A twenty-nine-year-old woman came to the emergency department complaining of numbness and inability to move her legs when she woke from a nap earlier in the day. She had pain in her neck and back, and was unable to feel anything from her waist down. She also had numbness of her hands.
She had been in a car crash four days earlier. After the crash, she was seen and evaluated at another hospital. She had no numbness or weakness at that time.
Though this story made no sense to me, I was still worried and launched into an aggressive evaluation that included x-rays and consultations with a neurologist and a neurosurgeon. Every thing came back normal.
I gave her a shot for pain and soon she was completely normal. She walked out of the emergency department in no distress.
The second crash victim was a forty-seven-year-old man who complained of having chest pain for years. He blamed the symptoms on a car crash he had ten years previously. He had been seen in the emergency department many times for the same problem. He had also been seen many times by his primary care physician, a gastroenterologist, a pulmonologist and an orthopedist. He had x-rays, CT scans and MRIs, none of which showed any pathology. He had seen many different doctors for this same problem and was sick of it. He came to the emergency department that night for us to get to the bottom of his problem. He didn’t want any pain medication. He wanted to be diagnosed and fixed.
He described the pain as being in his lower ribs bilaterally but worse on the right. He said it felt like his ribs were broken apart and were tearing into his intestines and diaphragm.
Examining the patient and getting his story were all I needed. There was nothing I could do in the ED that night to find the cause of symptoms he had suffered for years and for which he had already had many negative tests. However, I was unsuccessful using this logic to reassure him he had no physical problem.
In order to show me he really had a problem, he stood, raised his shirt and pulled in his abdominal muscles. Being a thin man, this caused his lower rib margins to stand out. They were a little asymmetrical. This, to him, was evidence of pathology he knew was there.
I finally had to resort to the line I use in situations like this. I said something like: “I am sorry. I don’t believe you have a physical problem and you cannot convince me you do. I am also not going to be able to get you to agree with me. So, we are just going to have to agree to disagree.”
Off he went, miserable and sad, and completely unwilling to entertain the idea that all of his suffering might be coming from his mind.
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