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The diagnosis1
The Journal of Emergency Medicine, Vol. 20, No. 2, pp. 205–206, 2001 Copyright © 2001 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/01 $–see front matter
PII S0736-4679(00)00310-3
Humanities and Medicine
THE DIAGNOSIS Bonnie Salomon, Reprint Address: Bonnie Salomon,
MD, FACEP
Lake Forest Hospital, Lake Forest, Illinois Lake Forest Hospital, Emergency Department, 660 N. Westmoreland, Lake Forest, IL 60645
MD, FACEP,
ing problems. Everything came back normal— his blood sugar, his physical examination. I planned to give him some privacy and get the chaplain to talk with him. I went on to other patients, noting with chagrin the mounting number of charts of patients who still needed to be seen. I had little to offer Mr. Sarras besides a hand on his shoulder, and my own sad expression. It was time to move on. I picked up the pace since Mr. Sarras seemed “tucked away,” waiting for the chaplain, then most likely a discharge to home. I was interviewing a new patient with a headache when the chaplain grabbed me and pulled me aside. “You better come and see him,” she urged. What now, I thought, chest pain or shortness of breath? What symptom? “What’s wrong?” I asked Mr. Sarras. His head was turned to the right. His lips were tight, like they were preventing an escape of words. “Mr. Sarras,” I bellowed. “Can you look at me? Can you talk to me?” No answer. No movement. Not even a blink. His eyes looked at the wall. He was a new patient now, muted and motionless. He was somewhere else. He was no longer an ED patient talking to a doctor about a physical complaint. There was a storm inside of him, but his body became completely, utterly still. The chaplain clutched her notebook, and asked me what was I going to do now? There are times when the rhythm of Emergency Medicine goes off tempo, and this was one of them. My usual history, physical, laboratory
Most Emergency Department (ED) charts contain a small rectangular box for the patient’s diagnosis. The diagnosis is like a period at the end of a sentence—it is the conclusion to all that came before it. Just a word or two gives the reader an impression of why the patient came to the ED, and hints at what will become of him or her. “Acute Ankle Sprain,” “Congestive Heart Failure,” “Migraine Headache.” No chart is considered “complete” without a diagnosis. Mr. Sarras was brought by wheelchair into the ED during a typically busy nightshift. I wondered why the charge nurse rushed this young guy into one of my critical care beds. He was sitting bolt upright, staring straight ahead, his fingers clutching the arms of his wheelchair. What could he possibly have that’s so bad? A nurse filled me in. He was upstairs in the ICU visiting his wife who was recently in a fire. The fire had killed their daughter, and now the wife was moribund. The ICU doctors had just asked Mr. Sarras to take his wife off life support. He must have appeared acutely ill to them, and so he was rushed to the ED. He was a healthy appearing man in his late thirties, a bit pale and a bit sweaty. I tried to talk to him in a gentle tone, and tried to get a history— did he pass out, did he have chest pain? He mumbled some quick answers, and turned away. I looked up at his cardiac rhythm on the monitor, more out of habit than out of concern for his heart. His vital signs were fine, he had a normal rhythm on the monitor, and didn’t appear to have any life-threaten-
Humanities and Medicine is coordinated by Richard M. Ratzan, Medicine, Farmington, Connecticut
RECEIVED: 15 September 2000; ACCEPTED: 30 October 2000 205
MD,
of the University of Connecticut School of
206
B. Salomon
tests, disposition rhythm was out of sync. Mr. Sarras, at first, seemed like a near faint due to emotional upset: a benign phenomenon. Now he was nearly catatonic. His brother arrived. “I’ve never seen him do this before,” he said, full of sad wonder. There was no psychiatric history. His brother sketched a life story of ups and downs, marital problems, a brief drinking problem years ago. Mr. Sarras was estranged from his wife at the time of the fire, but he was trying to get back with her. The fire had taken their child, and now was going to claim his wife. I couldn’t just discharge Mr. Sarras to his brother’s care. He wasn’t moving or talking. I couldn’t administer any medication or perform any test to take care of him. No bandage could cover his wound. What was a common emotional response now veered into the realm of the psychotic. I admitted him to psych. The man had come to the hospital to visit his dying wife, and now he was himself a patient. The death of his child, and the imminent death of his wife consumed his sanity, and what was left was my silent psych patient in bed 4. Mr. Sarras had become that—the psych patient in bed 4. My rhythm was back. I had a disposition: admit to psych. It was time to move on. If I dwelled on the enormity of this man’s loss, perhaps I too would be consumed. A nurse handed me Mr. Sarras’ chart some time later. “You forgot to write in a diagnosis,” she said. A diagnosis for Mr. Sarras. I needed to write something in the rectangular box to satisfy the monster bureaucracy that is modern medicine. I came up with a
phrase that sounded clinical, technical, and acceptable: “Acute Grief Reaction.” It fit nicely in the box, and seemed to summarize the case. “Sounds good to me,” the nurse said, and she whisked Mr. Sarras’ papers into the pile of completed charts. It sounded good to me, too. But I knew three words, “Acute Grief Reaction,” could not begin to describe this man’s pain. Here was a man who had lost a child in a horrible trauma—a fire—and now was on the verge of losing his wife, a wife he wanted to love again. His grief was so strong that it stole his speech and movement. Perhaps a poet or a novelist could do more justice to his condition than a doctor’s quick clinical note. The writer and doctor Anton Chekhov seemed to instinctively understand the power of grief. In his short story, “Misery,” he tells of a sleigh-driver whose young son has just died in the hospital (1). His passengers show little interest in the man’s grief, and there is no one who will listen to his sorrowful story: “His misery is immense, beyond all bounds. If . . . (his) . . . heart were to burst and his misery to flow out, it would flood the whole world . . . ” At the end of the story, the man finally tells everything to his horse, who “munches, listens, and breathes on her master’s hands.” Mr. Sarras’ grief also seemed “beyond all bounds.” And like Chekhov’s cabman, he appeared to be unable to release the fullness of his misery. There is no Chekhov to describe his tragic losses or his muted response. There was only “Acute Grief Reaction”; Mr. Sarras’ epitaph on a busy ED nightshift.
REFERENCES 1. Chekhov A. Misery. In Reynolds R, Stone J. eds. On doctoring.
New York: Simon and Schuster; 1995:48 –9.
PII S0736-4679(00)00310-3
Humanities and Medicine
THE DIAGNOSIS Bonnie Salomon, Reprint Address: Bonnie Salomon,
MD, FACEP
Lake Forest Hospital, Lake Forest, Illinois Lake Forest Hospital, Emergency Department, 660 N. Westmoreland, Lake Forest, IL 60645
MD, FACEP,
ing problems. Everything came back normal— his blood sugar, his physical examination. I planned to give him some privacy and get the chaplain to talk with him. I went on to other patients, noting with chagrin the mounting number of charts of patients who still needed to be seen. I had little to offer Mr. Sarras besides a hand on his shoulder, and my own sad expression. It was time to move on. I picked up the pace since Mr. Sarras seemed “tucked away,” waiting for the chaplain, then most likely a discharge to home. I was interviewing a new patient with a headache when the chaplain grabbed me and pulled me aside. “You better come and see him,” she urged. What now, I thought, chest pain or shortness of breath? What symptom? “What’s wrong?” I asked Mr. Sarras. His head was turned to the right. His lips were tight, like they were preventing an escape of words. “Mr. Sarras,” I bellowed. “Can you look at me? Can you talk to me?” No answer. No movement. Not even a blink. His eyes looked at the wall. He was a new patient now, muted and motionless. He was somewhere else. He was no longer an ED patient talking to a doctor about a physical complaint. There was a storm inside of him, but his body became completely, utterly still. The chaplain clutched her notebook, and asked me what was I going to do now? There are times when the rhythm of Emergency Medicine goes off tempo, and this was one of them. My usual history, physical, laboratory
Most Emergency Department (ED) charts contain a small rectangular box for the patient’s diagnosis. The diagnosis is like a period at the end of a sentence—it is the conclusion to all that came before it. Just a word or two gives the reader an impression of why the patient came to the ED, and hints at what will become of him or her. “Acute Ankle Sprain,” “Congestive Heart Failure,” “Migraine Headache.” No chart is considered “complete” without a diagnosis. Mr. Sarras was brought by wheelchair into the ED during a typically busy nightshift. I wondered why the charge nurse rushed this young guy into one of my critical care beds. He was sitting bolt upright, staring straight ahead, his fingers clutching the arms of his wheelchair. What could he possibly have that’s so bad? A nurse filled me in. He was upstairs in the ICU visiting his wife who was recently in a fire. The fire had killed their daughter, and now the wife was moribund. The ICU doctors had just asked Mr. Sarras to take his wife off life support. He must have appeared acutely ill to them, and so he was rushed to the ED. He was a healthy appearing man in his late thirties, a bit pale and a bit sweaty. I tried to talk to him in a gentle tone, and tried to get a history— did he pass out, did he have chest pain? He mumbled some quick answers, and turned away. I looked up at his cardiac rhythm on the monitor, more out of habit than out of concern for his heart. His vital signs were fine, he had a normal rhythm on the monitor, and didn’t appear to have any life-threaten-
Humanities and Medicine is coordinated by Richard M. Ratzan, Medicine, Farmington, Connecticut
RECEIVED: 15 September 2000; ACCEPTED: 30 October 2000 205
MD,
of the University of Connecticut School of
206
B. Salomon
tests, disposition rhythm was out of sync. Mr. Sarras, at first, seemed like a near faint due to emotional upset: a benign phenomenon. Now he was nearly catatonic. His brother arrived. “I’ve never seen him do this before,” he said, full of sad wonder. There was no psychiatric history. His brother sketched a life story of ups and downs, marital problems, a brief drinking problem years ago. Mr. Sarras was estranged from his wife at the time of the fire, but he was trying to get back with her. The fire had taken their child, and now was going to claim his wife. I couldn’t just discharge Mr. Sarras to his brother’s care. He wasn’t moving or talking. I couldn’t administer any medication or perform any test to take care of him. No bandage could cover his wound. What was a common emotional response now veered into the realm of the psychotic. I admitted him to psych. The man had come to the hospital to visit his dying wife, and now he was himself a patient. The death of his child, and the imminent death of his wife consumed his sanity, and what was left was my silent psych patient in bed 4. Mr. Sarras had become that—the psych patient in bed 4. My rhythm was back. I had a disposition: admit to psych. It was time to move on. If I dwelled on the enormity of this man’s loss, perhaps I too would be consumed. A nurse handed me Mr. Sarras’ chart some time later. “You forgot to write in a diagnosis,” she said. A diagnosis for Mr. Sarras. I needed to write something in the rectangular box to satisfy the monster bureaucracy that is modern medicine. I came up with a
phrase that sounded clinical, technical, and acceptable: “Acute Grief Reaction.” It fit nicely in the box, and seemed to summarize the case. “Sounds good to me,” the nurse said, and she whisked Mr. Sarras’ papers into the pile of completed charts. It sounded good to me, too. But I knew three words, “Acute Grief Reaction,” could not begin to describe this man’s pain. Here was a man who had lost a child in a horrible trauma—a fire—and now was on the verge of losing his wife, a wife he wanted to love again. His grief was so strong that it stole his speech and movement. Perhaps a poet or a novelist could do more justice to his condition than a doctor’s quick clinical note. The writer and doctor Anton Chekhov seemed to instinctively understand the power of grief. In his short story, “Misery,” he tells of a sleigh-driver whose young son has just died in the hospital (1). His passengers show little interest in the man’s grief, and there is no one who will listen to his sorrowful story: “His misery is immense, beyond all bounds. If . . . (his) . . . heart were to burst and his misery to flow out, it would flood the whole world . . . ” At the end of the story, the man finally tells everything to his horse, who “munches, listens, and breathes on her master’s hands.” Mr. Sarras’ grief also seemed “beyond all bounds.” And like Chekhov’s cabman, he appeared to be unable to release the fullness of his misery. There is no Chekhov to describe his tragic losses or his muted response. There was only “Acute Grief Reaction”; Mr. Sarras’ epitaph on a busy ED nightshift.
REFERENCES 1. Chekhov A. Misery. In Reynolds R, Stone J. eds. On doctoring.
New York: Simon and Schuster; 1995:48 –9.