Exaggeration

If you bring your teenager or young adult child to the ER and that person helps “sell” your symptoms to me, I feel sorry for both of you.

Today, I saw a 42-year-old with chest pain and shortness of breath. Her daughter described how Mom “couldn’t breathe” when she woke up, and Mom reported her breathing got worse all day. You probably picture someone struggling to breathe based on that description—i.e., could not breathe in the morning, and now at 3 p.m., it’s worse.

You would be wrong. The patient was breathing as comfortably as I was, speaking in full sentences, with a heart rate of 55, normal respiratory rate, and oxygen saturation. Clearly, she was not in distress.

I remembered this patient. She had a callus last month when I saw her. (Yes, a callus.) Oh yeah, and she needed a work note.

I feel sorry for both of you because you and your daughter are not living in reality. “Can’t breathe” sounds quite extreme. At the very least, it sounds serious. But this patient was in no way seriously ill. Somehow, collectively, they had turned minor symptoms into crisis symptoms. It was apparent in the earnestness of the daughter’s voice as she described her mother’s pain and difficulty breathing that this was clearly an emergency.

But it wasn’t. I felt like I was being punked. I was wondering where the camera was because, as the three of us sat and talked, there was no urgency whatsoever to the situation except for the description of things that were not real.

When you’re really sick, you don’t have to convince me. I can tell. You don’t have to “sell” your symptoms, and in most cases, when you are trying to draw my attention to just how sick you are, it reinforces to me that you are not sick. This daughter was also adding things her mother didn’t say, but things that sort of don’t add up. She was talking about how her mom had some terrible pain in her back yesterday but was still able to do all the cooking and preparation for Christmas dinner. Medical emergencies don’t respect holidays. If you’re actually ill, you usually can’t do all the things it takes to make Christmas dinner.

So, I have to play along with the charade. Calling out what appears to be complete nonsense based on my years of training and experience, combined with her objective vital signs, isn’t enough for patients. The caveat is that I can’t feel what she feels. She tells me she has severe chest pain, can’t breathe, and her chest feels tight. I can’t prove or disprove any of those things. I can say she looks well and point out the reassuring vitals, but me calling out the nonsense is the equivalent of telling your spouse to calm down in the middle of a heated argument. It never goes well!

Instead, I massage the conversation. I point out from the very beginning that we’ll look for the usual life threats and concerning things but may not find any disasters. When I report back as the results come in, I again suggest that we aren’t going to find an answer. “The EKG looks fine, your chest X-ray looks good, all the blood work, including the test for any heart damage, is normal.” I even add again before I send her home that I rechecked the EKG and CXR (because I actually did) and tell her again, “I’m not finding a good reason for your symptoms, but we didn’t find any disasters, so you’re safe to go home.”

That’s when she adds, “Oh, can I get a work note?”