The All or Nones


courtesy wikimedia commons

There’s a type of patient that we see every so often in the Emergency Department that I like to refer to as the “all or none” or the “really bad or nothing at all.” Basically meaning this: at the end of their hospital stay, they’re either going to have no obvious diagnosis or something really, really bad (cancer, some weird, bad chronic disease, bad injury, or some permanent damage).

It’s typically a young, otherwise healthy person who gives a concerning story for Badness (“I’m 29 and all of the sudden I developed a really bad tightness on my chest, felt naseous, broke out in a sweat, and feel like I can barely catch my breath”) or have some scary presentation (3 year-old with what seemed like a minor head injury who alternates between vomiting and lethargy, or the healthy but now diaphoretic and pale 22 year-old with hematemesis and bright red blood per rectum).

Just playing the odds, most of these patients do just fine: their EKGs are tombstoneless, their troponins are negative, their CT scans are unremarkable and their endoscopies are clean, but it’s these zebras that really challenge one’s differential diagnosis. Sometimes their disease processes don’t even fit with their risk factors or age, so you’re already behind trying to find the zebra among the pack of black and white-striped horses.

The All or Nones make Emergency Medicine interesting. Often, you can pretty quickly get a differential and disposition for the patient just based on their age, risk factors, and one-liner: looks like a kidney stone, sounds like a COPD exacerbation, quacks like acute coronary syndrome. And you can usually predict how a patient’s going to due while in the department: most people who come in stable and well-appearing are going to stay that way. But the All or Nones keep you guessing: what’s going on with him? Why did her crit drop? Is he going to crap out on me? The All or Nones keep you on your toes and make you uneasy. They put you on alert and on edge. Right where we dumb ER docs like to be.

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