Clinical Cognition

vivianimbriotis | Jan. 22, 2025, 6:23 p.m.

"My jaw hurts!"

"Hi," the words rote, mind still on the last patient (bipap, intubated, arrested, died), "my name's Viv, I'm one of the emergency doctors. Tell me about this jaw pain." My eyes feel gritty.

"What do you mean?! It hurts!"

Right, so much for open questions.

"When did it start?"

"Well I've had it for a while now, but it's gotten worse!"

"What does 'a while' mean? Days, weeks, months, years?"

"Oh, probably just today. No wait, it happened a few times yesterday and the day before, but then got better."

We natter along - the pain isn't really "sharp" or "dull" or "heavy" or "cramping", it's "bad". Doesn't radiate. Not triggered by anything. Not worse with eating. This is going too slow.

"Any other problems?"

"Bit of a headache."

Shit, giant cell? Right, Viv. Open question "Tell me more about that" answered with a shrug, okay fine, now explode the symptom. Just like medical school.

"When did that start?...where in your head? nauseated? changes to your vision? weakness? changes to sensation? noticed anything strange when you brush your hair? fainted? any funny turns?"

Okay clock's ticking. Waiting room filling up while I'm here. Politeness levels falling as the review continues.

"Do you have any medical problems?"

"No, none at all." Bullshit.

"Are you on any regular medications?"

"Oh yes, I can't even remember them all. Here--"

Ah yes, a Tupperware box filled with - aha, brown paper bags with loose, unlabelled pills. A box of lasix that went out of date in 2011. Kilograms of paracetamol. I want to go home.

"You take all of these?"

"No, I don't take the blue ones except on every second Friday, done that for years now. And there's a puffer in there but I don't use it because it made my asthma worse."

Based on a story written in pharmaceuticals I assign some acronyms (COPD, HTN, GORD, CCF) and move on.

"Mind if I listen to your chest?" They never do.

There's a heart in there. There's a murmur. There are lungs which sounds like most lungs. I waste some time feeling this blokes temporal arteries and checking his eyes, his lymph nodes, his sensation. Belly soft, ankles puffy. Need to move faster.

Blood tests taken, sent to lab. The boss is busy, can't talk to them. Rub my eyes. Feel clammy. Haven't eaten. Look at the waiting room - chockers. Chest pain, abdominal pain, mental health crisis, possible stroke. Take a moment to feel overwhelmed. Grab the boss as they walk past.

"Hey I've got a 66 year old guy with a three day history of jaw claudication that I think might be from giant cell, or --"

"Does it hurt when he eats?"

"No, it's more random--"

"That's not jaw cladicstion. It's just jaw pain. Especially if it doesn't involve the temporalis. Work him up for ACS." AKA heart attack (but can't resist another acronym). I feel quite irritated that I have worked so fucking hard on my history and exam, and the boss has no need of any of that to make a determination. Must be bullshit inference. This guy doesn't know Bayes Rule, he hasn't heard of the Many Armed Bandit Problem, he hadn't read Jayne's. I want to go home. I should have stayed in science.

I pick up a lady with some abdominal pain and condemn her to the scanner. Brain-turn-off medicine. Meanwhile, someone in ED is screaming for help. How long have they been screaming? How did I get so good at tuning out agony? I pop my head into her room and promise to get some some pain killers. Can't find a nurse - someone is sick in resus, no one is on the floor. Can't get narcotics out of the locked cupboard on my own. Give up.

I look at my computer screen - troponin 300. Goddamn it. ACS.

I call cardiology and personally go break the news along with a tablet of aspirin.

"You've saved my life today," he tells me. "You were so thorough." No I wasn't. I was inefficient. Wasteful. Arrogant. Stupid. This was a failure.

"Thank you," he says, eyes locked with mine. He needs to believe it, it's an important narrative for him. I nod and go check the waiting room.

Six hours later, I walk past his bed and pop in for a chat. His pain is fine. I tell him he can't eat anything after midnight and then check my phone - 11:37pm.

"I'll be right back."

The ED fridge is empty so I sneakily steal an armful of sandwiches, yogurts and juices from one of the wards, attracting a few curious, red-rimmed glances from my fellow night staff. I return to the ED bay and dump my trove on the bedside table.

"Oh wow, you even found dessert! Thank you!"

This time it feels kind of good.