All was aflutter. The sixtysomething Chinese woman squirmed on her stretcher, hands trembling over her chest while her two daughters hovered anxiously. The emergency room din mounted as a note from the patient’s family physician appeared under my nose: “Status post neck sprain x 2 days, complaining of neck pain, bilateral arm numbness, weakness, dyspnea, need to rule out acute cervical disk herniation.”
The patient’s expensive-looking clothes and red hair—set off by loud gray roots—were my first clues. The note reinforced my initial impression: numbness (suggesting damaged nerves) and trouble breathing (suggesting asthma or pneumonia) for two full days? This had to be anxiety.
Trying to keep an open mind, I flipped to the triage nurse’s note. The chief complaint read, “Dizzy, lower back pain, neck pain x 2 days.” No help. Then the woman’s whole body began to shake. Now I wasn’t so sure about my diagnosis.
“Elsa,” I called out to her nurse. “She needs to be out of the hallway and into a room, on a monitor.”
“We’re very full.”
“She needs a room.”
Ten minutes later, translator at my side, I got a second shot. The daughters gathered round. The woman looked calmer as the monitor flashed normal vital signs: blood pressure, pulse, oxygen saturation, breathing rate—all A-OK.
The symptoms had begun while she was making love to her husband two days earlier. Sudden dizziness at first. Then he pulled her to the side, which triggered shooting pain down her arms. How hard had he yanked? Not so hard. Had they been quarreling? (First rule of whodunits: It’s always the spouse.) No. Had the symptoms worsened or changed over the past two days? No. Was she a nervous type of person? No. Any psychological problems? No. Otherwise healthy? Yes—a little high blood pressure, nothing more.
“Do you feel pain anywhere?” I asked, placing my hand on her head. “Here?”
Then on her chest: “Here?”
A burst of Mandarin: “My back.”
The daughters piped up. “Her back has been hurting for months.”
“But why is she here today?”
“Dizzy. Very dizzy.”
Aha. Maybe vertigo. “Like the room is spinning?”
“No.” (That would have been too easy; vertigo is common and usually benign.)
“And no chest pain?”
“What’s wrong with her?” one daughter wanted to know.
“Beats the heck out of me” would have been the honest answer. To buy some time, I resorted to the Universal Doctor’s Dodge: “We’ll run some tests.”
It had to be anxiety. Those vague, unconnected symptoms could only be psychological. Besides, my patient looked fit as a fiddle. This was classic attention-seeking behavior: The oversolicitous daughters, the dyed hair, the fluttering.
Fifteen minutes later, one of the daughters accosted me in the hallway. “My mother’s numb from the neck down!”
“Not possible,” I almost blurted out. If the spinal cord were compressed enough to cause total body numbness, there should be arm or leg weakness too.
Back in the room, my patient had launched an energetic imitation of Lamaze breathing: puff, puff, puff. “Why is she doing that?” I asked the daughters.
“It makes her feel better.”
It was making me feel worse. Was I missing something? Again I checked the strength in her arms and legs. Normal. Then it hit me: Hyperventilation can cause numbness. This was anxiety. I found Elsa.
“Let’s give her Ativan (a Valium-like drug), one milligram IV. She needs to calm down.”
I returned to her room and told the family, “This will make her feel much better.” Emboldened by my own decisiveness, I continued, “We’ll get a CT scan of the neck.”
The first doctor had raised the possibility of a bulging disk. The CT scan would appease him and the family. Problem was, getting a neck scan for a presumed neurological deficit meant we had to rule out stroke as well. Otherwise, the radiologists would think I’d lost it.
“And we’ll get a scan of the head,” I added. The smiles widened.
Twenty minutes later, I peeked into the room. The woman lay back, eyes closed. Success. A daughter walked over and whispered, “She has not had the CT scan yet. When?”