Consult-Liaison Education Lessons Medicine

Red Herring (I).

I sat in the emergency room and flipped through a magazine. I wasn’t actually reading; it was a way of distracting myself from all the noise.

Three hours had passed. No one had seen my patient yet.

The nurses, bless them, were kind to my patient. They brought her food and noticed that she was taking gigantic bites, but not swallowing any of it. The pocket of food in her cheek expanded and desperation stretched across her face.

“You don’t have to swallow it if you don’t want to,” I said, worried that she would inhale the food. “You can spit it out.”

A nurse saw us and grabbed some paper towels. “Here, spit that out. I’ll get you some soup. You look like you’re struggling to eat that.”

My patient obediently spit out the wad of food and looked relieved.

“Can you please document that in your notes?” I asked.

“Of course. I’m sorry that no one has seen her yet. Do you want another magazine?”

“No, I’m okay, thanks,” I said. She nonetheless returned a few minutes later with two magazines from last year.

Three hours earlier, I had shared a clipped account of her history to the triage nurse and she sent us to the medical side of the emergency room. I supported this decision, as I wanted my patient evaluated for medical concerns. That was the chief reason why I went with her. My patient would not be able to describe the problem. She’d say she was fine.

Upon learning that I was a doctor, the unit nurse pulled the emergency room attending physician away from a computer and asked me to talk to her. I immediately launched into my patter, summarizing why we were there.

I saw it happen and almost wanted to laugh: Her features hardened. The muscles that allowed any possible soft expression on her face tensed up. Her face showed nothing but muted anger.

“I don’t even know if I will see her. I’m going to go away now,” she said at me. As she was walking away, I heard her mutter, “Why didn’t she go to psych?”

During my entire time in the emergency room, she never came near us again.

My patient did not want to go to the emergency room.

“But we have to,” I said, trying to sound calm. I wished I didn’t feel as frantic as I did.

“I don’t want to go,” she said, literally hopping from one foot to another. She wrung her thin fingers together and fear overwhelmed her face. Those sunken temples seemed to sink further as she frowned.

“I know you don’t want to go, but we have to,” I said, pointing at the scale. “I said that you would have to go to the emergency room if your weight dropped below 100 pounds. Remember?”


“What is your weight today?”

“99 pounds.”

“And what did I say would happen if your weight dropped below 100 pounds?”

“I’d have to go to the hospital.”

“That’s why we’re going to the hospital.”

“But I don’t want to go to the hospital.”

“We’re going to the hospital. I’m coming with you.”

We sat next to each other in the back of the car.

“You’re coming with me, right?” she asked, her eyes looking abnormally large in her head.

“Yes. I am going to be with you until a doctor sees you. I want to talk to the doctors directly, too.”

I had written up a document that summarized pertinent information about her: name, birthdate, diagnoses, medications. I wrote down the details about how her weight had fluctuated over the past year, how she went to a different hospital just six months prior for the same reason. I wrote how she had needed two blood transfusions, how they had dropped a camera down her esophagus to look around for disease. Except for mild inflammation, everything was normal. I wrote that I had reduced her psychiatric medications; she didn’t need to take so many. I wrote that she was fine, that her psychiatric symptoms hadn’t changed in months. I shared my fears that her symptoms were due to medical reasons. I didn’t want the hospital staff to follow the red herring that was her psychiatric diagnosis.

Back in the emergency room, the nurse had asked her to take off only her shirt and put on the hospital gown. My patient peeled everything off with no shame. As she pulled herself onto the gurney, everyone saw her gaunt buttocks through the gown flap.

The hours passed. The emergency room was busy. More gurneys were pushed into the room and people were muttering, screaming, upset.

She looked at me. I smiled with my lips, but not my eyes. We continued to wait.

Part one of an ongoing series. Read more for