The Customer is NEVER Right - A Nurse Practitioner's Perspective
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Another Prison Sentence! (Long but worth the read!)

During the three-hour drive to another locums job, four weeks ago, I found myself thinking about how many little things in my private life had fallen off the planet. More bitching some will say, however, as I mentioned at the beginning of taking on this blog, these are stories I could no longer share at home as it was not fair that of all people my number one fan and greatest supporter would have to bare the brunt of these redundant stories. Yes, redundant, as one reader of the book stated, and I agree. Yet, another reader of the book found the stories to be so outrageous she could not believe they were even true, however, she made no mention that the stories were similar in any way.

Nonetheless, redundant or not, stories that are now affecting my personal life for no reason other than I will not cater to exaggerated unrealistic emotional expectations, entitlements or so-called VIP, as I have not killed a patient I have cared for. Not that killing a patient is ever a good thing, however, for those healthcare workers it is not the end of their careers, and likely much less significant in their private lives, as redundant patient complaints have affected mine.

So, on my 153-mile trek from home to a rural emergency department (ED) I thought, that after three years of traveling to work locum jobs I had missed the simple and insignificant routine of applying gel in my hair. Yes, hair-gel, something the TSA does not appreciate in ones carry-on bag and rather than deal with that I have chosen not to carry it at all and why I was thinking of it at that moment as I was driving and not flying.

I realize that sounds silly, hair-gel, however, one notable thing before I began working locum jobs, among many, was that I was always well groomed, well dressed, my face either clean-shaved or neatly trimmed, to include ear and nose hairs, my finger nails nicely trimmed, my gig line (shirt collar, shirt buttons, pant button, belt buckle and zipper) straight, yada yada yada. However, for some time now in those three years it has not been the top priority, for no reason other than I cannot carry the hair-gel, nail clippers, razor and, sometimes, I forget the electric razor at home.

On top of that, I also made an effort of arriving to work on time, something that was so notable by colleagues that some commented, “You are like clock work. Always on time.” A comment I found odd, to say the least, and to which I always replied, “I know. It’s a bad habit I have.” Part of being timely also included that I was ready to start seeing patients the moment the clock struck the hour I was to begin my shift, as I never made it a habit to go around the ED to say hello to others. All habits I took for granted, thinking it was expected rather than extraordinary, until an employer brought to my attention that colleagues had complained, and were even upset, that I had a habit of going straight to seeing patients without saying hello or acknowledging others at work. “This is work not junior high school. I come here to work not to be popular,” I told my employer. However, my employer thought it was more important that I appeased coworkers, as well.

Sadly, I do not find myself asking where am I headed in my career, although dissatisfied and a question commonly asked by others when dissatisfied, as I have concluded that what I enjoy doing most, working in the ED, has reached a dead end. Instead, what I ask myself is where am I headed in life? A question that never entered my mind, EVER! It is not that I doubt myself, but that in the past, my life and career simply fell in place without me EVER knowing, asking or caring what I would be doing next, not to mention in five or ten years, and that is no longer.

Currently I, literally, work week-to-week or month-to-month, at times not knowing if I will be working next week, next month or being dismissed from a contract because the facility I am working at has hired a permanent healthcare provide thus I am no longer needed. Because of those dynamics I also live paycheck to paycheck, another first as an adult. All in all, an unhealthy life-style for a number of reasons but worst of all is not being home.

In the past I simply applied for a job, a school, an adventure and then applied myself and there I was, getting it done, and pleased with every outcome and even rewarded with accolades. However, and again for the first time EVER, as for today, tomorrow, next week, next month, a year away, I am clueless! I have no idea what my life will be. Never has that been so. NEVER!  As I have always lived the moment and have lived my life as described by this quote I found at the Foundation for Better Life,“[staying] so busy loving life I never had time for hate, regret or fear,” A quote, by Karen Salmansohn, that I thought characterizes me.

Why am I clueless about my life? Because, for the first time in more than thirty years of continuous employment, I find myself with the insecurity of not being hired full-time and sometimes not working at all for weeks or months at a time and because of that, I find myself living paycheck to paycheck. I realize that is bitching, as today many are without work, and I should be glad that at least I find a job every now and then. However, I chose the career I chose knowing I would always be employed and even today when many are without work there is a shortage of healthcare workers across the nation. In our nation, that has never been more the case than the present, as the Affordable Care Act is just months away from going into full swing and the availability for healthcare workers will be scarce. Yet, here is one healthcare worker not working because I will not bend over to exaggerated unrealistic emotional expectations. Because if I did bend over, and although likely I would hate every day of work, I would be employed and have no reason to be bitching.

In the book I made mention that as a child, my siblings and I never went to bed without a meal. However, I left out that I could not confirm the same for my parents, not during their childhoods as that was a given, but when we were children who depended on them I cannot say with certainty they never went to bed without a meal. I mention that here because I know what it is to find oneself in that predicament and although far from there today my parents, siblings and I been there, a life we hope never to find ourselves again. This time, all because someone decided I am a greater risk than an access to an organization and that is what is so uncomfortable for me, to say the least.

On that note, what makes matters worse is one’s psyche, of which NEVER before was an issue to include returning home from war. Because for some reason being unemployed for no reason other then healthcare administrators defining my customer dissatisfaction baggage as a greater risk to the organization than the healthcare I provide as a benefit is disconcerting. I realize others work locums because it has benefits for them and in public I say the same, claiming the flexible schedule allows me to not work when I do not want to work so that I can do things that I enjoy. However, in private, that is not the case as that one benefit does not make up in the least for not being home after every shift.

However, none of that bitching means that I do not enjoy the work of helping others, it simply means that my professional and personal pride, candid demeanor, professional conscientiousness, projected self-confidence, honesty, integrity, loyalty and command for respect does not fit a subservient work environment where the demand of my employer is that I bend over for every expectation healthcare administrators want me to accommodate. I tried that yet have failed every healthcare employer and have failed for no reason other than that I was not meant to be manipulated, broken, weaken, injured or depressed and I guess some find that offensive. Nonetheless, I have tried yet failed.

On that note, imagine how warm and fuzzy I felt when I read a recent Forbes story that identified nursing as being the fourth unhappiest job and that realtors had the happiest jobs. More disappointing is to look at it in this manner, nursing the epitome of helping others not only compared to an industry partially responsible for our country’s financial collapse but also outshined by that same industry.

Now it is the fourth week I been at this ED, and although I have heard accolades from patients and even the facility’s CEO, yes the CEO, who, when we were introduced on the second day complimented me on the care I provided a patient. However, for me, I can only recall the number of times I have had to bow in order to keep this “gig”, as one colleague called the locum jobs I take, knowing they are jobs very few, if any, would take if they had a choice.

The below patients with the asterisks are the ones that stand out while here:

*A patient who needed refills for hydrocodone/acetaminophen 7.5/500, Neurontin and Depakote, her chronic pain cocktail. The patient needed the refills at 5:30pm because she was going out of town that night, to another state via a three-hour flight and the nearest airport from here was three hours by car. Of course, the patient was aware of those logistics for some time and had planned, accordantly, to see her PCP the week before for the same, medication refill, but missed that appointment and missed the rescheduled appointment at 4:30pm, one hour before I saw her. However, the patient did not appreciate that I wrote for ten (10) tabs of the hydrocodone and not the 180 tabs she wanted and “what I normally get”, as she said showing me the empty bottle of her previous prescription. I had NEVER seen a bottle for hydrocodone with a manufacture’s label that is something one would find at a pharmacy for stock dispensing.

*A 30-year-old with knee pain while walking without a fall. The same self-limiting knee pain he has had since childhood, and for which he had never sought medical attention before I saw him because, however, this episode was different. The difference, the pain had not resolved, although he had not taken anything for it because he had never had to take anything for it before. Also different with this episode, he could not extend his knee completely. Despite those two differences, he was able to bear weight and ambulate with a slight antalgic gait. Other than some mild soft tissue tenderness the physical exam was unremarkable. However, the patient requested an x-ray of the knee that was not clinically indicated and I bowed saying, “Sure.” Ordered the x-ray and completed the discharge instructions. After the x-ray I shared with the patient the normal findings but then he requested an MRI of his knee and after a long discussion I informed him I could not justify an MRI, however, that took a long discussion before the patient yielded. As I walked away the patient requested crutches and after informing him there was no need for crutches the patient insisted on crutches. Crutches he got. When he requested for “something stronger” than the NSAIDs I wrote in his discharge instructions I said, “No.”

*I was but two-steps into a room where I found a 45-year-old standing and leaning over an over-bed table while she was scrolling through her cellphone when I introduce myself. “Hi. My name is Jose. I am a nurse practitioner. What is your name?” The patient firing back, “I was told I was going to see a doctor. Not you [NP].” So without another word on the third step I did a rear march and walked back out of the room. At the nurse’s station I repeated to the nurse who had provided me the patient’s chart, “The patient said, ‘I was told I was going to see a doctor. Not you.’” Being my first week at that facility I added, “I have no idea if you guys [the facility] cater to that [behavior] but I would be glad to send her on her way.”

Sadly, the nurse said, “If we do not see her now she will come back by ambulance.” Based on the knowledge that the patient was well known to the facility. Regardless, I answered the nurse, “Arriving to the [ED] by ambulance does not elevate a patient’s acuity to emergent.” However, I was a guest at the facility, that being a benefit of locums, as I have no stake in the organization. Nonetheless, with that incident I was made aware of the facility’s poor management of manipulative behavior. However, having worked in many facilities, this one was consistent with many others who allow such behavior.

How did healthcare get here? How does a patient get to dictate that they will be seen one way or another, even if that means running up the bill, not to mention, taking an ambulance off service to run a non-emergent patient to the ED? A bill taxpayers will be on the hook for as some in healthcare believe patients may make poor judgment decisions and should not be held responsible to pay for those poor decisions.

Rather than cater to such, I would implement a policy that when a patient is dismissed from the ED for being inappropriate and returns by ambulance under the pretense that the ED cannot dismiss them without the risk of violating EMTALA, that patient will be required to pay that ambulance bill. If after the medical screen exam the patient is found to be non-emergent and denies or claims unable to pay the ambulance bill at the moment of discharge the police will be called and the patient charged with larceny.

Why? If the same person went to Wal-Mart by taxicab and declined to pay the cab the police would be notified and the person charged with larceny as well. So why is it any different when a patient takes advantage of the only profession genuinely dedicated to helping others.

Making matters worse, when a patient refuses to be seen my me, I then have to apologize to the physician. Not that a physician has ever expected such apologies, as they always brush me off, but because the administration won’t apologize and I feel personally responsible for increasing the physician’s workload. Worst of all, for no reason other than administrators want the patient’s wishes granted.

*Than there was a patient’s family who said to me, at least three times, “Thanks Bud”. I realize petty, however, I address patients by their names and when I cannot recall their name, which is often, I address them as either, “Sir” or “Ma’am”. Never by nicknames or any other name the patient may want to be called other than what is their name on the chart. I know. I know. Petty, and although one physician mentor I admired asked me a number of times to lower my expectations, I do not and will not, address, talk, or interact with patients as I do with my family and friends. Because of that, I have always corrected patients or family who called me “Bud…Dude…Boo…etc.” the moment they said any of them. I also correct them the moment they use any profanity. However, this family member I ignored as I had been working here two days and after the CEO’s accolades I did not want to jinx that.

*Then another family member, of a different patient, called me “Dude” which I have always found offensive in a professional interaction between a healthcare worker and a patient. We are not bosom buddies for patients to call any healthcare worker “Dude” because if I called every patient I saw “Dude” it is likely most, if not all, would complain.

As just mentioned, I always correct them the moment they spoke the words, “Do not call me Dude. My name is Jose.” Unfortunately, I wanted to stay employed so after my knitted brow looked up to the family member the moment it was said I carried on as if I had not heard the offensive diminutive.

I mention this redundant story because at discharge, the patient, not the “Dude”, asked for “something stronger” for a simple finger laceration and I declined. Unfortunately and without concern that I was present, the “Dude” said to the patient, “Don’t worry I know where we can get some.” Once again, the knitted brow looked up, but so what, I had bowed cowardly to being called “Dude” for the sake of keeping a job, so now I would bow just as cowardly to hearing that the family would find “something stronger” for the patient.

*Unfortunately it does not end there, early into the job I saw a one-year-old the parent brought in due to a runny nose and non-productive cough for eight days without seeking medical attention prior to me seeing him. During the assessment I found the child to be playful and although crying during the physical exam he was consolable by the parent and returned to self-playing after the exam. Nonetheless, the child was diagnosed with bronchitis clinically and because I was going to prescribe him an antibiotic I did not order a chest x-ray, however, not before an extensive discussion with the parent to defer the x-ray and the parent verbalized understanding and agreement. Done!

Nope. Because if so, I would not be writing about the child, so the parent brings back the child five days later. “He is not any better and he keeps coughing.” The symptoms about the same, runny nose, non-productive cough, no fever and had not followed up with the pediatrician. The physical exam again unremarkable, other than some dried nasal snot and did I mention, not once during either visit did the child cough as the non-productive cough was mostly at nighttime. Regardless, the parent wanted a chest x-ray the second time around. Which! Survey says! Was unremarkable. Including the radiologist’s final report. And. And. After the x-ray findings were discussed with the parent the parent expressed satisfaction, as if the chest x-ray were therapeutic, despite the unnecessary radiation, information not shared to avoid a complaint.

*60+ year-old with an inguinal hernia for more than two months who expressed, “It has been a lot worse than this before.” He also informed me that he been to at least two other EDs where he was prescribed Vicodin but had not followed up with a surgeon to have the hernia repair. The hernia was easily reduced with positioning. At discharge, when the patient asked for pain medication I declined, emphasizing the need to follow up with general surgery to have it repaired was more pertinent than pain medicine.

*The main attraction in the area I am working in is a river and in the four weeks I been here I have seen lots of ear pain of all ages, if not the most ear pain I have ever seen, ever. Most findings were consistent with wet cerumen in the canal but everyone wanted antibiotics in case it got worse and everyone, especially the children, wanted to continue to play in the river. However, a handful of those patients, all children, had unremarkable findings on examination yet their parents all wanted medicine, likely antibiotics, in case it got worse. One parent suggesting before the physical examination that I look in both ears “just to make sure what ear it is in” the parent not knowing a physical exam includes both ears not to mention other systems.

*I found a 26-year-old laying right lateral with her head supported with her right hand and smiling, like excited, when I walked into the room. The patient’s complaint was a severe headache 10/10, not that I asked her to rate her pain. The headache for two day and she was out of her migraine medicines. After her exam, which was unremarkable, the patient requested a work absence note for two days, the day before I saw her and the day I saw her, and I said, “No.” Adding, “Ma’am, I cannot justify you not going to work today but definitely I will not include yesterday.” The patient left with the note for that day but left dissatisfied due to she did not get a note for the day before.

I know. I know. I sound like a broken record but for those who have not read the book or other blogs, I do not possess superpowers capable of determining what an employee can or cannot do at work. On that note, healthcare should not be the decision making parent between an employee and an employer. If you do not want to go to work, for whatever reason, illness, injury, pleasure, that is not a healthcare issue, that is for you to discuss with your employer.

On the same note, do not seek medical attention after a work related injury “just to have it documented that it happened at work”. Healthcare is not a notary to your mishaps. If you injured yourself at work and want it documented tell your employer. Not to mention, most would not seek medical attention if these injuries were not work related and much less if they had to pay the bill themselves. So, why get healthcare involved? Unless, just another opportunity to run up the bill.

The same if you are not injured during a motor vehicle crash, do not seek medical attention just to have it documented. Because being in a motor vehicle crash alone is not a medical condition and much less a medical emergency, it does not matter how many times the vehicle rolled or if the engine block is in the front seat. Instead, be happy that you were not injured and go get yourself a Big Gulp at 7-11 to celebrate.

*As for a “Return to Duty” evaluation, what superpowers does any healthcare worker have to determine whether an employee can return to their duties? Yet, I have seen a handful of those patients here as well. The most absurd one being a 24-year-old who suffered a chemical burn to both his eyes after a fire extinguisher discharge was blown in his eyes by the wind almost three weeks before I saw him, the day he returned to work after released by the Ophthalmologist who treated him. However, the 24-year-old forgot his “Return to Duty” form, and although the patient had been working most of his 12-hour shift, his employer had him come in to obtain a “Return to Duty” evaluation.

It being a small rural town, and the three PCP offices in town not having same-day appointments, the options are limited to where the patient can get a “Return to Duty” evaluation the same day, if such an evaluation is even necessary. The irony of it all was that it did not matter to the employer that the one the Ophthalmologist provided the patient was left at home, some 150+ miles away, although to me it could have been that the dog ate the form for all that mattered. Yet, the employer thought that somehow a different healthcare worker would find the story more truthful than the employer did, me not knowing, or even if it mattered that the employer knew or not know, or if the story was even true. Regardless, in this case of irresponsibility, lack of attention, immaturity or just plain disregard by the patient, and neither a medical issue, and again, a discussion for the employee and the employer on whether or not he can do his job.

*Because of that position of mine, regarding return to duty and other work related non-medical issues healthcare has decided to referee, a different patient thought it was appropriate to call me an asshole!

“Hi my name is Jose. I am a nurse practitioner. What is your name?” What I always say. That is my script. NEVER! Have I told anyone they can call me an asshole. NEVER! And much less, have I ever called a patient or family, an asshole.

My script continues, “What brings you in?” “I need a return to work slip,” the patient replied. “Why?” I asked. During her explanation of the employers policy the patient unknowingly stated she was given days off from work, however, she did not think those days were sufficient and she decided on her own, without medical follow up, to take four additional days off. After the patient finished her long and convoluted melodramatic story I asked, “So if you decided, on your own, to take additional days off, without a healthcare provided involved, then, why can you not, on your own, tell your employer you are ready to go back to work?”

My question falling on deaf ears as the patient reverted to her long and convoluted tragedy, as if I had not heard her, but I did hear her as I really try to follow patient’s stories. However, with this patient, I may have heard stuff she did not want me to hear initially and now she was trying to back peddle the story. “But Ma’am, if you decided not to go to work on your own, why does healthcare need to get involved?” I asked, again.

BOOM! The patient exploded, “Because when you saw me you didn’t do anything for me and I had to come back and be seen again in the [ED]. And that doctor gave me some medicine and gave me some days off. But I did not feel better so I took some more days off. If you are not going to give me the return to work note, you asshole, than I will go somewhere else where they will give it to me.”

Not recognizing the patient, I was concerned the moment she mentioned that I had seen her and not done anything for her. Did I miss something? However, the moment she said the words, “you asshole,” that concern vanished and the knitted brow bore a hole through her forehead without me saying a word. Which seemed to make her uncomfortable as she gathered her things and abruptly walked out of the room. Unfortunately, not before repeating the word under her breath, “Asshole.”

As she walked out and I walked to the nurse’s station I said to the patient, “Have a great day,” and then the thought of calling her employer to let them know what just happened entered my mind. However, that would have been a HIPPA violation. Oddly, it would not have been a violation had the patient been seen for a work related injury/illness as those are exempt from HIPPA, with regard to sharing with employers, and something that bothers me when it comes to patient confidentiality.

Instead, I asked a nurse to pull up the patient’s chart with regard to the two visits the patient mentioned. The chart review revealed the following:

I saw the patient 18 days ago. On exam she had an erythematous pharynx with a number of vesicular lesions and I recall telling her she had a viral pharyngitis that likely would get worse before better but would resolve over time. However, she did not seem convinced saying, “I have had strep throat a number of times before and it feels just like that.” So I swabbed her throat and it was negative. At discharge I gave her, my all to common viral illnesses spill, “If you do what the doctor says you will get better in 2 weeks. If you do NOT do what the doctor says you will get better in 14 days. Two weeks. Fourteen days. It is the same. Viral illnesses run their course and there is not much you can do for them…yada yada yada.” She seemed okay with the explanation and the treatment plan and was discharged back to work.

The patient returned to the ED three days later, not better, however that chart did not document the patient was worse. Although I recall telling the patient she might be worse before getting better. The vital signs on the second visit did show she had tachycardia at 120bpm, which was new, and a SpO2 of 99% on room air (RA).

The following diagnostics were ordered on the second visit:
CBC: Unremarkable
CMP: Unremarkable
CXR: No Acute Disease
SHCG: Negative
Strep: Negative
MonoSpot: Negative

Interesting enough, on the second visit the patient was diagnosed with 1) Pharyngitis, which was my primary diagnosis as well, and 2) Bronchitis, my diagnosis was URI. However, unlike when I saw her, on the second visit the patient was prescribed Keflex x10days, Albuterol inhaler, Medrol Pak; and provided a work absence note for three days.

As interesting, the chart reflexed wheezing and rales during auscultation of her lungs, although her SpO2 was 99% on RA with a respiratory rate of 12bpm, yet, the patient was not given a breathing treatment or steroids in the ED, while waiting on blood test, but were both prescribed at discharge. All of which are possible, but nonetheless, interesting.

More interesting were the facts that 1) Despite the barrage of unremarkable diagnostics 2) Despite the barrage of prescribed medicines and 3) Despite the three days off the patient was not any better and 4) why she, on her own, without medical follow up, took an additional four days off.

Another interesting fact, usually, if you have a bacterial infection and take antibiotics you notice some improvement by day thee of taking the antibiotics. However, that is rarely the case if the source is viral, as antibiotics do NOTHING for viral illnesses. Yet, another example!

However, the patient was not upset with anyone but me. Not because her illness progressed as I described it, even after the barrage of “unnecessary” diagnostics and medications, but because I declined to provide her with a work absence note for time off that she took on her own. Interesting!

Do not get me wrong, I get it, workers compensation, disability and unions, were established to protect employees from terrible employers. However, today, more employees take advantage of their employers under those pretenses than employers took advantage of employees. On that note, I would argue those entitlement programs have out lived their intentions and the same programs, intended to help, can be blamed for more harm than benefit to our society today. Just my two sense [sic].

*Continuing with memorable patients, I saw an 18-year-old, accompanied by his parent, who came in within the hour of being stung by an insect, or so he thought. When I asked the patient, “What brings you in?”

The patient replied, “I hope you can tell me what I was stung by.”

In my mind, my head dropped into my hands and I shook it violently until I could hear my brain rattle inside, then ripping it off my shoulders throwing it down the hall, the neck still attached. However, unable to behave in such matter in front of patients I said to him instead, “But I was not there. What makes you think I can tell you what bit you?”

“Well, I hope you can look at it and tell me.”

Not sharing with the patient I said to myself, “What superpowers do I have that I can identify what bit this patient just by looking at his arm?” However, after looking at his arm for some time I shared with him that I was not able to find the site where he was stung so I asked him to show me where it was.

However, after twisting and turning his arm he said, “I can’t find it either.”

Then the mother jumps in, “Well he is allergic to bees and mosquito bites.”

“What happens when he gets bit by a bee or mosquito?”

“The area swells up.”

“Just the area where he got stung?” I asked.

“Yes. Just the area where he gets stung. It just swells up,” she replied.

“Does he swell up anywhere else? Or is it just the local area where he was stung?”

“Just the local area,” she said.

“Does it itch or does he break out into hives?”

“No. Just right where he gets stung gets red and swells up.”

“Do you ever have to take anything it? I asked.

“No. It gets better on its own,” the two of them said simultaneously.

Huh, I thought to myself and said to the patient, “That is a local reaction everyone gets when they get stung, be it a bee, mosquito or any other insect and not necessary an allergic reaction.” I then listened to his lungs and heart, looked in his mouth, and looked at his arm, one more time, where the patient thought he was stung and nothing got my attention.

Before going to see the patient the nurse mentioned the patient’s medical complain was that he was “stung by a mosquito” so on that comment I summoned my superpowers and said to the patient, “Maybe it was a mosquito.” However, it was just after midday and the temperature outside was hovering at about 110F. Yes, there is a river near by but, being in the desert, it was not likely there was any pooled water anywhere out here. And even if there was, most mosquitos are crepuscular (dawn or dusk) feeders and during the heat of the day are resting in a cool place, if such cool place exists in a desert, waiting for the evenings to begin feeding again. However, the patient seemed to be okay with that answer so I left it at that. Not that, medically, it really mattered what had bitten him.

*The next day, at about the same time I saw the mosquito patient the day before, I walk into a room to see a 45-year-old who has a “migraine” headache for the past four days and none of her medicines at home have worked for her migraine and the reason she came in. That was a Thursday. On Saturday of that same week she was scheduled to see a Neurologist some three hours away. And although she has had the same migraine for “years”, as she said, and although it had not changed she was scheduled to see a Neurologist in two days. The patient was the mother of the patient stung by the mosquito, or so my superpowers tell me. When I ask the mother if she had the headache the day before she says, “I did.” Huh. She seemed as comfortable the day before as she did the following day, yet, after “years” of the same migraine, she needed to see a Neurologist.

*A 17-year-old with knee pain for two months without trauma, injury, treatment or seeking medical attention prior to me seeing her that day. The patient able to bear weight and ambulate without difficulty. Oh, I almost forgot, the much needed x-ray unremarkable.

*A 37-year-old with knee pain for two weeks, also, without trauma, injury, treatment, or seeking medical attention prior to me seeing him that day. The patient able to bear weight and ambulate without difficulty and the much needed x-ray, also, unremarkable.

*A 65-year-old who had abdominal surgery two weeks prior, and before me seeing him and unknown to me, had just left his surgeon’s clinic where he was for his follow up appointment, to have his staples removed, but came to the ED for pain medication refill. “What brings you in?” I asked.

“I need a refill for my pain medicines.”

“Pain medicine for what?” I asked.

“I just had surgery here,” the patient opening his shirt to show me the dressing on his abdomen.

“When are you supposed to follow up with the surgeon?”

“This morning. I was just there and left because they told me it may take another three hours before I got seen and I can’t wait that long.”

“Really. Three hours. But I thought you said you had an appointment.”

“I got there late for my appointment and the next one is in three hours but I can’t sit there for three hours so I set another appointment to see him [surgeon] next week at his other clinic to have the staples taken out but I need something for pain. I called my regular doctor because I have other chronic pain and he gives me pain medicine for that but he told me that I needed to see the surgeon for this other pain. So I am here.”

“Sir, this is not your surgeon’s office and that is who you need to see. I am not going to give you anything for pain when it is the surgeon you have to see.”

“I cannot wait three hours to be seen.”

“I suggest you go back to the surgeon’s office and see him today at whatever time they have available because I am sure he would like to see your surgical incision before he writes for any pain medicines.”

And without disagreement the patient stood up and walked out saying, “I guess your right. I will try to see him than.”

*Then my first complain in the past four weeks, or at least a complain to the ED Manager who mentioned to me that the 26-year-old with right upper back pain for one day after lifting a heavy object at work was asking to be seen by the physician. According to the ED Manager, “The patient felt that you [NP J. Torres] did not take him seriously and he wants to be seen by the physician.” Unknowing to the ED Manager, I was writing the same patient’s discharge instructions while I waited to see his x-rays when she approached me, by the way, x-rays that were not clinically indicated but ordered at the patient’s request.

However and I should have known better. That after a physical exam that revealed some focal right thoracic paraspinal muscular pain with palpation and trunk rotation and that while discussing the treatment plan with the patient to return to duty with limitations after that day off, as he did not believe he could return to work that day, apply heat, NSAIDs, a muscle relaxant and the patient still asking, “What about something for the pain?” I should have expected the patient to complain.

“All of that is for the pain,” I said.

“A muscle relaxant and anti-inflammatories? That’s it," he fired back.

“Yes Sir. That combination should work.”

“What about x-rays? You did not get any x-rays. I mean, I don’t mean to tell you what to do but you don’t have x-ray vision.”

Now this story, or best stated, disagreement with patients about wanting x-rays or diagnostics not clinically indicated, or "something stronger", now that is definitely redundant and a broken record. The worst of those being, “You didn’t do anything for me!” As the name calling patient said. Patients do not know, but when they make those claims I want to reply like a GIECO commercial, “You are SO right. I did ABSOLUETELY nothing for you. However! I did save you a TON of your hard earned money, or the taxpayers’ hard earn money, not to mention I did not contribute to the deficit your child will have to deal with for the rest of their lives (as I have no children).” And, if I wanted to hide behind patients, as so many do, I could add, “I also did not expose you to the side effects of unnecessary medications, not to mention, not putting you through the rigmarole and discomfort of unnecessary diagnostic test. So yes! You are so right to say that! I did nothing for you. Oh, yea, how did I forget? I also did not exposure you to unnecessary radiation as well. What was I thinking?”

However, critics, or frustrated colleagues will try to dress me down with the intent to get me to change my ways by arguing, “Jose, you did no one any favors by not catering to that patient because here they are again. If you had taken care of their needs [expectations] in the first place they would not have come back for another [unnecessary] visit.”

I do not blame colleagues for their actions as they are trying to keep their jobs. Instead, I point to healthcare administrators, as they are the ones responsible for where we are in healthcare today. And to them I say, “If you are going to be a manager, the least you can do is take care of your house.” Like the hotel I stayed at which posted the signage below in each room.

The hotel chain was not trying to become the next Bed, Bath & Beyond, instead it was simply trying to keep or discourage people from stealing their linen and appliances. Because when I asked the front desk about their popular linen sales the clerk I spoke to could not recall the last time he had sold any of the items to anyone, especially hotel guest.

Along those lines for healthcare, when a patient returns, for no reason other than “No one did anything for me” or because they are “not better” after told that is the course of their illness and the redundant diagnosis is the same and/or consistent with the initial diagnosis than that patient has “approved a corresponding charge to their account” which they will pay before leaving or, yes, police will be notified of the patient’s desire to take what is not theirs.

However, returning to the patient with back pain and wanting x-rays, because the patient agreed that he did not have midline or vertebral pain or pain from his lungs I asked him, “X-rays of what, Sir? None of your pain is bone or lung related.”

“What about my ribs? What if I popped a rib?”

“I do not think so. But if you want x-rays sure I will order them but I am going to document in the chart that they are your request and not clinically indicated.” So I ordered the x-rays and was waiting to see the images when the ED Manager showed up.

Nonetheless, the patient’s exaggerated unrealistic emotional expectations were met and the patient was seen by the physician who after looking at the rib x-ray commented, “Oh you ordered ribs?”

“I ordered them not because I had an indication for them. I ordered them because that was what the patient asked for,” I shared with the physician.

“I agree,” the physician replied back to me. Adding, “They [x-rays] look fine. I gave him some pain medicine and discharged him.”

In my mind I thought the same thing, as I too gave the patient something for pain and had discharged him. I just did not give him narcotics.

*However, not surprisingly, at the locums Family Practice clinic before coming here I saw another 26-year-old who had injured his index finger, to include a flexor tendon, and he could not flex his finger. Since the injury, five weeks prior, the gentleman had not been working and he was coming in to have his work disability form completed and after an extended discussion where the gentleman said to me, “I feel that I am not able to do my job.” I said, “No, sir. I cannot justify you being on disability. If you are not able to perform your job because of your finger than you will have to find another job because you are going to lose the one you have.” I also told the patient that it did not matter what his job was, “I cannot deem you disable because of one finger when the rest of your body and brain work just fine. This is not a medical issue. This is an issue between you and your employer to make with what you have or you will lose your job and, today, it may not be so easy to find a new one.” I guess the patient understood saying, “I will talk with my employer and see what other job I can do up there.” However, before our conversation someone had suggested to him to file for disability.

*Then, back in the current ED, after the upper back pain that complained I did a Pop Warner Football physical exam for a boy. The next patient right after the boy was a 70-year-old with knee pain after loosing grip of his truck’s handle and falling to the ground from about a two-foot height while at work three days before I saw him. The 70-year-old, seven zero and not a typo, had not taken anything for his pain and he had not sought medical attention prior to me seeing him. During my exam the 70-year-old gentleman was able to bear weight and ambulate with a slight limp but worse when he flex the knee to climb on a step. The knee also had some swelling with an effusion and some tenderness along the knee joint line so I thought an x-ray of the knee was appropriate but the patient did not think so but agreed to the x-ray after a discussion.

Surprisingly, the 70-year-old’s knee x-ray was unremarkable except for an effusion. I wrapped his knee with an ace wrap and discharged him to return to work with some restrictions that included no squatting, kneeling, crawling or climbing ladder and no prolong standing or walking for more than 60 minutes at a time with a 10 minute rest in between. The restrictions were for the next two weeks but the patient, again a 70-year-old, thought that was a bit excessive and instead said he was willing to follow the restrictions for one week and then see his PCP for a reevaluation to see if he still needed the restrictions for another week. And when I suggested some rest, applying cold, elevation, and NSAIDs for pain the patient said he had not taken anything for pain adding he did not need anything for pain.

Healthcare pundits claim that pain is whatever the patient says their pain is but I disagree. Pain is not the issue. The issue is coping or not coping with your pain and here was another example of that. The 26-year-old could not, did not, or did not want to cope with his back pain. The 70-year-old could not, did not, or did not want to allow his pain to affect his activities of daily living, to include work. Yet the 26-year-old had no objective findings and the 70-year-old did.

So, if pain is whatever the patient says it is, what do we tell patients who say they feel great, yet their BMI is 40, and when you suggest treatment for their obesity they are offended by your suggestion? What do we tell patients who have high blood pressure but say they have no symptoms and feel great and decline treatment? What do we tell patients who say they do not have a smoking problem, or an alcohol problem, or a problem with recreational drugs and when you suggest treatment decline? For those refusals to treatment we do not take what they say at face value, and hopefully, try to convince them otherwise. However, sometimes we fail to convince them and despite that we do not press those patients knowing all those conditions increase a patient’s morbidity. However, when a patient says their back pain or tooth pain or ankle pain is one hundred of ten we take whatever they say at face value. Yet, no one has ever died because of pain. Who comes up with this stuff?

When pain is disproportional healthcare workers should be concerned. However, when one shares their concern that the disproportional pain may be compartment syndrome or necrotizing fasciitis and the patient disagrees, saying they only need something for pain, then that is no longer disproportional pain. Instead, it is simply exaggerated and unrealistic expectations and not a pain issue at all but poor coping. On that note, coping skills are improved with education, not narcotics.

*That was not it for the first four weeks, and yet another first as well, as I commonly walk out of the room when the person, patient or parent, I am speaking with decides to talk on a cellphone while I am speaking with them. As if not enough, the policy at this ED is “No cellphones”. However, and regardless of the policy, the parent with this patient asked me to speak on the cellphone with the parent not present to make sure the antibiotic prescription for an uncomplicated otitis externa was “okay” with the parent on the cellphone, who was a fire chief or something. However, when the “fire chief” asked for refills on the prescription, because the patient “gets a number of these ear infections throughout the year,” I said, “No.” However, that was not sufficient for the “fire chief” as I had to decline the request for a refill on the antibiotic a second time, AND, AND, explain myself to the “fire chief” because he wanted to know why I would not include a refill, again, all this just to stay employed.

Nonetheless, wondering how many times the “fire chief” gets asked about how he fights fires, I explained to him that antibiotics were not universally refilled because if the taken antibiotic did not work the first time it was likely a second round of the same would not work either thus needing to be changed, just something I learned in school.

*Then I saw a patient I had seen two days before for a sore throat. During the initial visit the 70-year-old gentleman had a barrage of complaints that included: headache, dizziness, sore throat, unable to swallow, chest pain, shortness of breath and vomiting without nausea for four days and, despite his multiple comorbidities that include diabetes and hypertension, he had not sought medical attention prior to me seeing him. When I asked him, “Of all those symptoms, which is the most concerning?” “My sore throat,” he said. Adding, “Because I cannot swallow.”

Despite the fact the gentleman stated he could not swallow, when I walked into the room he was supine with the head of the bed at a 45-degree angle and he was able to manage his secretions in that position. And. And. When he learned that I spoke his language, as he did not speak English and had a translator with him, he took off on a rant, without ever getting short of breath or unable to manage his secretions. However, it got to the point where he was saying so much and so fast that I had to ask him to slow down, as I could not keep up with everything he was telling me, and most of it was not related to why he was there. Once he was able to stop talking I was able to finish a through physical examination that covered all his symptom, and them some as he was 70-years-old with a list of comorbidities and I did not want to miss anything. Yet, the exam was completely unremarkable except for a little erythema and a single tiny vesicle on his right soft palate.

After much discussion with the patient, that his pharyngitis was likely due to a virus but because he was a diabetic and 70-years-old I would prescribe him some penicillin. On top of that, I also shared with him that if it was a bacterial illness he should feel better in 2-3days but because it was likely it was a viral illness he would continue to have the sore throat and some of the other symptoms for another 5-7days but should complete the antibiotics regardless.

The gentleman seemed to be okay with that explanation and the treatment plan. After ignoring the family who was there to translate I made a comment to her in English, “I hope you do not mind that I fired you but it is much easier if I talk to the patient.” The young lady, likely a granddaughter but maybe even a great-granddaughter as she was easily at least 50 years younger than the patient, was thrilled that she did not have to participate in describing the patients symptoms or having to describe any of the other subjects I discussed with the patient as she did not say a single word during the entire interaction between the patient and I.

Nonetheless, the gentleman showed up two days later because he was not better, yet not worse. The second time there was an older woman, than the first time, with him who likely was at least 20-30 years younger than the patient, but not his spouse. This time the patient’s only medical complaint was his sore throat and that he could not swallow as the plethora of other symptoms seemed to have resolved. Again, I found him in no apparent distress, able to manage his secretions and again, talkative without difficulty, a hoarse or muffled voice as he was two days before.

The second time I limited the physical examination to his respirations, heart sounds, abdomen, neck, ears, nose and throat. And yet again, all unremarkable, to include the previously noted erythema and vesicle in his pharynx had resolved. In that sense, the physical signs had improved although the patient stated the symptoms were the same and just like I had explained it to him two days before with regard to a viral pattern. Yet, here he was again, this time with a family member that wanted to participate in the conversation, I believed it was because she felt the patient had been duped before.

However, for the sake of keeping my job I went over what I had discussed with the patient during the initial visit, again, the second time including the family member, although the gentleman was more than likely able to care for him self. And. And. Likely, at home, the 70-year-old gentleman did not tolerate his authority being questioned by others, to include that of family members. Nonetheless, I went over it with the family.

When I thought she was satisfied she says to me in English, “Well, are you not going to check his blood level?”

“What blood level?” I asked.

“His blood level for his Coumadin…or Warfarin. He has to have it checked every week.”

“I have no reason to check his blood Ma’am. That is something he has to do with his [PCP] because that is who needs to get the values so that they can make whatever, if any, adjustments to his Coumadin.”

And I turned to the patient and said to him, “Your doctor should give you a prescription to have your blood checked and you need to take that prescription to the lab to have it done.”

Almost on cue, the family asked the patient if he had the prescription, as if she knew that and it was not news to her, asking him, “Where is that yellow paper you had to have your blood checked?” My head almost snapping off my neck the double take was so violent. However, I did not dare to share for fear to lose my job, but really, you know that he has his blood checked every week, for years, and that the prescription is written on a yellow paper and you are asking me why I am not checking his blood. Where is the candid camera? Then as if nothing had occurred the two stood up, the patient climbing off the exam table, the family standing from the chair she sat in and both walked out of the room, without a word or even a good-bye, as if I was not there. Not to mention not a “thank you” either, as those are rare when exaggerated unrealistic emotional expectations or hidden agendas, like a blood test not getting done when requested by the patient’s family.

*Along that line, I have seen a number of other patients here with sore throat and ear pain as mentioned, and as mentioned I prescribed unnecessary antibiotics, as those were the expectations of the patient and/or family, to include a “fire chief”, as antibiotics were not indicated for most. Why have I been so inappropriate, if not negligent? Because what I have learned, and thought this would be a lab to prove such wrongness, if not negligence, was to lower my expectations of patients as an admired mentor asked me to do years ago. As for here, and likely what I been running up against for so long in my practice, that it is much easier, and much more significant as it was what the patient had in mind, although inappropriate, to prescribe an unnecessary antibiotic than it was to provide an extensive discussion as to why an antibiotic, and a refill for such, was not indicated and even inappropriate.

On that note, when I read the April 2013 edition of Prescriber’s Letter (a monthly CME publication that prides itself in “Unbiased recommendation [healthcare workers] can trust on new developments in drug therapy”) it stated, “[Healthcare workers will] see even more emphasis on limiting antibiotics in kids with acute otitis media (AOM).” However, that is not news! And not something we need to keep telling the choir. Instead, that is something healthcare administrators need to be told so they have “justification” to support healthcare workers when parents demand an antibiotic for ear pain, whether AOM or because their infant was pulling at their ears. Because as Dr. Doyle mentioned in his book, Suck it up, America, a lot of things resolve on their own, to include AOM as pointed out by Prescriber’s Letter. On top of that, Prescriber’s Letter also mentioned that 20 kids need to be treated for one of them not to have ear pain at 2 to 7 days yet one of every 14 kids will develop GI symptoms or rash.

I did not make that up. That comes from a reliable source yet when shared with the public, or healthcare administrators, it does not matter if it does not meet the patient's exaggerated unrealistic emotional expectations.

To say the least, none of the mentioned experiences were pleasant ones and, cumulatively, could lead anyone to emotional exhaustion, depersonalization and a low sense of personal accomplishment. However, those experiences are not what leads to BURNOUT, has healthcare pundits have labeled those who reach such professional fatigue, a label I find offensive to say the least and here is why: Healthcare workers are not professionally exhausted from helping others, even if that includes helping the continuous parade of human misery we see in healthcare day in and day out. Instead, what leads to their fatigue is the increasing burden healthcare administrators have forced onto us of having to bend over to accommodate exaggerated unrealistic emotional expectations and, on top of that, add on patients’ and family’s sense of entitlement and so-called VIP mindsets.

On that note, what healthcare pundits have labeled as BURNOUT is nothing more than healthcare workers not wanting to follow the herd or drink from the rancid Kool-Aid that healthcare administrators are serving the only workforce genuinely dedicated to helping others. A Kool-Aid that is spiked with healthcare workers (1) losing their autonomy, (2) having to cope with our decisions constantly being questioned by administrators and (3) the increasing burden of having to bend over to accommodate exaggerated unrealistic emotional expectations.

So then, its not the continuous parade of human misery or the endless acts of helping others that leads to professional fatigue and so many of us to walk away from helping other. Instead, it is the sense of powerlessness in a system that chews up healthcare workers when we push back.

Having said that, and although I was asked to smile more by a patient’s family, again, not all experiences here have been negatively memorable. At least two or three patients had mentioned I was a great doctor, regardless, that I told them I was a nurse practitioner and not a doctor.

*One patient boasted I was the most thorough provider she had met and jokingly I told the patient to tell my boss, pointing at the nurse, so that I can get a pay raise. Sadly, the institutionalized nurse, no fault of his but instead of the indoctrination by healthcare administrators, took advantage of the fan fair and asked the patient to fill out a customer survey related to her experience.

*Then there was the 78-year-old who asked me for a hug after I prescribed her some prednisone due to the NSAID and the Percocet given to her by her PCP, two days prior, were not working for her arthritic knee pain. Although not a fan of hugs or kisses from strangers, I would not say I was a virgin, however, most have been while on humanitarian missions and not in the USA.

*On that note, before I saw the 78-year-old hugger, I saw a gentleman I wanted to hug. He was a patient I saw after his pet dog bit him. I know that sounds outrageous coming from me that I would want to hug anyone, however, when I saw the gentleman I found him to be more depressed than in discomfort from the bite. While repairing the laceration the gentleman shared with me that he had surrendered his dog to animal control to be euthanized as the dog had bit someone else before. Any animal being euthanized strikes a chord with me, however, this story was even more tragic.

When I asked the gentleman why the dog bit him he told me that his other dog had died suddenly, that same day and the other dog was laying next to the body, and when the gentleman went to remove the dead dog the other dog bit him. WOW! No fault of his, the gentleman did not know it was likely the dog was mourning the other dog’s death (click to learn about animal grief). So yes, I thought the gentleman mourning his two best friends would have likely benefited from a hug.

So do not tell healthcare workers we are uncaring, lack compassion or BURNED OUT when we do not sob over ear pain or accommodate exaggerated unrealistic emotional expectations!

*Then there was the appraisal by the hospital’s CEO as I hinted to earlier. When introduced to the CEO she commented, “You have been here one day and already you helped one of our patients.” Taken aback by her words I simply responded, “I help every patient I see.” The patient the CEO spoke of was a patient who had a simple axilla abscess for two weeks before the patient went to see her PCP and from there was sent to the hospital for admission. However, due to some misunderstanding the patient ended up in the ED instead of inpatient. Later I would learn, the PCP’s intent was to have the patient admitted over night for pain management and the following day perform an Incision & Drainage (I & D) of the abscess under procedure sedation. Why? Because, as the patient told me in the ED, “I [patient] do not want to feel any pain.”

After asking for an ED staff to assist, for no reason other than to bare witness in case the patient complained, although having the vetted ED staff present never mattered before. Because, as I mentioned in the book, healthcare administrators do not care what healthcare workers witness if a patient complains. However, it was my first shift here and maybe, just maybe, this one time the administrator would stand by their employee if the patient was not satisfied.

After I informed the patient the pros and cons to having the procedure done with local anesthesia versus procedure sedation the patient verbally consented and a vetted ED staff witnessed the conversation between the patient and I. Again, not knowing if that mattered or not, however, what was more significant was how pathetic it was to how I have to practice. Because despite my extensive vetting, to include my fingerprints filed with the board of nursing in three different states, AZ, NM, and TX, that is insignificant when a patient complains.

Although the patient had some crying, of which the patient was aware of when she consented and what she feared, the procedure was done and the patient went home to her family. The alternative would have been spending the night in the hospital just for procedure sedation the following day, after being kept without food or drink throughout the night. The patient going home with pain medications, not because of the abscess, but because I cut through her skin. I also send patients home with antibiotics but this patient did not want an antibiotic because her PCP specifically told her she wanted to wait on the wound culture result before starting her on an antibiotic. A choice I was comfortable with due to similar simple abscesses were treated with I & D only, and without antibiotics, just a decade ago, so not a big deal and the culture results would be back in 48 hours during which the patient would follow up with her PCP to decide on a treatment plan.

That was the patient that the CEO was boasting about that I helped, a simple abscess that likely I kept from running up the bill, into the thousands I might add, simply because she did not want to have pain for another five minutes. Yet the administration was willing to entertain because the unbearable pain was whatever the patient says it is, rather than calling it a lack of coping skills. Because, how dare you question a patient's pain and, or is it really or and not and at all, worse, that the patient may complain.

*It was too bad the patient, or better yet patients, the CEO was boasting about was NOT the family plan of five, a 3-year-old, a 10-year-old, a 15-year-old, a 16-year-old and the parent, all with the same upper respiratory infection (URI) for 2-3 weeks. And of course, none of them had sought medical attention prior to me seeing them, coincidently, it just happens to be the same day they were all approved for Medicaid. Neither child, nor the parent, appeared ill or even needed medical attention for that matter, yet all were here. Adding insult to injury, all were here fifteen minutes before the end of the shift. I could have easily left them for the ED physician to see, however, I did not, and likely no other healthcare worker would have either, so I saw all five of them in that last fifteen minutes.

I mention the family plan because that will be the scene at a clinic or ED near you on day one of the Affordable Care Act going into full swing. "A big *ucking deal", as our Vice-President whispered to the President the day it was passed in Congress.  Now we just wait for the day everyone will suddenly seek medical attention for whatever has ailed him or her prior to such entitlement, not to mention those wanting to know if what bit them was a mosquito, the endless request for work absence notes, the runny noses, the knee pains since childhood and maybe hope that now, with insurance, they can get it checked out, and the back pain as well, so that they can apply for disability.

*It was also too bad the patient the CEO was boasting about was NOT the 90-year-old with an infected foot who needed to be admitted for intravenous antibiotics or risk losing the foot, becoming septic, and/or dying due to the infection. However, the gentleman shared with me that he had his pet dog sitting in the air-conditioned cab of his idling truck in the hospital’s parking lot and because of that he could not stay. “No problem,” I said. Adding, “Its not like you are having chest pain. We can give you the first dose of antibiotics and the next one will not be due until 12 hours from now. That way you can take care of finding someone to care for your dog and then come back when that is done and we can admit you to the hospital then.” The gentleman agreed and was admitted the next morning when he returned.

*Another patient the CEO was NOT boasting about was an 11-year-old with an open fracture of her left finger that was neglected at another ED, however, the customer service at the other ED “wasn’t bad,” the patient’s mother said when I asked her. “We went in. The doctor saw her immediately. They took an x-ray. Then they soaked it, put that bandage and splint on, and we were out quickly. They did not give her antibiotics because she is already taking some for her ear infection.” Done!

Not! “So why did you bring her here?” I asked the mother. “Just for a second opinion. I do not know if she [patient] got the right treatment. If you think that it’s fine than I am okay with it but I do not think it was done right,” the mother answered. Medicine is medicine is medicine I always say. Because of that I was doubtful that the care was inadequate and said to the mother, “I cannot imagine it not being done right if you were seen at another ED but let’s take a look.”

Wrong! When I peeled the splint and dressing off it was obvious appropriate care was not provided to this child. I was, and still am, furious. Clearly, I could see she had a complete nail avulsion not to mention a laceration that could use a couple sutures, however, and I shared with the parent, “Without numbing the finger I doubt she can tolerate me exploring her finger.”

Seeing the terror in the child's face I did not think she would allow me to do a digital block of her finger so I asked one of the nurses to help me hold the patient’s arm. With the mother’s verbal consent, the nurse and I held the left upper extremity, and the mother held the patient in her arms while I did the digital block. The child cried and screamed at the top of her lungs but eventually it was done and I could explore the fingertip.

Besides the obvious complete nail avulsion, the entire nail bed lifted as a flap revealing a tuft fracture, and then there was the volar laceration where the finger pad burst under the crushing force of the metal door that smashed her finger. After exploring the wound I discussed with the mother what I found, what my plan was to repair it, and the possible outcome, the mother verbalizing she understood and agreed with the plan.

While the finger was numb, and I was sterile, I washed the finger, removed the nail and washed it, washed the finger again, covered the fracture with the nail bed and sutured it in place, with the nurse holding the finger I sutured the volar aspect of the fingertip, then I trimmed the nail, washed it again, and sutured it back to where it was supposed to be.

I then took a moment to show the mother what I did and the mother expressed much appreciation and said she was satisfied with the outcome. A dressing and splint were applied. Discharge instructions were discussed with the mother and her questions answered to her satisfaction, the mother saying, “That was less time than we took at the other place and it was done right.” However, I shared with the mother that I did not get an x-ray as she did not want the cost as an x-ray was done already at the other ED and she could pick that one up for her follow up appointment.

I lost count to the number of times the mother and father thanked us for the work we did. However, at one point I mentioned to the mother it was the nurse who deserved the credit as I did not believe a second opinion for a open fracture treated at another ED was necessary. Thinking to myself, as the standard of care was pretty much straight forward. However, I did share with the mother that what I had done was nothing extraordinary, leaving out the fact that it was the standard of care for this type of wound.

Of course, I did not hear from the CEO with regard to any of those patients as none of them had any drama. However, I would have to say, “I help every patient I see.” And I am always satisfied with the care I rendered, even if that patient does not agree or is not satisfied with my care. I am. Because it is what, at a minimum,I would do for myself and my family, as the saying, or justification, goes. However, that is not what matters, as the 11-year-old’s mother rated the customer service at the other ED as, “wasn’t bad”, despite the product was blatant negligence. I am neither tooting my horn nor singling out the blatant neglect here. Instead, I am simply pointing out that once again customer service is filler for a product’s shortcomings.

*Then there was the patient who I did not know where to place in this blog as the experience was not a complaint or a compliment, but greater, it was honorable. And of all the ones shared definitely worth inclusion among all of my bitching after the patient said she was curious of my lack of smile and directness, adding that it was “without fluff or sugar-coating”. However, instead of asking me to smile more as others have this patient asked if I served in the military. My answer, “Yes, Ma’am.” She then thanked me for my service and shared with me the reason she asked was because she was “all to familiar with the character type” as her husband had a similar character and he too had served in the U. S. Army, a combat medic as well. However, when she told me he was a healthcare administrator in a nearby facility a huge smile erupted on my face and jokingly I said to her that I was disappointed with him. I then shared with her that I had written a book about customer service in healthcare and gave her the business card for “The Customer is NEVER Right”. Excited, she took the card from me and said, “He will appreciate this.”

By the way, the patients mentioned were not all the patient I had seen in those four weeks. Those were the memorable ones, and sadly, again, and redundant, mostly the negative experiences. As those who bragged, although few, but nonetheless bragged, that I was “Da Bestest of the Best” as Bu La’ia says, are lost among the greater crowd of those satisfied.   

With all that said, finally, I close this long and redundant blog with these last thoughts.

Some question if my humanitarian mission exposure to poverty, despair, and lack of healthcare access is to blame as to why I am insensitive with patients from our nation, where we have so much yet complain about it and are impatient with those trying to help. My answer, “NO!” Adding, “I am not insensitive to patients. As a matter of fact, I actually listen, diligently, to what patients tell me and it is actually what they tell me that sets off “Red Flags”. Something I comment about when nurses say, “The patient did not tell me that,” to which I reply, “That’s because I waterboard patients.” Meaning that I do not want to hear their long drawn out convoluted melodramatic stories about nothing. I want them to answer my pertinent questions, skipping all the unnecessary fluff or filler in between. In doing so, some patients feel like they been waterboarded, or what one patient in the book described as, “You are like a drill sergeant.”

With that said, I would have to say, I have NEVER had a sick patient complain. The only patients who have ever complained were those with exaggerated unrealistic emotional expectations, entitlements and the so-called VIP
On top of that, I would add, “I do not travel to see different things. I travel to see things differently.” If anything, those humanitarian experiences have made me a better healthcare worker. As Mark Twain said, “Travel is fatal to prejudice, bigotry, and narrow-mindedness.” In that sense, I have come to appreciate what the body is capable of healing without medical intervention, and more so, I have witnessed what the body is capable of doing despite everyday aches and pain. Having said that, not catering to exaggerated unrealistic emotional expectation is not limited to the USA, as I have dismissed the same exaggerated expectations during humanitarian mission outside the USA as well.

On that note, by no means am I suggesting our great nation pass on modern medicine and technology. Instead, what I am saying to our nation’s citizens is, “Lets not grab everything in front of us just for the sake of grabbing. Instead, leave those things for those incapable of getting to where we are in life, as likely, they are worse off than us and would benefit the most.”

On to another closing topic, because of my frequent travels for locums work friends and family ask me all the time about where I am headed to next, as if leaving home to go work where no one else wants to work were exciting. Instead, as a colleague at one of those sites poignantly pointed out, “We are all here for a reason.” That reason, not humanitarian, not pleasure, and, most definitely, not because the pay is great. Instead, because we are NOT able to stay employed full-time elsewhere, he hinted, while twisting and pulling the serrated dagger he had just impaled in my weeping helping heart. How enlightening! Another colleague labeling it “A prison sentence.” Even more enlighten. And although I cannot speak as to why others take these jobs I can tell you that for me, it is because I will not bend over.

With that said, none of these jobs away from home are pleasurable or exciting. To add insult to injury, while getting ready for work at another locums job one morning I stopped to watch a tourism commercial that caught my attention. The commercial mentioning that we humans have some 25,000 mornings, and, if lucky, we might catch the glimpse of a sunrise. Twenty-five thousand. How many of those have I spent away from home for no reason other than I will not follow the herd or drink their Kool-Aid?

So quit asking me about my travels for work, as I do not enjoy them. If anything, they are nothing more than just “Another prison sentence.” And likely the next job will be the same, “Another prison sentence.” And for no reason other than, as mentioned by others, I have the “testicular fortitude” to tell patients, families, and healthcare administrators, in their presence and not just to the choir behind the nurse’s station, “No.”

I end this bitching session with the quote that follows as, with the book and these blogs, I try to convince companions today what others will eventually come to realize and learn later:

"A third danger is timidity. Few men are willing to brave the disapproval of their fellows, the censure of their colleagues, the wrath of their society. Moral courage is a rarer commodity than bravery in battle or great intelligence. Yet it is the one essential, vital quality of those who seek to change a world, which yields most painfully to change. Aristotle tells us that “At the Olympic games it is not the finest and the strongest men who are crowned, but they who enter the lists.... So too in the life of the honorable and the good it is they who act rightly who win the prize.” I believe that in this generation those with the courage to enter the moral conflict will find themselves with companions in every corner of the world."

NOTE: Believe it or not, after working here for four weeks, and with eight weeks left on the contract, I have been given a 30-day notice of dismissal. This time, not because of patient complaints but because the facility I am working at has hired a permanent healthcare provide thus I am no longer needed. Mother %$&*#@! Once again, time to find another locums job, "Another Prison Sentence", where I will have to prove myself, worthy of the work I been educated to do, before I am accepted by the staff at that facility. Not to mention the bothersome it must be for references with the redundant request to provide references for me. All which I appreciate but I am sure they are beyond tired of the kind gesture. This SUCKS! What a way to make an honest living!

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