u/Incorrect_Username_

Started out in triage that day.

First patient, 20-something female with complaint of "generalized abdominal pain"

Joke to the nurse, "well, this could be just about anything. Let's bring her in and get clocked in for the day"

Patient strides in. Overall she looks well-enough. She's young. Healthy. Physically fit. She smiles at us.

She was two weeks postpartum and was convinced the pain and vomiting were just part of recovering from pregnancy. It had been a remarkable year. She had gotten married, moved here for work, and delivered her first child—a son.

Vitals are stable. Exam is reassuring. No focal tenderness, distension, or rigidity. Nothing appears apparently off.

Then I noticed her eyes

They’re big and impossibly bright.

The kind of eyes that smile at you before the rest of her face did. They were really quite striking.

But then... something isn't quite right about them... are they… just the faintest wash of yellow? Only slightly, one could've believed you were imagining it.

We start the workup. Labs look mostly good but sure enough the bili and LFTs are a little bumped. So we order the CT scan.

As the images become available I scroll through it.

Base of the lungs...hm well, that’s odd...

keep scrolling...

"oh no"

The words leave my mouth involuntarily. My stomach drops

I'm no radiologist. I didn’t need to be.

Read comes back, sure enough metastatic … liver, lungs, lymph nodes... and finding of singular focus, there's a mass in the gallbladder

Those big beautiful eyes stare right through me as I begin to talk. There's disbelief. Surely we're wrong. She's just sick from the pregnancy recovery, right? Her gaze slowly becomes hollow.

As we talk it sets in. We're progressing through stages of grief minute by minute.

There are conversations in medicine that no amount of training ever truly prepares you for. My responsibility was to tell her the truth. My hope was that I could do it without taking away every ounce of hope she still had.

I used every shred of tenderness, kindness, and strength I could muster while trying not to betray my duty to be honest with her. I talk to GI and our oncology diagnostic team to arrange the follow up and go over every detail

---
A few weeks go by and a young patient checks in for fever. Sure enough its her.

She comes in a wheel chair this time. Her obvious physical fitness has become more liken to a skeleton. This time, she does not appear "well-enough". Her eyes are a bit sunken in but still striking even now as she stares, trying to smile through them. HR 135, fever 102. Septic workup starts, she gets admitted.

I add her chart to my list of patients. I look back and she's had a bunch of office visits. She was diagnosed with metastatic cholangiocarcinoma. She's undergoing treatment.

I follow her chart, she ultimately gets discharged in about 8 days.

---
A few months later I'm getting ready to go to the hospital with my wife. We're expecting our son and it's time to go in for induction.

I'm not sure what inspired me while I'm sitting on the spouse's bench/bed in the delivery suite, but it jogs my memory.

So I check back on that patient’s chart. There were a stream of follow ups and treatments after her discharge. There were also a few additional ER visits and some admits.

Then... the office visits, treatments, ER visits and all other notes just... stop.

I'm holding my son now. He's just barely older than her's was when I met her. Sometimes it's hard to fathom how easy it is to take health for granted... and how cruelly that can change.

I’ve forgotten innumerable patients, labs, and CT scans. But I have never forgotten those eyes.

Started out in triage that day.

First patient, 20-something female with complaint of "generalized abdominal pain"

Joke to the nurse, "well, this could be just about anything. Let's bring her in and get clocked in for the day"

Patient strides in. Overall she looks well-enough. She's young. Healthy. Physically fit. She smiles at us.

She was two weeks postpartum and was convinced the pain and vomiting were just part of recovering from pregnancy. It had been a remarkable year. She had gotten married, moved here for work, and delivered her first child—a son.

Vitals are stable. Exam is reassuring. No focal tenderness, no distension, or rigidity. Nothing else appears apparently off.

Then I noticed her eyes

They’re big and impossibly bright.

The kind of eyes that smile at you before the rest of her face did. They were really quite striking.

But then... something isn't quite right about them... are they… just the faintest wash of yellow? Only slightly, one could've believed they were imagining it.

We start the workup. Labs look mostly good but sure enough the bili and LFTs are a little bumped. So we order the CT scan.

As the images become available I scroll through it.

Base of the lungs...hm well, that’s odd...

keep scrolling...

"oh no"

The words leave my mouth involuntarily. My stomach drops

I'm no radiologist. I didn’t need to be.

Read comes back, sure enough metastatic … liver, lungs, lymph nodes... and finding of singular focus, there's a mass in the gallbladder

Those big beautiful eyes stare right through me as I begin to talk. There's disbelief. Surely we're wrong. She's just sick from the pregnancy recovery, right? Her gaze slowly becomes hollow.

As we talk it sets in. We're progressing through stages of grief minute by minute.

There are conversations in medicine that no amount of training ever truly prepares you for. My responsibility was to tell her the truth. My hope was that I could do it without taking away every ounce of hope she still had.

I used every shred of tenderness, kindness, and strength I could muster while trying not to betray my duty to be honest with her. I talk to GI and our oncology diagnostic team to arrange the follow up and go over every detail

---
A few weeks go by and a young patient checks in for fever. Sure enough its her.

She comes in a wheel chair this time. Her obvious physical fitness has become more liken to a skeleton. This time, she does not appear "well-enough". Her eyes are a bit sunken in but still striking even now as she stares, trying to smile through them. HR 135, fever 102. Septic workup starts, she gets admitted.

I add her chart to my list of patients. I look back and she's had a bunch of office visits. She was diagnosed with metastatic cholangiocarcinoma. She's undergoing treatment.

I follow her chart, she ultimately gets discharged in about 8 days.

---
A few months later I'm getting ready to go to the hospital with my wife. We're expecting our son and it's time to go in for induction.

I'm not sure what inspired me while I'm sitting on the spouse's bench/bed in the delivery suite, but it jogs my memory.

So I check back on that patient’s chart. There were a stream of follow ups and treatments after her discharge. There were also a few additional ER visits and some admits.

Then... the office visits, treatments, ER visits and all other notes just... stop.

I'm holding my son now. He's just barely older than her's was when I met her. Sometimes it's hard to fathom how easy it is to take health for granted... and how cruelly that can change.

I’ve forgotten innumerable patients, labs, and CT scans. But I have never forgotten those eyes.

Hey, friendly neighborhood ER doctor here.

I feel like in the ER we regularly see the lower end of the psychiatric spectrum. Patient's with recurrent psychotic breaks, substance abuse, food and housing insecurity, and all manner of other circumstances that keep them sick. Many of these patients are unable to have normal conversations, let alone a highly complex thoughts... honestly you can get a bit jaded about it all

But I had a patient the other day... and I must say this makes me so fascinated in what you all may experience on a regular basis...

45-ish yo M with a history of well-controlled bipolar (off meds, currently) comes in.

From the get go he's wide-eyed and speaking fast, it appears like possible mania, but different than I usually see. He's well-groomed, well-dressed, well-spoken... So I ask him what brought him in and he just unloads.

Him: "I'm going to be honest with you. I've been up for several days. I'm having some really complex thoughts and I need to get evaluated"

Me: "What are these thoughts?"

Him(speaking rapidly): "You know. It's just human nature. Our original sin. We fear 'other'. From tribes to expanding empires, nation-states and politics, down to different fucking football teams. We want to define people as and hate them for being the 'others'. It prevents us from being a truly functioning society. We've got a lot of complex problems we're not ready to solve man. AI, population inversion, wealth inequality, diminishing resources... no one is ready for these things man"

(my internal monologue...like yeah dude, 10/10, no notes, I kinda agree).

Him(continuing): "So i've just been worrying about and thinking about it non-stop. I think we need solutions and I have some but I'm worried about it. I think I might need thorough psychiatric evaluation to evaluate the veracity of my thoughts"

Me: "okay... What are your thoughts that make you feel you need evaluation"

Him(excitedly): "I think that I may have insight... I believe God has chosen me to guide us through this. He's talking to me and I can unite us. I know it sounds crazy but I think I'm here for this reason..."

From here on he digressed a bit and it fell apart the more he talked but I was like "Damn, he was so close!"

It was truly fascinating. I once heard a med-school professor say that if all the professions were sat a dinner table together that psych, EM, and trauma would have the "best stories." And for the first time in awhile, I saw how fascinating and unique some of the psychiatric conditions can be. It's still sad, but it's uniquely astonishing at the same time.

It shines light on how people can become cult leaders or how Kanye (etc) can gather such a following. They are powerful before the fall in some ways. He was wide-eyed, spoke with conviction, he had big thoughts and it really is magnetic. There's a real gravity to people when they are high-functioning like that.

Just thought I would share.

Edit:
To address some accusations of me violating privacy

1. I misrepresented the timing of this
2. That is not their real age
3. That is not their real gender, or is it? Who knows
4. There are no details about where this occurred
5. I paraphrased and edited what transpired. There’s some artistic license here in order to tell a story. Some things are added, some left out, some entirely false.
6. Maybe this never happened at all and I just wanted to have a discussion

If this is real, the person who had this interaction could read it and not know it was them. This was just supposed to be a conversation about the intensity of mania for those who don’t see this side of it often

Shoutout
- Academic and private healthcare institutions
- governing licensing bodies
- CMS/DEA/PDMP
- healthcare affiliated applications
- professional emails and servers
- and everything else

… mandatory periodic password changes weaken cybersecurity. It’s an outdated recommendation. Please stop asking us to change it every 90 days.

I can’t do your mandatory compliance modules if I get locked out of my account because I forgot if the password ends in !! or ??

Thank you for your attention to this matter.

I was working today and came across two of my nurses sitting together taking pictures of their screens.

Curious what they were doing, I inspected the screen and it wasn’t patient related (fortunately) … it was questions… Medical questions.

So I asked what were they doing.

They were taking online tests for their DNP programs. Take pictures of the questions on the screen and ChatGPT answers instantly.

To my obviously quizzical expression one said “look, everyone’s got ChatGPT now and it gets everything right anyway”

I’m normally pretty pro-APP (at least PAs, that’s all we have) and I think they’re a great asset and part of the team… I’m also typically pro-technology and think it will bring about amazing changes…

but if you can degree-mill-ChatGPT your way to medical positions and be entrusted to care for people without any further real checks and balances… what the fuck are we doing?

Edit: clarifying a few points

1. Yes they were studying to be some kind of NP ..as a few people have asked… no I don’t know what kind of program. I know there are several nursing titles and acronyms and no offense but I just don’t know what all the letters mean outside of NP
2. They completely justified it. There was a band wagon fallacy to it. "If everyone is doing it, why shouldn't I?"
3. I’m sure this happens in all forms of education, med school included, but at least med school has dozens of nationally-standardized, proctored, in person exams before you graduate.
4. I realize this may backfire for them when it comes time to certifying exams. But from what I understand, they aren't that difficult (per NPs in this very thread). If that is the case, they can BS their way to NP via online curriculum and take their shot at a pass/fail test that tells us they are capable of being a "provider". Sorry but that is scary and if these two girls are doing it, you know others are as well. The online NP programs are more at risk than ever of providing us completely incompetent providers. Brick and Mortar NP programs with rigorous testing are more important than ever.

Hey psych bros, this is your friendly neighborhood ER bro

I wanted to ask if you all have had any luck in the longitudinal care of a subset of patients.

I’m sure there has been posts here (as there have been in every medical subreddit) about the concerningly rapid rate of MCAS, POTS, GP, EDS, FD, chronic Lyme, MECFS, PNES and so on.

Obviously the rate of recent occurrence is statistically questionable and there could be a whole discussion therein…

Often these patients have been to the ER innumerable times, seen cardiology/gastroenterology/neurology/immunology etc with no real medical treatments that help.

I want to know if there has been any success in the longitudinal care of these patients from a psychiatric perspective?

I ask because there seems to be a component of this that is surely psychological - not saying it all is, but at least partly. They often have a list of comorbid psychiatric diagnoses and the diseases themselves appear to affect their identity and sense of self, they have severe rumination on their condition, poor symptom tolerance, poor stress reactions and often difficult interpersonal skills (I may have worded some of this poorly, I am but a lowly ER physician and this may not be the common vernacular among psychiatric professionals for these symptoms and patterns). Additionally it all seems to correlate with online communities, forums, Reddit, TikTok/IG/med twitter stuff that seems to be amplifying everything.

Are you able to help?

Can any of us help?

I don’t get to see the long-term outcomes of any of my psych patients most of the time because if they do well… they don’t come back.

Truly, for the patient’s sake it would be great to have some answer.