The Customer is NEVER Right - A Nurse Practitioner's Perspective
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"You are so nice," a patient said.

Working at a Locum emergency department, it’s 2:00am and there is about three inches of snow on the ground outside and still snowing, likely the reason I have not seen a new patient in almost three hours when I am handed a new patient’s chart. A twenty-five year old male with a migraine headache I can see in the waiting area alone in no apparent distress watching television.
I call him by his last name, while sitting he leans over, grabs a soft drink bottle from the ground, then stands up, and walks into the examination room. As he enters the room I introduce myself, “Hi. My name is Jose. I am a Nurse Practitioner,” and I close the door behind him as he sits on the examination table. When I turn around he is leaning downward placing his soft drink on the table’s step as I ask him, “What is your first name?” To which he replies but I did not hear well, “I have a migraine.” Not sure what he said I asked, “What?” And repeats, “I have a migraine.”
“I asked you for your first name,” I said and he replied with his first name. After confirming his name with the chart I ask him, “What brings you to the emergency department?”
“My migraine,” he replied.
“What about your migraine?” I asked.
“I have a migraine headache,” he said.
“Do you have a history of migraine headaches?” I asked.
“Yes,” he said.
“What do you take for it?” I asked.
He named the medicine and I asked him “Are you out of it?”
“Yes I am,” he said.
“Is this like your regular migraine?” I asked.
“Yes it is,” he said and just before I began my physical examination he said, “Is there another doctor I can see?”
“Sure,” I replied and walked over to the main emergency department where the physician was busy with four patients and I said to the charge nurse, “This patient wants to see the doctor.” I placed the chart at the nurse’s station and walked back to the computer to write about it because just before I was given the patient’s chart I had just begun to write about a grandparent who was not satisfied with my care either, a few days earlier, and requested to be seen by someone else.
I have no idea what I said to the young man with the headache that got him upset but whatever it was he was upset. Maybe he sensed I was suspicious about a migraine headache at 2:00am with three inches of snow outside and still snowing. It was likely I was suspicious, but not because he was a drug seeker as I do not get caught up in those concerns. I was suspicious because here was a young man who was in no apparent distress, at 2:00am with three inches of snow outside, bending over to either grab his soft drink or place it on the ground with a complain of a migraine no different than past migraines and he was in the emergency department.
This emergency department was the one where the patient advocate introduced in a previous blog mentioned he appreciated it when healthcare workers gave him a heads up to potential complaining patients. It is likely the young man with the migraine headache would complain.
The toddler I was starting to write about was one of the first patients I saw the first week at this emergency department. The toddler had runny nose and fever and I was trying to look in his ears, something that is not an easy task for whoever has to hold them and because of that I ask parents to hold the child in one manner that works best for me and them. Just before I began I asked the toddler’s grandmother to hold him in that manner, however for some reason she would not hold the child in the manner I asked and the child was thrashing all over the place. A number of times I tried to get the grandmother’s attention to hold the toddler in a certain manner and she would not hold him in the manner I asked her.
After a few more times of asking the grandmother to hold the child in the manner I asked the grandmother finally did, except she was leaning forward and I asked her to sit back in the chair so she would not hurt her back as I knew the toddler would begin trashing shortly. However, in the request to sit back I left out why I wanted her to sit back.
Unfortunately, the grandmother snapped back at me, “Just look at his ear there!” while she held him on her lap but the child continued to thrash all over the place. “Ma’am, hold him the way I asked you,” I said but she did not. Instead she asked an older child with her to get her spouse as I tried to convince her it was best to hold the child as I asked her but she would not and the child continued to thrash and I could not look in his ear.
Eventually the grandmother got up saying, “I want to see someone else” and off to the waiting area she went where I could hear her telling others how bad I was. The patient’s grandfather entering the examination room where I sat completing work on the computer and he asked me, “What is your name?” “Jose,” I said. “What is your last name?” “Torres. My name is Jose Torres,” I replied. “Are you Mexican?” the grandfather asked. “No. I am not,” I said looking at him. I have no idea why he asked me if I was Mexican, nonetheless, I was upset he asked me.
Again, I was trying to be helpful, however, the grandmother became overwhelmed with the crying and thrashing toddler and I was the bad guy. For the remaining shift all I thought of was the grandparents complaining. I know the patient advocate asked to give him a heads up if I thought a patient would complain but as I mentioned before, How would that benefit me? It wouldn’t so I chose not to call him.
After the toddler, the next patient I saw came in by ambulance after being seen the day before when he was diagnosed with a skin abscess. At some point in the history I ask the patient, “What is different today?” “It’s not better,” he said. “Did you take your antibiotics?” I asked and he says, “They didn’t do anything for me.”
“Really, they did not put you on antibiotics,” I said.
“No. They didn’t do anything,” he replied.
“Huh, I find that hard to believe,” I said.
“I am telling you. They didn’t do anything for me,” he argued.
So I look on the computer and tell him, “An antibiotic was prescribed for you.”
“I am telling you. They didn’t do anything for me,” he said again.
“Did you go to the pharmacy to pick up the antibiotic?” I said.
And the answer was, “No.”
“So you came in tonight because you thought you needed an antibiotic but left here yesterday and did not bother to ask, ‘What about the antibiotic?’ Now come on, that doesn’t make any sense. You were supposed to go to the pharmacy to pick it up. Now, the pharmacy is closed. Wait here and let me see if I can get you that antibiotic,” I told the patient.
I go to the pharmacy with the emergency department pharmacist and I bring back the antibiotics and give them to the patient who says to me, “You are so nice.” Are you kidding me, when all the patient had to do was go to the pharmacy himself and picked up the antibiotic the day before, before leaving the hospital.
Now he has to sit in the waiting area because he does not have a ride home after coming to the emergency department by ambulance. While he sits and waits I hear him say to other patients waiting, “I was here yesterday and they didn’t do anything for me and this guy just got me some antibiotics today.” To which I got up from the chair and reminded him in front of everyone in the waiting area, “Now come on, they did do for you yesterday. It was you who did not do for yourself. All you had to do was go to the pharmacy to pick it up,” I said. And he corrected himself, “He is right. They did give me antibiotics and I forgot to go get them before I left yesterday.”
I cannot win and critics will likely say I yielded to the second patient after the first patient complained. Not likely but I can see how critics may think that. However, tonight’s migraine patient was something else. I am sure he was from the five percent USA Today found held the feeling that business did not care about them.
No soon I began typing, the next patient showed up at 3:30am in three inches of snow and still snowing. A thirteen month old brought in by the parent because of runny nose and cough for four days without seeking medical attention prior to arrival, four clear and dry days to say the least, and the symptoms had not changed. Not to mention the pediatric clinic would be open in four and a half hours at 8:00am, although by then there might be another inch or two of snow on the ground. 
It’s not that I mind seeing those patients, as they are the bread and butter of emergency care, but if you try to tell them about their poor decision making they get upset. I am sure the headache hurts and could even get worse but if you are prone to migraine headaches you probably should never let the medicine that works run out.
If your child has a cold and is playful after you give him Tylenol for his fever, waiting four more hours to drive in the light of day is probably a better idea, not to mention the snow.
Healthcare workers are not bad people. We work in the only industry dedicated at helping others; no other industry can make that claim. Your toddler is not the first thrashing toddler we tried to look in his ears. Let us do our job and let us do it the way we know best.
And if you go to seek medical attention make sure you pay attention to your instructions, like picking up an antibiotic before you leave.

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