It rained heavily all morning and when the storm finally abated, patients came flooding into the Emergency Department. Each day in the ER, a common complaint or mini-epidemic seems to emerge. Today we had our own deluge: chest pain. In less than two hours, I had treated three patients who complained of pain in their chest.
Each patient had received an evaluation including an electrocardiogram, a chest X-ray and blood tests to check for signs of a heart attack. One of the three already had strong evidence of a heart attack and was simultaneously being treated medically and prepared for a surgical procedure to open a blocked blood vessel to his heart.
Once the patient's condition was stable and the cardiology team had taken over, I breathed a sigh of relief. It was early in my shift, but I already felt the fatigue that sets in when danger has passed. I thought wistfully about crawling into bed and calling it a day. I tentatively reached to pick up the chart for my next patient. The chart announced a 28-year-old female with no past medical problems. My spirits rose. Something straightforward, I thought with relief. Then to my dismay, I noted the patient's complaint: "chest pain."
I entered the small white exam room and closed the door, hoping to diagnose a case of asthma, rib inflammation or some other common and highly treatable ailment that is often the explanation for chest pain in young people. Given the events of the morning, however, the possibility of another patient with a heart attack lurked steadfastly in my mind. I greeted my patient with the intensity of a fireman responding to a fire.
The young woman responded quietly, and aside from a sad look in her eyes, she appeared to be the picture of good health. She had flawless honey-brown skin, sculpted cheekbones and rose-petal lips. Even her smallest movements, such as smoothing imperceptible wrinkles from her sweatshirt, were done with the grace of a dancer.
Not a likely candidate for a heart attack, but I remained unconvinced, aware that heart attacks are more often missed in women. I began quickly and methodically reviewing her symptoms, listening to her heart and lungs and pushing on her ribs and stomach to see if I could elicit any pain.
Throughout my questions and evaluation, the young woman alternated between looking at the floor and gazing sadly at her husband, a handsome man with broad shoulders and a mustache. He sat in the corner, hunched over and brooding. I had seen this kind of interaction before, in the case of women who had been abused by their partners.
Gently, I asked her husband to leave the room so that I could complete my exam. He acquiesced with a nod of his head and stepped into the hallway, shutting the door behind him. I asked my patient more personal questions. "Has your husband ever hurt you in any way--physically, emotionally--psychologically?"
Definitely not physically, and he had never been abusive, she told me.
Sensing something omitted, and struck by the way she had cradled hands over heart as she had explained her symptoms, I softly enquired:
"Are you and your husband OK?"
The answer was no.
She cried. She explained that she was suffering not from heart attack but heartache. Her husband planned to leave her; he no longer felt the excitement he did when they married a decade ago. He believed he had found someone else, someone who could make him feel happy again.
Ever since he broke down and told her these things, she had a sick feeling in her stomach, an ache in her chest and trouble sleeping. I invited her husband back into the room and he verified her story. They both looked at me scared, wounded, hurt.
I hadn't expected this, especially here in the emergency room. I have at my disposal an arsenal of impressive machines, state-of-the-art technology and potent medications--all designed to deal with the vicissitudes of bodily malfunctions. Yet suddenly I felt so ill-equipped, so vulnerable.
I faltered and began to recite my standard set of recommendations for the physical manifestations of stress and depression.
"Perhaps you should try some morning sun, exercise, spending time with friends or others who can offer support .... You might consider marital or personal counseling." I continued my litany of various treatments for acid stomach and "heartburn," which may contribute to chest discomfort in times of stress. Take special care to avoid accidents and injuries, which are more common when one is sad or in mourning.
Then, somehow, I was no longer in "clinician mode." My tone became gentler and the words seemed to flow from a deeper source, perhaps from the echoes of conversations I have had with patients as they approached the end of their lives. Over time, these patients have shared with me the collective revelation that for all one has done in life, what truly matters in the end is the love and relationships that one has shared.
"You have had nearly 10 years of marriage and a 6-year-old daughter with this lovely woman," I explained to the husband. "She is your best friend, and you are hers. Be certain that you are making the right decision before you go your separate ways. And if you do part, then do so with respect, love, kindness and great somberness, because there are few people whom we will love deeply in our lifetimes. Whether it is in a year, in 10 years or at the end of your life, you may look back and say, 'Wow, I really loved that woman."'
His face softened, he turned quietly and looked at his wife. I saw that despite my clumsy words he had understood.
I can't say that what I told them today made a difference. They left, walking close together, and I doubt I will see either of them again. But the imprint they left on my mind is indelible. I was moved that they opened up to me and honored that they listened carefully to my reply.
It is the great secret of physicians that in the service of treating the human body we are often rewarded with a glimpse of the human soul--even if it is only our own.