve had some difficulty voiding. It would have been easy for me not to take you seriously. To chalk everything up to ongoing chronic pain and send you home, the way people with multiple co-morbidities can often be overlooked. Instead, I’m quite concerned.
Your physical exam shows me that you are certainly in a lot of pain. Just moving on the bed is a struggle. All of the right tests are positive. More important, all of the wrong tests are positive from your perspective. As I’m wrapping things up, you have only one concern. Please, make this pain better. It’s the same concern as everyone else with pain who walks through the door. It’s a simple, yet complicated request.
I leave the room believing that you did indeed have cauda equina syndrome. I approach my staff and recount your case. We go back to see you together and then proceed to prepare you for transfer to a facility with an MRI and a neurosurgery team.
I don’t know if I really made your pain much better—you were still fairly uncomfortable when I left to go home. I do know that you made me a better clinician that day. I could have all too easily put your chart back after seeing your complaint and your co-morbidities. On paper, you were a difficult patient. In person, you couldn’t have been further from it. You were gracious, patient, and kept calling me doctor even after I corrected you, telling you I was just the medical student. You reminded me of the important lesson that everyone should get the same care when they present to the ED, regardless of the snap judgment based on those three little lines of triage note plus your abbreviated medical history.
Even if you hadn’t turned out to have a serious condition, it shouldn’t matter. You came in because in your eyes, it was an emergency, and you felt you needed treatment. So does everyone else who comes in to the ED. In their eyes, they are having an emergency. Thank you for reminding me not to be frustrated by complaints that don’t seem emergent. Thank you for being such a patient, gracious patient. I hope we made you feel better and answered your questions. I won’t forget.
Competing interests: None declared.
