When You Hear Hoofbeats Think Horses - Not Zebras

A New Year's Eve ER story about the importance of believing your patient, thinking outside the box and not missing a zebra's stripes.

Anyone who’s chronically ill will tell you that it’s important to avoid the emergency room at all costs. Many of us have uttered the words “I won’t go to the hospital unless I’m literally dying.”

Being in the hospital is a risky proposition for us. It requires that we surrender autonomy and control of our bodies to people who often don’t understand the nature of our conditions.

ERs are dangerous at the best of times. It’s where the sickest people are, they’re often overcrowded and filled with triggers that can impact our baseline. Even IF you get through an ER visit without a hospital acquired infection - you will more than likely experience a severe setback due to the punishing nature of the environment.

The scents, the noise, the lights, the poking and prodding. The hours spent upright in uncomfortable chairs because there are no beds available. The energy wasted trying to convince hospital staff that you know your body best and yes - something is very wrong.

Chronic illness is just that - chronic. We live with it every day of our lives. The ER is meant for acute issues and as such is woefully ill equipped to help us when we need it.

If you’ve been in an accident, have a sudden medical emergency requiring surgery and/or something with a clear and easy fix? The ER is great. If you’re experiencing a complication related to chronic illness? Good luck.

Unfortunately there are times we have no choice but to go - and one of the worst times is over the holidays. ERs are understaffed and often flooded with patients who can’t get in with their regular doctor until the New Year.

What Are You Doing New Years Eve?

A few years ago I had a serious cardiac issue on New Years Eve. I was at a small gathering of friends when I became tachycardic, nauseous and sweaty. I was dizzy and felt “off”.

One of my friends offered to take me to the hospital but I said there was no way I wanted to risk being in the ER on New Years Eve.

Instead I excused myself and went to lay down in their bedroom - praying that whatever was happening to me would pass.

It didn’t pass. By midnight I could no longer endure the pain and discomfort. I was becoming dangerously dehydrated from sweating profusely and I was struggling to keep fluids down.

Reluctantly I called an Uber (the holiday surge prices were a nice slap in the face) and proceeded to my nearest ER.

I arrived at triage with a heart rate of 190. My blood pressure was dangerously low (60/40) and I was still sweating profusely.

The waiting room was crammed with people - many of them clearly inebriated.

Because of my cardiac symptoms I was seen relatively quickly, leading me to falsely believe maybe THIS ER trip would be different. I was wrong.

The doctor comes in and the exchange goes as follows:

Dr: “How much did you drink?”

Me: “I don’t drink”

Dr: “Tell the truth - if you don’t we can’t help”

Me: “I’m allergic to alcohol. I’ve had nothing to drink”

Dr: “Don’t lie”

Me: “I don’t drink”

Then he huffed and walked away after scribbling some stuff in my chart.

Ironically one of the main reasons I was afraid to go to the ER was that I’m so allergic to alcohol I worried exposure to people who smelled of booze might make me worse.

Yet this doctor was utterly convinced I was lying and my dehydration was due to excessive alcohol consumption.

He was thinking horses - not zebras.

Here’s the thing - I get that most patients in the ER with symptoms of dehydration on New Years have likely been drinking. But if your patient tells you they’re allergic to alcohol - if you witness their vitals change in response to alcohol based hand sanitizer, if you don’t smell ANY alcohol on them - you need to think outside the box. You need to believe your patient.

It was heartbreaking to be dismissed in this manner. They ran IV fluids including a banana bag ‐ but it was obvious they were doing it because they thought I was drunk ‐ not because they believed that something was wrong.

My vitals immediately started to stabilize from the fluids ‐ at which point I asked the doctor WHY I was so dehydrated. I told him ‐ clearly and confidently ‐ that I had not been drinking.

That I consumed ample amounts of water and electrolytes and kept getting more dehydrated. That it seemed like no amount of hydration was improving my situation.

I was scared and looking to the “expert” for an answer.

Photo by Geranimo on Unsplash

Image Description: A photo of a zebra with a black background

His response?

“Whatever you tell me is confidential ‐ if you have a drinking problem you can admit it. You were stumbling a lot when you came in.”

It was all I could do not to scream. Of course I was stumbling … my blood pressure was 60/40. It’s a miracle I was even standing upright.

I stuck to my guns and told him repeatedly that I don’t drink. That even the smell of booze makes me sick. That I needed help figuring out WHY I was dangerously dehydrated.

He was unrelenting. His bias was impairing his ability to recognize that maybe - just maybe - he had a zebra in front of him. Stripes on full display begging to be recognized.

I finally suggested he order a blood alcohol level because I knew it would be zero. His reply? “I already did that.”

Of course he did… because he wanted his “gotcha” moment. He needed to be right and that need was obscuring his ability to properly treat his patient.

The test came back and exonerated me. My blood alcohol was zero. My electrolytes were wildly out of whack, my troponin (an enzyme that measures heart damage) was elevated and all signs pointed towards a cardiac event of some kind.

At this juncture you would think he would say sorry right? Or perhaps be concerned and try and figure out WHY a seemingly healthy young patient is presenting with severe tachycardia and dehydration?

Nope. Once he ruled out alcohol ‐ he told me it must be “anxiety.”

He got my blood pressure up to 80/50 and waited for a repeat troponin to show improvement (which it did). The IV fluids I was given had improved my tachycardia and given my heart a much needed rest. On paper I looked “all better” even though we had no idea why this had happened to me in the first place.

He began preparing my discharge papers, all the while telling me I was “fine” and there was nothing to be done.

People who are “fine” don’t faint for no reason. They don’t have a heart rate of 190. They’re not presenting with a blood pressure of 60/40. They don’t get so dehydrated they need IV fluids. I was not “fine”.

None of that mattered of course. In the span of a few hours I had been accused of being a drunk, diagnosed as overly anxious and then told nothing was wrong.

We did blame, misdiagnosis and gaslighting all in one visit!

If you’re a healthcare worker, please realize that not every patient you see is a horse. You will see some zebras. You may not come across us very often, but when you do it’s important you recognize our stripes.

Just because you don’t know the answer doesn’t automatically mean it’s the patient’s fault. I was blamed for my symptoms because the doctor I saw was incapable of thinking outside the box or moving past his own bias.

I’m not saying an ER doctor should be expected to diagnose every zebra who comes through the door - I know their job is to rule out life threatening issues, stabilize and send you on your way.

What I AM saying is that it’s important to treat patients with respect and be humble enough to consider the possibility that you’re missing something. Don’t automatically assume the patient is lying, faking or at fault.

Photo by Maxim Tolchinskiy on Unsplash

Image Description: A photo of a telemetry machine showing heart rate, SP02 and blood pressure

What Stripes Did He Miss?

I was undiagnosed at the time - but presenting with classic symptoms of POTS/Dysautonomia. If the medical team had been more focused on my history and symptoms ‐ and less on accusations and judgement ‐ perhaps they would have figured it out.

Instead I was sent home frustrated and sad ‐ once again feeling let down by a system that is supposed to help you when you need it.

Anxiety is a real diagnosis. It’s not a term to be thrown about whenever a patient looks nervous. It requires a full mental health assessment be performed - yet all too often it’s used as a descriptor for anything a doctor can’t explain.

The “anxiety” label hurts patients. It can and does impact our care. It clouds the judgement of future healthcare workers we interact with and makes them more likely to write off our physical issues as “all in our head.” It should not be used lightly.

POTS patients almost always look nervous. The condition is a literal malfunctioning of the autonomic nervous system.

When I’m in a flare I’m tachycardic, breathless, sweaty and shaky. I often stumble and fall down. I’m dizzy and sometimes slur my words.

I can understand WHY a doctor might think someone presenting this way is anxious or drunk ‐ but at a certain point you have to believe your patient.

You have to do your due diligence as a medical professional before slapping an incorrect diagnosis on a patient.

Sadly I went through these battles for years. Multiple specialists and ER doctors dismissed me as either “fine”, “anxious” or both.

It took me passing out in public and having an advocate go with me to the ER to finally be taken seriously. For more on the long road to a POTS diagnosis - please read my article below:

"It's Just Anxiety"... Or Perhaps They've Misdiagnosed You

Whatever is a Zebra to Do?

If you think you may have POTS and you’re struggling to get a diagnosis ‐ please know you’re not alone. Many patients are misdiagnosed for years.

The best advice I can give is to bring an advocate to ALL appointments and ask for orthostatic vitals. Remind them anxiety isn’t positional! If your heart rate changes considerably while upright - that’s an indicator that you may be suffering from POTS.

If you’re a healthcare worker ‐ please learn the signs and symptoms of this debilitating condition.

We are seeing more and more people with POTS following COVID infections ‐ and the longer it takes them to be diagnosed the more harm is done. There may not be a cure but there are treatment options. The faster a patient is introduced into care the sooner they can begin to adapt and accommodate their new reality as a POTSie. Early diagnosis can also help reduce injuries and other issues that come from fainting spells.

If you’re a zebra - it can help to manage your expectations for what will happen when you go to the ER. You should never have to accept substandard care - but it is important to recognize that the ER is never going to be the place to treat or manage chronic illnesses.

I know we often have no choice but to go to the ER - so it helps to remember that their purpose is to rule out immediate threats to life or limb. Once they’ve done that and ensured you’re “relatively stable”… they’ve fulfilled their duty.

This is incredibly frustrating when you’re suffering - I’ve been there. You don’t want to be “relatively” or “temporarily” stable - you want to be “better”. Unfortunately that’s almost never going to happen in an emergency room setting.

The best we can hope for is a temporary reduction is symptoms (in my case the IV reduced my tachycardia and improved my blood pressure) and a rapid referral to an outpatient provider who can help.

My Ask of Healthcare Workers

Listen to your patient. Respect that we are the experts in our bodies. We may not have medical training - but that doesn’t mean we can’t bring value to the diagnostic process.

Especially where rare conditions are concerned - we may even know more than you. That’s not a slight or an insult. We live with these conditions 24/7 so it’s in our best interest to devour as much information about them as possible. We have the time to be laser focused on whatever disease we’re dealing with - you don’t.

That’s ok. We understand and don’t expect you to be the expert in all things zebra. We just expect that you will listen and respect us when we tell you we know something is wrong.

When you tell a patient they’re wrong, “fine”, or accuse them of anxiety, you impair their ability to seek help in the future. You make them distrustful of the medical system. You compound their trauma. We know when we’re being dismissed. We know when you think we’re attention seeking. It hurts us.

If you don’t know ‐ say so. We will understand. Just don’t blame or gaslight us.

Lastly ‐ let us be a partner in our care. Listen, believe and respect our unique understanding of our bodies. I know healthcare workers are busy and overworked but that doesn’t mean you should ignore the value a patient brings to the diagnostic process. You can learn a lot from a detailed history. Pay attention to the clues we’re giving you. Withhold judgement and keep an open mind.

I am forever grateful to the doctor who finally figured out that I had POTS ‐ as she opened the door to treatment options and lifestyle modifications that restored some quality of life.

But sadly I will never forget all the doctors who dismissed me.

When you work in healthcare you have a tremendous responsibility. Lives are in your hands. Mistakes, misdiagnosis and abuse can maim and kill.

One bad experience can wipe out many good ones.

Never forget we’re people too ‐ and we need your help and compassion.

In 2025 let’s make a commitment to watching for the zebras. Let’s mask up for patients. Let’s promise to be partners in the healthcare process. Let’s listen, believe and absorb what patients are saying. Let’s resist the urge to gaslight and blame.

More patients are being diagnosed with chronic illness every single day - we must work together to ensure they receive better treatment than those who came before.

Have you had a bad ER experience? Or been in the hospital on New Years Eve? Leave a comment below! Did you have a good New Years Eve this year? Is there anything you hope will change in 2025?