As the nurses and I were working to save Andrea, it suddenly occurred to me that five minutes had gone by without my speaking to my patient. She was still pale but more alert. Her brow was furrowed and drenched in sweat. The senior resident in obstetrics and gynecology walked briskly into the room as I brought Andrea up to speed.
“Andrea, you’re in shock but we’re treating that with blood,” I said to her. “The gyne resident is here. She’s going to ask you some questions and examine you. She will try to figure out where the bleeding is coming from and stop it. I’ll let her fill you in on the details.”
That was when Andrea’s eyes locked onto mine and her pale hand reached over and grabbed my left arm in a vice grip.
“I’m not going to die, am I?”
“Not on my watch,” I told her.
The OBGYN made good on my promise, saving not only Andrea’s life but her womb.
The rush you feel when you help save someone like Andrea is much better than sex. The rush I get from making a quick diagnosis and getting a patient on the fast track to a save can fill me for days with pleasant thoughts. I get a little buzz each time I tell the story of someone like Andrea. That’s the kind of drama that still makes it possible to get through long night shifts—even after thirty years on duty.
* * *
Unfortunately, there’s another kind of drama that fills the ER all too often—not from patients who are dying but from those who are convinced they’re dying. They are the polar opposites of the Andreas of the world—irritatingly over-anxious in deportment and underwhelming in illness and injury.
We have a rich, disdainful cornucopia of slang terms for patients like these.
A nurse in her early twenties who works in an inner-city setting in the southern United States and blogs under the pseudonym Hood Nurse says such patients suffer from a condition referred to by the amusing name status dramaticus. “It refers to patients who come to the hospital and start falling down on the ground,” says Hood Nurse. “They put on a whole show for us.”
Status dramaticus is a totally made-up bit of slang inspired by the term status asthmaticus, which is a prolonged and severe asthma attack that does not respond to standard treatment. Status asthmaticus is a life-threatening condition that demands immediate attention. I’ve had to intubate such patients and put them on ventilators.
Dr. Jonathan Davis, an ER physician at a small hospital in Georgia, says both he and nurses he works with have used the slang version. “I think in some ways it sounds medical enough that if you were overheard, it wouldn’t sound as if you were implying that the person is crazy. Like a lot of words, for us it’s just a way of getting humour out of a situation where we’re all frustrated.”
Unlike status asthmaticus, status dramaticus is all performance and no life threat whatsoever. Call it 2 percent real symptoms and 98 percent exaggeration. I’ve long been impressed that patients with illnesses that are genuinely life-threatening do not have to convince health professionals that’s the case. They let their symptoms and physical signs speak for themselves.
“The person who is making the most noise is usually the least sick, in my experience,” says a triage nurse I’ve worked with for many years. “It’s the quiet ones in the corner that you have to worry about.”
By contrast, patients with status dramaticus go to great lengths to convince skeptical doctors and nurses that they are seriously ill and in need of urgent medical attention. They spend a lot of time telling you how sick they are, using verbal tone and inflection to add emotional leverage to their presentation.
Since they believe they have a medical emergency, they head for an ER. And the nexus point between the outside world and the ER is the triage desk, where nurses have the unenviable job of quickly sizing up all comers—from patients with hangnails to those at imminent risk of cardiac arrest. Not surprisingly, triage nurses get very good at recognizing patients who magnify their symptoms. Dr. Erin Sullivan, a veteran ER nurse who spent many a shift at a triage desk before switching careers to become a physician, is currently doing a residency in family medicine in Saskatchewan. She refers to these patients as dying swans: “The dying swans are the ones that go into histrionics with the triage nurse in the waiting room.”
The Dying Swan, a ballet created in 1905 by Russian choreographer Mikhail Fokine, depicts the last moments in the life of a swan. Describing a patient as a dying swan implies utter disbelief at both the magnitude of the patient’s symptoms and their import. Sullivan says dying swans often use flourishes such as wearing dark glasses and moaning or yelling about their symptoms. Like their stage namesakes, dying swan patients know how to get a response from the audience. “They know how to play the part,” says Sullivan, “clutching themselves, dry heaving into garbage bags and things like that.”
The role of the Dying Swan was created for renowned prima ballerina Anna Pavlova. Triage nurses use dying swan to refer only to female patients. They have another name for the guys. They’re said to have the “XY chromosome.” “A man and a woman both come to the ER with kidney stones at the same time,” says Sullivan. “They have the same size kidney stones, but you will only hear the man. The man is moaning and rattling the bed frame and yanking the call bell. And the woman is sort of lying there quietly. A nurse will ask what’s wrong with the guy and someone will answer, ‘He’s got the XY chromosome.’ And everybody laughs.”
That story would get a laugh in most ERs. The gender stereotype of the wussy man crying about his kidney-stone pain is considered acceptable by many health professionals—hardly surprising, given the tendency to treat men with contempt when they fail to suck it up.
What may surprise you is the proclivity of some people on my side of the gurney to extend the same contempt to members of certain ethnic groups. In parts of the United States with a large Hispanic population—now the nation’s largest ethnic or racial minority—it isn’t uncommon for some doctors and nurses to refer to patients of Hispanic origin who are loudly suffering from pain by the slang term status Hispanicus.
The Urban Dictionary defines status Hispanicus as “when a large Hispanic family gets together at a hospital to support a member of their family with a minor injury and have a sustained freak-out attack to show the support.”
Another slang term, ay-tach (pronounced “eye-tack”), pokes fun at the way Hispanic patients vocalize when they are in pain. “When they’re expressing pain, instead of saying ow or oh—what English-speakers might say—they say ay,” a resident explains.
The resident says that Hispanic patients tend to repeat ay-ay-ay in staccato fashion over and over again—the inspiration for ay-tach (sometimes called Tachy-ay). Ay-tach comes from the medical term V-tach, short for ventricular tachycardia, a rapid-fire, life-threatening heart rhythm disturbance.
Dr. Zubin Damania, a hospitalist (a doctor who cares for patients in hospitals) in Las Vegas and a well-known medical satirist who writes, produces and stars in his own videos as ZDoggMD, doesn’t use such terms. But he remembers hearing them when he was a resident at Stanford University School of Medicine in California, which is home to a large Hispanic population. “Oh yeah, they exist,” says Damania. “It’s big among the younger doctors and the residents and interns. It’s interesting because your first instinct is to think this is a racist kind of a moniker.”
Damania says that ay-tach is “a way of describing a slightly obese, middle-aged Latina who has some non-specific pain—a gall bladder or a functional [pain not caused by a recognized illness] abdominal pain where we don’t figure out what it is, or back pain. It also happens with pregnant women in labour.”
Dr. Peter Kussin, the Duke University Hospital respirologist, remembers similar terminology when he was a student at Mount Sinai School of Medicine (known today as the Icahn School of Medicine at Mount Sinai) in New York City back in the 1980s. “I can still get away with talking about how at Mount Sinai back then there
were rooms of four or eight patients,” Kussin recalls. “On the women’s rooms, you’d go in and you’d have Tachy-ay in one corner and Brady-ay in the other.” Brady-ay —based on a bradycardia, or abnormally slow heart rhythm—also is slang for a Hispanic patient moaning the Spanish word ay over and over, but at a much slower rate than the patient in Tachy-ay.
“We were pretty liberal in our use of slang—even at the limits of what would be acceptable,” says Kussin. “And then it disappeared.”
Kussin says that in the late 1980s, state regulators and professional organizations such as the American Association of Medical Colleges recommended that the use of slang be banned from training programs because it lacks professionalism and compassion.
“I don’t think it’s feasible to speak like that today,” says Kussin. “I think you have got to steer clear of race. You have got to steer clear of ethnicity. You have got to steer clear of gender.”
Damania says that status Hispanicus has started to disappear but he still hears ay-tach from time to time, mostly from doctors and nurses in the ER.
* * *
Doctors tend to like patients who are stoics more than we like those who demonstrate that the pain they feel is making them suffer. Having pain from a bona fide cause cuts no ice with many of my colleagues.
“When we say someone’s inflated their symptoms, it’s all our personal judgment,” says Georgia ER physician Dr. Jonathan Davis. “Of course, pain being a subjective thing, someone stubbing their toe could really feel as bad as someone with a ruptured aorta.”
Deep down inside, patients in status dramaticus probably know they aren’t dying. It’s just that they almost never admit it. They leave that frisson of doubt that maybe—just maybe—they do have a serious medical condition. I keep praying for a miracle of modern medicine that would have patients arrive in the ER with a sign on their foreheads that says something like “Symptom Exaggerator.” I’m still waiting.
Like me, Hood Nurse says triage nurses have to be on guard in case the patient with status dramaticus has a serious condition. “I think some people genuinely think something a lot bigger is going on,” says the inner-city nurse and blogger. “They’re just really freaked out and stressing, but for the most part, I think a lot of times people are just being ridiculous.”
Reinforcing the notion that status dramaticus is a performance, such patients raise their game in front of a live, captive audience of fellow patients, family members and bystanders in the waiting room.
“It tends to happen a lot more when the waiting room is full,” says Hood Nurse. “They just kind of see the writing on the wall and they want to get through the doors [to a doctor] a little bit faster.”
From her perch at the triage desk, Hood Nurse says, she sees patients with status dramaticus all the time. She says one—a young woman in her twenties I’ll call Wanda—came into the hospital complaining of abdominal pain. “Once we got her triaged, she was still trying to get up and roll around,” says Hood Nurse. “I’ve got visitors and housekeeping staff coming up to me telling me that this lady won’t get off the floor. She just refused to take a seat or co-operate in any way.”
Hood Nurse says she did not ignore Wanda. In fact, she left the triage desk to find the doctor on duty to order an injection of a pain reliever to make her more comfortable while she waited. But that didn’t satisfy Wanda. “She literally came up to the window in our little triage desk area. She was asking why she had to wait and I was explaining to her that we’ve got a lot of people here who are very sick and have been waiting a really long time—like eight hours.”
Wanda didn’t buy that explanation one bit. Frustrated at the ongoing wait, she became agitated. “She was literally having a hissy fit like a three-year-old. It was complete and utter meltdown.”
Triage nurses are nothing if not patient. They assess dozens of patients to see who goes in now and who can wait, keep track of those who have to wait hours before getting through the sliding doors, not to mention placate their families. Hood Nurse has seen many patients like Wanda and her abdominal pain—patients who demand to be treated immediately. The nurse says she has been spat upon and been subjected to verbal abuse.
What happened next was a bravura performance that earned Wanda the label status dramaticus.
“She just kind of very gently lowered herself to the ground and pretended to pass out,” recalls Hood Nurse. “I had to have my charge nurse come out there with ammonia caps [smelling salts] to get her to suddenly be ‘revived.’”
That certainly got the waiting room’s attention; every eye was glued on Wanda, every person wondering what was going to happen next. To the astonishment of many who watched her fall to the floor, Hood Nurse simply ignored Wanda after she was given the smelling salts. The tactic worked. “She figured out that her antics weren’t going to work,” says Hood Nurse. “She got up, sat in a corner, spent about an hour texting and then she unplugged her phone and went home.”
Hood Nurse is being modest. It takes experience to recognize that a patient like Wanda is in status dramaticus—and it takes guts to fend off bystanders who rush toward the patient to render assistance.
“This whole scenario plays out in front of all these visitors,” Hood Nurse recalls. “There was one guy who was really sweet. He thought she must have finally passed out from the pain. He offered to help to get her up off the floor. I had to reassure him that she was going to be okay. He was completely taken aback—just astounded that somebody would do that.”
A genuine fainting episode—not the kind Wanda had—is known by the clinical term syncope, a brief loss of awareness from which the patient recovers spontaneously and does not require treatment. Faints range in severity from a benign loss of consciousness called vasovagal syncope to a life-threatening form called cardiac syncope. Patients who experience the latter usually fall face first as they faint, and often break their noses or other bones of the face when they fall. For Hood Nurse, the fact that Wanda protected her face by sliding gingerly to the floor was the tipoff that she was faking it.
And faked fainting is not the only pseudo-serious condition that Hood Nurse has witnessed. She has also seen patients develop a case of something she and her nursing colleagues call spontaneous paralysis.
“Honestly, it’s not even that notable anymore because we get one per shift,” says Hood Nurse. “They act like they can’t walk. Or they’ll come in for some complaint that’s not related to paralysis and yet they require a wheelchair. They may come in with generalized weakness. Maybe they’ve been vomiting. They act like they can’t move, when there’s no physical reason why that should be happening.
“It often happens when they’re accompanied by family. They’ll act like they’re too weak to do anything. They want to go to the bathroom but they refuse to stand up. They make you lift them up on the bedpan.”
As with someone who pretends to faint, the hallmark of spontaneous paralysis is how quickly the performance ends. “The doctor will come in and tell them there’s nothing wrong with them and tell them they’re going home,” says the triage nurse. “They literally stand up and walk out of the ER.”
Unfortunately for ER physicians and nurses, very few dying swans or patients with status dramaticus or spontaneous paralysis get up and walk out of the waiting room. Most of them make it through the sliding doors.
A lot of anxious patients inhabit the ER. According to the Anxiety and Depression Association, 40 million Americans have an anxiety disorder—nearly one in five Americans aged 18 and older. Patients with an anxiety disorder are three to five times more likely to seek medical attention than people who aren’t anxious. All told, they cost the U.S. more than $42 billion a year. Add in stress-related illnesses and lost productivity, and the cost is close to $300 billion a year. The problem of anxiety is also reflected in high rates of consumption of anxiolytics (anti-anxiety meds) such as Lorazepam and Alprazolam.
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br /> There’s even a bona fide clinical term for what’s afflicting people who come to the ER repeatedly in search of reassurance about their health: it’s called health anxiety. While most people experience momentary jitters about their health or the health of a loved one, health anxiety is a more pervasive state of fear about disease and dying that becomes so preoccupying that it interferes with the ability to work and enjoy life. According to one report, up to 30 percent of the population experiences intermittent fears about their health; from 3 to 10 percent suffer from significant health anxiety.
The triggers to a bout of health anxiety include everyday symptoms such as a skipped heartbeat, a headache, a wave of nausea or a bout of abdominal pain. Like many ERs, the one in which I work has an area called the rapid assessment zone, or RAZ. The laudable idea behind the RAZ is to identify patients that we can assess, treat and send home without requiring a referral to a specialist or a stay in hospital. On the plus side, the RAZ concept has significantly improved our ability to see a large segment of the patients we see in very timely fashion.
Another thing I’ve noticed is that triage nurses have an uncanny ability to put many of the patients with health anxiety into RAZ—prompting one of my colleagues to say that RAZ really stands for “rapid anxiety zone.” Not a shift goes by without seeing a patient or two in the RAZ with health anxiety. The trouble is, these patients don’t come in complaining of health anxiety. They come in complaining of chest pain, shortness of breath, dizziness, heart palpitations, abdominal pain and sometimes nausea. The main clue to the true origin of their maladies is the fact that they are young and otherwise healthy. That rather vague observation is not much to go on.
The Secret Language of Doctors Page 7