the mondays...

It is a universal truth that Monday is the absolute worst day of the week to present to an emergency department. Somehow, the gravitational forces of the universe align to draw the maximal number of people into an already overcrowded waiting room. And yes, everyone in the waiting room happens to be sicker than you are. In fact, I often tell patients that a long wait is a good sign in my line of work. It likely means that your vitals signs are stable and that you have a statistically lower chance of dying. If you have the misfortune of coming in on a Monday night, and you're brought straight back to a room, it's time to start worrying...

Last night was no different. I came in to a department in shambles. The wait times were up to 7 hours with no end in sight. Patients streamed into a crowded waiting room filled with patients too sick to be angry. A few patients at a time kept coming up to the desk, glaring at the triage nurses, and walking away. Welcome to Monday night. I wasted little time. I plucked a blank sheet of paper from the printer, folded it into fourths, whipped out my pen, and went to work...

Everyone comes to the ER wanting something. Pain medicine. Reassurance. Testing. Hand-holding. Some come to make sure they're okay. Others come because they're already sure they aren't okay, and want me to confirm it. Some come for pity. Attention. Others are more pragmatic with their needs. Antibiotics. Medication refills. Work excuses. Disability paperwork. Documentation for frivolous lawsuits. But often, I run into good, honest people that just come to be heard... People that have asked themselves why bad things happen to good people. And as I sit and listen to them, I lose myself in their lives. Life is, after all, a mystery. People, yes even good people, happen upon bad things...

I looked at the board. I groaned. Chest Pain. Chest Pain. Abdominal Pain. The next chief complaint read four letters: "SICK." I walked to the far corner of the ER to room 36 and was surprised to find a pleasant, smiling 61 YO woman sitting calmly with her daughter. She appeared comfortable and in no visible distress. Knowing that she had already been waiting for 3 hours, I walked in, summarily apologized for the wait, washed my hands, and shook hands with her and her daughter. I introduced myself and quickly sat down. She explained that she had a lump in her breast. When I asked when this started, she said "Days." I sat still. Silence often forces reconsideration. After a few seconds, she contemplated, and then nonchalantly filled in, "Well, maybe it's been longer..." It was a more decided tone. "Several months..."

"What changed that made you come in today?" She explained that over the last few days, the underwire of her bra had irritated the breast tissue and that there was an area that was draining. Again she corrected. "Maybe a few areas." As I lifted her gown, I explained that we should probably just take a look to see-

The breast was an angry, red mass of tissue with mutiple areas of ulceration and drainage. I placed my hand to her chest and felt her breast - a sack of smooth stones beneath a thick rind of skin. "Peau d'orange" skin. The ominous French term referring to the dimpled appearance of a breast inflicted with inflammatory breast cancer. This was bad. So bad I didn't need to be an Oncologist. It looked locally invasive. Her daughter, nervous, looked over in a state of horror. Her mouth opened and the words seemed to die in her throat. She was awe struck, and fought back tears as she stood behind her mother. She looked away. I looked up at her as she let out, "She never told us... she never said anything... she never even complains..." The next 2 hours were filled with labs, IV antibiotics for infection of the tissue, and discussions about the possibilities - discussions about cancer. What lay in store for her was a dizzying array of outpatient testing: mammography, core biopsies, CT scans of the chest, abdomen, and pelvis, CT PET imaging, Node sampling. I don't know how much either registered after the word cancer. I promised that I would order some of the necessary CT scans to expedite her workup and get things moving.

Minutes later, I got a call from the radiologist asking why this patient needed multiple CT scans. He academically explained that a malignancy workup should be done as an outpatient, that she didn't need this done in the middle of the night, especially by an overworked radiologist. I offered up that patients in the ER often come in after neglecting issues for a long time and may not follow up as instructed. He pleaded that he was already so far behind with ER studies. He knew too, that I was far behind. "Don't you guys have a long wait already?" Painful, but true. He was right. A long ER wait on a Monday night is not just a possibility, but a certainty. In the end, he swayed me...

I held off on discussions of neo-adjuvant therapy, radiation, chemotherapy, and possible salvage mastectomy. Instead, I gave her a dose of IV antibiotics and a prescription for Bactrim. I gave her the name of several of our top oncologists and surgeons and tried to reinforce that she needed immediate follow up. I discharged her and kept moving through the Monday night traffic. By the end of the shift, I was irate. Perhaps I was angry with not doing what I thought was right. Perhaps I was angry for not doing what I wanted. After all, I hate being told what to do. I mean, if it was my mother in Room 36, would I have let her walk out the door after 6 hours with only a script for antibiotics? As I drove home, I kept asking myself when doctors stopped being doctors...

The next day I woke up and thought to myself, maybe the radiologist was right. I was getting to attached. What sense would it make to keep her in the ER for another 4 hours getting these tests? I mean, after all, you really can't do this job without a certain level of detachment. A certain objectivity. She would get the studies she needed and she would follow up as we discussed. Of course she would. As I got to work the next morning, I sleepily dialed her phone number to follow up with her. I wanted to find out who she was planning on seeing, and what plans she had already made. Mondays can be so painful. I was still recovering from last night's shift and didn't even register when the automated voice clicked in... "We're sorry. You have reached a number that has been disconnected or is no longer in service. If you feel you have reached this number in error, please try again." Please try again...