Hmmm......?????

In the States I worked in the ICU and in the ER. While I love taking care of super sick patients, toward the end of my time there I really came to love the ER. I loved being bored one second and then crazy busy the next.....never knowing what was going to walk in the door.

The hospital I work at here doesn't really have an ER. During the day they have an outpatient clinic which everyone goes through and the man running the clinic decides on the treatment plan and who will be admitted to the hospital, etc. The outpatient clinic closes at 5pm though, so after that the bench outside of the nurses station kind of serves as the ER. The patients that come after five are seen by a nurse and either given minimal treatment and told to return to the outpatient clinic in the morning or are admitted, stabilized and wait to see a doctor in the morning. Since I am working evening shift (3p-10p) my partner in crime and I see the patients that come after hours.

So last night it was kind of slow (I know, the word you never EVER say in the ER). We were sitting on the bench outside the nurses station when we saw a man being carried by a few friends of his coming down the hallway. (Note: small jump in adrenaline here....) :)

His friends sat him down in the bench and I started getting his vital signs while my partner started asking what happened. Here's the story. Apparently this guy was in bush working on his farm. He heard a voice call his name but didn't see anyone....and he got scared. He walked back to the village and his friends found him in this state. Wait. What? Chief diagnosis: being scared?

He is sitting on the bench saying "why, why, why, why" over and over. Vital signs: BP 124/82 (normal) pulse 112 ( a little high but nothing to write home about). He was breathing about 40 times a minute which is pretty fast but his lungs were totally clear. Denies abdominal pain. So his vitals look pretty normal except for his breathing. When I asked why he is breathing so fast, they can't tell me. When I asked if he's in any pain, they said that he was complaining of back pain and then pain all over his body.

I'm confused.

So, he was in the farm working, heard a voice, got scared and is now breathing really fast, can't walk and is having back/generalized pain. Huh? I felt like I was missing something.

"So he was scared then, but what is his problem NOW? Why is he here now?" I ask his friend.
"Well look at him, he's sick!"
"Ok, but his vital signs look pretty normal (his breathing had slowed down at this point). You said he is having back pain. Is this new? Did he hurt himself while he was working?"
"Well he had an accident 12 years ago and has had back pain one other time but he did not hurt himself while he was working. He just walked back to the village and was like this."
"So he didn't hurt himself?"
"NO!" (Friend getting a little frustrated with me at this point because I'm just not getting it).

I do a quick neuro exam and look at his pupils. When I open his eyes they are initially looking straight ahead but as soon as I open his eyelids they roll back. He's able to follow commands (like when I tell him to stop saying "why, why, why, why") and when I ask him to stand up and walk he does so, although shakily. Alright, I think I've got it figured out. I've seen it in the States a few times and these patients always seem to come in when I'm really busy with other critical patients. It's called "Take me to the hospital because I want some attention" disease. It drives me crazy.

I know, I know. I need to work on my compassion because obviously something's wrong if they feel like they have to fake a disease to get some attention but I've always struggled being patient with these people because I find it really annoying. God's got some work to do on me yet.

Anyway, cynical ER nurse that I am after I decided what was going on I was irritated. I didn't want to give this guy the attention he what he wanted so I told him that we would give him a shot for the pain and some medicines he could take at home and he could follow up with the outpatient clinic in the morning.

His family did NOT approve.
"You can't send him home like this! He's sick!"
"Ok, what's wrong with him?" I ask. "I can find no medical reason for why he's acting the way he is."
"But he's sick!"
"But WHY??? If you can tell me something else that's going on, I'd love to keep him here but I don't see any sickness!"
"But you have to keep him here!!!"

After going back and forth for a little while my friend decided that we'd keep him here overnight for observation. Fine. Whatever. Faker.

The next morning I was discussing this case with a doctor who's lived here for years and he said that this isn't actually all that uncommon. People will come in after seeing something or hearing something and just be terrified.
Now I felt sheepish. Maybe this guy really WAS just scared! The fact is, that the spiritual world is VERY real here, and very real to these people. In my ignorance (combined with probably a little arrogance and cynicism) I'd brushed aside this guys fear and decided that he just wanted attention. Humble pie for breakfast.

In moving here to practice medicine, I had to add a lot more diseases to my list of differential diagnoses due to the tropical stuff we get here that I never saw at home. And although I have always tried to tend to the spiritual needs of my patients, I think might look a little different here.
I'm happy to say that the patient did end up going home....with no medical diagnosis ever given. Hmm.......