Many things color our clinical pursuit of truth. It’s seldom as clear as we think it is. Despite our desire to be pure scientists, interactions with humans are far more complex than those we have with molecules or energy, for instance. (Although even there, we are in our scientific infancy and are just understanding the incredible complexity and nuance of the physical sciences, much less the ineffable beauty and intricacy of the biological sciences on which the practice of medicine is predicated.)
Our diagnostic skills are never used in a vacuum. Sometimes they are driven by other forces, namely societal influences. For instance, they revolved around COVID for a couple of years. Before that, they’ve often revolved around pressure from other physicians (tell the ER you need to get a CT). Mostly these days, they’re around concerns about respiratory illness. ‘I need a COVID, RSV, flu test, etc.’
It’s easy to go down certain pathways when this happens, to ignore other signs in the path to please the patient. Some of this, of course, is a habit developed in the era of customer satisfaction. The same way we give too many antibiotics, so patients won’t throw a fit and complain.
And yet, so often the things people want are things that ultimately don’t matter. They often don’t understand the situation. They aren’t stupid. They just lack expertise. Sadly, so do some in healthcare. ‘You have COVID and pneumonia!’ Or ‘your 1 month old has sinusitis.’
In the midst of every clinical decision are a subjective reality and an objective reality. The two are in flux, dynamically oscillating in the physician’s mind as we encounter the patient, make the initial assessment, and derive an initial clinical diagnosis.
How that internal play interacts with the outside world of health misinformation, healthcare corporate pressures, and the personal predilections of each patient defines the full patient interaction.
Individually, each decision is usually made rationally. But two rational systems, when superimposed, create chaos. Now imagine multiple systems of decision-making, all superimposed, all creating layers upon layers of chaos.
This is the mental landscape of an emergency medicine physician. This is what I experience. Let me elaborate with a few vignettes from recent clinical encounters.
Elaine was 84 years old and was on the floor when her frantic family stopped by to see her for a scheduled family lunch. They had talked with her by phone yesterday, and then an hour before arriving. Both times she seemed alert and appropriate, but said a few things to them that seemed abnormal. Her normal erudition was stumbling and halting, her words repetitive.
When the family arrived, the evidence of her normally ordered life was still in place, only with a few papers on the floor, and a few notes scribbled on a pad on her table. She was awake, but confused and babbling when they called the rescue squad to take her to the emergency department. A ‘health nut’ according to her family, she ate well, stayed very well hydrated, walked daily and took only a daily aspirin.
When she arrived to the ER, it was unclear what had happened, but because of her behavior, because of this striking change in a remarkably functional retired teacher, she was subjected to a stroke evaluation. The external assumption, based on required metrics, based on the belief that foremost all such changes represent a cerebrovascular accident, all of ‘the things’ were done; the EKG, the labs, the CT scan and all in a timely manner. Her tearful family focused on the fact that her own parents had both suffered ‘strokes’ and had died from them.
Her treating physician, attempting to discern the truth of the situation, had many options. But of course, because of the national focus on stroke, was forced immediately into that pathway first.
The CT scan showed nothing obvious, but it was probably too early to show anything. The consulting neurologist saw her and was deciding how aggressively to treat her when her labs rolled in, slowly, with a low sodium level of 110. The truth of her situation was not that she had a stroke but that she had drunk far too much water. Over the ensuing days, this became more and more clear as she became more lucid and expressed her desire to stay healthy, unlike her parents.
What was not evident in the initial search for truth was her behavior. What we assumed was that her age and family history put her at higher risk for stroke. What we pursued was what was revealed by family and required by policy. What was unknown was what her parents actually died of in the 1960s. There was no official diagnosis, no autopsy. Even then, all we had was an assumption and a conveyed message that the patient’s parents died of a stroke. Everything else remained unknown.
Danny was a thin, disheveled 30-year-old man who was found outside in the cold night of a West Virginia Winter. He was believed, at first, to be dead. A passerby stopped and touched his cold, blue-tinged skin, covered in a faint dusting of fresh snow which highlighted his skin color in the bright light of a cell-phone flashlight. The police were called. The police knew Danny, that he was ‘simple’ and often homeless. They knew Danny’s family, his drug use, and his police record.
‘Danny? Are you OK Danny?’ The officer keyed his microphone, ‘we need EMS, and maybe the coroner.’ When EMS arrived, Danny moaned and an ever so faint pulse was found in the left side of his scarred neck. The medic’s thermometer read 72F. His monitor showed a slow but steady heart rhythm and he was taken to the ER. He was resuscitated, warmed, given Narcan and had every lab drawn. ‘Do you think he was shooting up? Or suicidal?’ The doctor quizzed the paramedics and police. It was a busy night, full of flu and COVID patients, sick people with emphysema and heart disease and other homeless individuals with clinical complaints sufficient enough to garner a night of warmth in the ER. There was precious little time to explore nuance. The halls were filled with people and there were no more warm blankets. The snow fell more, and the large white flakes seen against EMS headlights outside were oddly beautiful in contrast to the internal chaos, where so many patients had so many stories, and truths were blurred as if by thick winter clouds.
Danny woke slowly, his temperature rising until he became agitated and kicked off the blanket. Staff gently redirected him as he yelled, ‘they’re trying to kill me! They sold me!’ Eyes rolled when his drug screen showed methampetamine, opioids, benzodiazepines and marijuana. ‘Party pack,’ the staff joked. The marks on his formerly blue arm were now visibly red and angry, forming a long streak from his right hand to his chest.
His agitation worsened and his temperature, first normalized, rose to 104F, and his confusion worsened, his heart, which formerly had nearly slowed to death now raced to 150, and it became clear that Danny was septic. His story, like so many of those confused and altered, a mixture of confusing signals, where the truth was hidden by drugs and ‘mental illness,’ by social situations and the environment, and by the exigencies of the night’s business where he was one among dozens, one confusing story in a swirl of never-ending narratives.
What was not known until much later was that his sepsis was not from his arm, but from his perineum and the abscess around his rectum. Danny was not lying. His truth was real. They had tried to kill him and he had been sold, many times, for drugs. This bit of the story just wasn’t available when he first arrived, and in the ensuing madness, there was no way to know how powerfully it would have impacted the pursuit of the objective reality, the clinical diagnosis, by those treating him.
But this last time he was sold, he was also sick and feverish, coughing and crying, fighting and felt it just wasn’t ‘worth it’ anymore. Given a hit of heroin by his tormentors, he was dropped by the side of the road on a frigid night, with no question as to what would (conveniently) happen by morning.
Danny, broken and abused, did not die from hypothermia, or (simply) from drug abuse. He died a week later in the ICU, from complications of both drug abuse and sexual abuse, as infection overwhelmed his body and he simultaneously fought withdrawal from the many things which anesthetized his troubled life.
Carol, age 47, had escalating behavioral problems for the past year. A well-regarded realtor who knew the market in her area like the back of her hand, sudden found that her business had fallen apart. Her family recalled her as a woman particular about clothes and behavior; a Southern lady who still went to tea parties with friends, and whose daughters had navigated the rich tradition of cotillion with all the grace of their elegant mother, years before. And yet, the woman in tailored suits and designer bags, the woman who hosted tail-gating with friends and taught vacation Bible school was now handcuffed to her portable ER bed, because she had just finished screaming at her husband and left her adult daughters in tears.
She was dressed in incarceration orange and had been arrested for shop-lifting. When the police contacted her family, they insisted that she be committed for a mental health evaluation. Carol was healthy except for some mild depression, for which she took an anti-depressant. In the moment, however, she was angry with everyone and refused to talk to the staff in the ER where she was brought.
When she did, it was in short, angry and profane diatribes against the husband she said she hated and the daughters she said never loved her; daughters who now stood in the hallway, tears causing their well-placed mascara to stream down faces that looked much like their mother’s.
‘How long has your mother been like this?’ Her physician asked, hoping for some clinical direction to pursue. Her symptoms recently emerged, developing over the past twelve months like some surprise infection. Everyone’s life was disrupted. There was some family history: A grandmother with schizophrenia, a father with bipolar disorder. It seemed as if it fit a pattern for there to be some breakdown in this high-functioning woman who pushed herself in every endeavor.
‘Fine, examine me if you have to,’ she tossed her hair in anger. Her physician looked over her scant medical records; she was remarkably well. Examining her, expecting nothing, expecting only more paperwork, she found nothing. Well, nothing but a slightly larger right pupil.
Her labs, her drug screen, nothing. She asked the patient, ‘do you have headaches?’ ‘Like you care you bitch. But yeah, what about it?’ Her daughters mouthed ‘I’m so sorry!’
Later the CT scan, which she initially refused, showed a meningioma, a benign tumor that, according to the neurologist, likely caused her behavioral changes. A year later she came by, tumor resected, bringing cookies and her business cards, acting as normal as can be, her truth hidden beneath anger and assumptions, freshly covered in masquera and smiles.
Our clinical pursuit of truth is colored by many things, and is seldom as clear as we think it is. It is affected by the quality of our science and by the presumptions and assumptions we bring to light. It is impacted by the interpretation of data, which can be as varied as the science itself.
We are endlessly distracted and always tired, and so are the people from whom, and about whom, we hope to glean some glimpse of reality to offer some aid. Patients have their own reasons for leading us astray; most of them unintentional. The chronology of health issues can be overwhelming and hard to track; the names of diseases, medications, procedures, hospitals and physicians can be lost in the fear and complexity. Sometimes discomfort and fear obscure the truth.
Occasionally, the truth is hidden because of fear of judgment, or because of genuine evil, when someone lies about an abused child, or about the way in which they received the wound they have (which occurred while gravely wounding someone else). Not everyone is kind or forthcoming.
The truth, even on a good day, is elusive. We would do well to remember that. And perhaps judge ourselves less harshly when it seems even harder than ever to discern the truth.