Caeser’s forum: Sometimes things are not as they appear

Dave Caesar, clinical director of emergency medicine, Edinburgh Royal Infirmary and St John’s Hospital, Livingston, looks at the importance of communication

The trick is to breathe easy

IT is an unusually calm Wednesday morning in the emergency department, and I am working in the ‘minors’side, where we see most of the patients who make their way to hospital with bumps, bruises, scrapes and sprains, minor illnesses and the occasional curve ball.

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I say most, as some of these patients may well need a more involved assessment in our ‘majors’ area, and some may be asked to see their GP instead.

The tranquility is shattered by a fracas near the reception desk. I make my way out to see one of our junior doctors, a lady who scrapes five feet tall and is one of our more timid colleagues, being shouted at by a gentleman who must be a good 15 inches taller than her and who has arrived at department with a lump on his chest.

“She’s calling me a druggie! Wha’s goin’ on, man?”

He is not happy, pacing around and breathing hard – it’s time to defuse this before it gets out of hand.

“Come with me, sir, and I’ll see what we can do for you.”

Out of the waiting room, into a private cubicle space, eye-to-eye, look and listen hard, and get to the root of the problem.

It would be fair to say that this man was not born with a silver spoon in his mouth. He bears the bodily and emotional signatures of a man who may well have a history of substance abuse, chronic poor health and social deprivation. Having clocked this, I am always mindful that patients displaying these characteristics are that much more likely to have a serious disease process, but can be more difficult to engage with and convince of the right treatment despite this.

He tells me that he came to the emergency department because of “this lump, man”. He shows me his chest, and points to the lump. He says it has been there for “weeks, man”. “I was tellin’ that lassie and all she asked was if I injected.”

Probably not the right tactic for a meaningful doctor-and-patient relationship – however relevant – I’ll have to have that conversation with her later.

I look at the “lump” and for the life of me can’t see one. Now what?

I ask him again, and what he shows me is his lower ribcage, which, when you compare it to the other side, is a little prominent. I listen in to his chest and note that the air entry to that left side is absent. This is starting to make more sense now.

We get him a chest X-ray and it confirms our suspicion that the lung on the left side of his chest has leaked air into his chest cavity.

In fact, it has leaked so much that his lung, which may normally have around three litres of air in it, has been compressed to the size of a golf ball. It is all this leaked air between the lung and the chest wall that is pushing his ribs out. This also prevents the lung from expanding, so he is unable to breathe freely, and his brain will be deprived of oxygen – one of many causes for agitation and aggression.

We move him to one of our procedure rooms, and drain the leaked air through a tube inserted through his chest wall. He does not transform into Lord Fauntleroy with full use of both lungs, but a potentially life-threatening condition has been treated.

Emergency Who’s Who

ONE of the many interesting things about working in the emergency department is that nearly everyone you speak to, from all walks of life, has an opinion about which patients should be there, and which should not.

The difficulty is that very few patients come in with their diagnoses pre-determined, and that all patients who do attend believe – rightly or wrongly – that they are having some sort of medical or social emergency.

Teasing out which patients with which conditions need a full assessment and rapid treatment versus simple reassurance, or even redirected to an alternative setting, is one of the key skills of the emergency department team, and one that we are uniquely trained to execute.

Take our patient above as an example. Many onlookers may have viewed him kicking off in the waiting room as an aggressive time-waster who deserved to be removed from the department with no further assessment. If that attitude had prevailed, it may have been a death sentence for him.

His was a rare but genuine case, but highlights the importance of giving all patients due consideration, even if that assessment ultimately requires the patient to be seen in another setting.