Dr Rosie RileyAll patient identifiable information and some details have been changed.
The emergency department is heaving and noisy, but we’re doing well. The waiting time is now down to 3.5 hours from 5.
Next patient I see is a young woman with chest tightness and palpitations. She says the sensation of her heart racing woke her from sleep this time and she thought she was having a heart attack. These attacks are more frequent now and getting stronger. Her GP has investigated these events with a 24 hour ECG and ultrasound of the heart, but all seems well, and reassuringly she doesn’t have any symptoms when exercising or risk factors for heart disease.
Air entry into her lungs is clear and I can’t hear any worrying murmurs. No peripheral stigmata of disease. Her ECG shows her heart is running normal speed, with the right action from the heart chambers occurring at the right time, in the right order. It’s normal.
Her 1 year old daughter is with her, playing happily.
I’m reminded of when I was a fourth year medical student. I saw a young woman with mild abdominal pain when I was on placement in the Emergency Department. The mildness of her symptoms had confused and annoyed me. Why was she here with 2 months of abdominal pain that hadn’t changed?! Was she not aware that it was winter and had she not thoroughly considered the NHS’ finite resources? A&E was for emergencies. I hadn’t yet graduated, yet was so entitled to judge who came and went through this hospital. But I’ll never forget her.
As I presented her history and examination findings to the Consultant, ensuring he knew full well that I was not impressed by her health seeking behaviour, he gently suggested that I look beneath the presenting symptoms. Why was she here, really? It’s not really about the mild abdominal pain. It hadn’t been.
Humbled, more gentle and decidedly shouldering less of the full burden of NHS resource allocation, I sit here today. “How is everything at home?” She hesitates and her body language changes. I know what this means and I know where I need to go. It would be easy to feel like I can’t ask these things, that perhaps she’ll be offended or she’ll laugh it off. But she knows I want to know what’s going on. She knows that I care about the answers and that I’ll believe her. Rapport, body language and a safe space are our allies. This is where the doctor-patient relationship is truly wonderful.
She tells me that she’s been quite stressed recently. She’s a single mum and having to work hard to pay bills. Perhaps it’s anxiety causing these symptoms.
Silence.
Her ex-partner and father of her child has been shouting at her. More than normal. He has done for many years, but it’s been terrible for the past two months. She starts to cry and I take her hand. Her daughter saw and heard him shouting. He can’t control what he says when he’s angry.
Silence.
I’m aware that every moment of this is precious. She’s never told anyone before, but today she’s decided to make someone a steward of her vulnerability and her secret. She’s been hugely courageous and I will not waste this time.
“I believe you and I think you’re amazingly brave to have told me today”. Her shoulders relax and a weight has lifted. In this precious space I ask about physical and sexual abuse, whether she feels threatened now and whether he has ever threatened or harmed her daughter.
The answers come, all in her timing and control. Gently, I suggest that his behaviour sounds abusive and is never OK — what does she think of that? She nods, agrees and cries again.
We slowly discuss details of available support and the importance of finding a kind GP to walk her through this journey. She acknowledges that I have to discuss her daughter with social services and the paediatric senior nurses. She consents to an adult safeguarding referral. Once everything is done, both she and her daughter are safe to go home. A bag will be ready with ID, money, a change of clothes for her and the little one, by the door, just in case.
The waiting time is now up to 4 hours. I take a deep breath, and get ready to see the next patient.