Letter to the Editor
Reading Dr. Ravi Morchi's recent Diagnosis Deconstructed column made me think of my favorite question to middle-aged patients whose diagnosis is not clear. (“An African Tribe and the Most Vital of Signs,” EMN 2011;33:13.) When was the last time you saw a doctor? Or, when was the last time you came to the emergency department?
When the answer is in decades, even the man in the street would know something is wrong. Most people have had a twisted ankle, a deep laceration, a bout of abdominal distress, or a bad headache, yet they did not seek medical attention. But this time, they have made contact with the medical system or emergency department, and something is really wrong.
When I arrived for the day shift, a 72-year-old man had already been in the ED for a few hours. His “workup” was complete, but the attending physician had no disposition on him. Via phone call from the physician's sleep room, he told me everything was done, and all I had to do was call the family doctor. It had been a quiet night; there were no other patients in the ED. I made it clear to the sleeping emergency physician that he ought to finish the patient before he left, but I did review the chart and check the KUB (which did not include the domes of the diaphragm).
And then I spoke with the patient. He was a milkman, who had never stopped delivering milk during his entire work history. At 2 a.m., he drove his full truck to the ED because of severe abdominal pain.
Though now he was resting comfortably on the gurney and thinking about returning to work, I explained that we needed to do another x-ray, which showed that there was free air in the abdomen: a perforated ulcer.
Elizabeth Nolan, MD, PhD