Occasionally, a patient will come into the ER with a profound sense of foreseeing their immediate death. A foreboding that, despite their complaints and physical findings not matching up, death might be knocking on their door.
I'm not talking about how some people think they may die young. Or that they may die a tragic or traumatic untimely death. Haven't we all had that thought at one time or another? Rather, I'm talking about that patient who is lying in their cot, looking somewhat stable, piercing into your eyes with their frantic own. "Please don't let me die," they say, before you can even begin to sort out their history and perform a physical exam.
This kind of talk and behavior, as you can imagine, may be quite unsettling, both for the patient and the providing medical team. In most circumstances, that dramatic foreshadowing deserves some attention.
Recently, an elderly male had been rushed to our emergency department from the radiology department, where he had been undergoing an outpatient, IV contrast-enhanced MRI. After the MRI nurse had pushed his contrast into his IV catheter, the patient began flailing and screaming.
"I can't breathe!" Help me!" "I'm going to die!"
The MRI nurses looked for a rash. They found none. They listened to his heart and lungs. They sounded good. They reviewed his extensive MRI checklist but found no documented allergies of suspicion.
"I'm going to die!" the patient yelled again. His frantic nature became contagious and, within a few minutes, the patient was being wheeled into our department. Room 21.
I remember hearing the concerning page overhead. "We need a doctor in Room 21, stat." As luck would have it, I was just walking out of Room 22, the next-door room, after explaining some results to that patient. I hurried into Room 21 before the page was even finished.
Entering, I found an elderly male, 75 maybe, in a loosely-tied hospital gown, sitting upright in his cot. "Are you the doctor?" he asked, focusing his worrisome eyes on me. As I nodded yes, I glanced up at his cardiac monitor, which was showing a stable cardiac rhythm, good oxygenation on room air, and a slightly elevated respiratory rate. As I was looking, an automatic blood pressure reading had cycled and that, too, was normal.
"Help me, doctor," he exclaimed, his eyes remaining fixed on mine, his voice cracking, "I'm going to die!" To add a dramatic flair, one of the overhead fluorescent bulbs began flickering its last hurrah, casting intermittent shadows on the patient's face. An interrogation room atmosphere.
I quickly introduced myself, shaking this patient's hand, as I listened to a brief overview given by one of the two nurses. As she finished, I still hadn't heard what I wanted to hear--a solid reason for this patient's words and behavior.
It was time to interrogate. "Sir," I said, "has anything like this ever happened to you before?" No, he replied. "Are you having chest pain or calf pain with this shortness of breath?" No. "Have you had any recent cough or cold symptoms?" Again, no. "Any trauma or falls?" Nope. "Have you ever had any allergic reactions that may have caused a similar reaction?" You guessed it, no.
I was told this patient's brother, whom he lived with, was going to be escorted to Room 21 shortly. I looked forward to talking to him. In the meantime, I did a thorough exam on this patient and found nothing remotely concerning. He had no rash. He had no wheezing or stridor. He had normal heart sounds.
"Sir," I asked him point-blank, "do you have a history of anxiety or nervousness?" He shook his head "no." "On any new medicines?" Another nod "no."
Even though we approached this patient as a possible allergic or anxiety reaction, based solely on his MRI-department history, he still warranted a thorough work-up, because of his age and several cardiac risk factors.
We ordered a stat EKG, a portable chest x-ray, blood work, including some screening cardiac enzymes that would elevate if there were any concurring ischemia to the heart, and a d-dimer, a blood marker that, if positive, raises one's suspicion for a blood clot.
The patient's brother still hadn't arrived by the time I reviewed the patient's EKG and chest x-ray, both normal. I had someone go look for him as I reviewed the patient's blood work results, hot off the presses. Surprisingly, normal.
I was in Room 21, explaining all the good results to the patient, when a smiling, elderly man was escorted into the room by one of our techs. If you took away the patient's nervousness and sense of dread, this arriving man would have been what I imagine this patient to look like. Obviously, it was the patient's brother.
Being told that his brother had finished in MRI, this man had gone to the cafeteria to grab a bite while waiting for an official discharge. The brother had not been told of the situation in the MRI suite.
"So Frank," the brother spoke, shaking his disapproving head, exasperated, "you did it again, huh?"
"Did what?" Frank asked, now glancing sideways out of his eyes at me.
"Have another nervous attack," the brother said. "I told you to make sure you told everybody you have anxiety and are on medication for it. You didn't, did you?"
I looked incredulously at Frank, who now fully avoided eye-contact with me. I looked at the brother. "I point-blank asked your brother if he had anxiety or nervousness and he told me 'no.'"
"Of course," the brother said, "he always denies it. But he has about five or so attacks a day. He seems to be more and more preoccupied with dying these days. " He looked at his brother, the patient, before turning back to me and continuing. "Did he tell you he was going to die?"
I shook my head "yes." The nurse shook her head "yes." Frank, even, shook his head "yes." "Well," Frank's brother continued, "I hear that about five times in a day. Frank gets all worked-up, insisting that I will be living alone by the end of the day." The brother hesitated, as if he was going to add a quirky little comment to that last statement, but bit his tongue.
"How does Frank look to you now?" I asked the brother.
"Like he always does," the brother replied. That reply was music to my ears. Frank looked at his brother, piercing eyes and all, and spoke quite dramatically. "That's enough, Elmer."
Elmer wasn't intimidated. "You're right, this is enough." I stepped out of the room only after refereeing the minor argument that ensued. And ordering some Vitamin "V" for Frank.
It turns out that Frank had held his morning medications, including his valium and anti-depressant, in preparation of his MRI. Unfortunate, since some people without anxiety still require an anxiolytic to get through MRI testing. After a social service consult, I called Frank's family doctor with a report of what happened and, more importantly, to get a follow-up appointment for the next day.
The family doctor was surprised that, somehow, Frank's medications and history of anxiety were not conveyed to the MRI staff, which could have preempted an ER visit. It made me think, though, that if you point a finger, four are still pointing back at you. The family doctor had ordered the test and knew this patient better than anyone else. I would have assumed he would have alerted the MRI team to Frank's recent bouts of anxiety.
"May I ask," I questioned, still a little perplexed, "what was the reason for Frank's MRI?"
"Oh, sure," his doctor replied, "it was a brain MRI to rule out any recent or remote stroke activity. He's been getting real forgetful lately."
So, as it turns out, the forgetful patient forgot to share his anxiety issues.
I walked back into Frank's room to explain his follow-up plan, only to find Frank and Elmer both calmed down, watching a baseball game on TV. "So I'm not going to die, Doctor Jim?" Frank asked one last time.
I shook my head no. "Sorry, Frank, not today you aren't."
Not on my shift, anyway...
As always, big thanks for reading...I hope everyone had a great weekend. Next post will be Wednesday, May 12. See you then...