Doctor, You Need to See This
A routine request, an unexpected discovery, and a reminder that experience deserves to be trusted.
Emergency physicians see a lot of things. Blood. Broken bones. Vomit. Things people accidentally swallowed. Things people intentionally swallowed. And almost every shift, someone wants to show me a specimen. "I saved what I threw up." "I brought a stool sample." "Doctor… can you take a look at this?"
I understand why. If something came out of your body that doesn't look right, it's frightening. You want the doctor to see exactly what you saw. I'll admit it, though. Most of the time, I politely decline. Not because I don't care. Because after years in the emergency department, I've learned that what came out of the body usually matters far less than what's happening inside it.
If someone is vomiting, I'm much more interested in why they're vomiting than what the vomit looks like. Their story, vital signs, physical exam, blood work, heart tracing, and imaging almost always tell me far more than the contents of a plastic bag. So over the years, I developed a habit. "That's okay. We don't need to look." Until one patient changed my mind.
The One Time I Was Glad I Looked
She arrived by ambulance after several days of nausea, vomiting, and diarrhea. She looked exhausted. Dry lips. Weak. The kind of dehydration you can recognize before a single lab result comes back. As the EMS crew rolled her into the room, one of the paramedics stopped me. "Doctor… before we leave, you've got to see what she threw up." He held up the emesis bag, the small container used to collect vomit. "We're wondering if it's… part of her stomach." I smiled. "It almost certainly isn't." The stomach doesn't simply shed pieces of itself.
We started the usual workup. IV fluids. Blood tests. An electrocardiogram, or ECG, which records the heart's electrical activity. Her abdomen was soft. She wasn't having severe pain. Nothing suggested she needed an emergency CT scan. Then her nurse asked. "Can you look at it?" I smiled again. "Probably not necessary."
A few minutes later, the cardiology nurse practitioner caught me in the hallway. Before becoming an NP, she'd spent nearly three decades as an emergency nurse. "I know you're busy," she said. "But in all my years… I've never seen anything like this." One experienced clinician is worth listening to. Three independently telling me the same thing? Fine. Let's take a look.
I expected spoiled food. Maybe mucus. Maybe absolutely nothing. Instead, I found myself staring at a long, white, rope-like structure. About six inches long. It wasn't food. It wasn't mucus. It certainly wasn't part of her stomach. I stared at it for a second longer than I meant to. Then my brain landed on a possibility I hadn't seriously considered. A worm?
The Detour Nobody Plans For
Not exactly something you expect to see in an emergency department in the United States. Parasitic worms are organisms that can live inside the human intestine, feeding quietly and going undetected for months. They're common in many parts of the world, but thanks to modern sanitation and food safety standards, relatively uncommon here. When someone walks into an American emergency department with nausea and vomiting, parasites are usually nowhere near the top of the list. So I went back to her bedside. "Have you traveled recently?" She nodded. Then she told me a story that suddenly made everything fit.
She had traveled to the Caribbean to visit family. While she was there, she was struck by a car and fractured her hip. Because of the injury, she couldn't safely fly home, so what was supposed to be a family visit turned into nearly three months in a foreign country. Three months recovering from surgery. Three months learning to walk again. Three months away from home, navigating a healthcare system she didn't know.
She eventually made it back to the United States, but the bad luck wasn't over. The hip repair hadn't healed correctly. She would likely need another operation to fix it, something she understandably didn't want after everything she'd already been through. Somewhere during those unexpected months abroad, she had almost certainly picked up an unwanted passenger.
Meanwhile, the tests we'd already ordered were telling a different story. Her ECG showed atrial fibrillation with rapid ventricular response, often shortened to A-fib with RVR. In atrial fibrillation, the heart's upper chambers fire chaotically instead of squeezing in a coordinated rhythm, causing the heart to race. Her pulse was running at nearly 140 beats per minute. A normal resting heart rate is 60 to 100. That was the most urgent problem in front of us. She was admitted for IV fluids, medications to slow her heart rate, and further evaluation. The suspected parasite added an important piece to the picture. Specialists in infectious disease and gastroenterology would determine exactly what it was and how to treat it.
Sometimes Medicine Surprises You
I've thought about that patient many times since. Not because of the parasite. Because of what almost happened. I almost didn't look. And to be fair, most of the time, not looking is still the right decision. Emergency medicine is built on patterns. Common things are common. Most patients who come in with vomiting don't have parasites, and a bag of vomit rarely changes the diagnosis.
But medicine has a way of keeping you humble. We spend years learning to recognize patterns because patterns save lives. In medicine, we're taught that when you hear hoofbeats, think horses, not zebras. It's good advice. Most of the time, it's exactly right. But most of the time isn't all of the time. Every once in a while, a zebra really does walk through the door. This one just happened to arrive in an emesis bag.
Looking back, what stays with me isn't the worm itself. It's everything that came before it. A paramedic who thought something wasn't right. A nurse who asked me to take a look anyway. A seasoned clinician who quietly said, "I've never seen anything like this." That made me pause. It reminded me that medicine isn't practiced in isolation. We learn from our patients, but we also learn from each other. Sometimes the most important clue doesn't come from a blood test or a CT scan. Sometimes it comes from the people around you who have spent years seeing the same things you have.
After all these years, I still love that about emergency medicine. Just when you think you've seen almost everything, a patient reminds you that you haven't.
By Dr. Karim Ali, Emergency Physician