A few nights ago, but on the same night, I saw a string of patients that were a bit interesting to say the least. Not interesting in the form of challenging diagnoses but interesting in the sense of which ones were going to complain.
The first patient I saw that night was a 23-year-old female whose medical complaint was rectal bleeding. After introducing myself, as I always do, “Hi. My name is Jose. I am a nurse practitioner,” the patient said to me she had a single episode of dark blood in her stool earlier that day. Adding that when she called her primary care provider (PCP) she was told to go to the emergency department. Aside from the rectal bleeding she had no other symptoms. No nausea, vomiting or diarrhea. No abdominal pain. No dizziness and no lightheadedness. Nothing.
When I asked if she was straining with her bowel movements she asked, “What is that?” “Strain?” I asked. “Were you pushing to have a bowel movement?” I added. “No,” she replied. Then she asked, “What is bowel movement?” “Pooping. Going number two.” A family member in the room injected.
Really? “Going number two.” This was a 23-year-old female and she never heard of having a bowel movement? Worse, she still calls it or only understands it as “Pooping” or “Going number two”. Interestingly, the patient claims she had a history of “IBS” as she said. IBS is Irritable Bowel Syndrome. So, she had IBS but never heard of the term bowel movement. None of that made sense. Well, maybe if she had IBS and was 6-years-old but I would think a 23-year-old with IBS would have heard of the term bowel movement at least once or twice. I mean, come on! IBS has everything to do with bowel movements so how can someone with IBS never heard of bowel movements.
Anyway, after getting through that and a completely unremarkable physical exam, during which the entire time the patient must have thought was funny as she kept laughing with the family member in the room, I said, “I need to do a rectal exam.” At that point the family member, NOT the patient, said, “Are we going to see a doctor? We [the patient and family, I guess] have been here for two hours and not seen a doctor.”
It’s interesting how, despite me using the same rehearsed introduction over and over, some patients hear me announce I am a nurse practitioners and others claim I said I was a doctor. Regardless, I do not try to reason with anyone regarding their discontent with nurse practitioners versus them wanting to be seen by a physician. Well, except in clinics where I been the only healthcare provider and where I say, “I am it. There is no other provider here. If you do not want to be seen by a nurse practitioner you will have to go elsewhere.”
However, when not alone, like in the emergency department, I say, “You want to see a doctor (or someone else)? Sure. I will put your chart back up and when one is available they will come see you.” And I walk out and move on, because like I mentioned in the book, that is not an issue of mine as I do not get concerned or caught up with patients’, family’s, or other healthcare workers’ discontent towards nurse practitioners versus physicians. Those are issues for those persons to wrestle with as nurse practitioners, and physician assistance for that matter, have been significant healthcare contributors and accepted by an overwhelming majority for decades and the literature supports those claims.
Nonetheless, I put the chart back in the rack and grabbed the next one waiting to be seen.
Unfortunately, as if the theme for the night were evolving, the next patient was a 50-year-old female whose medical complaint was, “Bleeding from down there.” “Down there where, Ma’am?” I asked. “Down there, “ she repeated without making eye contact or even acknowledging I had walked in the room because she was too busy texting on her phone as I tried to speak with her. “Is down there vaginal or rectal?” I asked. Again, without looking away from her texting she said, “Down there.”
Just as I was about to say, “Ma’am, I will be back when you are done with the phone,” she finished texting and turned towards me saying she had a single episode of bleed, from down there somewhere, that morning. Yet, she waited to come into the emergency department that afternoon, when I would see her just after 7pm, and she was no longer bleeding, imagine that. She also added that she had been menopausal for more than 48 months and did not know why she would be bleeding.
As I tried to figure out where she was bleeding from I asked questions to which the patient said, “Can I [patient] see a woman because you do not know what I am taking about.” “Sure,” I said and walked out of the room to put her chart back in the rack as well. Lucky for her there was a female provider on that night. Because sometimes the gender the patient request is not available and those patients’ exaggerated unrealistic emotional expectations cannot be accommodated as they wish. Because of that, it is common for those patients, male patients included, to leave without treatment or they complaint that there was no one of their gender, or both, leave and later complain.
However, I found it ironic that the patient did not know if “down there” was vaginal or rectal as she was not able to distinguish if the bleeding she had earlier that day was vaginal or rectal. Yet, she wanted to be seen by a woman provider because I, a male, had no idea what she was talking about, as she said because I was not a woman. Or, was it that she had bled so long ago in the day that she had forgotten where it was from.
Nonetheless, for the second time that night, I put the chart back in the rack to be seen by the attending physician, who was a female, and I grabbed the next chart waiting to be seen, who I am sure appreciated being seen so soon. However, I was concerned if having to bow and surrender to patients that night was going to be the pattern.
Fortunately, I was able to see a number of patients that did not have issues. Well, I did see a 27-year-old male who did not have a medical complain but like he said, “I have a question for a nurse or a doctor.” “What is your question, Sir?” I asked. And the patient asked back, “Can I sleep on the concrete ground?” “What?” I asked. And the patient repeated himself, “Can I sleep on the concrete ground?” “Sir, you can sleep wherever you want,” I said.
Of course the patient did not know I sleep on the ground all the time. Sometimes there is concrete and sometimes it might only be ground, dirt or grass. Sometimes, it might not be on the ground at all. I will sleep just about anywhere but that was something the patient did not know and I was not going to share with him.
However, the patient told me he wanted to ask a nurse or doctor because he was staying at a homeless shelter where he was offered to sleep on the ground but he claims he was told not to sleep on the concrete ground after he was given “IV therapy,” he said.
“What kind of therapy was it, Sir?” I asked.
“I don’t know. But I was given IV therapy and they told me not to sleep on the concrete ground,” he replied.
“Well, Sir. I cannot see why you cannot sleep anywhere, whether concrete or not, and regardless that you got IV therapy or not,” I answered.
“That is why I came to ask a nurse or a doctor. Because when I got IV therapy, three months ago, I was told not to sleep on the concrete ground,” he told me, again.
Confused, and trying to keep from laughing as I searched for the candid camera in the room, I asked, “What was the IV therapy medicine you were given?”
“I do not know. I just remember they told me not to sleep on the concrete ground,” he repeated.
“Sir, this is not a medical issue. This is an issue you have to resolve with the staff at the homeless shelter,” I said.
“I know it’s not a medical issue. I just want to ask a nurse or doctor if I should be sleeping on the concrete ground at the homeless shelter because I was told not to sleep on the concrete ground,” the patient repeated, again.
“Again, Sir. You can sleep wherever you want. I cannot see why you cannot sleep on the concrete, whether you had IV therapy of any medicine or not,” now I was repeating myself as well.
I have no idea what was the patient’s intent as he never clearly stated his intent but if I had to guess, and guess after the fact, the patient was looking for a “Doctor’s Note” that prohibited him from sleeping on the concrete ground. Having said that, again, after the fact, I am sure some touchy-feely Florence Nightingale healthcare worker suggested to the patient that sleeping on the ground was not good for him.
Unfortunately, the patient got me, someone who chooses to sleep on the ground, concrete or not. I not only sleep on the floor at home but will sleep on the floor just about anywhere and have slept just about anywhere as well, ground or not.
In the military I recall sleeping in a number of unorthodox places. During Basic Training I slept on the floor under my bed, except the night before linen exchange, so that I did not have to make my bed every morning and could instead spend those five-minutes of making the bed to sleep. During a survival training exercise I was evading capture from the Opposing Force and in order to do so I moved at nighttime and during the day I climbed a tree to stay off the ground and tied myself to the tree so that I would not fall while I slept. At a training school where we were only allowed to stand and prohibited from sitting or leaning against anything I sought out the Port-A-John to get a five-minute power-nap and a break from standing all day. As if not enough, a few times I slept in my wall locker, sitting on top of the three-drawer dresser in the wall locker, for no other reason but to keep others from finding me when I needed to catch up on my sleep.
Those sleeping disarrangements [sic] were not only in the military. While in nursing school, because I went to school full-time and worked full-time, I slept in a number of unexpected places as well. During clinical I took power-naps on the bathroom floors a number of times and at work the best place was in the chapel, under the pews where unexpected parishioners had no idea I was sleeping under them. One morning I recall I was too tired to drive to class, after working the night before, so I pulled into the southbound shoulder on Highway 59 in Houston, Texas, right across the George Brown Convention Center, just so that I could get some sleep. I know now, not the best spot, not only was it a busy highway but I could feel the car shake as eighteen-wheelers drove about three to four feet away from me at 65 miles per hour, if not more. Unfortunately and despite the danger as well, I overslept and arrived late to class.
Anyhow, when I said to the patient, “Sir, you can sleep wherever you want.” I meant it. Not because I was less caring or compassion than the touchy-feely healthcare worker who might have suggested to the patient not to sleep on concrete but because where one sleeps is really irrelevant at a homeless shelter. Think about it, you are being allowed to stay at the shelter and for that alone you should be thankful. Otherwise, you would be sleeping outside where I doubt you will find a “Sealy Posturepedic™” bed or a “Sleep Number™” bed. Not that I said that to the patient but it crossed my mind and almost escaped my tongue.
Again, not knowing what was the hidden agenda the patient said to me, “It is going to be your fault if something happens to me.” “Sir, I have nothing to do with where you sleep nor is it a medical issue. That is a decision you have to make but I see no reason why you cannot sleep on the concrete ground,” I said to him before he stormed out of the room.
After the previous exchange I saw a few more patients and just before midnight I saw a 25-year-old female with pelvic pain for three days and for which she had not sought medical attention before I saw her that night. After listening to her symptoms I told her she had a urinary tract infection. Well, she did not think that was correct and insisted it was “a whole lot worse than that”. “Like what?” I asked. “I do not know. That is why I am here.” She said.
Huh? Not the, I [patient or family] do not know and the reason I came in, for a healthcare worker's expertise, but when the healthcare worker tells you what they think you do not believe them because that diagnosis is not dramatic enough. That way of thinking is so popular with patients who complain I have defined it as the crux of those with exaggerated unrealistic emotional expectations.
Okay. Then what can it possibly be? Thinking I could be wrong and giving the patient the benefit of the doubt I interviewed the patient with a list of other questions of just about every differential diagnosis that could possibly be similar to a urinary tract infection. Something the patient found odd as well, I guess, because she asked me, “Why so many questions?”
She was right, why so many questions, as I have given up on review of systems. What I have learned is that many patients exaggerate their symptoms, for whatever reasons, and providers end up having to chase those exaggerated symptoms not only for medical-legal reasons but, today, more so to placate to the customer’s experience.
Granted, the review of systems is an important part of pinpointing the patient’s medical complaint to the diagnosis. Having said that, what I have learned through experience is that if the patient does not mention a sign or symptom it likely is not pertinent to the visit. HOWEVER, and that is a HUGE HOWEVER, if asked during a review of systems it is likely the patient will acknowledge such sign or symptom even if not related to the current medical complain; as was the case with the last patient and her three-day old pelvic pain.
Anyhow, I thought to myself and only thought to myself, because I knew that if I shared with the patient she would complain, “Well, I just told you that you have a urinary tract infection but you did not believe me so now I have to ask unnecessary questions to see what it is I can possibly be missing. That is why I have to ask questions. It’s not like the interview is to see who I might sit you next to at the annual Thanksgiving Dinner I have for complaining patients at my home and much less to see if you want to be a friend on Facebook.”
Nonetheless, the additional questions still pointed to the diagnosis being a simple and straightforward urinary tract infection. On physical exam there was nothing that changed that diagnosis either except that the patient complained that everywhere I touched her abdomen it hurt. Although none of it was a pain I was impressed with, as I push pretty hard and the abdomen was soft without guarding, rebound, rigidity, distention or any masses, anywhere, but it hurt everywhere I pushed.
Fine. For the sake of the customer’s experience and knowing that a common complain from those with exaggerated unrealistic emotional expectation is, “They didn’t do anything for me,” I placated to the patient’s exaggerated expectations. Saying to her, “I will order a CT scan of your abdomen and pelvis with contrast just to make sure I do not miss anything,” and she agreed. Again, for no other reason except that the patient did not believe that a simple urinary tract infection could explain her pelvic pain, despite she was not in any discomfort or distress and did not appear ill in any manner. Serenity now!
So, what seemed to be a simple urinary tract infection, for which the patient could have been discharged hours before, now included oral contrast and intravenous fluids and dye. As if not enough the patient then asked, “How long is this going to take?” Another common complaint from those with exaggerated unrealistic emotional expectations, "It took too long." Unfortunately, the CT was absolutely unremarkable. I say unfortunately because it almost seems that some patients want to find something significantly wrong with them and a urinary tract infection is just not enough. Some three hours after I had initially seen her and tried to discharge her with a diagnosis I said, “Ma’am, your CT was absolutely unremarkable. You [STILL!] have a urinary tract infection.” Then, as if nothing had occurred, she replied, “Oh. Okay. Thanks.” And left.
Towards the end of the shift, that same night, I saw a 30-year-old female with a history of asthma with a medical complaint of an asthma exacerbation after exposed to dust at work the day before and her inhaler was not making her any better. However, when I saw her she was in no respiratory distress and although somewhat evasive she spoke in full sentences without difficulty or becoming short of breath during the conversation. As if not enough, her lung sounds were clear with good inspiratory and expiratory aeration and her SpO2 was 100% on room air.
Again, for the sake of placating exaggerated unrealistic emotional expectations, and more important, wanting to keep my job, I offered her some prednisone and an Albuterol breathing treatment in the emergency department. Interestingly, however, after the breathing treatment nothing had changed. Which was somewhat suspicious because in some patients, because of the increased aeration after a breathing treatment with Albuterol, one might appreciate a wheeze that was not there previously. However, that was not the case with this patient. Something else common after an Albuterol nebulizer treatment is a ventilation/perfusion disassociation, which in turn causes the patient’s SpO2 to decrease. Not the case with this patient either as she maintained a SpO2 of 100% on room air after the treatment as well. That is if she took the breathing treatment as prescribed. Because although the respiratory technicians set up these treatments if the patient is in no distress or is accustomed to them the patients are left alone to finish them on their own. Because of that, I question if the patient took the treatment because another side effect of the Albuterol is an increased heart rate, however, not the case with this patient either.
What I am saying is that although the patient was given an Albuterol nebulizer treatment nothing had changed on reexamination yet the patient claimed she had improved significantly and expressed she was ready to go home. Okay, but when I presented her discharge instructions the patient looked through the pages and kind of hesitant asked, “Can I get a note?” “A note for what?” I asked.
After the patient hesitated the family member in the room injected, “A note for work.” I held my words and said nothing because it was 6 am, and one hour to finish my shift, but there was no reason why this patient could not go to work that day. As I walked back to the computer to print a work absence note I thought, for what reason would you need a note for work when there was nothing wrong with you?
Some will say I am cynical, but it then hit me, I initially saw the patient just after 5 am on a Friday where the following Monday was a federal holiday. So then, is it possible the patient was looking for a work note hoping to get out of it a four-day weekend? I do not know. However, even if it was not the patient’s intent or idea, what I do know is that it is ALL about the customer’s experience and that includes the family’s experience too from what I been told. On that note, pun intended, “One work absence note coming up,” even if without reason.
Ironically, and I may have mentioned it before and although critics have found some of these anecdotes redundant or like a broken record, repetitive, here is another one. Since I have been working at this assignment, by far, not only have I written the most work and school absence notes but the most cumulative in eleven years. Had I only known I had such powers of excusing people from school or work, especially in Junior High and in High school, I would have made so much money back then I could have been retired and would not have to work today. Oh well, a missed opportunity there.
Despite that, I continue to say, "No!" to patients requesting days off before I saw them. Those request just do not sit well with me.
I would not say that night was a bizarre night but instead a night of sweet surrender, bowing to one patient after the next, in order to say employed. Although I did decline the homeless gentleman’s request, though his was not a work excuse but more along the lines of a request for an upgrade. Again, he should be glad the shelter was willing to not only take him in but likely provided him a meal or two and even a place to shower or wash up at.