The Elephant in the Room

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    That our emotions and our health are intertwined, rather than separate parts within the whole is becoming more generally accepted in the mainstream. As health care providers, we talk about providing care for the mind, body, and spirit, but are we really walking our talk? In the Emergency Department, we are experts in diagnosing physical ailments, but we face significant obstacles when it comes to addressing the mind-body connection in a meaningful way.

    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 step father 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. Some day, I will name you. Just wait and see.
    Last edit by Joe V on Nov 4, '16
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  3. by   chrisrn24
    Love it! So true.
  4. by   Armygirl7
    "As long as health care is profit driven, this will ever be the case. "

    If only we could change the compensation scheme! Like higher compensation for holistic care that includes counseling, nutrition and exercise prescriptions! I always think if you made a vaginal delivery reimburse @ $20k and a C-section reimburse @ 2k we'd see a sudden shift in the stats! Suddenly all those "failure to progress" labors would be progressing just fine (but at their own natural pace).

    The ER is just too blunt an instrument when sane people present with psycho-somatic illnesses. We're just not equipped with time or proper personnel to name the elephant.... part of the general dysfunction of our healthcare delivery system - mental health and physical well-being are tied in a million ways yet we keep them separated in our minds and in our community health services (if we have ANY!).

    Great post Stargazer!
  5. by   NurseGirl525
    Until you lived it, you just have no idea. It gets to the point where you are so stressed out and sick and the Elephant doesn't even want to take you to get looked at. He's ****** that he's there and that he has to wait. He's upset that he's not doing what he wants to be doing which is sitting in front of the TV eating the meal that she cooked for him because if she doesn't he berates her and makes her feel bad. I probably have 20 examples from over the years of what my husband did to me and how he would just drop me off at the door and leave and I was there all by myself because HE couldn't handle the wait at the ER. My health declined for a very long time because of the way that I was treated and how stressed I was. Stress exacerbates symptoms greatly.

    My seizures increase when I am stressed, my immune system goes down and I get pneumonia, my fibro is worse when I am stressed. But you know what, now that I am getting a divorce, I am the healthiest I have been in years. And finding the courage to leave, was the absolute hardest thing I have ever had to do. Harder than the 5 classes plus being a single mom this semester, harder than being sick even.
  6. by   bebbercorn
    I agree with you, Armygirl7. I was just thinking as I read this "If only I had the time to take the elephant out of the room." There are so many missed opportunities to address important aspects of patient care such as this, simply because we don't have the time and resources. Siiigh.
  7. by   Altra
    Stargazer, I think we must have worked together today.

    Thank you.
  8. by   IrishErin
    Love this post! We just had a discussion at our last staff meeting about nurses in our ER wishing we could have more mental health training and more access to mental health resources/services. This way we would be better prepared to help our patients as a whole, rather than half treating an illness and punting them to community mental health.
    Considering how many patients we see with one or more mental illnesses that could possibly be exacerbating their physical illnesses, it makes sense that we should be better equipped to talk to our patients rather than feel uncomfortable due to 'the elephant'
  9. by   VivaLasViejas
    This post is an example of what's right with nursing, and what's WRONG with health care. We all know it, and yet it seems we are powerless to change things. Sure wish the powers that be would listen to nurses!
  10. by   tokmom
    This just isn't isolated to the E.D. These are the people that get admitted, want their dilaudid and we spend thousands of dollars trying to figure out what is wrong with them.
  11. by   AntelopeTongue
    Stargazer, this sums up my shift last night as well. Couldn't have said it better! It's difficult being in a situation when one half of you is really irritated by it and rolling your eyes on the inside, while the other half truly wants to help solve the real underlying issue. Unfortunately in the ED there are often not enough resources available, and time is usually very limited. Definitely conflicting emotions going on in those situations. Your elephant in the room analogy.....totally on point and very well put.
  12. by   Mully
    Great post!

    Sometimes it's not so easy to identify who the elephant is.
  13. by   madwife2002
    Great Article
  14. by   LakeEmerald
    We start out as nurses wanting to help heal the sick, but realize we can only help fix their bodies. We can't fix their lives, though we wish we could. Beautiful dream, though.