Maybe it’s a Southern thing. Maybe it’s a human thing. But I’m always amazed at this little interaction:
45-year-old man comes to the emergency department with severe abdominal pain. Receives immediate triage to the patient care area. He receives rapid IV access and narcotic medication for his pain. Hundreds of dollars of lab work are drawn, and an EKG is obtained just to be on the safe side. CT scan of the abdomen and pelvis, with oral and IV contrast is also obtained.
In the end, his pain is resolved, his vital signs are normal (as they were at the outset), his labs are normal and his CT is unrevealing. A gall bladder ultrasound is done as an afterthought and is also normal.
‘Mr. Adkins, I think we can let you go home. Your pain is gone, and there is no obvious finding to suggest its source. I’m happy to report no appendicitis, no abscess, no diverticulitis, no aneurysm, no perforated ulcer, no gall-bladder disease. Maybe it was gas. Who knows? But you’re fine.’
He appears surly. ‘You mean to tell me I come down here to this ER and you’re telling me there ain’t nothing wrong? I wasted all my time for you to tell me that? I’m here with pain and you ain’t done nothing and you’re telling me to go home? Well that’s just crap. I’m telling you something is wrong and I’d appreciate it if someone would try and figure it out.’
Something is going on in this little scenario that I can’t quite figure out. Maybe, Mr. Adkins was comatose while we treated his pain and spent thousands of dollars looking. Maybe, Mr. Adkins wants desperately to be sick and to therefore validate his general unhappiness. Maybe, he wants a reason for more pain medication. Maybe, he’s just looking for a fight. But whatever the reason, I see it more often than I’d like.
Many people are just simply disappointed when they learn that nothing is wrong. In a society that is over-medicated and over-medical, in a culture in which we have made a priesthood of health and a sacrament of lab tests and radiographs, in a time when sickness is as much an identity as an affliction, being told you’re well is like being excluded from a club.
Even parents, rather than saying ‘Yeah! My child is well!’ sometimes wander off and complain that we ‘didn’t do anything.’ And seem disappointed that we ‘wasted their time to tell them nothing was wrong!’ Would they feel better if we diagnosed cancer?
The desire to be sick, and the disappointment at wellness, is a unique phenomenon of modern medicine, to be sure. I think I’ll call it ‘Leap Syndrome.’
I have to agree with the patient. He came to the ER with severe abdominal pain. That is something wrong. He wants to know why, exactly. I understand that specifying exactly what was wrong can be difficult and sometimes impossible, but he still wants to know. Everyone in this situation wants to know why they wound up in the ER; he was just a little more assertive than most.
nevins
15 years ago
All too telling for the finances of the system. The patient has no skin in the game other than their ‘time’. Someones money was just spent, but it wasn’t theirs. Perhaps instead of offering inappropriate antibiotic prescriptions, we should start giving out work excuses; pad them with a few extra days for necessary convalesence and that should molify the masses.
zara
15 years ago
Gee, or maybe the guy was in agonizing pain, which leads him to assume that there must actually be something wrong with him that you just haven’t found. And is terrified that it’s going to come back worse than ever. That’s not to say that the ER has done anything wrong or that there necessarily is some underlying cause that could and should be treated, but it seems to me that the man’s reaction is perfectly normal and understandable.
“Maybe, Mr. Adkins wants desperately to be sick and to therefore validate his general unhappiness. Maybe, he wants a reason for more pain medication. Maybe, he’s just looking for a fight.” Maybe you’ve drawn an improper conclusion Perhaps Mr. Adkins didn’t want to be called a liar. His observations (arguably less keen & expensive than our own) had convinced him of illness. You can care for Mr. Adkins without challenging this conviction using phrases such as: “We were unable to find a cause. This does not necessarily mean that there is nothing wrong. I wish there were more tests available,… Read more »
Bruce
15 years ago
I can understand why this would be frustrating for you. The thing is, these types of patients probably have no idea how many things you have ruled out before saying “you’re not sick”. In his mind, he felt really sick, then the triage nurse agreed with him and whisked him into the ER where they immediately started hooking him up to all kinds of weird tubes and pumping him full of some pretty strong painkillers. Now he’s thinking, “I was right to come here, I’m in bad shape!” Then a few hours later, he’s told that actually he’s fine? I’m… Read more »
Sarah
15 years ago
Oh, Dr. Leap, I don’t think it’s a Southern thing. I’ve worked (LPN2) in a rural ED in Northern NM for about 25 years and we have seen this consistently over the years. I worked, for a while, with a doc who had been an Army doc before he reincarnated into an itinerant ED guy, and he had, what was to us nurses, the hilarious habit of telling almost every patient that they had the worst ear infection that he’d ever seen. He’d prescribe them all a whopping dose of Rocephin (we accused him of owning stock in the company… Read more »
EEJ
15 years ago
My wife has had 4 bouts of severe stomach pain. Every time we go to the Emergency Department, we wait a few hours and the pain is gone by the time they get around to examining her, and they can’t find anything wrong. Sure, they’ve run a few tests (very few), and can’t seem to find anything wrong with her. However, her pain is bad enough that she is crying, so I know there has to be a reason. Unfortunately, even with healthcare, an ER visit is not cheap, so the last 2 times we went to the ER, her… Read more »
mck
15 years ago
eej-
might i submit that if her pain is resolving spontaneously and the tests are normal and, lo and behold, she’s still alive after all this time, it *might* not be an EMERGENCY and would be better investigated in the outpatient setting, possibly with referral to a gastroenterologist, rather than in the EMERGENCY room? and crying doesn’t mean it’s serious, it just means she’s crying. people with completely non-serious pain bawl their heads off and those with life-threatening conditions can be completely stoic. just thinking aloud….
Mel
15 years ago
Maybe people get upset because they have been in pain and just want an answer. If you find the problem then hopefully it can be treated, cancer or whatever…better then not knowing. My guess is most people have better things to do then spend their whole day in the ER, only to be dismissed. It’s scary to think that the next person you treat might be dismissed because you caterogize him or her. I think a better answer then “nothing is wrong” is that “we just can’t diagnose it”…..that might help you when you’re sued.
Why is it that ER docs don’t know how to say the statement “I don’t know.”? Believe it or not, that can go a lot further with a patient than almost anything else. I hate it when they think they know better than the specialists. I’ve had too many bad experiences with ER docs to trust them completely – and they never every say “I don’t know.” Now, specialists will say “I don’t know.” Maybe my experience is not normal, but it really does seem the only group as a whole in physician land that says “I don’t know,” is… Read more »
For the past 4 years I had bouts of extreamly severe pain. I would call my doctor and was told to go to the emergency room. In the emergency room I was told that they could tell I was in pain but this isn’t the setting to find out why the pain was there. The last three times it happened I just waited it out at home without medical help. What was the use? No one was going to attempt to find the cause, and I’ll be treated badly if the Dr. or the Nurse decide I’m just there for… Read more »
Maggie
15 years ago
What did people do before there were the technological wonders of ERs? Probably drank herb teas, or died. I woke in the middle of the night once in such bad pain I could not get up to call an ambulance. I lived alone. I was resigned to death. Finally I fell asleep and woke the next morning pain free. Never happened again. I’d been on a strict fat-free diet for two weeks and I decided my belly didn’t like it. Ever since, I’ve used that night of pain to justifiably enjoy my steaks, bacon and buttery potatoes. My cholesterols are… Read more »
as an rn a rural ed, i too am baffled by this ‘syndrome’. and i feel for the patients who suffer from severe pain that is undiagnosable. i just wonder why the patients who, after tests are done and life threatening conditions are ruled out, feel the need to ‘blame’ the ed doc. that’s what we do in the ed. for ongoing symptoms the patients should follow up with their own doc or a specialist. it’s very frustrating to try to help a person in pain and never have success. particularly when the patient is either in severe pain or… Read more »
EEJ
15 years ago
Just wanted to reply to “MCK”, albeit a bit belatedly. MCK, I appreciate the response, but as you are the only one that responded to me specifically, I guess we’ll just have to keep on keeping on, and hope the pain doesn’t return. My wife has a good threshold for pain, and isn’t one to cry about trifling pain. The problem is that the ER can’t find anything by the time she is admitted (because the pain is gone and labs show up normal), and send her to follow-up with her primary physician. The primary physician can’t find anything wrong… Read more »
TOLER
15 years ago
GEE. THIS HAPPENED TO MY UNCLE YEARS AGO. THEY SENT HIM HOME AFTER THESE INITIAL TESTS. HE WENT BACK THE NEXT DAY WITH THE SAME PAIN. THEN THEY DID AN MRI OF HIS BRAIN. FOUND A BLOOD CLOT PUSHING ON CRITICAL NERVES. HE DIED WHEN IT EXPLODED AN HOUR AFTER THEY FOUND IT. THEY SAID HE WAS HOURS LATE FROM SAVING HIM ON THE ER TABLE. WAY TO GO ER GENIUSES WHO SEND PEOPLE HOME IN SEVERE PAIN.
{"id":null,"mode":"form","open_style":"in_place","currency_code":"USD","currency_symbol":"$","currency_type":"decimal","blank_flag_url":"https:\/\/edwinleap.com\/wp-content\/plugins\/tip-jar-wp\/\/assets\/images\/flags\/blank.gif","flag_sprite_url":"https:\/\/edwinleap.com\/wp-content\/plugins\/tip-jar-wp\/\/assets\/images\/flags\/flags.png","default_amount":100,"top_media_type":"none","featured_image_url":false,"featured_embed":"","header_media":null,"file_download_attachment_data":null,"recurring_options_enabled":true,"recurring_options":{"never":{"selected":true,"after_output":"One time only"},"weekly":{"selected":false,"after_output":"Every week"},"monthly":{"selected":false,"after_output":"Every month"},"yearly":{"selected":false,"after_output":"Every year"}},"strings":{"current_user_email":"","current_user_name":"","link_text":"Leave a tip","complete_payment_button_error_text":"Check info and try again","payment_verb":"Pay","payment_request_label":"EdwinLeap.com","form_has_an_error":"Please check and fix the errors above","general_server_error":"Something isn't working right at the moment. Please try again.","form_title":"EdwinLeap.com","form_subtitle":"If you enjoy the content you read here, please consider dropping something in the tip jar!","currency_search_text":"Country or Currency here","other_payment_option":"Other payment option","manage_payments_button_text":"Manage your payments","thank_you_message":"Thank you so much! I appreciate the tip!","payment_confirmation_title":"EdwinLeap.com","receipt_title":"Your Receipt","print_receipt":"Print Receipt","email_receipt":"Email Receipt","email_receipt_sending":"Sending receipt...","email_receipt_success":"Email receipt successfully sent","email_receipt_failed":"Email receipt failed to send. Please try again.","receipt_payee":"Paid to","receipt_statement_descriptor":"This will show up on your statement as","receipt_date":"Date","receipt_transaction_id":"Transaction ID","receipt_transaction_amount":"Amount","refund_payer":"Refund from","login":"Log in to manage your payments","manage_payments":"Manage Payments","transactions_title":"Your Transactions","transaction_title":"Transaction Receipt","transaction_period":"Plan Period","arrangements_title":"Your Plans","arrangement_title":"Manage Plan","arrangement_details":"Plan Details","arrangement_id_title":"Plan ID","arrangement_payment_method_title":"Payment Method","arrangement_amount_title":"Plan Amount","arrangement_renewal_title":"Next renewal date","arrangement_action_cancel":"Cancel Plan","arrangement_action_cant_cancel":"Cancelling is currently not available.","arrangement_action_cancel_double":"Are you sure you'd like to cancel?","arrangement_cancelling":"Cancelling Plan...","arrangement_cancelled":"Plan Cancelled","arrangement_failed_to_cancel":"Failed to cancel plan","back_to_plans":"\u2190 Back to Plans","update_payment_method_verb":"Update","sca_auth_description":"Your have a pending renewal payment which requires authorization.","sca_auth_verb":"Authorize renewal payment","sca_authing_verb":"Authorizing payment","sca_authed_verb":"Payment successfully authorized!","sca_auth_failed":"Unable to authorize! Please try again.","login_button_text":"Log in","login_form_has_an_error":"Please check and fix the errors above","uppercase_search":"Search","lowercase_search":"search","uppercase_page":"Page","lowercase_page":"page","uppercase_items":"Items","lowercase_items":"items","uppercase_per":"Per","lowercase_per":"per","uppercase_of":"Of","lowercase_of":"of","back":"Back to plans","zip_code_placeholder":"Zip\/Postal Code","download_file_button_text":"Download File","input_field_instructions":{"tip_amount":{"placeholder_text":"How much would you like to tip?","initial":{"instruction_type":"normal","instruction_message":"How much would you like to tip? Choose any currency."},"empty":{"instruction_type":"error","instruction_message":"How much would you like to tip? Choose any currency."},"invalid_curency":{"instruction_type":"error","instruction_message":"Please choose a valid currency."}},"recurring":{"placeholder_text":"Recurring","initial":{"instruction_type":"normal","instruction_message":"How often would you like to give this?"},"success":{"instruction_type":"success","instruction_message":"How often would you like to give this?"},"empty":{"instruction_type":"error","instruction_message":"How often would you like to give this?"}},"name":{"placeholder_text":"Name on Credit Card","initial":{"instruction_type":"normal","instruction_message":"Enter the name on your card."},"success":{"instruction_type":"success","instruction_message":"Enter the name on your card."},"empty":{"instruction_type":"error","instruction_message":"Please enter the name on your card."}},"privacy_policy":{"terms_title":"Terms and conditions","terms_body":null,"terms_show_text":"View Terms","terms_hide_text":"Hide Terms","initial":{"instruction_type":"normal","instruction_message":"I agree to the terms."},"unchecked":{"instruction_type":"error","instruction_message":"Please agree to the terms."},"checked":{"instruction_type":"success","instruction_message":"I agree to the terms."}},"email":{"placeholder_text":"Your email address","initial":{"instruction_type":"normal","instruction_message":"Enter your email address"},"success":{"instruction_type":"success","instruction_message":"Enter your email address"},"blank":{"instruction_type":"error","instruction_message":"Enter your email address"},"not_an_email_address":{"instruction_type":"error","instruction_message":"Make sure you have entered a valid email address"}},"note_with_tip":{"placeholder_text":"Your note here...","initial":{"instruction_type":"normal","instruction_message":"Attach a note to your tip (optional)"},"empty":{"instruction_type":"normal","instruction_message":"Attach a note to your tip (optional)"},"not_empty_initial":{"instruction_type":"normal","instruction_message":"Attach a note to your tip (optional)"},"saving":{"instruction_type":"normal","instruction_message":"Saving note..."},"success":{"instruction_type":"success","instruction_message":"Note successfully saved!"},"error":{"instruction_type":"error","instruction_message":"Unable to save note note at this time. Please try again."}},"email_for_login_code":{"placeholder_text":"Your email address","initial":{"instruction_type":"normal","instruction_message":"Enter your email to log in."},"success":{"instruction_type":"success","instruction_message":"Enter your email to log in."},"blank":{"instruction_type":"error","instruction_message":"Enter your email to log in."},"empty":{"instruction_type":"error","instruction_message":"Enter your email to log in."}},"login_code":{"initial":{"instruction_type":"normal","instruction_message":"Check your email and enter the login code."},"success":{"instruction_type":"success","instruction_message":"Check your email and enter the login code."},"blank":{"instruction_type":"error","instruction_message":"Check your email and enter the login code."},"empty":{"instruction_type":"error","instruction_message":"Check your email and enter the login code."}},"stripe_all_in_one":{"initial":{"instruction_type":"normal","instruction_message":"Enter your credit card details here."},"empty":{"instruction_type":"error","instruction_message":"Enter your credit card details here."},"success":{"instruction_type":"normal","instruction_message":"Enter your credit card details here."},"invalid_number":{"instruction_type":"error","instruction_message":"The card number is not a valid credit card number."},"invalid_expiry_month":{"instruction_type":"error","instruction_message":"The card's expiration month is invalid."},"invalid_expiry_year":{"instruction_type":"error","instruction_message":"The card's expiration year is invalid."},"invalid_cvc":{"instruction_type":"error","instruction_message":"The card's security code is invalid."},"incorrect_number":{"instruction_type":"error","instruction_message":"The card number is incorrect."},"incomplete_number":{"instruction_type":"error","instruction_message":"The card number is incomplete."},"incomplete_cvc":{"instruction_type":"error","instruction_message":"The card's security code is incomplete."},"incomplete_expiry":{"instruction_type":"error","instruction_message":"The card's expiration date is incomplete."},"incomplete_zip":{"instruction_type":"error","instruction_message":"The card's zip code is incomplete."},"expired_card":{"instruction_type":"error","instruction_message":"The card has expired."},"incorrect_cvc":{"instruction_type":"error","instruction_message":"The card's security code is incorrect."},"incorrect_zip":{"instruction_type":"error","instruction_message":"The card's zip code failed validation."},"invalid_expiry_year_past":{"instruction_type":"error","instruction_message":"The card's expiration year is in the past"},"card_declined":{"instruction_type":"error","instruction_message":"The card was declined."},"missing":{"instruction_type":"error","instruction_message":"There is no card on a customer that is being charged."},"processing_error":{"instruction_type":"error","instruction_message":"An error occurred while processing the card."},"invalid_request_error":{"instruction_type":"error","instruction_message":"Unable to process this payment, please try again or use alternative method."},"invalid_sofort_country":{"instruction_type":"error","instruction_message":"The billing country is not accepted by SOFORT. Please try another country."}}}},"fetched_oembed_html":false}
I have to agree with the patient. He came to the ER with severe abdominal pain. That is something wrong. He wants to know why, exactly. I understand that specifying exactly what was wrong can be difficult and sometimes impossible, but he still wants to know. Everyone in this situation wants to know why they wound up in the ER; he was just a little more assertive than most.
All too telling for the finances of the system. The patient has no skin in the game other than their ‘time’. Someones money was just spent, but it wasn’t theirs. Perhaps instead of offering inappropriate antibiotic prescriptions, we should start giving out work excuses; pad them with a few extra days for necessary convalesence and that should molify the masses.
Gee, or maybe the guy was in agonizing pain, which leads him to assume that there must actually be something wrong with him that you just haven’t found. And is terrified that it’s going to come back worse than ever. That’s not to say that the ER has done anything wrong or that there necessarily is some underlying cause that could and should be treated, but it seems to me that the man’s reaction is perfectly normal and understandable.
“Maybe, Mr. Adkins wants desperately to be sick and to therefore validate his general unhappiness. Maybe, he wants a reason for more pain medication. Maybe, he’s just looking for a fight.” Maybe you’ve drawn an improper conclusion Perhaps Mr. Adkins didn’t want to be called a liar. His observations (arguably less keen & expensive than our own) had convinced him of illness. You can care for Mr. Adkins without challenging this conviction using phrases such as: “We were unable to find a cause. This does not necessarily mean that there is nothing wrong. I wish there were more tests available,… Read more »
I can understand why this would be frustrating for you. The thing is, these types of patients probably have no idea how many things you have ruled out before saying “you’re not sick”. In his mind, he felt really sick, then the triage nurse agreed with him and whisked him into the ER where they immediately started hooking him up to all kinds of weird tubes and pumping him full of some pretty strong painkillers. Now he’s thinking, “I was right to come here, I’m in bad shape!” Then a few hours later, he’s told that actually he’s fine? I’m… Read more »
Oh, Dr. Leap, I don’t think it’s a Southern thing. I’ve worked (LPN2) in a rural ED in Northern NM for about 25 years and we have seen this consistently over the years. I worked, for a while, with a doc who had been an Army doc before he reincarnated into an itinerant ED guy, and he had, what was to us nurses, the hilarious habit of telling almost every patient that they had the worst ear infection that he’d ever seen. He’d prescribe them all a whopping dose of Rocephin (we accused him of owning stock in the company… Read more »
My wife has had 4 bouts of severe stomach pain. Every time we go to the Emergency Department, we wait a few hours and the pain is gone by the time they get around to examining her, and they can’t find anything wrong. Sure, they’ve run a few tests (very few), and can’t seem to find anything wrong with her. However, her pain is bad enough that she is crying, so I know there has to be a reason. Unfortunately, even with healthcare, an ER visit is not cheap, so the last 2 times we went to the ER, her… Read more »
eej-
might i submit that if her pain is resolving spontaneously and the tests are normal and, lo and behold, she’s still alive after all this time, it *might* not be an EMERGENCY and would be better investigated in the outpatient setting, possibly with referral to a gastroenterologist, rather than in the EMERGENCY room? and crying doesn’t mean it’s serious, it just means she’s crying. people with completely non-serious pain bawl their heads off and those with life-threatening conditions can be completely stoic. just thinking aloud….
Maybe people get upset because they have been in pain and just want an answer. If you find the problem then hopefully it can be treated, cancer or whatever…better then not knowing. My guess is most people have better things to do then spend their whole day in the ER, only to be dismissed. It’s scary to think that the next person you treat might be dismissed because you caterogize him or her. I think a better answer then “nothing is wrong” is that “we just can’t diagnose it”…..that might help you when you’re sued.
Why is it that ER docs don’t know how to say the statement “I don’t know.”? Believe it or not, that can go a lot further with a patient than almost anything else. I hate it when they think they know better than the specialists. I’ve had too many bad experiences with ER docs to trust them completely – and they never every say “I don’t know.” Now, specialists will say “I don’t know.” Maybe my experience is not normal, but it really does seem the only group as a whole in physician land that says “I don’t know,” is… Read more »
For the past 4 years I had bouts of extreamly severe pain. I would call my doctor and was told to go to the emergency room. In the emergency room I was told that they could tell I was in pain but this isn’t the setting to find out why the pain was there. The last three times it happened I just waited it out at home without medical help. What was the use? No one was going to attempt to find the cause, and I’ll be treated badly if the Dr. or the Nurse decide I’m just there for… Read more »
What did people do before there were the technological wonders of ERs? Probably drank herb teas, or died. I woke in the middle of the night once in such bad pain I could not get up to call an ambulance. I lived alone. I was resigned to death. Finally I fell asleep and woke the next morning pain free. Never happened again. I’d been on a strict fat-free diet for two weeks and I decided my belly didn’t like it. Ever since, I’ve used that night of pain to justifiably enjoy my steaks, bacon and buttery potatoes. My cholesterols are… Read more »
as an rn a rural ed, i too am baffled by this ‘syndrome’. and i feel for the patients who suffer from severe pain that is undiagnosable. i just wonder why the patients who, after tests are done and life threatening conditions are ruled out, feel the need to ‘blame’ the ed doc. that’s what we do in the ed. for ongoing symptoms the patients should follow up with their own doc or a specialist. it’s very frustrating to try to help a person in pain and never have success. particularly when the patient is either in severe pain or… Read more »
Just wanted to reply to “MCK”, albeit a bit belatedly. MCK, I appreciate the response, but as you are the only one that responded to me specifically, I guess we’ll just have to keep on keeping on, and hope the pain doesn’t return. My wife has a good threshold for pain, and isn’t one to cry about trifling pain. The problem is that the ER can’t find anything by the time she is admitted (because the pain is gone and labs show up normal), and send her to follow-up with her primary physician. The primary physician can’t find anything wrong… Read more »
GEE. THIS HAPPENED TO MY UNCLE YEARS AGO. THEY SENT HIM HOME AFTER THESE INITIAL TESTS. HE WENT BACK THE NEXT DAY WITH THE SAME PAIN. THEN THEY DID AN MRI OF HIS BRAIN. FOUND A BLOOD CLOT PUSHING ON CRITICAL NERVES. HE DIED WHEN IT EXPLODED AN HOUR AFTER THEY FOUND IT. THEY SAID HE WAS HOURS LATE FROM SAVING HIM ON THE ER TABLE. WAY TO GO ER GENIUSES WHO SEND PEOPLE HOME IN SEVERE PAIN.