Back pain, bruises and unwanted company

Another night shift in the Emergency Department goes off with a bang. One drunk gentleman wields his post-surgical bloody hand at us all, claiming he got in a fight after being discharged, his bandages ripped off, and his fresh stitches ripped out. Why can’t we do our jobs properly and re-stitch his hand this instant, expletive, expletive? He’s already been thrown out of another hospital’s Emergency Department tonight. He hangs on to ours by the skin of his teeth, police waiting for our signal, like animals stalking their oblivious prey. He’s lucky and not quite abusive enough on this occasion.

I inwardly groan when I read the presenting complaint of my next patient’s triage notes. Back pain. A symptom, when combined with the emergency setting and not following trauma, most commonly results in one of two long-winded pathways. The first being triggered if this patient’s back pain shows sinister features of spinal cord compression. A time critical condition demanding urgent contact with the neurosurgical team, an urgent MRI scan and possibly an overnight operation.

The second long-winded pathway is why I inwardly groan. Muscle spasms can feel like you’ll snap in half. Patient’s scream, cry, beg and plead for pain relief. Rarely is this a new pain with a quick fix. Time is taken to control the , whilst explaining to the desperate patient that objectively this doesn’t look like cancer, broken back bones or cord compression. Sadly there’s not much more we can do in the emergency setting.

My patient in her mid-40’s, staggers and wails as she’s called to follow me. My heart sinks instantly. She’s walking, a good sign, albeit slowly and dramatically. Her pain is long standing, as I suspected, with little change besides pain to suggest to her that this was now an overnight emergency. I begin examining her neurology, aware of my growing frustration and impatience with her inconsistent reaction to movement. My tricks and techniques suggest the back pain is largely behavioural with an objectively less severe muscular pain. I take some deep breaths and close my eyes. She’s able to sit up rather quickly for someone who just a second ago screamed when I attempted to move her leg a few centimetres.

I lift her shirt to examine her back and see two purplish green marks. They were . My heart sinks, for real this time. “How did you get these?” I asked gently. I’m instantly aware of a smaller bruise on the soft of her left cheek. “And this?” She looks down and cries harder. “I fell on a door handle and hit my face”. We both know that isn’t what happened. I’m not rushing now, my impatience has vanished. A slight guilt settles on me as I change my tone, pull up a chair just before her, take her hand and reset my empathy button.

I proceed, exploring this vulnerable territory. My usual questions, the silence, the body language, that sadly yields so many unexpected hidden stories of abuse, is not yielding today. She had decided not to tell me, despite the door handle story changing for the third time. “I’m really worried someone is doing this to you. That someone is hurting you.” I say gripping her hand. She stays quiet, silent tears running down her face. Her back, no longer the central source of her pain. “You don’t have to tell me today”. She nods. I assure her that the Emergency Department is a place of safety for her if she feels threatened. “You will get help here, you will be believed.” I walk her down to the x-ray department, now unsure whether this back pain is truly non-traumatic.

Once back at the nursing station, gathering my thoughts and writing my notes, the nurse in charge comes up to me. She had just been accosted boisterously by my patient’s female friend who had arrived 3 minutes ago. Demanding that she sit in on the consultation this instant, that she is the only one who knows her friend’s medical history. “I need to be with her! She can’t be in there all on her own.” She is informed that, of course the patient is fine being alone with the doctor and is instructed firmly to wait in the waiting room.

Something is not right about this situation. Alarm bells are ringing for myself and the nurse in charge, but only with out combined insight. Who is this new person? What if she is the perpetrator? I need to speak to the patient alone again and hopefully her body language will speak as clearly as it did before. But the pair are now reunited, how am I going to separating them without raising any concern?

The nurse and I walk as a team to the bay where the patient is now lying, friend standing by her side. “Right.” I stride in as confidently as I can. I mustn’t give away my inner tremor. My racing pulse. “Hi there, I’m Rosie, one of the emergency doctors. I’m going to perform another examination if that’s OK with you (patient) so if you (friend) would kindly wait in the waiting room, I’ll call you back in once I’m finished, it will only take a few minutes OK thank you.” Nurse leads the friend away, none the wiser. No options. Routine.

The curtains are thin, so I watch her walk away. Confident that she didn’t suspect anything and that she can’t hear my next questions. Quietly, I ask my patient about her friend, again does she feel safe, again does she ever feel threatened. The nonchalant shake of her head was enough to take the edge off my concerns. “She’s just my friend.” I look into her eyes sincerely and feel more at ease.

Again I emphasise that if she ever wanted to tell anyone she feels afraid, feels threatened, she can always come to A&E. She nods again. A nod which validates my concerns and suspicion that someone has definitely done this to her.

“I know you don’t want to tell me today what’s going on. But do you give me permission to tell your GP that I’m worried about this?”

She nods.

“Do you give me permission to complete an adult safeguarding referral? Someone from Social Services can contact you. If you want to you can talk to them about anything that’s going on.”

She nods again.

I know there’s no more for me to do. This may be the first of 30 times she needs to be asked before she’s ready to tell. The next time will be easier, for her and the one who asks.

Back pain, bruises and unwanted company

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