The calm before the storm.

I could see it revving up. Her voice was growing louder and there wasn't any eye contact. Arms twitching in a tightly folded position, seated with crossed legs and a foot that kept rhythmically kicking. Whatever it was that was going on wasn't good.

Nope.

I wasn't involved actually. At that moment, I just happened to be down in the Emergency Department looking for a patient who'd already been wheeled upstairs. I'd popped over to one of the computers to check a few labs before hustling upstairs to find my sixty-something year-old man with heart failure.

She was propped on the edge of a gurney just a few feet away from where I was standing. A young doctor was speaking to her and a nurse was nearby doing industrious things that appeared to be in preparation for the patient to be discharged. And me, I could just see it. This patient did not look happy. But it was more than that. Her fuse appeared short.

Very short.

And so. Like someone rubber necking at a car wreck, I stood frozen and watching. Some perverse part of me wanting to be able to say, "See? I told you so" and needing proof of the outcome before I could.

Terrible, I know.

I could overhear bits and pieces of it. Mostly the issue seemed to be that she wanted a "head-to-toe CAT scan" which her doctor didn't seem to think was indicated. Her agenda wasn't being met and she wasn't too thrilled about that.

"What if I got cancer?" she said.

"Ma'am," he responded, "from what I've seen so far, we shouldn't expose you to all the radiation."

"I am fine with the radiation. I want you to check me all the way out for cancer. From head to toes with a CAT scan. It's my body. I know what I need."

And that young resident doctor just sighed and tried once again to take a different angle. None of which was working.

Now. You'd think that this wasn't really a big deal, right? But here is the part I could discern--partly from working at Grady for a long time but also just from something I felt in my gut: Her impulse control was on 'E.' And that meant 'E' as in empty.

"We're going to go ahead and discharge you now. I'm going to schedule you a follow up appointment in the Primary Care Center, okay?" That's what he said to her. Easy enough.

But that twitching foot started going faster. Her chest was heaving in and out and her eyes were flitting all about. She was sitting on the edge of that hallway bed and, from what I could see, was all alone. No loved one appeared to be pacing nearby.  It was just her. A young woman who appeared, really, to have not a single medical problem. But clearly something was wrong.

Very.

And so. It all began to swirl in slow motion. The nurse tried to hand her the after visit summary and her arms stayed tightly pressed to her torso. Her lip curled and her eyes rolled. Her nurse tried a little bit more, hand making karate chops to her flattened palm to reason with her one last time. All of it at a snail's pace. At least, from my perspective. The nurse then walked away, clearly exasperated but fighting to hold on to any threads of empathy. And that young woman swept her hand across the bed, flinging that discharge paper work to the floor. My breath hitched as everything went silent. In the pregnant pause, I watched them float down to the slick linoleum like feathers.

And then, someone hit fast forward.

First came the expletives. Loud, unruly and landing all over the emergency departments in awkward, awful splats. B-words and F-bombs screamed with reckless abandon, not to the individual caregivers per se, but to the system, the moment, the everything. And I just stood there like some terrible voyeur watching it all unfold. Wondering, wondering, wondering what had broken this young woman down so much that she'd unravel like this and lose every shred of impulse control?

What?

Was it a shitty existence at home? Screaming kids and no help or money? A horrible childhood that left her with so much noise between her ears that she couldn't quiet it no matter how hard she tried? Someone not nice awaiting her, with nasty words and swinging fists? Mental illness that was under treated? Or not even diagnosed?

Or.

Just a young woman who had none of those issues at all. Who just happened to be a bit nervous about her health and who was hoping for fool-proof means of making sure it was all clean?

Maybe.

And so. I tried making eye contact with her. Hoping to untrouble her waters from afar which is really a crazy and rather self important thing to believe I could do. But I did anyway. And, of course, it didn't work.

Eventually security came. Bear hugged her and lifted her feet above the ground. One of her shoes flew off and she was reduced to one bare kicking right foot and one sneaker-covered left one. They were nice-ish too her, despite her vitriol, but still they had to do their job. Which was to protect the other patients and the staff in the ER.

Sigh.

Now. I wish I could tell you that his ended with me walking over and hugging her. Me giving her a card to come to the clinic and her promising through tear-streaked cheeks to do just that. But it didn't. It ended ugly. Like, as angry as she was, there wasn't a way to do this in a dignified way. There just wasn't. So this was it. A lumpy ending that left everyone trapped in that awkward moment where you glance all around like you didn't see what just happened.

And that was that.

As I walked out of the ED, I started thinking. Thinking about that aura before the meltdown. Those folded arms, that tapping foot, that complex scowl. I replayed it and wondered what, if anything, could have been done to preemptively strike. To throw baking powder on the grease fire before it blows up the kitchen.

And no. I'm not criticizing my emergency medicine colleagues at all. Quite the contrary, actually. I guess I just wondered if, with that kind of knowledge, that kind of premonition if you will, what I would have done. And would it have even made a difference.

I guess the thing is. .  . . loss of impulse control is never normal if you ask me. Sometimes it's due to some mood altering substance, sure. It wears off and provides a sound explanation. But other times it is just life. Big fists punching or little tiny fists pummeling all at once. . .manifesting as nothing to lose.

Sigh.

I just want to be a better doctor and human being, man. I think we get these little prickles under our skin for a reason. Sometimes it's all because you need to haul ass and get out of the situation. But what if, in this line of work especially, it's a signal to rush in? To try your best to knock the door down before it gets blown off and hits you in the face?

Honestly, I don't know the answer to that. I don't. But that's what I'm thinking about tonight. And what I will likely be thinking about for a long time.

Yeah.

***
Happy Thanksgiving-eve.