Sick or not sick?

“Sick or not sick?” This is the question that preoccupied me throughout my emergency medicine subinternships as a fourth-year medical student. Simple in concept, yet vexing interpretation, save for extremes at each end of spectrum. On away rotation, I am easing into rhythm an evening shift and browsing board new patient. One pops up whose triage vitals are all highlighted red: febrile, tachypneic, tachycardic, hypotensive, hypoxic … this patient sick immediate impression. Eager to discover what chief complaint “SOB” would reveal, head over room while nurse placing young mid-20s female on monitors. sick, think myself again lay eyes her first time: cachectic, chest heaving out with breath, glazed-over look bulging eyes, betraying mixture confusion panic. ask brings receive myriad complaints: “I can’t breathe,” “My back hurts,” feel weak ….” sick. The history difficult draw out. answers get either tangential confused single words uttered between labored gasps air. “Let’s give some oxygen fluids,” tell nurse, feeling confident stating obvious. note petechiae legs mind (freshly indoctrinated by study USMLE questions) zones meningococcemia. Sepsis, no matter cause, seems stand sure. if she has ever used drugs says no. strange rash forearms forming random knots skin; maybe there autoimmune phenomenon going on? quickly finish exam present attending. After stumbling multitude symptoms findings, straight point. “This sick,” bluntly conclude. We go together, attending examines those peculiar bumps antecubital fossae asks drugs. Her mother, silent point, interjects: “Honey, when was last time you used?” “Tuesday,” replies, hesitant make eye contact us does. Track marks, course, realize, admonishing naivety. Endocarditis, likely fulminant, jumps top differential. leaving, apologize swear denied drug use me. She calmly responds believes it understandably afraid be treated differently we knew user. tells lucky getting see such critical While correct, indeed fortunate encountering witnessing late-stage (what fear end-stage) presentation; obvious opposite true herself. What struck most upsetting initial denial use. admitting us, being “just another addict.” At thought few weeks prior; IV expressed gratitude “treating like human being” after draining abscess. Looking back, help but wonder one point health care professional. then imagine our current having similar unpleasant interaction led hesitancy seek illness, despite progressive debilitating symptoms. X-ray comes showing diffuse bilateral opacities. started BiPAP antibiotics eventually sent upstairs ICU. have done could, situation looks grim. next day, come early morning check status; dreaded warning entering chart deceased flickers onto screen. dejected, cannot say surprised. review bulky vegetations revealed echocardiogram cannonball septic emboli found CT chest. now dead. Compassion easily bright-eyed, student his sub-I’s. requiring I&D easy treat being, only because human, also green eager physician-in-training who excited opportunity perform simplest procedures. But field arguably highest rate burnout medicine, day compassion will falter. all, odds stacked against If silver lining story imparted following lesson: treating patients dignity saves lives. had feared stigma associated anticipated reprisal from whom depended lifesaving treatment, might onset symptoms, fact. saved her.