One of the reasons I chose emergency medicine is because I love the spontaneity our specialty offers. No shift is exactly the same. Anything can happen at any given time. Unfortunately, that spontaneity can put you in situations that you might never expect.
Explore This IssueACEP Now: Vol 38 – No 06 – June 2019
I was working a shift in our rapid care area for low-acuity patients when I met a young man in his 20s who presented with the chief complaint of rash. His rash had started three days prior, and he had completed a course of amoxicillin for pharyngitis a week earlier. He denied fever, chills, recent travel, and exposure to known sick contacts. The rash started on his neck, spreading to his torso and extremities. He had no significant past medical or surgical history. He reported using amphetamines and cocaine recreationally. On exam, the patient was well-appearing. He had a diffuse erythematous palpable morbilliform rash involving his face, torso, and extremities, sparing his palms and soles.
His history and exam prompted me to think that he had a simple drug reaction secondary to the amoxicillin. Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome were also on my differential, but the patient was well appearing with no history concerning for systemic involvement. My initial gut reaction was to discharge him home with expectant management. Yet something about his story did not sit well with me.
I decided to consult dermatology to get recommendations on workup and management. After my consultation, their initial thought was that his presentation was likely due to a drug eruption. They recommended that I obtain a complete blood count, basic metabolic panel, liver function tests, HIV test, and urinalysis. Results were coming in, and my concern began to diminish. I was on the verge of printing his discharge paperwork when I got a call that changed everything.
“Doctor, your patient’s HIV test is positive,” said the lab tech over the phone. I was stunned; I assumed the test would be negative. An attending once told me to never order a study unless you have a plan for what to do with the result. That day, I did not have a plan for this HIV result. More specifically, I did not have an idea for how I was going to share the unexpected news with him.
I took the patient out of our crowded rapid care area to a private room. I sat him down in a chair and looked into his eyes and told him his HIV test was positive. The look on his face was something I will never forget. The moment after sharing the news felt like an eternity. I watched the stages of grief unfold before my eyes as the patient tried to wrap his mind around this diagnosis. I tried to console the patient and inform him that he could live a long life with proper HIV treatment. Yet I felt my words fell on deaf ears. The hardest part about medicine is being able to bear witness to suffering.
After spending some time trying to coordinate this patient’s follow-up, I walked back into the room to find it completely empty. He eloped. I can only imagine what was racing through his mind as he secretly walked out of the emergency department. I made frantic attempts to reach him by phone to no avail.
He left the emergency department with a result he was not expecting. I left the emergency department that day remembering to always expect the unexpected.