Amy: I’ve mentioned that I spend part of my week teaching family doctors in a family medicine residency program. This is an excerpt from a hospital consultation I did with a medical student

The Case: The  student and I did our best imitation of Sherlock Holmes as we entered the patient’s room. Sandra, a twenty-seven year old woman, had been admitted to the hospital with a mysterious case of vomiting. I say “mysterious” because all of the standard investigations revealed nothing out of the ordinary with this young woman’s physiology.

I  knew that Sandra’s vomiting had begun around four months ago, around the time she experienced an ectopic pregnancy. Physically she appeared to have recovered fully from this event. In our weekly bio-psychosocial hospital rounds, the residents had universally been struck by Sandra’s cheerfulness. “She doesn’t seem sick”, they agreed. Hmm…was she inventing this symptom? We entered her room with little to go on.

images-3As we settled ourselves on the chairs in front of her bed, we noted with admiration Sandra’s elaborate tattoos which stood out dramatically on both upper arms. At our invitation, Sandra described the meaning of her tattoos, which revealed her to be an intelligent and sensitive young woman. With her open face and bouncy blonde ponytail, she was indeed cheerful, but in an alive, attractive way. The medical student and I were enjoying this conversation.

As we turned our attention toward her vomiting-–the reason for her hospitalization–-we all became slightly more serious. She said, “They tell me it might be all in my head. They can’t find anything wrong with me.” A CT scan still awaited, but no one expected to find anything amiss. I began to ask Sandra some specific questions about her illness and what she thought was going on.

She talked about the ectopic pregnancy four months ago. It was more complicated than I realized. She was almost five months pregnant, though she only realized she was pregnant during her fourth month. She had a steady boyfriend, had been taking the pill, and hadn’t intended to become pregnant.

unknownShortly after confirming the pregnancy, Sandra had begun having quite a bit of pain, but she attributed this to “pregnancy”.” “Boy you’re tough”, I commented. She smiled. Soon the pain was excruciating, she was admitted to the hospital where the ectopic pregnancy–-and burst fallopian tube-–was discovered. Emergency surgery followed. As she finished telling this part of the story, she said, almost triumphantly, “But I still have another tube!”

I was struck by the intensity of this drama, although she recounted the story in a rather matter-of-fact manner. But I knew this is no small event in the life of a woman. I wanted to fill out the story, and Sandra willingly offered details. When I asked her what she thought her vomiting might be about, she mentioned that her own mother had had an ectopic pregnancy–which the mother only recently revealed– and began vomiting afterward, due to remaining fetal tissue. Sandra wondered if she might be suffering from the same condition, but that possibility had been ruled out.

I had to dig to find out how Sandra felt about the pregnancy. She reiterated that she hadn’t intended to get pregnant, that it was a “surprise”. I asked, even though it was unintended, was she excited? She said, “yes, I started getting excited.” As we talked, I realized that Sandra seemed out of touch with her emotional reactions after such a difficult ordeal. She talked about her boyfriend’s feelings though: She described him as a “real softy” who was both upset at the ectopic pregnancy and “broke down and cried” because he arrived late when she underwent surgery. She said, as she comforted him, “Who’s the patient here?” We all smiled.

images-3As Sandra told her story, I punctuated my end of the conversation with “that must have been difficult”, or “that sounds rough”, in order to help give her permission to acknowledge this traumatic event. When I asked if her mother talked about her reaction to her own ectopic pregnancy, Sandra replied, “My mother never talks about her feelings. She keeps everything to herself. ” I thought to myself…as usual, there’s no escape–-like mother, like daughter.

As I continued to ask about Sandra’s vomiting, she said that she often woke up at about 3:00am and couldn’t fall back to sleep. She might feel queasy and vomit, or try to eat something if she could. I asked when her 3:00 am wakefulness began. “After the ectopic”, she responded. By now I had a pretty good idea of the diagnosis: This young woman was grieving and didn’t know it. Maybe she didn’t want to let herself know it.

I began talking quietly to Sandra. I said it sounded like her body was telling her that she’d been through a lot, that sometimes we absorb a lot of stress without realizing it. I added that I thought she probably had some grief related to the loss of the pregnancy, not to mention the trauma of losing her fallopian tube. Sandra asked, “Do you think I’d be feeling that after all this time? Four months?” “Of course!” I replied. “Four months is nothing!” I always feel that people think grief should be a short-lived affair, rather than the meandering, lingering experience it often becomes.

images-3Much to my surprise, Sandra started to cry. This was an unexpected, dramatic turn-around for the young woman who wanted to be seen as easy-breezy. Tears trickled silently down her cheeks. She made no attempt to wipe them away. I nodded like, “It’s ok. This is good.” I looked at her and said, “Those are cleansing tears”. The three of us talked softly for another ten minutes or so. Though the tears appeared to come out of nowhere, they were long overdue. We encouraged Sandra to share these tears with her boyfriend. She confirmed that he would be “fine” with her tears. “He’s a real mush.”

As we finished to meeting and left the room, both the medical student and I felt that something meaningful and healing had happened for this young woman. And we had our diagnosis: Undigested grief.

The medical student commented about how “different” this kind of interview was from what she had been taught. She said “we have all our medical stuff” (making a straight motion with her arms), but I think she enjoyed this kind of in-depth exchange where we all got to use more of ourselves. The whole interview lasted about forty minutes. When I think of the time–and money–spent on all the investigative tests, I think this kind of in-depth interview probably qualifies as a cost-saving device.

Like good detectives, we gave the patient time to talk and followed the clues closely, not knowing where they would lead us. We developed our diagnosis by observing and listening deeply. Mostly, we recognized the need for human beings to grieve following a loss, with the recognition that denying that grief can set the stage for a host of symptoms masquerading as illness.

The patient was discharged the following day. Her symptoms subsided and did not return. 

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