The Worry

“Another nosebleed?” I sighed to the nurse.

“Yup, just one good old nosebleed, now stopped of course,” she replied. “Room 7 – Lucas*. Cute kid, but nervous.”

The emergency department was filling quickly. Thankfully, this could be a quick in-and-out patient. Nose generally bleed from harmless causes – too much picking, or dry air, or irritation from being stuffy. A good 15 minutes of pinching at home will almost always stamp the flow. But without a proper pinch, noses can gush, horror-movie style, leaving a sizable crimson puddle on the floor and a scared parent.

I knocked on Lucas’ door, entering to find a slender boy kicking the side of the exam table with his sandaled foot and rubbing the crusted blood from his nostrils.

“Hi, I’m Dr. Julia. I heard you had a nosebleed – seems like it’s stopped now.”

“Yup, it stopped when the nurse pressed on it.”

“Great. Well let’s take a look.”

His aunt hovered nearby as I examined him and asked about his recent health. Then I asked the most important question.

“So what are you the most worried about?”

Lucas sat silently for a few moments, staring at his shoes. His aunt jumped in.

“Well Luke’s mom died about 6 months ago from leukemia. Nosebleeds were her first symptom.”

Here was the true cause of their evening trip to the emergency room.

I rarely check lab tests in children with self-resolving nosebleeds, but to reassure Lucas and his aunt that this nosebleed didn’t mean blood cancer, I ordered a complete blood count.

Worry swirls in the pediatric emergency department, permeating the waiting room, hovering in the halls, exploding loudly in the trauma bay, lurking quietly in each exam room. Worry is why families come in. It spurs them to leave their beds at 2 am, hustle into the car, pay a copay, and wait, sleep-deprived and anxious. I’ve found each family’s worry to be a particular blend of life experience, myth, cultural belief and Google searches.

I’ve cared for hundreds of healthy children rushed to the ER for what myself and the nurses find to be minor complaints – nosebleeds, diarrhea, coughs, a few hours of fever, falls that leave a goose egg on a forehead. Medically, most of these do not require midnight ER trip.

Generally, after a dose of ibuprofen, an ice pack, a wound dressing, a popsicle, these children look entirely well – smiling, twirling, bouncing around the room. I tell their parents my exam found no signs of serious illness, reassuring them their child should be better with a few days of rest, fluids and love.

Yet often their parents sit with legs crossed tightly, lips pressed firmly, eyes glaring, fingers fiddling. They are still anxious. They worry the fever could be the first sign of malaria, dengue or chikungunya – infections their grandmother warned of from her Caribbean childhood. They worry fever causes brain damage, or if the number is above 104 the child will die, or if the fever comes back when the Tylenol wears off something must be unusual. They worry the head bump is a broken skull or a brain bleed, or it will leave their child unable to do well in school. They worry the nosebleed will cause their child to bleed to death, or it’s from meat stuck up the nose, or it’s the first sign of cancer.

Over the years I’ve learned to anticipate some of these worries, making sure to address common myths preemptively, yet every day new anxieties come up that I could never have predicted.

It can be tempting to chuckle at these odd parental theories, to exclaim “Can you believe what this father thought!” and share an eye roll with the rest of the staff, becoming increasingly annoyed as our shift fills with patients with minor illnesses and their associated strange concerns – what we often term the “worried well”.

But we can easily forget the benefits of our medical training – how we have learned what to worry about – which problems are major and which are minor, what symptoms are red flags and what are nothing to fret about. Our patients rarely have such knowledge. What is routine for doctors and nurses is rarely routine for patients and their families.

When I find my frustration building as I yet again explain that fever is generally not dangerous, the hives are not deadly, the vomiting and diarrhea is a common virus that will pass, I pause to recall my pre-medical self and my own weekend of weird worries.

I was a healthy 25 year old when a routine physical found a large mass in my abdomen. The mass was confirmed by CT scan on a Friday, yet I had to wait until Monday to hear from a doctor what the mass was exactly.

I spent that weekend imagining what now seem to be the strangest of possibilities, though at the time they seemed perfectly feasible to me. My health knowledge was limited to a few months of a tepid high school health class, a two-week medical terminology course required for my public health graduate program, and what I thought were educated Internet searches.

I was sure the mass was a weird abdominal abscess like in that case report I read on someone’s blog. Or it was an intestinal blockage, but without the vomiting and constipation like WebMD listed as common symptoms. Or maybe it was an ovarian teratoma, like the freak show specimens full of teeth and hair that popped up on Google Images. Or a calcified ectopic pregnancy like I heard about on a recent podcast. No, it must be a fungus ball in my liver, I thought, maybe seeded from the cut I had on my foot a few weeks ago.

I was worrying about all the wrong things. Never once did I entertain the true diagnosis – retroperitoneal liposarcoma. I had never heard of liposarcoma, a cancer derived from wayward fat cells. I had no framework for thinking about abdominal masses, and why should I? I had never had one before, nor did I have any real medical training.

Now as a physician, I aim not only to address my patients’ pathophysiology, but also their worries. I make sure to ask them directly about their perceptions, myths, fears and anxieties. I work to let go of my own presumptions. I try to embrace my role as an educator of when to truly worry. If worries stay hidden, the patient is not completely treated, leaving without their true reason for coming to the doctor addressed.

As I figured they would be, Lucas’s blood test results were normal with no signs of leukemia. He and his aunt went home with moisturizing nasal ointment and relief. I moved on to the patient in the next room, asking, “So what are your worries today?”

*All names and identifying details of patients and their families have been changed to protect their privacy.

Learn More:
An interesting project on patient worries