part0034

“There must be something wrong!„ Franco insisted. “Doc, I’ve got chest pain, I can’t breathe, I’m going to die, I can feel it!„ he shouted, starting to tremble. Franco paused to inhale a deep breath of oxygen from the mask adherent to his face, which fortunately muffled out the volume of his panicked outbursts.

Dr. Purcell, the ER physician, inhaled slowly and sighed, trying to calm his inner frustrations. “Mr. Miller, we have checked your heart, the tests are all negative, we should –„

“You must have missed something, check again!„ Franco barked. “You’re not hearing me! I want to call my father!„ he ordered, believing he needed an advocate.

“No problem,„ Dr. Purcell replied, heading for the door, thankful he could finally escape this uncomfortable encounter.

As he walked towards the nursing station, he reviewed the details of Mr. Miller’s presentation: 25-year-old male, central chest pain of two hours duration associated with arm paresthesias and shortness of breath … similar episodes in the remote past; episodes becoming more frequent of late. His cardiac enzymes were repeated and returned negative – this was not a heart attack , Dr. Purcell assured himself. Mr. Miller’s chest X-ray was normal, his electrocardiogram was normal, and additional blood work to rule out other conditions with similar symptoms was pristine.

His deliberation was interrupted by a commotion coming from Franco’s room. Upon entering, Dr. Purcell found Franco pacing the length of the stretcher.

“You need to give him something to calm him down,„ the nurse beseeched, “and his father wants to talk to you,„ she added, handing Dr. Purcell the phone.

“Ok, give him some valium,„ he ordered, while writing the dose on the chart and balancing the phone on his shoulder. From the other end, a male voice began berating accusations and threatening litigation for the inadequate and inappropriate care of his son Franco. Dr. Purcell, losing patience, hung up and stormed out of Franco’s room.

Security guards appeared at Franco’s door. Franco stopped pacing. He started to cry. “I just want help, I need to get well,„ he sobbed. He was discharged, escorted from the department and advised to return if things changed or worsened.

Despite consulting his family physician and investigations in the ER being negative, Franco was never reassured. “No doctor really knows what’s going on with me,„ he explained to the physician on his subsequent ER visit. “I’m so frustrated, I can’t understand why I have pain if it’s not my heart. I can’t stand not knowing what’s going on, why I feel this way. I can’t sleep at night now that my pain is getting worse. I’m so worried.„ The ER doctor charted in the diagnosis box: “chest pain nyd„ – denoting chest pain not yet diagnosed, meaning: not classifiable based on current diagnostic criteria. What it should read is “patient suffering not fully understood.„ The ER physician threw the chart in the pile to be signed off and moved on to the next patient.

It was late on a Friday night when Franco returned again to the ER. He was plagued by fears of having a sinister disease that doctors couldn’t diagnose. Since his last visit, he had not returned to work as a laborer in a furniture store, thinking the physical exertion might strain his heart. Likewise, he ceased his daily jog. At home, as tensions mounted; he and his girlfriend began arguing. Furthermore, without his minimum-wage income, Franco was no longer able to assist his mother financially, and as an only child, this was painfully burdensome. Franco felt guilty and useless. Concurrently, his chest pain episodes became more frequent and disabling.

That Friday night, Dr. Johnston was starting her third back-to-back night shift. As she trudged over to the nursing desk, already fatigued, the nurse slapped a chart in her hand, “Good luck with this frequent flyer,„ she smirked. Dr. Johnston never liked that term – frequent flyer. Although it simply referred to someone who repeatedly returned seeking care from the ER, it conveyed a negative, attention-seeking undertone. Dr. Johnston looked down at the chief complaint, printed in caps at the top of the chart: CHEST PAIN.

The nurse called over her shoulder, “I put his old chart on the desk for you.„ Dr. Johnston glanced over at a voluminous file folder, its papers askew. She glanced up at the rack of pending patients to be seen: empty. Her heart became lighter, “ Okay, let’s see what’s been done for this gentleman, „ she thought, ready to tackle the tome before her. As she digested the facts, she realized that Franco had previously had every appropriate investigation done over the past few months to ensure there was nothing life-threatening occurring within his body. His heart, lungs and gastrointestinal tract had been probed, poked and peered into. Nothing appeared abnormal, nor could the tests to date explain his symptoms. She read how he had called his father as an advocate, but that had escalated the already strained situation. Previous physicians felt unsafe in his agitated presence. He became verbally abusive. Dr. Johnston paused. “ Why is he convinced he is sick?„ she wondered. She strode into his room, determined to get to the bottom of things once and for all. Dr. Johnston pulled up a stool and sat down parallel to Franco’s bed. His hair was greasy, and his eyes fatigued, but he shook her hand with strength and forced a smile upon introductions. “Franco, I’ve read your chart, but I want to hear what’s going on in your own words. Why are you convinced that your chest pain is from your heart?„

“Well, doesn’t it usually indicate a heart attack?„ Franco asked. “Not always, sometimes it can feel like a heart attack, but can be the result of the mind’s response to stress,„ Dr. Johnston paused, giving him time to digest this. “How are things at home?„ she cautiously inquired.

“You’re the first doctor to ask me that,„ Franco replied. “I’m afraid. The fear of not knowing what’s causing the pain has taken over my whole life. I’m not the same person I was a year ago. I need to get better. My mom and girlfriend are relying on me. My dad is working out of the country; I’m the only one they have.„

“How long have you had the increased responsibility of caring for your mom?„ Dr. Johnston asked.

“For the last four months,„ Franco admitted. “What if –„ “Just a minute,„ Dr. Johnston interjected. Although not usually wanting to interrupt a patient, she didn’t want him to get worked up, and so she probed on in a different direction. “I realize you have ‘what if’ concerns … what-if you never get well again – I’ve read your chart … but ‘what if’ I could help you get better?„

Franco looked up from the bed. His voice quivered, “Really, you can?„ “Well, let’s review what’s been done.„ Dr. Johnston walked him through step-by-step investigations and clarified how a physician rules out diseases. She explained, “You’ve had all the tests necessary to confidently exclude a heart attack and other life-threatening conditions.„ Dr. Johnston itemized the tests and what they ruled out and why she could, with assurance, confirm the absence of organic pathology as the source of his chest pain. “What we haven’t excluded yet is a diagnosis of panic attacks,„ Dr. Johnston suggested. Worried he may become defensive, she continued on, “These can cause as much chest pain and fear of death as a heart attack, but the good news is there is treatment for this and you can continue working and jogging and helping your mom.„

The first tentative smile emerged. “I never thought of panic attacks, but it makes sense, my mom has them all the time.„

Dr. Johnston remained in the room, seated at his bedside for another 30 minutes. It was so quiet in his room that the nurse came to check o n

Dr. Johnston’s safety, only to find the two absorbed in conversation, appearing as friends and allies. Indeed, an alliance had formed, and together they were devising a management plan.

Dr. Johnston had perceived Franco’s anxiety but couldn’t understand it. Instead of ignoring this incongruence, she explored it, without preconceived notions. She attentively listened to Franco’s symptoms, validated his concerns, respected and addressed his fears and en route, gained his trust. He valued understanding the process of diagnosis and how physicians could confidently rule out diseases he was worried about. This time, he was reassured. He had been heard and he could now hear the physician’s advice for treatment. Previous physicians had focused on ruling out diseases, without attempting to heal his suffering through communication. The faith he had lost in his care and his health care providers was slowly being restored by Dr. Johnston’s meticulous explanations. It was a mutually satisfying visit, and the last one for Franco for a very long time.