The Elephant in the Room

Anna Flaxis, BSN, RN

We know that lifestyle choices affect our physical health. Smoking, drinking alcohol to excess, eating too much junk food, inactivity....these things cause real physical problems for many people. The diabetic who drinks Coca Cola, the person with COPD who smokes a pack a day, we see it day in and day out in the Emergency Department.

But there is another dimension to our physical health that those of us on the front lines get a frequent glimpse into. It's the mind-body connection. I firmly believe in the mind-body connection. I believe that we can make ourselves sick simply through psychological and emotional means. I believe that if you have emotional pain so intense that you try to suppress it or deny it, it will come out in physical complaints. Takotsubo Cardiomyopathy is a good example of this.

We've all seen it- the 30-year-old female with increased stress in her life presenting to the Emergency Department for vomiting and abdominal pain, for the sixth time this year. And, for the sixth time this year, we will be performing blood tests, ultrasounds and CT scans, and pumping her full of Dilaudid and Phenergan, which will not "touch her pain" no matter how much we give her. The only relief she will experience is if she is so full of pain medication that she is completely snowed.

She will tell us that her symptoms are well controlled with the medication we've already given her, but then after a heated phone conversation with a significant person in her life, her nausea has returned and her pain has increased. We overhear parts of her phone conversation, where she says things like "I didn't ask for this" and "I can't help it" and "It's not my fault", and we silently roll our eyes at the hyperbole and drama of it all.

And you know what? She's partly right. Most likely, she grew up in a dysfunctional household with an alcoholic mother and a stepfather who sexually abused her from the ages of 5-15, until she was finally able to get out of the house by running away, getting pregnant, or hooking up with another abusive man. She is right. She didn't ask for that, and that is not her fault. It's not her fault that she has no tools to deal with the stresses in her life that might seem like normal life stressors for a lot of us.

And so, she comes to the Emergency Department because her belly hurts and she can't stop throwing up. And she's irritating because she tells us exactly where to put her IV, and breaks down into sobs if it takes more than one try, and tells us she's a 12/10 pain after having had multiple repeat doses of Dilaudid, and none of her blood work or imaging studies reveal any physical cause for her symptoms. She wants blankets and ice chips and help to the bathroom, seemingly unaware that we are dealing with other people who are actively trying to die.

And then there is the Elephant in the Room. He's sitting there in the corner staring at us, but we cannot make eye contact, we cannot acknowledge him. We dutifully push the Dilaudid and Ativan, because the doctor ordered them and "pain is what the patient says it is and exists when the patient says it does", all under the watchful eye of the Elephant in the Room.

I think it's time we start naming that Elephant. I think it's time we start bringing him into the clinical picture. I think we can do this in a way that is compassionate and gentle and respectful. We talk about nurturing the mind, body, and spirit of each and every patient, but do we really do that?

And, I think I am dreaming. Because naming the Elephant in the Room does not help the bottom line. As long as health care is profit driven, this will ever be the case.

Elephant in the Room, I know who you are and what you're up to. Just because I don't acknowledge you does not mean I'm not onto you. Someday, I will name you. Just wait and see.

The Elephant in the Room

About Anna Flaxis, BSN, RN

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