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Happy 6th month Anniversary (Knock on wood!)



This month, June 2014, I celebrate my sixth month at the current locums assignment. Although told at the beginning of the assignment that patients here were not known to complain I still find it hard to believe that I have yet to hear from administrators that a single patient has complained. Of course, in no way am I disappointed and much less am I hoping for any complaints, however, I am astounded. Not so much that I have not had a single complain made against me. But because I know that I have seen a number of patients whose exaggerated unrealistic emotional expectations I have not catered to and that alone has ALWAYS been reason enough for those patients to complain.

Nonetheless, six months and no complaints is just way out of the ordinary.

In no manner am I superstitious, yet I am hesitant to write about this marvel thinking I might jinx myself as I doubt I have found the formula to avoiding complaints. Granted, I have commented about the number of school and work notes I have written at this assignment, more than ever cumulatively. However, I very much doubt those school and work notes are the reason for the absence of complaints.

Nonetheless, here follows a spectacle of patient encounters that I have collected, from the past six months, and who I thought would have complained. However, although I been dealing with this black-cloud of “[t]otal lack of self-awareness and insight”, as a critic of the book wrote on Amazon, for over a decade now I am still not able to tell which patients will complain and which will not. Having said that, something that sticks out the most at this assignment is that more than ever before patients here are thankful for the care we provide them. Something I have mentioned a number of times as well, not only here in the blog but to my family and friends, to the staff at this assignment and to the Emergency Department Director as well.

Could that one variable, thankful patients, be the reason for a lack of complains? I cannot say. In the book, I wrote that it was a common belief among healthcare works that few patients were appreciative but I did not find that to be the case. Instead, I thought most patients express their appreciativeness and at this assignment that has even been more notable. So much so, that here and NEVER before, I have had patients tell me, to my face, that I was rude yet they extended their hand to shake mine telling me they appreciated the care provided. However, I am not sure if the gesture was that they were congratulating me for being rude or for the care I provided or that somehow I was able to accomplish both, be rude yet take good care of them. Granted, that may have been two or three patients but nonetheless it happened, not to mention, I NEVER initiate handshakes with patients, even if pundits claim that a handshake will set a good and favorable first impression.

As already mentioned, I recall the Director telling me, “Patients here do not complain.” A statement I not only found bizarre at the time, but more so, a statement that has puzzled me from day one and lead me to ask myself, “Does that mean patients here do not have reason to complain or is that they are not verbal when dissatisfied?” Something I did not ask and something I have not learned yet either. Keep in mind, the previous emergency department I worked at there were no complaints either and even the patient advocate assured me there had not been any complaints filed against me with him either. I would think that if anyone it would be the patient advocate who would know if complaints were made or not. At the current organization I have no idea if there is a patient advocate or not. Nonetheless, here I am at six months and I have dodged complaining patients. I just find it hard to believe.

I say I have dodged because what follows is what I believe is nothing but exaggerated unrealistic emotional expectations from the past six months, in no specific order and much less none of it is my fabrication as I am not that creative. Having said that, and to the patient’s benefit, keep in mind that all these interactions I write about are always after the fact and filtered through my memory as I try recall them without bias as best as I can. One more thing, as you read the book and as you read these blogs, don’t judge my words. Judge my intent.

I saw, actually I did not see, well maybe. At change of shift I assumed care of a patient whose medical evaluation had not been completed due to labs were not back in order for a CT of the Abdomen/Pelvis to be done. No problem. I just have to disposition the patient once the results are back. Got it. The patient was a 30-year-old female with a complaint of abdominal pain for about a month that had not gotten better, not worse, but not better.

An hour into my shift things were coming apart for the patient where she had to submit herself to having blood drawn for the third time as previous specimens were hemolyzed. Eventually the blood was obtained, however, the patient expressed she did not want to wait any longer and was going to leave against medical advice. Okay with me. I always tell patients threatening with leaving against medical advise, “This is not a prison. If you want to leave you may do so, however, your decision to leave is not without risk to include a worsening condition, permanent disability or death. Keep in mind; if things change just come back. We do not hold the fact that you left against medical advice against you.” Some stay but most leave after that dissertation. However, with this patient I did not have to give her my spill because shortly after I was told that she was leaving for whatever reasons she decided to stay and complete the evaluation. “Okay,” I said.

From what I was told at shift change the patient had abdominal pain for about a month and was seen in the emergency department initially. After the emergency department the patient followed up with her primary care provider (PCP) and on this day she was being seen for the second time, for the same one-month-old abdominal pain, by her PCP who referred her to the emergency department.

Nonetheless, about three hours into my shift the patient’s diagnostics were back. The blood, urine and CT were all unremarkable. With the results interpreted I went to share with the patient. “Hi, my name is Jose. I am a nurse practitioner. What is your name?” After the patient identified herself I mentioned to her, “[The previous healthcare worker] and I changed shifts at 8pm and I was left with your care to be completed. How long have you had this abdominal pain?” I asked.

“Since before I saw YOU a month ago,” she fired back.

So I did see her. “Well, like before your work up today was unremarkable and you will need to follow up with your PCP,” I shared with her.

“I did,” she said and in an angered tone added, “and that was who sent me here.”

“Well, you will have to follow up with that person again for continuity of care because everything that was done tonight none of it showed anything that points to your abdominal pain,” I shared with her. I then added, “Abdominal pain is very common and it is common that in the emergency department we may not reach a specific reason for your abdominal pain. However, that is not to say you do not have the pain and why you need to follow up. So that your PCP, though continuity of care, can continue to pursue other differential diagnoses and eventually a confirming diagnosis.” Another very common dissertation I give, this one with regard to abdominal pain.

Later, the patient’s nurse came by to share with me that the patient was not happy with me and the nurse suggested the attending physician see the patient. “For what?” I asked. “This patient was seen by someone else earlier today. I was simply sharing the results of her test and they were unremarkable regarding her pain. There is nothing anyone else can do for her. Not me and not the attending. So why get someone else involved? Remember, the patient wanted to leave against medical advice earlier and now she is not happy that her results were unremarkable, to include that of a CT of her abdomen and pelvis with IV and PO contrast,” I said to the nurse.

“She did not like you,” the nurse said and added, “The patient said you did not care.”

“Again, this is a patient who was going to leave against medical advice before she knew I had assumed her care at 8pm. Did she not like me then either, before she knew I was taking care of her? Not likely. The patient was already upset for whatever reason and likely before I even came to work. She is likely frustrated as she saw me initially, her PCP twice and here she is still tonight with the same pain yet no answer as to why. I have nothing to do with that. I am simply trying to discharge her tonight. I guess I can tell her she has a huge mass in her colon that has metastasized to her liver, kidneys, bladder and lungs,” unfortunately I said.

Of course, the patient created such ruckus that the charge nurse and nursing supervisor got involved and I got asked by the charge nurse, “Do you think the attending physician should see this patient?”

“That is for you to decide. I do not see why. It’s not like I am going to kill the patient by discharging her inappropriately. The patient is upset at whatever it is she is upset with and I just happen to be the last person to talk to her. Why add another person for her to be upset with,” I said to the charge nurse.

“Maybe the patient will not complain if the attending physician sees her,” the charge nurse suggested.

“Again, the patient is upset at whatever exaggerated unrealistic emotional expectation was not met for her. Getting the attending involved is not going to change that but add another person to the list of persons she is upset with,” I replied.

Later, after talking with the patient, the charge nurse comes back and says to me, “That patient is really upset.”

“That is not going to change anything for me,” I said and added, “Look at all the attention she has gotten. Not to mention, she was discharged almost an hour ago and is still in the room and other patients in the waiting area have to wait until she vacates that room before they can be brought back. I am done. I discharged her an hour ago. It no longer has anything to do with me. Now it is you who has to find a way to get her to move on,” I said to the charge nurse.

“Well,” the charge nurse said, “is there anyway she can have a doctor’s note?”

“What!?! Are you [freaking] kidding me!?! Is that what all this was about!?! A note to not go to work! Is that the compromise!?!” I was fuming but said to the charge nurse, “One doctor’s note coming up!”

Later that night, after the dust had settled and during a quite unrelated moment, the charge nurse asked me, “Why did you go into nursing?”

Offended, to say the least, but not something I shared with the charge nurse, I said to him, in the calmest manner I could muster, “Really? I went into nursing to help others. I went into nursing from the beginning. Nursing was not an alternate plan after something else did not work out in my life. I went into nursing at age fifteen. [Not because others in my family were nurses because no one on either side of my parents, or either side of both my grandparents (that is eighteen aunts and uncles and too numerous to count cousins) for that matter, was a nurse before me. I did not go into nursing because of an ill family member either. Nor did I go into nursing because of some epiphany I had. I went into nursing because I want to help others.] I know patients say I do not care but I do. I know patients say I lack compassion but I do not. I will tell you that no one has the patient’s best interest in mind than the healthcare worker caring for that patient and that includes me. That may not be over the patient’s hidden agenda but it is over the patient’s own concerns. The fact I do not cater to patients or that they cannot handle the truth does not mean I care less.” Not only did I find the charge nurse’s question offensive I was fuming that I was asked. The charge nurse’s answer, “Okay.”

Granted, had I known being a nurse required bending over at every whim of others or allowing others to walk all over me THEN, most definite, I would not have become a nurse.

Having said that, I am not a fan of healthcare’s right of passage culture either and although I realize I am still the new kid on the block who has to prove himself I could care less what others think of me. On top of that, I will not allow others to define me either, not patients and not colleagues, new kid or not!

How about that for a performance at starting a new job, not to mention, how to win the hearts and minds of not only patients but also those one has to work with.

I saw a 14-year-old male who was brought in by his parent after the patient purposely, although without suicide intent, took one additional tablet of a prescribed medicine he was started on a month before. The parent’s concern was that the patient was having a reaction to the medication, and she was correct. However, the symptoms were not toxicity but an intensification of the medication’s side effects. Something the parent would not have known and why she brought him to the emergency department.

Because the dose the patient was started on was half of the standard dose I was not convinced the patient had taken ONLY one additional tablet, as one additional tablet would have been a standard dose. Call me cynical but it’s just the way our emergency medicine brain works. With that in mind, I ordered the complete medical work up as if it were a suicidal gesture, which is the standard of care and in the patient’s best interest.

The primary concern and the reason why the parent sought emergent medical attention was because of the patient’s heightened anxiety; unknown to the parent anxiety was a 10-20% chance side effect of the medication in question and if anything it was likely an additional dose would intensify that side effect. So when the patient stated he was unable to breath, a common complaint of patients having an anxiety or panic attack, the parent nervously, and rightfully so, expressed her concerns. However, now the parent was an off-the-record patient and because of her nervousness and concern I tried to reassure her that the patient was breathing fine and after she seemed convinced I stepped out of the room to see other patients.

It was not long before the patient’s nurse asked me to return to the patient’s room after the parent expressed I was not doing anything for her son. When I returned to the room I asked the parent what was her concern and she asked if she could take her son, “Somewhere else where they will take care of him.”

With me, it is well known that when patients ask to leave against medical advice I rarely keep them from their wishes. However, that decision is limited to adult patients only and who are awake, alert, oriented to person, place, time and situation but more important, are capable of appropriate decision making. That does not include children or anyone dependent of others. Because of that I said to the patient’s mother, “Ma’am, at the present time I am not convinced your son’s symptoms are from an additional tablet of his medication. Right now is not the best time to take him elsewhere. I acknowledge and understand your concerns, however, I am currently trying to not only make your son comfortable but also trying to figure out what is going on. You taking him elsewhere may not be in his best interest at the present time. If you insisted in doing so I would have to notify Children Protective Services because you would be endangering your son.”

As imaginable and one of the greatest reason as to why patients complain, my words never reflect my intent and here was another example of that as the parent herself began to have an emotional storm. “Ma’am,” I said and added, “you are making matters worse for your son by making him more upset than he already is.”

Almost on cue the son began to cry as well, with tears and stating he could not breath, while he was in no respiratory distress and the SpO2 on his finger read 100% on two liters of oxygen.

OXYGEN! What the hell!?! Oh yea, I remembered. The nurse had asked if she could put oxygen on the patient and I had said, “Sure.” Not because the nurse thought the patient needed the oxygen, as his SpO2 was 100% on room air, but because she thought it would comfort the patient and the parent so I had written the order for the nurse earlier and forgotten. But then remembered. Although at that moment I almost had an aneurysm.

With the parent in tears in front of me and the patient crying as well, that he could not breath, I look over to him and without thinking I told the patient, “Put the prongs in your mouth.” I said that because I recall on physical exam the patient’s nasal turbinates were swollen and likely that is what the patient was describing as “I can’t breath!” It’s not that he could not breath but that his nose was so swollen and congested from crying that it was difficult to breath through his nose.

Not expecting the instant resolved from the patient I was caught of guard when he shouted, “I can breath again,” and the parent instantaneously calmed down as well. As if a switch had been thrown somewhere and the two of them, the patient and the parent, were instantly gratified. I left it at that and without a word I walked out of the room.

When I walked out of the room I asked the nurse if she taught the “family”, because it was no longer a patient issue, might benefit from the behavior health crisis counselor who was present in the emergency department evaluating another patient I had seen and the nurse mentioned, “You have nothing to loose.” So I went back to the room and asked the parent if she would be interested in consultation with the crisis counselor and the parent agreed. However, had the counselor not already been in the emergency department it was something I would not have offered.

After the crisis counselor visited with the “family” the counselor asked if there was anything I could do for the patient because he was having nasal congestion and “could not breath”. Initially I said to the counselor there was not much I could do for nasal congestion, however, after thinking about it a bit more I asked the nurse to spray some Afrin in the patient’s nose to see if it would help.

After the crisis counselor’s recommendation about the “family” I went back into the room to let the parent know of the findings and that after observing the patient for some five hours in the emergency department he was going to be okay. Not to mention, his nasal congestion had improved significantly with the Afrin. The parent then stated she was comfortable taking the patient home and following up as already scheduled.

It happens, the patient had an appointment the next day with Behavior Health to titrate the same medication the patient had taken an additional tablet of. Huh!?! I guess he will able to share with them that he cannot tolerate an increase of the medicine since he already experienced such increase and it did not go well.

I saw a 32-year-old male with two days of abdominal and back pain that was not better with Pepto-Bismol and because of which he missed two days of work. The work up was unremarkable. However, his blood pressure was significantly elevated and when I went to discharge him I asked about his elevated blood pressure, to which he admitted not taking his medication since he “ran out”. I, of course, gave him my blood pressure spill, however, he did not seem interest or concerned. When I pushed the issue in his interest and asked, “Sir, are you not concerned of the consequences of your blood pressure being so high, like having a stroke or a cardiac event not to mention the hidden effects on your kidney, vision and heart?”

He simply said, “No. I just need an excuse for work.”

Without another word I said to him, “Here you go. Have a nice day,” and gave him a work note because that is what healthcare has become, the appeasing of exaggerated unrealistic emotional expectations. However, unknown to the patient, the work note I provided him said he could return to work the day I saw him and not as he requested, for the days he had missed.

What is going on in healthcare? Are these the 40 million patients the Affordable Care Act (ACA) is supposed to have the best interest in? What a waste in so many aspects and at so many levels. Let me be clear, in no way, shape or form is this about President Obama or any other politician with similar intent. Actually, I applaud President Obama for his intent to include everyone in healthcare. However, as you will find in the anecdotes that follow not everyone needs healthcare. Even worse, some of them actually take it away from those who do need it.

Granted, these are anecdotes and because of that do not represent the bigger picture. However, so is the premise that everyone needs healthcare. Because if you were to ask the patients in these anecdotes, if they needed healthcare, they all will tell you they do. Not because they do BUT because you asked them if they needed it. Why? Because despite our nation, as a whole, being a one percenter, when compared to the other 192 nations on the planet, and known around the world for abundance many here will put their hand out for offerings regardless if they need it or not.

This patient, and others listed, children included, is just one of many I have seen over the years who according to politicians and their enablers so desperately need access to healthcare. Let me be clear, in no way does my statement say they do not need healthcare. Instead what I am saying is, “Do patients need to seek medical attention when the patients, themselves, know their condition is self limited and/or insignificant?” When I say that, I do not mean ONLY those who do not have access to healthcare but those who do have as well, whether through insurance or paying for it themselves.
This patient was a great example of my point above. Even if he did have abdominal pain and was not seeking a work note, did he really need to seek medical attention? Ask the patient himself who taught he was well enough to return to work without prior medical attention EXCEPT when he came into the emergency department not because of illness but because he needed a work note.

And! And! More significant, this patient confirmed another one of my points; although he knew he had high blood pressure he was not as concerned or interested for his health as I was for him when I mentioned his blood pressure.

Having said that, I know critics will chastise me that it is my role to convince him and I agree. However, I will say this, Speed Limit signs and Do Not Litter signs are not only there to remind us but more so for us not to be surprised by saying, “Nobody told me,” when penalized. Because guess what, whether you saw the posted sign or not the sign is irrelevant, especially with littering, as everyone knows littering is illegal so why do you need a sign.

Being newly diagnosed with hypertension and not concerned or interested is one thing. But knowing you have hypertension and you not taking your medication or caring when told of the concerns is no reason for healthcare to post another sign. I guess we could go to his house every morning to ensure he takes his medicine, NOT!

Having said that, I am curious, well not really but how else does one begin the following inquiry. I am curious, would this patient, and others similar, have signed up for the ACA coverage if having healthcare insurance were not mandatory? Even if the healthcare were free. Would they sign up or would they wait to seek healthcare insurance until they experienced a significant event? Not my argument. Just curious, although not really.

Nonetheless, the attitude of abundance or what I call, “I was in the neighborhood so I thought I should get it checked out”, “They were performing free liposuction so I got in line”, or the demand for unnecessary diagnostics and/or medicines account for a huge chunk of what we spend in healthcare. Just my two sense [sic].

I saw a 50-year-old male with bilateral ringing of his ears and hearing loss, which has been intermittent (or not) for more than a year but worse in the last seven days. I think that was the medical complaint but not sure as the patient could not keep his own story straight. Anyhow, the patient stated ENT had seen him two times in the seven days with the last visit two days before I saw him in the emergency department.

“Is it worse today?” I asked.

“No. It’s not worse. Just not better,” he said.

Answers like that bring out my puzzled puppy look. Huh? Ears forward I turned my head one-way and then the other way.

“What do you mean it’s not better? You’ve had it for over a year and seen ENT for it two days ago. What do you think I am going to do in the emergency department to fix it?” I asked.

“I do not know. That is why I am here,” he replied.

Again, ears forward then right and then left. “Sir, you need to see ENT,” I suggested.

“I know,” he said and added, “It’s just that the doctor I saw the other day did not convince me he knew what he was doing. He is not my regular [ENT] doctor and although my regular [ENT] doctor came in when I was seeing this other [ENT] my [ENT] agreed with him without doing an exam on me.”

WHAT!?! I thought. You were not convinced with the ENT who saw you and when your regular ENT agreed with the ENT who did see you, to include an audiogram, you still did not believe him because your ENT did not do an exam? WHAT!?!

BREAKING NEWS! Patients distrust other healthcare workers trying to help them. Really? It’s not just me they distrust! WOW! And all this time I thought it was just poor little me they did not trust.

However, it’s NOT so much that patients distrust those trying to help them with good intention but instead that those who distrust us have other agendas.

Nonetheless, I found it hilarious this patient thought the ENT he saw was mumbling his words. I mean come on! You say you are losing your hearing. If so, I would think everyone you spoke to sounded like they were mumbling their words and not because the person is mumbling on purpose. Again, I cannot make this stuff up.

Having said that, the patient was able to hear me during my interview from about ten feet away regardless if I whispered during our interview, which I did intentionally to see if he could hear me, and he could.

Not to mention he was not consistent in stating his symptoms were intermittent versus persistent and when I pointed out his contradiction, intermittent versus persistent, he would not acknowledge he went back and forth on those two time periods. Even his wife in the room seemed confused with his story. I thought the patient was making it up as he went along but regardless there was nothing I could do that moment and likely neither could the ENT as the patient likely needed hearing aids if his story were correct.

Why did I question the story? Because, the patient himself stated he had an audiogram two days before and the ENT interpreting the exam told the patient that his hearing was fine. The wife was there and she agreed that the patient was told his hearing was fine. And when I asked the patient at the beginning of the interview if the hearing was worse than two days ago he said, “No. It’s not worse. Just not better.”

Unfortunately, this was all he said she said. How does this get defended in a court of law? Of course, I could write the patient’s inconsistency in the chart but who is not to say the patient would change the story in a court of law. How does that get defended then?

UPDATE: When talking with another healthcare worker during an unrelated discussion I was told this ENT does mumble his words, which I found even more hilarious. I shared with the healthcare worker that I had seen a patient who said the same and the other healthcare worker I was speaking with told me the patient was right, the ENT does mumble his words. HUH!?!

Unfortunately, because the patient’s medical complaint was hearing loss I doubted him making the assumption (and what happens when one assumes) that it was his hearing loss that made the ENT sound like he mumbled his words and not that the ENT actually did mumble his words. Who knew? However, if one were losing their hearing, would it be possible for them to distinguish another person’s mumbling versus clear speech?

Nonetheless, I had the privilege of seeing this patient about a month later for a different medical complaint.

The second time, the patient’s emergency department medical complaint was a cold sore in his mouth he had for a week. Mind you, this patient has a PCP and the Outpatient/Urgent Care Clinic opened in another three hours from when I saw the patient, and they take walk-ins.

Anyhow, after my physical exam I told the patient, his wife present, “Sir, it’s a cold sore. There is not much you can do about it.” After a short conversation I left to write his discharge instructions and a prescription for Acyclovir.

When I return to the room to discharge the patient all hell broke lose. The patient telling me, “I saw you before and because of you I lost my hearing…you are rude…you tried to put words into my mouth that I had said that my [medical] complaint was intermittent when it wasn’t…[yada yada yada].”

The gentleman’s claim was that I had suggested, or as he rattled away, put words in a grown man’s mouth. Okay, if so, if for the sake of argument the worse I did was to suggest that his medical complaint was intermittent it was to his benefit. Otherwise his medical complaint would have to have been persistent and being persistent for more than a year, alone, was not emergent and the fact it was not worse did not help his case either. I could not understand what he was getting at.

As if not enough, in his dissertation, I could not count the number of times he addressed me as “Dude”, which in conversations with friends I do not mind. However, those are chats with friends. When in conversation with patients, however, I do not appreciate being addressed as “Dude”.

Why? I do not talk to patients like they are family or friends and I do not expect them to talk to me as if our relationship were any more than healthcare worker and patient, that’s all. I doubt it VERY much patients would appreciate me talking to them the way I talk with family and friends as patients will be offended by my lack of a filter as family and friends tell me.

However, because my shift was near to end and knowing it was not going to end well with the patient’s already heighten drama I did not correct him to not address me as “Dude”, as I customarily correct patients. I did not do so for no other reason than because at that point I had labeled him a GOMER (Get Out of My ER-as revealed in the book "The House of God" by S. Shem) and I just wanted him gone.

Once gone and because the patient accused me of him losing his hearing I reviewed his EHR to see if the patient had followed up with ENT as I suggested when I discharged him from the emergency department. The answer, drum roll, please. Wait…wait… NO! Instead, he was seen twice, YES TWO TIMES, by his PCP for related and unrelated medical complaints to his hearing, lost or not. His PCP ordering a CT of the head as the patient complained of headache and the CT findings were, again, drum roll, please. No acute intracranial findings.

Another thing the patient said was that when I could not offer him a cure for his hearing during the previous visit and he mentioned to me, “I guess I am going to have to pray,” that I commented, “Sir, prayer is not going to help. You need to see the ENT.” The patient taking offense to my comment and telling me, “You offended my faith.”

It is very possible, and even very likely, that I did say that, however, my intent is NEVER to offend anyone in any manner, faith or whatever else. That is just the answer I would have given to family or friend as well. However, my point was not so much that prayer is not going to help, although more than likely it will not, but more important was the need to follow up with ENT.

One of my earliest memories as a nurse was a patient with breast cancer who when initially diagnosed declined conventional treatment and opted for prayer stating, “I will pray and ask the Lord for my healing.”

Well, it did not turn out in her favor and before critics jump on me let me add that my comment is not bashing prayer but instead being a realist. More so for me, after that experience I will ALWAYS tell patients to seek medical care and to not rely so much on prayer.

That was a patient I will NEVER forget as I saw her after she had declined medical treatment over prayer and when I saw her the cancer had eroded through the skin of her breast and rotted. The patient lived her entire life in the USA and not in some undeveloped country and I took care of her in an emergency department in the USA and not in some undeveloped country either. Although when I cared for her and she accepted admission her cancer was so advanced that she would succumb and die due to the cancer.

The point is not that prayer failed but that prayer did not work. Would the conventional breast cancer treatment offered her initially have kept her alive? I do not know but I doubt any religion is willing to challenge science in this regard with a double-blind placebo controlled study (treatment, prayer, placebo).

Nonetheless, as I tell family and friends, if your faith is real, regardless what your faith is, NOTHING should ever challenge it. Just as NOTHING challenges mine. So if my insignificant comment challenged the patient’s faith, as I would tell family and friends, “You better check your faith then.” However, not something I shared with the patient as he is not family or friend and likely would not be able to handle my honesty.

On top of that, if the patient says he lost his hearing it was not because of me but because he opted for prayer instead of the ENT as I suggested and his prayer did not work for him either. As it did not in the breast cancer patient either but that is another conversation of which I am not interested in, just pointing out the obvious.

Nonetheless, I thought his accusations were not only inappropriate but uncalled for as well because according to his chart and audiogram his hearing had not changed and who am I to challenge the science of an audiogram over his claims. Not to mention he could still hear me, unaided, from about ten feet during my interview.

For those noticing, I found it interestingly that this patient’s UPDATE was longer than the initial encounter. That just goes to show where drama leads, nothing more than theater. Maybe that was what Fred Lee meant when he compared healthcare to theater. It is not the medical care that matters but the DRAMA!

I saw a 5-month-old male brought in by his guardian, a relationship I commonly find concerning. I do not say that in a bad sense as I realize there is good intent. However, it shocks me how often I find the adults caring for the child always seem to be novices at caring for children, something that always throws me into hyper-vigilance.

A common question I been asked as a nurse practitioner is what is my greatest fear regarding patient care. My answer has always been, “That I miss the abuse of a child, an elderly or an adult.” Granted, missing a significant diagnosis for which I would be sued or lose my license is concerning. However, for me, nothing is more devastating than to returned a patient to the care of his abuser. Not that that was an issue with this 5-month-old but rather an explanation as to why I behave the way I do when seeing these patients.

Anyhow, when I encounter foster parents or guardian that look lost, yet are caring for an infant or child, I ask them about their lives before fostering or being a guardian and they always have a history of having had their own children who more commonly than not are adults now. So obviously guardians know what they are doing. I mean, they took care of their kids before and the kids are adults now, with children of their own. So then, why are these guardians asking me, “Can I [the guardian] give him [the child] water?” “Is it normal that she [the child] only poops every other day?” “How far should I insert the bulb syringe?”

Again, I realize these relationships are in the child’s best interest as these children more common than not come from broken homes. However, I question if the intent of the guardians is not so much in the child’s interest but instead the adult’s attempt at trying to get parenting right this time around. I don’t know. It just bothers me.

I recall an incident where a grandparent was the guardian and she became angered with me after I asked her to hold the child in a particular manner so that I could assess the patient. She just could not hold the child, as if she had never held a child during a physical exam. Is that possible? I guess. But she had adult children my age and I know my parents made sure we did not move when our doctor was looking in our ears. Anyhow, since then every time I see one of these children I am reminded of that incident and this one was no different.

The night I saw this patient the guardian stated the patient had a cough and a runny nose for three days during which he was seen in the pediatric clinic twice and in the emergency department once. Interestingly, during the emergency department visit, when I saw him, he had been seen in the pediatric clinic less than 24 hours before.

As interestingly, if not more interestingly, I had seen the 5-month-old twice of the seven times his guardians had brought him in for medical attention. That is seven visits aside his well-child check-ups in the five months he has been on the planet. Nonetheless, although the patient had been diagnosed in the pediatric clinic, twice, with an upper respiratory infection of viral etiology the guardians were not convinced, IMAGINE THAT, and the reason they came in to the emergency department, a third opinion I guess.

Within this blog, this is the second time patients, in this case parents, distrust the healthcare worker’s good intentions in trying to help them.

BREAKING NEWS! It’s not just me, or the ENT, patients distrust. Of course, it could have been a pediatrician who mumbles as well they distrusted. Forgot to ask.

However, as stated before, it has nothing to do with distrust but rather a hidden agenda. In this case, and for these patients, healthcare providers, myself included, can easily prescribe uncalled-for and unjustified medication, especially antibiotics and narcotics, or provide a work absence note without even seeing the patient. With that, the healthcare worker guarantying herself a five out of five rating on customer’s experience, WITHOUT even seeing the patient, as the exaggerated unrealistic emotional expectation diagnosis is “hidden agendosis”.

On the contrary, a healthcare worker who not only gets up from their seat and actually sees the patient, to include a history of present illness/injury, a review of systems, and, and, a physical exam concluding there is NOT, again, concluding there is NOT a need for an antibiotic, an x-ray, blood draw or a narcotic likely will NOT get a five out of five. Instead, at MOST that healthcare worker will get a four out of five if they were able to convince the patient of the treatment plan minus the expected perks. But more likely than not a three out of five, and even, a two out of five, and sometimes even a one out of five if the healthcare worker is unsuccessful in convincing the patient, despite the healthcare worker had actually seen the patient.

Such was the case for this 5-month-old that when I made mention I would write a prescription for an antibiotic, although not indicated for the child’s viral upper respiratory infection, the guardians lit up saying, “Thank you so much because no one else would.” As an attempt to soften the injury to my integrity I said, “I too do not think he needs an antibiotic [not to mention some of the consequences] but just in case since this is the third time you brought him in for the same thing.” And I walked out of the room.

I saw a, better yet, I tried to see what seemed to be an active not-ill appearing 5-year-old female who the parent described as, “She is sick,” after I asked, “What brings her to the emergency department?” Because I expect everyone in the emergency department to be either sick or injured I find that common reply to be a bit vague to say the least. Because of that, and in an attempt to seek clarification I added, “What symptoms is she having?” Which I think is a pretty simple and common sense follow up question to clarify the vagueness of the parents reply. Well, not the case, because had it been so I would not be mentioning this story.

Instead, the parent fired back, “Where is the other guy? I just told him all of this.” Another all to common statement from patients because they do not like to repeat themselves they say. However, it is a very common phenomenon that every time patients repeat their own history of their illness or injury the story changes somewhat. Because of that, and I might be alone as I am not sure about other healthcare workers, I like to get my own version directly from the patient and no one else.

The exception, if for whatever reason the patient is not able to tell the specifics than I will ask another person. Otherwise, as the adage says, I like to get my information directly from the horse’s mouth.

As if not enough, the parent became vile with her suggestion, “go find the other guy and ask him.”

“No!” I thought to myself and without a word I turned around and walked out of the room returning the chart to the rack to be seen by the next available provider. As I grabbed the next chart to be seen the patient’s nurse approached me and asked what happened in the room and I shared with him the parent’s hostility to my initial questions, I then went to see the next patient.

Interestingly, and all to common, the nurse went to try to defuse the tension and I could hear the nurse explaining to the parent our reason for asking the same questions. The nurse then came and shared with me that he had spoken with the parent. However, I had already moved on to see another patient and I shared with the nurse I would not return to the previous room, knowing the experience would not turn in my favor.

I have always made it a habit that when a patient, or family, disagree with me from the introduction I simply return their chart to the rack and do not share that experience with anyone. My reasoning, which I believe is in the patient’s best interest, I do not want to clout the next provider’s interaction with the patient. Nonetheless, with this patient, when the next provider did attempt to see the patient they had eloped, in other words, had left the emergency department without notifying anyone. Another dissatisfied camper [sic].

I saw a 7-year-old female brought in by her parent because the patient had abdominal pain. In the book I mentioned that abdominal pain is a very common reason for which patients seek medical attention in the emergency department and although in most cases the findings are benign we go through great lengths to ensure we do not miss an emergent condition that needs treatment.

In my experience, there is no population that statement is more accurate than in the younger pediatric population among whom, overwhelmingly; most cases are benign yet they are the greatest challenge to assess for a number of reasons. My greatest concern is always about “poking and prodding” children unnecessarily and a number of those stories are in the book.

Having said that, it is a HUGE relief to walk into any patient’s room, pediatric, adult or geriatric, complaining of abdominal pain and to find them sitting up on the edge of the bed with a big smile, and some mustard, yes mustard, on their face while they eat a day-old hospital roast beef sandwich. YUCK! Not the day-old hospital sandwich but the mustard, blah!

Good! No need for unnecessary diagnostics. A urinalysis should be sufficient and it just happens this patient had a urinary tract infection. Done! I shared with the parent the findings, treatment plan, need to follow up and reasons to return to the emergency department. DONE! “Have a great day. Thank you for coming and come again. Despite the pediatric clinic is open.” I did not say that but it did cross my mind. Anyways, this time I was really DONE!

Surprisingly, like I almost fell out surprisingly, the parent asks, “Do you think the urinary tract infection is because of her weight?”

WHAT!?! I kid you not I almost fell out. After coming back too and looking around for hidden cameras or to see if I was being set up I said, “Since you bring it up. It is very likely.”

In the book I told a story of an 8-year-old that weighed 80lbs and I told the parent it was not the runny nose that was going to kill her but her weight. Obviously, the story being in the book, that encounter did not go well and what I was told by administrators was to not confront patients regarding issues not related to their visits. Hoping to keep my job I have learned, as so many other healthcare workers, to look the other way. As was the case with this 7-year-old stuffing her face with a sandwich—and whom I tried to hurry out of the emergency department by simply saying, “She has a urinary tract infection.”

It was obvious I was bothered by the child’s weight. As a nurse, my role includes being responsible to care for the sick, promote health, and prevent illness and injury and maintain levels of health for others. However, since I was scolded for getting a parent’s attention regarding her child’s weight I no longer push the issue. The same goes for my mention that cigarette smoke is not good for children, regardless if you smoke outside the house or not, since you still carry the carcinogens on your clothes. Why? Because, as told by administrators, if it’s not related to the patient’s medical complain, “Skip it!”

“WILCO,” I said. WILCO—meaning, “I understand and will comply”, military jargon.

Although, really, I do NOT agree with the administration but I want to keep my job.

Anyhow, this 7-year-old weighed 120lbs. Her BMI (Body Mass Index) was 31. The National Institutes of Health (NIH) says a normal weight BMI is 18.5-24.9. However, I will tell you that in the ten-plus years I been paying attention to BMIs I have seen but a handful of patients in the USA with a normal BMI. More common is a BMI between 25-29.9, like mine, which the NIH classifies me as overweight. However, significantly more common in the USA is a BMI that is greater than 30 or what the NIH categorizes as obesity as was this 7-year-old child. Yet, healthcare administrators do not want us addressing those issues as it causes disorder between patients and the administrations goal of customer retention.

Again, the 7-year-old was 120lbs. and her BMI was 31. Unfortunately, because I been asked to not confront patients about issues not related to their medical complaints the fact the EHR listed in the 7-year-old’s active problem list: Childhood obesity, Snoring, Tonsillectomy, OSA (Obstructive Sleep Apnea) I should not address any of it. Why? Because her medical complaint when I saw her was abdominal pain and so the rest of her active problem list was not an issue OF mine. Well as a nurse it is an issue OF mine! However, administrators have changed the language from “an issue OF mine” to “an issue FOR me” as it was not related to the patient’s medical complaint.

Again, a 7-year-old with SLEEP APNEA!!! WHAT THE *&%$!!! Has anyone address this or are we, healthcare workers, all supposed to just add comorbidities to patient’s active problem lists and look the other way. The parent’s BMI, guessing, was 25-26, so where was the disconnect?

With all that, the parent was asking me. ME! Of all people, ME! The rude and uncaring healthcare worker who lacks compassion. If I thought the patient’s weight was an issue.

“What has her pediatrician told you?” I asked as I so pathetically passed the buck to someone else. Still somewhat paranoid that I was being set up I was not comfortable with the topic after berated by administrators so I wanted to be cautious.

“They told me not to give her sweets,” the parent replied.

Really? Sweets! Was that the best they can do?

Give me one moment. Let me grab that soapbox to climb on. “Ma’am, I have worked out most of my life and I have bad genes thanks to both my parents. I will tell you sweets are not the problem. The problem is lack of exercise. Period!”

“I will tell you this as well, it’s not that diabetes, high-blood pressure and heart disease runs in your family. The problem is that NO one in your family runs,” I added. A quote from a somee-card I found on the Internet.


The parent and I talked, for a while, about weight-loss beyond not eating sweets. We also talked about how the urinary tract infection could be due to the patient’s weight. I actually felt like I was being allowed to do what I was educated for and it felt GOOD!

The parent telling me the patient’s pediatrician had not mentioned the patient’s weight until the parent brought it up and that was after the patient had her tonsillectomy yet continued to have SLEEP APNEA. A 7-year-old!!! With SLEEP APNEA!!!

Not sure I am expressing my rage through these written words, THIS IS A 7-YEAR-OLD WITH SLEEP APNEA! IS ANYONE PAYING ATTENTION!?! AND THE BEST HEALTHCARE CAN DO IS TELL THE PARENT TO DECREASE SWEETS!!!

Luckily, the parent could tell I was bothered by the fact the 7-year-old had SLEEP APNEA and she allowed me to give her my best advise. ME! The rude and uncaring healthcare worker who lacks compassion.

I also shared with the parent that many healthcare workers do not confront patients with these sensitive issues due to patients file grievance complains that could cost the healthcare worker. However, that is not to say healthcare workers may not try to indirectly correct the problem for the patient’s sake. Like suggesting a tonsillectomy first.

Not that I shared this thought with the parent but look at this patient’s active problem list. Rather than telling the parent it was likely her SLEEP APNEA was because of her weight they performed a tonsillectomy. Yet, despite the tonsillectomy the patient continues to snore and has SLEEP APNEA! So what, listing it in the patient’s chart isn’t going to fix the problems. Even when the parent mentioned it the best attempt at correcting the problem was to decrease sweets.

Are you FREAKING kidding me!?! That is nowhere near aggressive enough to correct the problem. And for no reason other than administrators do not want sensitive issues addressed because discussing those concerns may lead the patient to complain.

I saw a family plan of two; both brought in by their grandparent, a 5-year-old male with a sore throat that night and a 14-year-old female with a bloody nose for two week.

However, the nosebleed was not the night I saw her, but the day before, for which she had not sought medical attention prior to the night I saw her or at any time in the two weeks before. Got it? Let me clarify. The nose was NOT bleeding the night I saw her but the day before. Got it? Good, because it only gets better.

When I looked at the order that the two patients were registered I noticed the 5-year-old was registered before the 14-year-old. Does that matter? Not necessarily. However, the grandparent shared with me that the primary reason for the visit was that the 5-year-old had complained of a sore throat an hour or two before they came in to the emergency department.

Not that it mattered either but I found it interesting nonetheless that the 5-year-old complained of a sore throat one to two hours ago and he was rushed to the emergency department. On the other hand, the 14-year-old had a nosebleed for two weeks and no one thought of her getting medical attention other than an afterthought when the 5-year-old complained of his sore throat.

As interesting, if not more, was a fact of which I did not ask about and would not have known except the grandparent mentioned that the two patients were not siblings, not that it mattered. Nonetheless, the 5-year-old lives with the grandparent and the 14-year-old lives elsewhere. Why did I find that detail interesting? Because this family plan visit was the epitome of the visit of convenience and here is why.

From what the grandparent told me, not that I asked as it has nothing to do with the care, she did not have transportation. However, when she called her daughter about the 5-year-old having a sore throat it was the daughter who suggested taking him to the emergency department. Now, because the grandparent did not having transportation the daughter volunteered to drive. In doing so, the daughter added her 14-year-old to the party although the 14-year-old had not had a nosebleed since a day or two before.

It made even less sense when I walked in the room and found the 5-year-old, the cause for the emergency visit, running around and climbing on and off the stretcher like it was an amusement park in there. Of course his exam was unremarkable, to include a rapid strep swab that was negative.

As for the 14-year-old, her exam was unremarkable as well. Not just for her bloody nose complaint but she also added on that she was having chest pain, passing out, dizziness, back pain, shortness of breath, abdominal pain and a few other ailments for which she had not sought medical attention prior to the night I saw her, despite it was her parent who did have the transportation. On top of that, when I was seeing her she would not stop giggling and laughing with her teenie-bopper friend, who although not a patient came along to join her friend.

Adding insult to injury, the Medical Screen Exam (MSE) provider had ordered a total workup on the 14-year-old because of her other medical complaints; chest pain, passing out, dizziness, back pain, shortness of breath, abdominal pain and yada yada yada. None of which I would have ordered based on physical exam but nonetheless I was still responsible for interpreting the patient’s ECG, chest x-ray, urinalysis and blood work, to include a complete cardiac panel. All of which were unremarkable. ALL! As was her physical exam.

When I told the grandparent the children were both fine the grandparent told me she only brought them in after her daughter’s suggestion. Interestingly, the daughter, the parent of the 14-year-old but not of the 5-year-old, returned home after dropping the party off at the emergency department and the grandparent had to call her daughter to come pick them up. Whatever!

As mentioned before, here was a grandparent guardian who consulted someone else, in this case her daughter, to ask what the grandparent should do for a 5-year-old with sore throat. I realized it is none of my business, and even less since administrators have TOLD me not to inquire. However, I am sure the grandmother must have had one of her own children have a sore throat before and I do not believe she needed consultation as to what to do with the 5-year-old that was jumping up and down off the furniture. Not to mention a resolved nosebleed needing emergent medical attention. Double whatever!

I saw, well I tried to see, a 27-year-old female who complained of an eye problem for two days. No wait. It was an ear problem for a week. No wait. It was a throat problem for a week. No wait.

“Ma’am, which ONE was the reason that made you get up and say, ‘I better get to the emergency department?’” I asked.

“All of them,” she fired back.

“No,” I said and added, “Of all those complaints pick one.”

“All of them,” more adamantly she fired back.

“Ma’am,” I tried to ask her again to pick one.

However, she yelled back, “Don’t call me that.”

Again, trying to get her to focus I said, “Ma’am.”

She covered her ears and yelled back, “I told you not to call me that!”

Now I was confused. Ma’am is like the most respectful manner to address a woman. Isn’t it? Yet she was acting like a 6-year-old.

“Ma’am,” I said again as I tried to get her attention.

She yelled back, again covering her ears, “I told you not to call me that!”

A family member, sitting in a chair with a child sleeping on her lap suddenly stood up while still carrying the sleeping child to join in and yelled at me as well, “She told you not to call her that. Why do you keep calling her that?”

What the!?! I thought to myself. Again, hoping to get the patient’s attention and without malice intent I said, “Ma’am.”

When suddenly as if I had invoked the devil’s presence the family member began to yell, “HELP! HELP!”

“What the hell is going on in here?” I thought.

Then, despite the sleeping child being four feet tall and the adult holding the child just over five feet, the adult carried the child passed me and out of the room to yell, “HELP! HELP!”

It was then that I figured out that things were not going my way and it was time to exit. I guess that is what critics label my “Total lack of self-awareness and insight,” as I saw none of it coming.

Once back at the workstation the attending physician asked me what happened after hearing the cries for help, as did everyone else in the emergency department. Almost laughing I said, “I have no idea. I went in to see the patient and they started yelling at me because I asked them to pick one complaint of many and because I called the patient, ‘Ma’am’.”

Nonetheless, I put the chart back in the rack to be seen by someone else and I went to see another patient. Interestingly, as I walked out of the other patient’s room I said to that patient, “Take care Ma’am.” Unknown to me, I said it loud enough that the patient who did not want to be called Ma’am heard it as she stood in the hallway in front of the other patient’s room having her visual acuity checked.

As I finished my farewell with the other patient and I stood in her doorway that patient replied, “Thank you and God bless you.” Which she said loud enough that the upset patient heard her. However, the upset patient did not have a melt down that I had called someone else Ma’am.

Yet, earlier, for no reason, the upset patient yelled at me for calling her Ma’am. Which witch is which? (An unrelated childhood memory I like repeating.)

I saw a 26-year-old male who had been having abdominal pain for four days before he sought medical attention on a day his pain was better. Now, why would anyone seek medical attention on a day his abdominal pain was better? And of all the places to go why would anyone go to the emergency department when feeling better? Clearly, it is no longer an emergency if you feel better.

So then, why now and why the emergency department? Wait. Wait. Now, the rest of the story. The patient claims he came into the same emergency department the day before but left without being seen (LWBS) because it was too busy. Now, the hidden agenda. The reason the patient sought medical attention after he got better was not because he was ill but because his employer’s sick policy requires documentation that the patient was either sick or seen at the EMERGENCY DEPARTMENT. Otherwise the employee will lose his job.

Interestingly, to say the least. Here is a policy that is so poorly written it dismisses the need to be “sick” by stating, “If you bring in a note that you were either sick or in the EMERGENCY DEPARTMENT you will be granted an excuse.” Clearly a policy anyone can take advantage of.

Why? Because everyone who comes to the emergency department receives discharge instructions that verify they were there. Whether sick or not, as this patient who came in after feeling better, or not sick at all, it does not matter. As healthcare workers, at least me, are unable to tell what you been up to instead of being at work.

Obviously to the employer, whether knowing or not, they crated a policy that states that if you were sick or not or need to be at the emergency department or not is irrelevant as well. Once again, healthcare is seen as the parent between employees and employers to justify an absence or restriction from work because employers are unable to do so on their own. Managers are great. Are they not?

Why can’t they, by themselves, solve these issues between employer and employee? If the employer does not trust the employee to be honest about missing work than why did the employer hire the employee or keep him around for that matter? Sadly, people were upset that Romney liked to fire people. I too like firing people! My reason, so that others worth keeping can be given the job of those taking their jobs for granted.

Nonetheless, wanting to keep my job but more important keep critics happy, NOT! I tried to give the patient the benefit of the doubt and with one of the clerks’ assistance we looked through the emergency department registry for the past four days, to include the DNA (Did Not Answer) list and the patient was nowhere to be found. Did it matter? Of course not as I continue to refuse to give excuses for days before I saw the patient. However, like I said, I wanted to look good in the eyes of critics who call me cynical or untrusting of this poor young man who was about to lose his job, NOT! Nonetheless, I made an effort to give the patient the benefit of the doubt, as he was about to lose his job, yet he was nowhere to be found on the registry lists. Of course, the clerk mentioned the patient may have come in but did not register and why his name was not found. “Oh! Okay,” I said as healthcare workers are always trying to be the champion for the patient.

Nonetheless, the extra effort did not really matter as the patient was leaving the emergency department with computer-generated instructions related to his discharge diagnosis. Even if the diagnosis was “Playing Hooky” it did not matter, as the employer’s requisite was not a diagnosis but instead that the employee had either been sick or seen in the EMERGENCY DEPARTMENT. The fact the patient told me he had just eaten ribs and rice 10-15 minutes before I saw him did not matter either as obviously his abdominal pain had resolved. Again, the medical complaint was not the reason the patient was seeking medical attention but the hidden agenda was. Not to mention his employer would ONLY accept documentation that he was in the emergency department and not from his PCP or an Urgent Care Center.

Being the caring and compassionate healthcare worker that I am, and knowing he was going to loose his job, I provided him with a work note that said he could return to work the day I saw him. However, this employer’s policy was so idiotic that it did not matter what I wrote on the note. What mattered was that the note came from the emergency department. SERENITY NOW! SERENITY NOW!

I saw a 22-year-old male concerned his tonsils were swollen after singing and yelling during a talent show competition. The patient said he was a rapper and sought medical attention at the emergency department after his symptoms did not improve after smoking medicinal marijuana, not prescribed for swollen tonsils but for his anorexia.

When I asked the patient why would he smoke the marijuana if it was for anorexia and not for swollen tonsils he said to me, “Because my tonsils did not get better after drinking a Monster™ drink.”

None of which made any sense. That’s like dropping a 50 lbs. weight on your great toe because it was itching and the hemorrhoid suppository you inserted in your rectum for the itching of your toe did not work.

It just makes no sense and why writing this now makes me laugh just like the night I saw the patient. Why? Because if you have anorexia you probably should not be drinking Monster™ drinks as they increase your metabolism leading to weight loss. On top of that, jumping around on stage yelling and screaming is not going to help you gain weight either. That is, if you are really trying to gain weight and the reason someone prescribed you medicinal marijuana.

Before I get beat up by critics, I have no problem with medicinal marijuana. But. Really? A 22-year-old anorexic rapper is not someone or reasons I would prescribe it for. But that is just me, again, I guess.

Nonetheless, the patient’s tonsils were just fine. However, because of his tachycardia I gave him intravenous fluids before I discharged him although that was not his concern. Because I am sure the reason a rapper on medicinal marijuana chugs down an energy drink is intentional in an effort to counter the marijuana’s side effects, which slows down the central nervous system, and one would not want impaired mental function to be the cause of losing a rapping competition.

I saw a 33-year-old male whose chief medical complaint was not illness or injury but, “I need a work note,” and he asked for it without shame as if that was what we did in the emergency department.

So I asked, “For what?”

“Because I had the flu,” he replied.

I found it interesting that he said, “Because I had the flu,” and not, “Because I missed work” or “Because my employer needs/requested one.” So I asked him, “Ok?” Although what I wanted to say was something else, “Soooooo…”

Anyhow, so I asked him, “Ok? You had the flu. What does that have to do with needing a work note?” I finished.

“Because the company policy is that if you miss three days you need a note to return to work,” he said.

Oh, so then it was not that he had the flu but that his employer requested one. I thought so. Because what the illness is or is not does not really matter. I say that because I customarily write work absences when the patient has a communicable illness, like the flu, and I do not write the diagnosis anywhere. Commonly I write, “Return to work after without fever, vomiting or diarrhea for at least 24 hours.” Open ended but the honest person would know when that is and would not risk co-workers from getting ill as well.

Anyhow, I asked the patient, “Are you saying your flu symptoms only lasted three days?”

“No,” he said and added, “I was out for seven days. Three work days and four days I was off.”

How convenient I thought but of course critics likely think I am being cynical again. I am sure if I had told the patient, “What a scam. If every time I wanted to have seven days off all I needed was to say I was sick for three.” Instead I told the patient, “Sir, I cannot give you a note for missing work from before you came in. All I can do is give you a note that says you were here today.”

Not sure why but the patient’s answer caused me to scratch my head, “Maybe I can come back tomorrow then [to pick up the work absence note],” he said. Like there was some other way to get a post-dated note. Like seeing someone else I guess. Huh?

I saw a 15-year-old female brought in by her grandparents, and guardian, for ankle pain after the patient twisted her ankle the day before. However, she had not taken anything for the pain or sought medical attention prior to me seeing her the day after the injury. In the room I noticed a pair of crutches the patient had been using due to she could not bear weight on her ankle. When I asked if she had injured her ankle previously the grandparent mentioned that the patient had broken the same ankle a year ago and why she had the old crutches.

The grandparent then added how “VERY CONCERNED” they were about the patient’s new injury. A statement that lead me to believe this was nothing more that exaggerated unrealistic emotional expectations, thus HANDLE WITH CARE-FRAGILE!

Finally, after all this time and after being asked to resign after so many complaints I have FINALLY caught on. Why? Because, if they were so VERY CONCERNED, why had they not given the patient anything for pain or sought medical attention until more than 24 hours after the injury. That disconnect is significant so I must be cautious.

With the help of the EHR I was able to find the x-ray of the same ankle a year ago and guess what? NO! Fracture. NONE! Of course I mentioned it to the VERY CONCERNED grandparent who said it was fractured and they had followed up in the orthopedic clinic. The latter was correct, as I had already read the orthopedic clinic’s note as well. Again thanks to the EHR, but the orthopedic surgeon documented an ankle sprain, and not a fracture, and recommended physical therapy for the ankle.

Guess what? NO! Physical therapy note. Why? Well I asked the VERY CONCERNED grandparent, “The orthopedic surgeon did not find a fracture either and diagnosed the injury a year ago as an ankle sprain and recommended physical therapy. However, it does not appear she went to physical therapy. Why?”

“We did not have time for physical therapy and it got better,” the VERY CONCERNED grandparent said. “Oh,” I said and told the VERY CONCERNED grandparent, “Well I will have the nurse come and apply a ace wrap as it will likely get better in a day or two.”

NOPE! Again, if so simple this experience would not have been on here. Instead, the VERY CONCERNED grandparent insisted I give her a consult for the orthopedic clinic because they were VERY CONCERNED that, “You [healthcare worker] might misread the x-ray.” The VERY CONCERNED grandparent adding how uncaring I was because “Obviously, she [the patient] cannot walk on it.”

DARN! Although I was caution I once again allowed my intent to help someone to get the best of my customer service skills and I missed catering to exaggerated unrealistic emotional expectations.

DARN! What is wrong with me? The fact the ankle was not swollen or bruised anywhere I found it hard I had misread the x-ray. Not to mention, again, because my intent is to help other, I had given the patient Ibuprofen and a cold pack on arrival and an ace wrap at discharge, something the VERY CONCERNED grandparents or even the 15-year-old patient herself, had NOT done themselves DESPITE they were VERY CONCERNED. Again, it was the LEAST caring, as the grandparent labeled me, who did do something, well lots, for the patient although it was them who were so VERY CONCERNED.

I rarely, if ever, follow up on patients. Nonetheless, I was curious about this patient and because the EHR facilitates follow up I did. With that, another helpful feature of the EHR at this facility is that we are notified of mistreatments, whether it is a urine culture that is positive and the patient was discharged without antibiotics or a misread x-ray, which is always possible, the EHR provides us those notifications so that we may correct the treatment.

Because the VERY CONCERNED grandparent specifically mentioned that I would misread the x-ray I wanted to know why that would be the case. Was there some reason that would be the case? So a few days later I looked up the patient’s x-ray that I had read and the radiologist did not mention a misread on the x-ray’s final report.

Again, with the EHR I was able to see that the patient had followed up in the orthopedic clinic and was diagnosed with an ankle sprain and referred to physical therapy again. And! And! Again, the VERY CONCERNED grandparents must have thought it was not necessary, as the patient had no documentation of attending physical therapy, again. Imagine that. And critics say my stories are repetitive!

I saw an 8-year-old female brought in by her parent because the patient had a single episode of vomiting at 3am that same day. Keep in mind, I work at night, 7pm-7am, and saw this patient at the beginning of my shift, some sixteen hours after the patient had vomited once. Interestingly, the patient has been seen in the pediatric clinic for the same symptom, although not this episode, without a confirmed diagnosis, according to the parent. Because of that the patient has been prescribed, and has at home, Zofran, an anti-emetic, yet the patient was not given a dose all day and despite that she had not vomited since 3am.

More interesting is that the patient DID have an appointment in the pediatric clinic earlier for the same episode I was seeing her at 7pm. HOWEVER, and that is a BIG HOWEVER, once at the pediatric clinic the parent did not want to be seen by the healthcare worker who picked up the patient’s chart that day although they had been seen by that healthcare worker in the past. Because of that the parent rescheduled an appointment for the following day with a different healthcare worker in the pediatric clinic. Sooooo, that was a wasted appointment that someone else could have used. But that is another issue.

Anyhow, I get to see the patient and in doing so the parent wants to share the long and convoluted past medical history, a history that likely the undesired healthcare worker in the pediatric clinic knew so well. Yet I really did not need to know for the sake of seeing the patient in the emergency department.

Do not get me wrong I know the past medical history is incredibly important. However, when I walked in the room the 8-year-old was eating beans from a to-go container. Now, if you have any kind of gastrointestinal issues it is likely everyone knows not to eat beans, especially if you have been vomiting.

Having said that, and more so after seeing the patient eating beans I no longer needed to hear the long and convoluted past medical history and that was why when the parent set off to mention it I stopped her. “Ma’am, wait. Did you say she threw up once?” I asked.

“Yes,” the parent replied.

“And before now, when did she eat last?” I asked.

“At about noontime,” the parent replied.

“What did she eat then?” I asked.

“She had pizza rolls,” the parent replied obviously not noting where I was going with the questions.

“Pizza rolls!?! And since then she has not thrown up? What was she eating when I walked in?” I asked. I wasn’t stalling I was just asking questions that would justify my intent to dismiss this patient.

“No. She has not vomited since 3am this morning. And that was beans she was eating,” the parent replied.

“Okay. Let me see if I have this right. She vomited one time this morning and since then she has kept down pizza rolls and beans and you said you rescheduled her to be seen in the pediatric clinic tomorrow and you already have Zofran for her at home. Did I get that right?” I asked.

“Yes, you are correct,” the parent replied.

“Good. Then I am going to discharge her from the emergency department and she can follow up in the pediatric clinic, tomorrow [some 14 hours away], as scheduled and if she throws up before then you can give her Zofran that you already have at home. Do you have any questions?” I asked.

The parent said, “No.” And I walked out of the room and went looking for the hardest man-made object in the emergency department to go bang my head. However, after thinking about that a bit longer and it being the first patient I saw that night I decided to preserve my skull and settled with praying at the workstation.

I guess the parent wanted to share the patient’s long and convoluted story with someone who had not heard it before and why she left the pediatric clinic for the emergency department. Not knowing she would get to see me, a very simple person who does not have a need for information overload and much less DRAMA to get to the conclusion that a patient is not sick and can go home!

Maybe the parent should start a blog so that she can share her redundant stories over and over with strangers who might, but likely will not, be interested. Just like I do!

I saw a 14-year-old female brought in by her parent after the patient had twisted her knee while walking at school at about noon the same day. The patient had walked on it the rest of the day, and again, I work at night, and she had not taken anything for her pain all day either. On physical exam, although the patient had a slight antalgic gait I was not impressed. Because while the patient stated it hurt her to move her knee while she was distracted I noticed her painful knee had no limitation.

Anyhow, I offered the patient Ibuprofen, since she not had anything for the pain, and the parent declined. “Oh! Okay then,” I said and went on to explain to the parent that the knee was sprained and likely would be fine in a day or two if the patient elevated it, put cold on it and took an anti-inflammatory. I also said, “She does not need an x-ray unless you want her to have an x-ray.” The latter part of those instructions is my rehearsed placating offer for those with exaggerated unrealistic emotional expectations.

Surprisingly, AGAIN, because I am not able to tell whom those patients are, the parent said, “That is the reason we came in so that she can get an x-ray.”

“Oh! Okay,” I said and added, “One x-ray coming up.” While sitting at the computer ordering the x-ray I also took the moment to write up discharge instructions with a diagnosis of knee sprain knowing the x-rays were going to be unremarkable and went to see the next patient.

On my way back from seeing the next patient I saw the 14-year-old with the sprain knee was back, AND! AND! She was now walking without a limp. Huh? I looked at the x-ray, grabbed her discharge instructions and called her from the waiting area back into a room. Again, the patient was not limping. Huh? I could not believe it so I did another exam of her knee and would you believe it the second time I was not able to reproduce pain in any manner. “What happened to your pain?” I asked.

“It was all gone,” the patient told me.

Huh? Another therapeutic x-ray, I guess, and another satisfied customer, I guess, as well. Not even a need for a school note. Huh? Who knew that x-rays were therapeutic?

I saw a 20-year-old male, who, when I walked in the room and introduced myself, decided he would lash out when I asked him his name and instead said in an angered tone, “I been waiting…”

However, because I do not entertain anyone’s dissatisfaction complaints I injected, “I do healthcare not customer service. I am here now. I can see you now but if you rather share your complaints with someone else I can leave and come back later after I seen other patients and you complained to someone else.”

Surprisingly the patient declined to pursue his complaint so I asked him again, “What is your name?” Then, as if nothing had happened we got through the history of present illness and physical exam and I told him I would see him again after an x-ray of his chest. Why? Because the patient had a non-productive cough for two weeks and had not sought medical attention before I saw him, yet, he was disappointed he had been waiting in the room just over an hour.

Nonetheless, the x-ray showed whatever and I discharged him with whatever treatment plan. Yes, whatever! Because the healthcare provided is not the intent of this anecdote. Instead, the intent here is that I do not entertain dissatisfaction complaints of any kind nor do I apologize for things I have no control over, not in my private life and not at work. Because despite some suggesting I lack self-awareness and insight what I will tell them is that I do not cater to drama and on top of that I rather be respected than liked.

I realized that at national conferences customer service advocates, like Fred Lee, and even managers at monthly emergency department meetings try to convince healthcare workers that the customer experience is easily obtained by surrendering oneself to simple compromises. Like extending your hand out in a handshake and apologizing for everything, to include the accumulation of snow outside, or whatever else is out of your control. THAT IS CRAP!

Why? Because that is not how those advocating such simple compromises behave with their employees and much less at home with their family. On top of that, apologizing it’s a full moon or that a nasogastric tube placement is uncomfortable or that it is hot or raining outside or that they had to wait does nothing for either of those occurrences and instead devalues the significance of apologies. As said, I rather be respected than liked and dislike than being fake with ours.

Nonetheless, after it was all said and done, the patient apologized, “For how I came off when you first came in,” he said.

“Sir, you have no reason to apologize. Like I said, ‘I do patient care and we are here to help you, and others, and we try to go as fast as we can. It’s not like we are goofing off in here.’”

He then said, “Thank you.”

And I replied, “You are welcome. Take care and get better.” And we went about our business. He to wherever he was going and I to see the next patient.

I saw a 28-year-old female with a request for a return to duty note extension for another five days due to she had not been seen in the orthopedic clinic for her left wrist fracture. “Oh,” she added. And not, “Oh,” like in, by the way, “Oh,” but like in a hidden agenda follows, “Oh.” The patient adding that the note include she could wear dark lens at work because she had two black eyes.

After a deep breath I looked around for the candid cameras. Why? Are you telling me your employer, who has seen you at work wearing a splint on your arm for the past week, is requesting you bring in a note because the previous note expired? OR! OR! Are you telling me you want to be able to wear dark lens while at work so that others do not see your two black eyes?

Not that I asked that of the patient as I would have likely been fired on the spot but that was what ran through my simple mind.

Adding to the craziness of the story, the patient works in customer service. Again, I cannot make this stuff up. How comical and appropriate that I would be the one seeing her? Guess what? I wrote her the extension to her fractured arm. Then, after several deep breaths, counting to 100 five times, more deep breaths and even tears, I bent over grabbing both my ankles and added in her return to work note, “Must wear dark lens until bilateral periorbital ecchymosis resolves”. Well, maybe not tears. I take that back. I guess I got a bit carried away.

Nonetheless, I wrote the note as she wished. Why? Because that was the exaggerated unrealistic emotional expectation behind why she was in the emergency department in the first place. Again, not for her wrist but to find a way to hide her black eyes and if I did not do “AS TOLD” it was obvious the patient would complain.

Since that patient I have thought of but not implemented a work absence note that read:

Patient’s name was seen at the emergency department on date of visit and may return to work on _______________ with the following limitations _____________________.”

The patient, or family or friend or whoever, would then fill in the blanks as they desired. However, below the above statement, in fine print, it would read:

“There is no clinical reason why the above named cannot return to work on date of visit. However, the above note was a request of the named person on date of visit for whatever reason or hidden agenda and the named person was told to complete as desired.”

Hopefully, the employer will notice the fine print. Why? Because school/work absence notes are about infectious illnesses healthcare must protect others from. And not about issues that employers and employees, as adults, are not able to resolve. And why, like children, seek out a third party, healthcare, to be the parent between them.

As mentioned, I have written more school/work absence notes here than the cumulative total of ever. Making matters worse, I have written most of them not because of medical necessity but because of the black cloud that follows me with regard to the customer experience. Keep in mind; I have worked as a nurse practitioner in over thirty, yes 3-0, different organizations. Of those, twelve being emergency department and all but two being larger than this one and some three times as large and where I saw some 4,000 patients annually. I have also worked in occupational health where EVERY patient was a work related patient. Yet, between all those facilities, all those patients, and in all those years combined I had never reached the number of school/work absence notes, cumulatively, I have written here.

Sadly, now I can add that I have pathetically, like a wimp, written one without medical necessity whatsoever that not only goes against the company’s policy but against my integrity as well. As if not enough, I wrote it for no reason other than to avoid the patient from complaining just so that she may cover up her two black eyes. How pathetic and on my behalf! Ugh! I am going to vomit!

However, it is not just the school/work absence notes alone. Adding more insult to injury, although not here alone but over the years, how many unnecessary antibiotics, over the counter prescriptions and diagnostics, to mention but a few, have I ordered just to keep customers happy? Despite the consequences.

I saw a 20-year-old female on her third visit in four days to the emergency department and it was the second time I saw her for the same medical complaint, abdominal pain with nausea, vomiting and diarrhea. However, in the three hours she was in the emergency department on the second visit I saw her she had not had any diarrhea or vomiting. Having said that, she did have retching that was spontaneous whenever someone walked into her room. Yet, the retching was not heard in the hallway from behind her room’s curtain.

Each of the three visits she had labs done. On two of the visits she had a CT of her abdomen and pelvis. Before I saw her, the second time, she already had a single x-ray view of her kidneys, ureters and bladder (KUB) and a CT of her head. Why the latter? I have no idea as the MSE provider ordered it. Nonetheless, the head CT, the KUB and her labs were all unremarkable.

On this day, previously borderline abnormal labs were within normal limits. Except for her urinalysis which was worse than it was on day two, the first day I had seen her and for which she was diagnosed with a urinary tract infection and prescribed an antibiotic that she claims she had been taken as directed.

DONE! However, we all know this is not going to turn out well because every time I have said, “DONE!” it did not go in my favor. What this time? Well, the patient wanted to be admitted she said. “Ma’am,” I said and added, “I cannot find a reason to admit you to the hospital. None of your test demonstrated a reason to admit you.” So I discharged her.

Not long after that, I was told the patient’s father, the father of a 20-year-old adult, wanted to speak with me in the waiting area. Guess what I did? I ran out the back door. Nah. I went to the waiting area. Why? For the sake of preserving the customer’s experience. So I went to the waiting area where I found a very upset parent, “Yes Sir?” I asked him.

“Did you tell my daughter to not come back?” he asked.

“Sir, come in and we can talk about it in a room,” I replied.

“No. We can talk about it right here in front of everyone [in the waiting room],” he fired back.

“No sir. I am not going to talk about a patient in the waiting area,” I replied.

“What do you have to hide?” the father asked angrily.

“Sir, it’s against the law,” I said.

The father continued to invite me into the waiting and became angrier when I declined and he became more upset when I told him if he did not come in to the emergency department from the waiting area I was going to close the door. The father never came in so I closed the door and went back to seeing patients.

With that, I will point out that the Emergency Medical Treatment and Active Labor Act (EMTALA) clearly outlines that ambulance services and hospitals that accept payment from the Center for Medicare and Medicaid Services will provide emergency care to anyone regardless of citizenship, legal status or ability to pay. On that note, a patient’s medical complaint or the number of times a patient shows up, among other variables, is irrelevant.

Granted, some blame EMTALA for the emergency department’s erosion from where major injuries and life-threatening conditions are helped to the epitome of dependency and entitlements by becoming a safety net for those without healthcare insurance and a one-stop-shopping amenity for those with healthcare insurance.

However, I see EMTALA’s greater good as that which eliminates refusal of treatment, to those unable to pay, citizenship or legal status and dumping, the practice of transferring or discharging patients due to high anticipated diagnosis and treatment cost. Having said that, EMTALA never intended for emergency departments to become primary care for the uninsured, a political pawn regarding access to healthcare and much less a convenient amenity for the insured.

Because of that, the Medical Screen Exam (MSE) was established by where a qualified healthcare worker determines if an emergent medical condition exists. If so, that patient must be treated until the condition is resolved and the patient is able to provide self-care following discharge. However, when a facility is unable to resolve the patient’s condition then the patient must be transferred to a facility capable of providing the higher level of care. On the other hand, when an emergent condition does not exist the patient can be discharged after a MSE. Unfortunately, most organizations struggle with the MSE but that is another conversation.

Having said all of that, NO! I have NEVER told, or tell, patients not to return to the emergency department. What I told her, and others, is, “You need to follow up with the outpatient clinic or your PCP. You should not have to come back to the emergency department unless you are worse or have some other concern.” That was what I said and nowhere in that statement does it say, “Do not come back to the emergency department.”

I saw a 20-year-old female with foot pain after bunion surgery five months prior to me seeing her. Despite having pain for five months I asked, “What is different if you have had the pain for five months?” Her answer was that the Ibuprofen and Naproxen she been taking was no longer working. “Did you mention it to whoever did your surgery?” I asked, although I knew the answer was going to be, "No," and was.

Why would you not bring it up with the person who did the surgery? Other than that makes sense. Because who tries to return Macy’s purchased products at Walmart? Or return Walmart purchased products at J. C. Penny’s or Macy’s for that matter? No one! That’s who! I am sure 100% of returned items are returned to where they purchased the item. So why would you go to the gastroenterologist about the surgery the podiatrist did, or to the emergency department for that matter?

In healthcare, especially in the emergency department, it is so common for a patient to come in for us to fix what someone else did it is unbelievable. Now granted, a recent surgery that is infected or causing more pain is a different issue and an appropriate reason to seek medical attention in the emergency department. But five-months ago and it has been painful since. That you have to bring up with who ever did the surgery.

So, this is the story, you consented with someone to cut open your foot and rather than go back to that person to let them know it did not turn out how you expected you come to the emergency department. Why? Because your foot has been hurting since the surgery five months ago. Okay, aannnnddddd, you want me to fix it?

NO! Not fix it just prescribe something for the pain.

None of those words exchanged but if I could have that was how the conversation likely would have gone.

OH! So you do not want me to fix it. You just want me to make the pain go away.

Again, conversation not exchanged because if so likely I would have been fired. Why? Because healthcare administrators do not want us to confront patients with truths but want us to pander to the administrations’ customers to retain customer loyalty. Kapish!

Anyhow, when I offer a steroid for the inflammation the answer was, “No.” And not, “No, thank you,” but just, “No.” Like, “No, that’s not what I came in here for.”

Instead, the patient asked, “Can’t I get some ‘oxies’?”

“What are ‘oxies’?” I asked.

“You don’t know what ‘oxies’ are!?!” she told or asked me in a tone as if I had no idea what I was doing.

“No. I do not know what ‘oxies’ are, Ma’am,” I replied. “Should I?” I asked.

“Oxycodone,” she replied.

“Oooohhhh,” I said and added, “No. I am not going to give you any oxycodones." Then I thought, “Can I write ‘oxies’ on a prescription script and the pharmacy will accept that?” Not likely. Huh!?! But nonetheless, immediately a big light bulb came on. I wonder what would happen if I did write a script for the patient that read, “Oxies 10mg 1 tab by mouth every 4-6 hours as needed for pain. Dispense: 1,001.” Then signed it, with my signature block and DEA number, on the “may substitute” line.

What a GREAT idea. Like Tony the Tiger GRRREEEAAAT! idea. Why? Because the patient, who just asked for “Oxies”, and believes that every healthcare worker should know what that is likely thinks the pharmacy will fill such prescription. And! And! Wait for it! Wait for it! It is likely the patient will leave happy as a lark, whatever that means, or at least until she gets to the pharmacy and the prescription gets declined.

Nonetheless, the patient suddenly stormed out of the room saying, in an angry tone, “I just wasted my time because you didn’t do anything for me.” I should have written her that prescription for “Oxies” and likely she would have left content and maybe even nominated me for Healthcare Worker of the Year. Oh well I guess. Another missed opportunity.

For those paying attention, I just cried foul about all the pathetic concessions I must make just to keep my job. Yet, I am able to continue to not bow to those seeking drugs. Why? Because, contrary to popular belief, drug-seekers do not complain. They may be manipulative and kick and scream, and sometimes literally, but they do not complain. I know. I know. Others will swear on their mother’s grave and say something like “..hope to die,” saying complaints against them came from drug-seekers.

But please, a little respect. For I am The Knitted Brow. Lord of the Patient Complaints! I have NEVER had a drug-seeker complain. NEVER. Not once. Not ever. As I just said, “I am Lord of the Patient Complaints.” Meaning that after being asked to resign from some ten jobs because of customer complaints I believe I would know that I have NEVER, NOT once, had a complaint come from a drug-seeker. NEVER!

Drug-seekers are NOT patients but addicts. Like addicts they are manipulative and they know healthcare workers not only have what they want but are not confrontational and if anything are accommodating, nonjudgmental, empathetic and will champion against suffering (like a good pain story). Addicts also know that although complaining might turn the tables in their favor they know that strategy is not sustainable as others will catch on to their game. Because of that, I ask healthcare workers to not use drug-seekers as scapegoats to healthcare’s problems of accommodating exaggerated unrealistic emotional expectations and also caution colleagues to not take drug-seekers for granted because bad stuff happens to bad people too.

This is my management of drug-seekers. First of all, drug-seekers do not come in complaining of second or third-degree burns, acute fractures, acute gunshot wounds, acute stabbing wounds or the likes for which I would prescribe a narcotic. Instead, drug-seekers make it easy for me because they come in with medical complaints for which I do not prescribe narcotics, drug-seeker or not. For example, headache-NO, tooth pain-NO, muscle skeletal joint pain acute or chronic-NO, narcotic refill-NO or the likes. Of course there is the exception, if a patient’s medical complaint includes pain due to cancer, and the likes, drug-seeker or not, it is very likely that patient’s pain will be addressed to the patient’s preference. Granted, I have had many drug-seekers get angry, kick and scream, and express their discontent and dissatisfaction. However, I have NEVER had a drug-seeker formally complain and when they leave dissatisfied I just move on to the next patient. DONE!

I saw a 23-year-old male who had a fractured foot and hand. However, I found it odd that his foot and hand were not in a cast but in a splint. Not an improvised splint that he could have made himself but one he would have gotten at any emergency department or clinic anywhere in the USA. Adding to the oddness of his medical complaint he was not complaining that his extremities were cold, numb, pale or in worse pain as might happen with a splint but more so with a cast. Instead, his medical complaint was pain. But again not worse pain but pain.

Interestingly as well, he was walking on the splint and carrying a child. When I asked him if he had crutches he replied he did but added, “They get in the way of carrying the kids.” Oh. Okay, I guess. I thought to myself.

When I asked him if he was scheduled to follow up with the orthopedic clinic for a permanent cast he replied that he had missed the appointment from a week ago. “Why?” I asked.

“Because I had other things to do,” he said.

Oh. Okay. I guess. Again, I thought to myself. The only thing left to ask was, “What brings you in tonight?”

“I have pain,” he answered.

Somehow he had run out of pain medication. I say “somehow” only after I noticed the EHR showed that he was seen at the urgent care clinic at the same hospital where the emergency department was. Not to mention, the same urgent care clinic was still opened at the time I saw him. When I looked closer at the EHR I also noticed the patient had been discharged from the urgent care clinic almost, not exactly but almost, two hours before I saw him. I also noticed he was discharged with a prescription for Tylenol with codeine. A prescription, which according to the EHR, had been dispensed to the patient about one hour before I say him and why I said that “somehow” he had run out of pain medications. Now, had it been he had run out of pain medications from a week ago I would not had stated that “somehow” he had run out of the medications. Not that I would have prescribed him any more, however, he was just dispensed pain medication an hour prior to me seeing him.

So I asked him, “What happened to the Tylenol with codeine you were given at the urgent care clinic tonight?”

“That stuff doesn’t work,” he said and added, “I need Percocets.”

Oh. Okay. I guess. Again, I thought to myself as I am sure if I had said that to the patient it is likely he would have complained that I was questioning him and his intentions. Which I was but I been told by healthcare administrators, over and over, not to confront patients because conflicts between healthcare workers and the customer experience jeopardizes the administration’s goal to retain customers. So I left it as a thought in my brain and moved on for the third or fourth time.

Instead, I told the patient, “Not that I would have given you any had I seen you before the urgent care. So, if I were you I would use the Tylenol with codeine until you get into the orthopedic clinic.”

Surprisingly, the patient too said, “Oh. Okay. I guess.” As if he had been hearing my confrontational thoughts from the beginning.

Again, I cannot make this stuff up but I guess if you did not get what you were looking for at the urgent care clinic it would not hurt to try the emergency department to see if you could get what you wanted there. What the heck, the emergency department is just next door to the outpatient/urgent care clinic. I am sure some of the patients seen in the emergency department  do the same, if they do not get what they were looking for they just go to the urgent care to see if they could get what they were looking for there.

I saw a 40-year-old female with a request for a medication refill. My rehearsed answer is, “I do not do medication refills in the emergency department. For that you will have to follow up with your Primary Care Provider.”

She insisted, “They have done it before.”

My answer to that so common response, whether they have done it before or not, is, “I cannot tell you what others have done or not. I can only tell you what I do and I do not do refills in the emergency department,” knowing that likely others have not as well.

The patient’s manipulative strategy went on and on until she reached the point where she realized I would not budge and she became angered, finally surrendering she yelled at the top of her lungs, “F@#k you!” as she stormed out the room.

I saw a 40-year-old female with left knee pain for more than one month. Her PCP had seen her for the same left knee pain two weeks before. On top of that, she was seen in the outpatient clinic for the same one-month-old knee pain the day before I saw her as well. The day I saw her she was not wearing the knee brace her PCP asked her to wear two weeks ago and despite her PCP and the outpatient clinic had prescribed her something for pain she asked me for “something stronger” and an MRI of her knee.

Keeping with myself I said, “No. And no.” Meaning nothing “stronger” and no MRI either. Instead, I shared with her she had to wear the knee brace her PCP had gotten her and to follow up with her PCP about the MRI, which may be justifiable if she was willing to entertain a possible surgery. Because, as I tell patients, “If you are not willing to have surgery what is the point of having an MRI. It’s not like MRIs are therapeutic and you already know there is something wrong with your knee, so why have one done.” Nonetheless, the request was not justifiable from the emergency department.

As one can imagine, and why an included anecdote, the patient was not HAPPY!

Most would say that for the purpose of following a patient’s course of treatment the EHR is a great tool and I agree. However, as for support to telling patients, “No,” as in this patient’s case I do not think so. My reason, I do not need the support of the EHR to say NO to exaggerated unrealistic emotional expectations. As with this patient, although there was a well documented course of treatment even if there wasn’t I would still have told the patient, “No. And no.” Again, meaning nothing “stronger” and no MRI either.

I saw, well the first patient I tried to see at the beginning of a shift one night was a 43-year-old female with right neck and shoulder pain but she stormed out of the room yanking the curtain open with her right arm. Yea, the arm that was in so much pain.

So what happened? Well, it went kind of like this. “How long have you had this ‘severe pain’?” I asked.

“Look it up in the chart,” she snapped.

“No. I do not look at the chart. I would think the patient would know how long they have had pain and why I am asking you rather than looking at the chart,” I said.

Obviously I set off a nerve as the patient abruptly got up from where she was sitting in a chair and, like I said already, using her right arm, the one in “severe pain”, she yanked the curtain open to get out of the room. In the hallway she looked around frantically until she made eye contact with the charge nurse and to who the patient complained that she did not want to be seen by me.

“Why?” I asked.

“Because you are rude!” she fired back.

Oh. Okay. I thought and I walked around her and the charge nurse back to my workstation where I returned the patient’s chart back to the rack and grabbed the next one.

So let me try to get this right. The patient says I was rude because (1) I asked her how long she has had the pain or (2) because I did not read her chart. Not sure “which witch is which” but one or the other or maybe even both. Ironic, I guess telling someone who is trying to help you, “Go read the chart,” is not rude.

Unfortunately, when the shift begins that explosive it just ruins the entire shift. Making matters worse, it did not get any better when the charge nurse asked the next provider to see the patient because, “Jose pissed off this patient.”

NO! The patient pissed herself off. But of course I would not say that out loud because someone might fire back saying, “[Jose, you have a] total lack of self-awareness and insight.” Oh really?

Nonetheless, later in the shift, when it was all said and done and I was walking down the hall I ran into this patient and she says to me, in front of the nurse’s station, “Sir, I want to apologize for being rude to you. My parents taught me better. I was in pain and that is why I behaved the way I did…yada yada yada.”

Never do I say to patients, “Apologies accepted.” NEVER. Instead, what I always say to them is, “There is no reason for you to apologize. But I want you to know that we are all here to help you and others.”

Earlier with a different anecdote I said I do not, nor expect others to, apologize for things one does not have control over and although patient’s can control these inappropriate outbursts I do not hold it against them.

However, this patient insisted in apologizing and the best answer I could muster was, “Okay.” Again, I do not accept apologies from patients but not because I am arrogant or lack self-awareness and insight. I do not accept them because I understand that patients seek medical or psychosocial care during some of the most miserable moments of their lives and in a place where most would rather not be. I get it. However, I have nothing to do with any of that and if anything I am on their side trying to help them. Not to mention, I do not go to their place of work to tell them how to do their jobs. So why do they think they can tell me how to do mine.

I saw a 14-year-old male brought in his mother claiming the patient had a cough. Oh yea, and a foot problem. So of course, I always try to focus patients on these visits of convenience where their thought is, “I am here. I matter as well get every aliment I have checked out.”

In this case it was the parent I had to focus that they were in the emergency department and with that I asked, “Which was the one thing that made you get up and say, ‘Oh, I’d better get to the emergency department.’”

Granted, I already know the first answer, as many will say, “All!” So, I try to refocus them again by repeating myself, “Which was the one thing that made you get up and say, ‘Oh, I’d better get to the emergency department.’” As a number of them do not just have two medical complaints as this one patient did but a list of four or five or more unrelated medical complaints like, “My tooth hurts…and I have a rash between my toes…and I need my blood pressure medicines refilled…and I have hemorrhoids…and I have an elbow that cracks when I do this…and I have penile discharge…” And when asked, “Which was the one thing that made you get up and say, ‘Oh, I’d better get to the emergency department,’” they still will say, “All of them.” Although none of them by their self is an emergency and all can be addressed elsewhere I try to at least address the one medical complaint that made them get up, whether true or not, and come into the emergency department.

Now, when working in primary care and patients have multiple complaints I try to address them all but then staff has told me that I could only address the medical complaint for which the patient had made the appointment or their insurance may not pay. I do not know if that is correct or not but I can see how by having the patient make another appointment would be advantageous in primary care practice.

Nonetheless, the parent was not happy that I would only address her most concerning medical complaint, “The cough,” she said. Okay! Done. Not so fast and not because at discharge the parent also asked for a medication refill for the patient and I declined but because of what came next, as if dealing with an unsatisfied parent were not enough.

Unknown to me, the parent was a patient to be seen as well. So not only was it a child with multiple complaints but it was also a family plan, another visit of convenience. The thought process, "I am here I might as well get checked out too." Nonetheless, the parent was seen by another healthcare provider who questioned me, “Did you see the son of this lady?”

“I did,” I replied.

“She says you did not address her son’s foot problem,” the other provider said to me.

WHAT!?! I thought to myself and instead said gently to the other provider, “What?”

“The mother says you did not want to address his foot problem,” the other provider repeated.

REALLY!?! Again, just a thought and instead I shared with the other provider, “I asked the parent which complaint was most concerning to her and she said it was his cough. So I addressed his cough.”

Being the new kid on the block and on probation, as human resources categorize new employees, I have to not only answer to others but I have to justify my EVERY action, or lack of action, to others as well. In healthcare, acceptance is exponential to the -100 power where healthcare’s culture is suspicious of new healthcare workers until those new healthcare workers have proven themselves and completed a right of passage at their new job; because our credentials are NEVER sufficient, that being another book in its entirety but worth mentioning.

Yet, a complaint from a patient or family against a healthcare worker is always taken at face value. That phenomenon being even more so a fact when a healthcare worker is new at an organization, that being a third book. Because of healthcare’s passive culture of accommodation I have witnessed healthcare workers siding with and defending inappropriate and even violent patients. Patients they just met, if even. Why? Because those healthcare workers believe they can be champions in an interaction gone badly and naively those healthcare workers feel compelled to make matters better, not realizing they are being manipulated by those patients.

Having said that, I was not surprised the 14-year-old I had just seen and discharged for a cough had his foot issue addressed and his medication refilled by the other healthcare provider. However, I cannot blame healthcare workers for being manipulated when the healthcare worker believes she is doing the right thing. Granted, it is likely the same championship attitude is not the case at home when their teenager pins one parent against the other in order for the teenager to get it her way.

Nonetheless, apart from patients, and like at every place I have worked at there is a right of passage and this locums job has not been different in any manner where I been told by the staff,

“You are too serious…too honest…too transparent.”

“You are like clock work, always on time.”

“You carry yourself with such confidence.”

“You dress so well and are always clean cut.”

“I like the way you conduct business. Honest and straightforward.”

All to which I always reply, “I know. It’s a bad habit I have.”

It’s almost like showing up to work on time and being honest and/or focused on the task at hand were bad things. I guess I not only lack self-awareness and insight but I am also out of touch with the social butterflies that have to visit everyone before they can get to work or those who are watching the clock for when their next coffee break is.

Not to mention when a patient blows up and I get asked,

“Why did you become a nurse?”

“How long have you been a nurse?”

Because maybe those answers might shed some light as to, “…why you are burned out.” As I have been told by groupthinkers who buy into the labels administrators place on the ones who do not fit their Magnet or U.S. News Best hospital narratives.

BREAKING NEWS! Not wanting to be a punching bag is NOT that one is burned out.

Because, when I mention, “…how much we do for those not appreciating. Yet those needing not getting…” the same persons suggesting I am burned out respond, “You are right.”

Then again, there are always the comments,

“You always look like you hate the world.”

“Do you wear long sleeves to cover your tattoos?”

Both which I would say might be playful, maybe, however, I get them asked so often, no matter where, that I have come to see those comments not as sarcasm but as concerns of others.

I remember in the U. S. Army I always told the soldiers I was responsible for, “People ask personal questions for two reason, and for two reason only. One, those people are concerned. Two, those people are nosey. None of you look concerned. Mind your own business.” However, I do not think I can share that with coworkers, as they might be offended.

However, what if I did have tattoos under my long sleeves? Or, what if I did hate the world? Or, what if the long sleeves hide my disfigured body? Would that explain it ALL?

Joseph Merrick (The Elephant Man) said, “People are frightened by what they don’t understand.” And why I share Mr. Merrick’s words with my critics, “I am not an animal! I am a human being! I am a man!”

I guess that is what being on probation at work means. Just because my education, my experience, my references and my job performance got me the job does not mean those same credentials will gain me inclusion into any organization. Being accepted is a social matter where others accept you, the individual, credentials aside.

With that said, I do not expect anyone to know me, not employers, not colleagues and most definite not patients. Because of that I do not I hide behind the phrase, “You don’t know me.” Because who you were does not matter. What matters is who you have become. Having that said, I did NOT just show up to work one day.

On the other hand, patients and family can say whatever they please and their words are taken at face value. They can behave as they like, to include being inappropriate, and they will find champions siding with them. Yet, healthcare workers are doubted and chastised when in disagreement with those same customers.

After all that has been said and done, be it patients, their families or coworkers, it is common that after dealing with any of the mentioned when I return to the workstation I kneel before the counter and state, “Lord, where do you find them? And why do you keep sending them to me?”

Just kidding! But the thought does enter my brain quite frequently. Another someecard.

After all that has been written in this current blog I would have to admit that at this one emergency department I have seen many ill patients and lots of them with quite a bit of pathology. On top of that, and most significant, I would have to say that most of the patients and their families here are very appreciative more than any other emergency department I have worked at and although not by desire I have worked at many.

Yet none of those thankful patients are included in any of the above anecdotes. Not one. Not because they are not deserving of the attention but because, as I mentioned in the book, those with the greatest medical needs complain the least, even if their outcome is death. Those most thankful know the intention of healthcare workers is not only to help but also in the patient’s best interest.

Sadly, as also mentioned in the book, because those patient’s positive stories are so many most of their stories mesh into one another and after so many it is difficulty to recall them individually. With that said, that fact not only tells us but confirms for us that thankful patients are many more than those who complain and are the reason so many of us come to work every shift! Because contrary to the administration’s propaganda one cannot get burned out from helping others!

Yet, and unfortunately, those who complain get the most attention, not only at the moment but in our memories as well. Not to mention, those who complain are the ones who need healthcare the least.

Again, I get President Obama’s intent and I applaud him to want to include everyone in healthcare. However, as is evidence by these listed anecdotes, not everyone needs healthcare and those less needing actually take it away from those who do need it more. Because, for the most part, as a cohort the above anecdotal experiences would have gotten better without medical attention. "Period," as the President said BUT I really mean it.

Having said that, a patient’s satisfaction or dissatisfaction has nothing to do with them being emergent or not, instead, it has everything to do with their exaggerated unrealistic emotional expectations. I have seen a number of patients who have told me, “I just was not sure [if the condition was significant or not] and I just wanted to get it checked out.” That is just fine as it is not the patient but the healthcare worker who is the subject matter expert. Patients have told me, “I did not know where else to go to have this looked at.” Again, that is just fine as well. I have seen patients who said, “I looked it up on WebMD and I think I have measles and I wanted to get it checked out.” Again, just fine as that is not the patient’s role to know the difference or to make the diagnosis.

So the issue is not that non-emergent patients seek medical attention in the emergency department, as that is what pays the mortgage. The issue is that those with exaggerated unrealistic emotional expectations get their feathers all ruffled when told, “That’s not measles,” and for whatever reason they are dissatisfied as if they were hoping to have the measles. That! Is where the disconnect lays. That! I cannot fix.

Why are those with exaggerated unrealistic emotional expectations dissatisfied when so many more are not? Simple, those who complain have a sense of entitlement or the belief that they have the right NOT to have their feelings hurt and when told otherwise they get all worked up. Having said that, I do not treat non-emergent patients differently, again, they pay the mortgage and reason alone to tell them, “Thank you for coming and come again.”

I saw, oh wait, I tried to see a 39-year-old male who listed on his intake sheet that his medical complaints were “chronic leg pain, malnutrition, hunger and thirsty”. After picking up the chart and on my way to see the patient the attending physician says to me, “Do you want me to see that patient?” Confused I looked at the attending and without me saying anything the attending added, [A healthcare worker] said the last time you saw that patient the two of you almost came to blows.”

Drama of course, not that I could recall the patient and what I told the attending was, “I do not recall patients but nonetheless I see every patient as a new patient regardless of what happened before.” The attending replying, “Okay. If you need me to see him let me know.” And off I went to see the patient. If anyone, it is the patient who remembers me and in those cases it is the patient who might not want me to see him.

According to the chart timeline, the patient had checked into the emergency department at 1808 and I went to see him at 1902. When I got to the room there was no patient. Someone’s belongings were in the room but no patient. When I mentioned that one of the nurses suggested the patient might be in the bathroom. At that moment there were no other patients waiting to be seen, which is very rare, so I sat at my workstation.

After sitting, for what I thought was an eternity, and there being no other patients to be seen, I returned to the same patient’s room at 1912. Someone’s belongings were still in the room but no patient. As I walked back to my workstation I mentioned to the nurse assigned to the room that the patient was not in the room and she replied, “I have not seen him either.” Still no new patients so I sat down to wait.

At 1925, still no new patients, so I went back to see the same patient and still no patient in the room. However, someone’s belongings were still in the room so I mentioned it to the nurse assigned to the room and she said, “I will overhead page him.”

Not what I wanted, as one of my pet peeves at ANY emergency department is when patients are sought out by staff and worse when they are paged overhead. The reason patients are paged overhead at this emergency department is because they might not be in the emergency department waiting area. Okay, and, what if they went home? When do you stop paging for them? What if they are unconscious somewhere in the hospital and they cannot answer the page, do you still dismiss them as if they had gone home? So what is the point of overhead paging when they could be home or unconscious in the bathroom and cannot reply to the overhead page?

With that said, I do not know why healthcare workers are compelled to seek patients out when the patients are not in the rooms they were put into. Granted, it was an hour from when the patient had signed in and when I went to see him but in that hour he was kept busy with triage, registration and being seen by the MSE provider before moved into a room. Being the only patient waiting to be seen he went straight into a room and not placed back into the waiting area. Once in the room, it was just moments from when I picked up the chart and went to the room to find the room empty. My thought is that if the patient is not in the room, other than being in the bathroom or the like, than the patient does not want to be seen. However, when I mention that, some of the staff is outraged that I would think that. So they overhead page patients three times before they annotate on the patient’s chart that the patient left without being seen.

So I too wrote each time, 1902, 1912 & 1925, on the chart that I had gone to see the patient and on the last attempt as I walked pass the nurse’s station I dropped the chart at the clerk’s desk for processing. It was not long after that the clerk asked me, “What is LWBS?” The letters I wrote on the chart under the three times I tried to see the patient. “Left without being seen,” I said.

Again, being the new kid on the block and as if being on human resource’s probation is not enough one also has to go through healthcare’s “right of passage” acceptance.

Because of those idiotology [sic] these explosive incidents with patients do nothing but cause mental anguish. Anguish that is for no reason other then the thought that the job I was hired to do would suddenly come to an end. Why? Because someone did not like that I do not smile as much as they would like, that I called someone Ma’am, that I told someone the severe symptoms they have are no more than an upper respiratory infection, that I declined to provide a school or work note or that I refuse to look for patients.

Mental anguish I did not return with after serving in war. Yet, here, in the emergency department, an overall safe place, as behavior health therapists say to their patients experiencing similar symptoms of anguish as I, I do not feel safe. Not because of the environment but because of having to walk on eggshells, as job security is not based on ability to perform the work I was hired to do but instead depended on keeping everyone happy.

Healthcare, the profession I chose decades ago to pay the bills by wanting to help others has diminished my character, my confidence and my person to nothing more than anguish.

Why? Because I am trying to stay employed, to pay the mortgage, yet I am preoccupied with the fact that others see me as the BAD person in these interactions. Not that it matters to me what others think of me, however, unfortunately, I need to keep a job.

I realize critics may not directly mock me by saying, “Poor little Jose. Everyone is picking on him.” However, it is obvious that when asked why I chose to be a nurse after a patient complains or told I lack self-awareness and insight I am being mocked. Not to mention that any opportunity to be a mentor in my chosen career, nursing, has passed. Having said that, I could care less, as this is not about a disgruntle employee as that time has long passed, but instead, this is about healthcare being taken down the wrong track.

It does not help when the best advise mentors can give is, “Just play along and you will be fine.” No! Work is not a game to me. None of it! Everything I do is in seriousness and more so with my job of helping others. To that I will add, I may not know the key to success but the key to failure is to try to please everyone!

Because of that, I will not apologize for being a NURSE, for being TOO serious, for being TOO honest, for being TOO transparent, for being TOO confident, for being TOO straightforward and I will NOT bow to exaggerated unrealistic emotional expectations! On top of that, to critics specifically, I will ALWAYS maintain solidarity with healthcare workers and NEVER side with inappropriate patients or families, whether they are abusive, manipulative, petulant, unreasonable or the CEO's daughter.

Nonetheless, getting back to the last patient, after the staff’s extraordinary effort they found the patient. Then they found me sitting at my workstation holding my face in the palms of my hands where I was contemplating how much longer before I am asked to find work somewhere else.

Not the staff’s fault, as they are doing what the administration pays them to do, but they tell me the patient was found watching a baseball game on TV, not in the emergency department waiting area but in another area of the hospital. More ironic was the fact that the patient stated he wanted to finish watching the inning, or something like that, before he came back to the emergency department.

As they told me that my face fell from my hands, my fingers moved through my hair, and my forehead slammed into the palms of my hands and from that position I said, “It does not matter to me.”

I said, “It does not matter…” because what I have learned over the years is that when I have said, “I do not care,” patients, families and others have taken those words to mean that—I did not care about…and those complaining always took the liberty to fill in the blank to their advantage. So now, although I have to think about it, I say, “It does not matter to me.”

What did matter with this incident and I shared with the MSE provider was, “Obviously this patient does not have a medical need and much less an emergent condition. Just discharge him from your point and don’t pass him to the back to take beds from others.”

Interestingly, after reminded of the incident I recall having this anecdotes as one I had listed. However, I decided to remove it, as I do not consider drug-seekers as patients but instead as addicts just looking for a fix. The only reason they are in your clinic or emergency department is so that they can justify their vice to themselves and those around them as therapeutic. Because once they have to get whatever their drug of choice is at $1 per milligram from a drug pusher on the street the addict knows they are no longer pain patients but addicts and no one wants to face that reality.

Granted, I know bad stuff happens to bad people, something I mentioned in the book and warn colleagues about and why I do not dismiss those with drug-seeking behavior. However, although I do not recall the person I do recall the incident, and this individual in particular was obviously manipulating the system and the healthcare workers trying to help him. Not only the time I DID see him but this time where I did NOT see him as well.

Nonetheless, I am surprised this list of dissatisfied customers have not cost me my job! Because from what I am told and reminded of day after day is that it’s about the customer’s experience! Although for many of us in healthcare it is nothing more than an assassination of our integrity yet it is what we allow in order to keep our job.

I did not count the number of anecdotes listed here and although listed I have no idea if they complained or not. On top of that, I cannot say if I missed any that did complain as well. What I do know is that I been asked to resign every time after seven complaints, good old lucky number seven, and although I have no idea how many were listed here and how many I missed who did complain, I know there were at least seven.

Nonetheless, knock on wood, I guess. Thanks for coming and come again. 

I AM A NURSE!

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