NOT ONLY THE EGYPTIAN RIVER - Part One

"Eighteen year-old female c/o abdominal pain," read the Chief Complaint section on the emergency department treatment record that I picked up in the midst of a busy evening shift. The venue was John C. Lincoln Hospital in Phoenix, early in my civilian days of emergency medicine practice. I was not residency trained. None of us were, because EM residencies barely existed in those days. We gleaned our knowledge base mostly from the trusting patients who sought our care. I worked about 192 hours a month, single coverage. I saw a many women with abdominal pain, but never anyone like this lady, from whom I learned several valuable lessons.

Approaching the bedside I observed a young, very obese woman in obvious distress, holding both hands over her lower abdomen. In between her paroxysms of pain, I asked the usual questions intended to quickly identify any potentially life-threatening source of her abdominal pain. When first evaluating a patient, regardless of presentation, the emergency physician must immediately look for badness, especially treatable badness, and intervene appropriately if warranted.

Abdominal pain infrequently harbingers "badness" in the true emergency sense. Patients usually define "badness" differently, as in "I really hurt" or "I'm really scared." Because they came to the ED they expect us to do something about it NOW. They want relief. We want a diagnosis. This difference in perspective sometimes generates early conflict in the ED physician-patient relationship. Said conflict often leads to a different sort of "badness," and often makes the subsequent evaluation more difficult for both the physician and the patient.

In many cases of abdominal pain, we can initially rule out true badness by the history alone. My interview of this lady tweaked my badness sense, but did not raise the titer to alarming levels just yet:

Pain is crampy in nature, started four hours ago rather suddenly, gradually increased in intensity, no fever or chills, no nausea, vomiting, or diarrhea, no urinary symptoms, last menstrual period started this morning, and she's always been irregular.

Needing more information I went directly to a focused physical exam. I felt her massive doughy abdomen and did not elicit any areas of rigidity or point tenderness, so maybe no badness there after all. But then the exam findings suddenly changed. A large contractile mass rose up to meet my examining hands. Quickly palpating the mass, I noted it extended most of the way up her abdomen. As the contractile mass relaxed, I thought I felt a small arm or leg move under my fingers. I quickly reasoned the need for a more accurate history.

"Are these cramps regular," I asked. "Yes," she replied, "they come about every five minutes."

"And tell me again, when was you last period, and how heavy was it?" I asked.

"Just this morning, not heavy."

Finally the right question: "When was the prior period?"

"I don't remember," she said. "A few months ago maybe."

She denied she could be pregnant, but I pretty well knew better by that point. A quick speculum and manual vaginal exam confirmed that this woman was indeed in mid-labor well on her way to delivering a full term infant. A couple of hours later, with the help of our reluctant on-call obstetrician, she delivered a healthy baby. Proverbially, mom and baby both did well, at least by our ER definition of lacking badness.

Over the years I've sometimes thought about this lady, although not so much about the emergency department drama. This case taught me most of all about the role of denial in the human psyche. Somewhere deep in her mind this young unmarried woman must have known or at least suspected she was pregnant. But so terrible to her were the psychological consequences, that her mind simply yet elaborately blocked that fact from conscious thought – even once the inevitable process of childbirth began.

This learning case was ultimately not about emergency medicine, or obstetrics. The most valuable lesson learned here came from the realm of mental health: Denial is a powerful yet subtle human defense mechanism that can ultimately wreak great havoc in one's life, greater even than whatever the psyche fears from the inciting event.

This was the first such case in my early emergency practice. I would not be the last...