The Customer is NEVER Right - A Nurse Practitioner's Perspective
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I have been at the current job now for a year and not heard of a single patient complaint. Let me restate that, not heard of a single complaint of where I have been pulled to the side or into someone’s office to be told that a patient or family had complained. The clarification only because I absolutely know that patients and/or families have complained and to say otherwise would not only be a fantasy but more so wishful thinking.
 
Like for example, the child guardianship/abduction debacle. Hands down that was a complaint, especially since an administrator got a whiff of it. Yet, I have no idea where that complaint went to and I am going to leave it at that. Now, in no way am I looking for complaints either. However, with the black cloud that has followed me everywhere else that I have worked at it is reasonable for me to be a bit paranoid at the slightest mention that someone is not happy. Having said that, that paranoia not so much because someone is unhappy but more so because I know that the end is near before I am asked, once again, to resign.
 
Of course, there is always the possibility that complaints have been file against me here and the administration is just waiting for the one that breaks the camel’s back before the pile of complaints are drop in front of me. Although something that has not happened before, it is possible, thus more reason for the paranoia.
 
I realize the before mentioned all sounds like distrust as I would be elated if instead this were the one job where the administration believes I am a greater asset to the organization than a risk. Unfortunately, I landed at this job, of a significant pay cut I must add, after what I experienced at the other jobs before here. On that note, it is because of those previous experiences that it is so hard to believe that I have found an organization that appreciates me and the work I do of helping others. Having said that, although unfortunate to admit, I can ONLY hope, rather than justify, that being appreciated by the current organization is the real reason why I continue to come to work as long as they will keep me.
 
On that note, I would have to admit that for the most part, everywhere I have worked at it is the staff that makes the difference and that fortune continues at this job as well. On top of that, as I have mentioned time after time here, in this forum, and to administrators and colleagues alike that the patients here have been the most thankful of all the places I have worked at, ever, and I have worked at many. However, that gratefulness is not something I have shared with the patients here but I wonder if it is the patient’s thankfulness that has made the difference of complaint absence. But who knows.

The only two other things that I can possibly pass as possible reasons are (1) this blog that has allowed me to deflect my frustration related to the complaints that I am aware of. (2) Although a far reach, the number of work notes I have passed out with my new outlook regarding that issue. “You want a work note? One work note coming up.” Because although the request for work notes continues to irk me somehow that transformation, to just pass them out at will, has allowed me to keep my sanity. Although, preserving my sanity is not sufficient and why I also document in the chart, “Work/school absence note provided per patient’s request despite not clinically indicated.” That being my disclaimer to, more importantly, preserve my integrity. I know that sounds ridiculous but it is what helps me sleep an extra minute or two of the many restless, if not sleepless, days, I say days because I work at night, as I continued to struggle with the idiotology [sic] of catering to EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS. More thought provoking, sleep I had never lost with regard to my time in the service, to include having served during war.
 
On a separate topic, but the gist of this blog, it is unfortunate that despite the great staff I been working with for the past year that I continue to sense that “some” feel, believe, are unsure or question my commitment to help others and why I been asked, “Why did you become a nurse,” or why the following anecdotes happen…happens…happened.
 
Just before entering a patient’s room that patient’s nurse pulled me aside to tell me to “be nice”. Two simple words that cause immediate rage in me. What the HELL does that mean!?! I would ONLY have to be reminded to be nice if I had “not” been nice in the past…or ever. Nonetheless, some just feel compelled to have to make such suggestions. Unfortunately, that undue prejudice is what I have labeled as healthcare’s altered ego, junior high school, where some think they are better or can do better than you, like being more compassionate or caring than someone else.
 
In this instance, the patient I was asked to “be nice” to was in the emergency department after being physically assaulted by an intimate partner. Unknown to the nurse, not that it is the nurse’s responsibility to know, my greatest fear is not that I would miss a diagnosis or make a decision that might injure or cause death to a patient. Instead, my greatest fear is that I would return a patient to their abuser. Now, although again, it is not the nurse’s responsibility to know my fear, is it really that bad that other healthcare workers feel that I, or anyone else for that matter, needs to be coached with being “nice”? Do those healthcare workers really believe they are the authority on caring and compassion?
 
I, like most healthcare workers, have a long record of being compassionate and caring. For me that long and transparent record has never been for the purpose of setting aside a place in heaven. Instead, that long record of helping others has always been because helping others just makes sense to me. That desire to help others despite being pushed back by some and to which Mother Theresa said, “The good you do today may be forgotten tomorrow. Do good anyway.” Now, just because I do not bow or pander to exaggerated expectations it does not mean my record gets dismissed, not that I bolster about my record and much less that I have to prove it to anyone, but for critics it is well documented.
 
Having said that, I know that Mother Theresa, the epitome of compassion and caring, had her critics too. Not that I am comparing myself to Mother Theresa, but despite everything she epitomized, she too, like me, said, “People are often unreasonable and self-centered.” Yet, despite her words I cannot imagine a healthcare worker ever told Mother Theresa, “Be nice.”
 
Although, I am sure that if Mother Theresa were a healthcare worker there would be at least one healthcare worker, again junior high-school, who would have told Mother Theresa to “Be nice” just because that one healthcare worker thought he/she could be better than Mother Theresa.
 
However, to give Mother Theresa credit, when she mentioned that, “People are often unreasonable and self-centered,” she also added, “Forgive them anyway.” I, on the other hand, chose not to waste my time with those persons and move on to those who are appreciative of the work we do.
 
Again, in no way am I comparing myself to Mother Theresa as I am far from her but that distance does not diminish my caring or being compassionate towards others.
 
Now, I know critics will call me out as I have said many times that I value the input of nurses and even have said that nurses are my conscious; so then why am I upset with their advice here? To those critics, I not only value the input of nurses but I am a champion for nurses as well. However, suggesting to another healthcare worker to “Be nice” is not valuable input but condescending, just like in junior high school where kids are mean to each other for no reason. I could not care less about the words and behaviors of others, as they do not matter to me outside of work. However, at work, where I earn my living to pay the mortgage, it sets a precedent and sends the greater message that I am incapable, unless reminded by others, of being nice to patient. And if that were the case, that I need to be reminded to “Be nice”, then shouldn’t I have to be reminded to “Be nice” with every patient and than maybe, although still doubtful, the suggestion to “Be nice” would be notable input. However, that is where the pretense of others is, as I am not asked to “Be nice” with every patient but only with those others think are deserving of being nice to.
 
On the flip side, there have been times, actually many more times than the times I been told to “Be nice”, when colleagues have asked me to see certain patients. Patients, who I guess, colleagues thought did not deserve being nice to. Now that is a problem and a big problem, as the picking and choosing of those worthy over those not worthy of being nice to is known as being prejudice and that is not me as I treat everyone the same.
 
Now, if the belief is that I need to be coached into being nice just because I will not bow or pander to exaggerated expectations than shouldn’t those colleagues coach me with every patient I see? Because wouldn’t it be more appropriate that every patient be treated equally rather than some picking and choosing which patients we need to be nice to versus not. And if not, where is the fairness?
 
Although I know I have the greatest number of complaints against me, and when I say that I mean MORE than any other healthcare worker worldwide, I know others are not immune to complaints. As even the most compassionate and caring, like Mother Theresa, have critics.
 
So what do colleagues, who criticize me for not “being nice”, say when a patient or family expresses discontent with them? Likely nothing as very few colleagues are willing to push back. Yet, I do not criticize colleagues for bowing, as the cost to push back is high. Unfortunately, that is the reason healthcare will continue to be punching bags.
 
Here is a quote that objects to the all to common practice of accommodating, “The more chances you give someone the less respect they’ll start to have for you. They’ll begin to ignore the standards that you’ve set because they’ll know another chance will always be given. They’re not afraid to lose you because they know no matter what you won’t walk away. They get comfortable with depending on your forgiveness. Never let a person get comfortable disrespecting you.”—phuckyoquote.
 
For no reason do I, or would I for that matter, hold it against the nurse. However, I guess that the word is out among colleagues that I do not care and that I lack compassion. In the book I cited a nurse with saying, “Jose pisses off 80% of the patients he sees.” I also hinted in the book that those words were more likely fabricated by an employer rather than original from the nurse. However, as time passes, I am beginning to feel it may be a more common sentiment with those I work with than those I work for.
 
On that note, the following are unheard stories of patients who did not complain and which I find to be more common than not. Yet, despite their prevalence some will say the stories are bias as they are filtered through my memories. I say they are stories worth sharing because despite the storyteller’s bias the outcomes remained the same.
 
-4-year-old brought in by the parent after the child had vomited three times in the last 24-hours. The last episode was while waiting in the emergency department waiting area and had not vomited since after given a single dose of Zofran on arrival. Unfortunately, after I saw the patient and thought the patient could be discharged, the parent insisted the patient be given IV fluids. WHY!?! For no reason but I knew that opposing that demand would not be in my favor as the anecdote in the book where the parent, crying to administrators, said I had tortured their child. Why would I as the research has shown, for decades, that the best rehydration is by mouth over intravenous?

If you ask me it is nothing more than drama and even attention seeking behavior. As I would imagine a better story to tell others would be, “He was so bad they HAD to give him IV fluids. He was that sick.” But what the hell do I know? Not to mention the research shows the best hydration is by mouth but parents, and adult patients as well, are not convinced no matter what. They want an IV. It infuriates me that a child must go through such a traumatic procedure for no reason. It bothers me even more when I am NOT able to convince others despite they came to us for our expertise. Yet, somehow, when our expertise falls short of their expectations or they are not catered to it is us who were wrong.
 
Nonetheless, after some Zofran by mouth the patient was able to keep down 200ml of juice and was discharged home to the care of the one with the great idea that he needed an IV, his parent. An IV he did not need as it was the Zofran that kept the patient from vomiting and not the IV.
 
Why give the Zofran by mouth when the patient had an IV? Simple, to prove the point that the same could have been achieved without the patient suffering the physical trauma and mental anguish associated with being restrained while adult strangers stabbed a needle into a vein while his parent, who unknown to the patient was the one with such stupidity, sat in a corner. YES(!) it always bothers me when children do not have a choice but I need to keep my job. I know how pathetic that sounds to compromise one’s integrity just to keep one’s job but that is the new and improved healthcare that we have. Not to mention, the time and money wasted on exaggerated unrealistic emotional expectations.
 
–So do not tell me I do not care!
 
-28-year-old-male with cellulitis of the same leg he had a transmetatarsal resection due to osteomyelitis. This time the patient did not want to be admitted because he had work to do. I got it! He had started a new job and did not want to miss work or the risk of losing his new job. Again, got it! Except, his reason made no sense because as I discussed with the patient the infection was not going to get better on antibiotics by mouth. Not to mention, he was a diabetic and had not been taking his medications, to include insulin, because of a number of excuses he gave. On top of that, a few years earlier he had gotten septic and gone into a coma when his same foot got cellulitis last thus the resection of his foot. As if not enough, the night I saw him he was in renal failure and because of that he needed to be transferred to a facility of higher care due to we do not have nephrology at the facility I work at.
 
All that I shared with the young man, who had NOT been contributing on his behalf to take care of himself. Yet, I could not convince him it REALLY was in his best interest to be admitted, let alone be transferred. He was obviously septic; he had fever, he was tachycardic, had a leukocytosis and a remarkable bandemia. Despite all that I could not convince his invincible attitude that it was his young age that was compensating, at the moment, and it was just a matter of time before he lost that battle. Yet, despite my best attempt to look out for his best interest, as sweat beads ran down his forehead, his response was that he was doing “just fine”.
 
I do not think so, I thought and said to him, “Actually, you are not doing fine at all.” As if not enough, he then tells me the “real” reason he does not want to be admitted was because, as he said, “No one ever knows what is going on.” Really!?! “Sir, you might believe we do not know what we are doing but I will tell you this. We are here to help you. You have an infection in your leg that is not going to get better with pills. You need a more aggressive treatment that includes IV antibiotics. If not, you will lose that leg not to mention the damage to other organs due to you being septic. So although you might disagree, with regard to what is in your best interest, we do know what we are doing.”
 
Mind you, those remarks, that no one knows what they are doing, came from a patient who has not been taking care of himself. That includes, but is not limited to, not following up in the wound clinic in more than three months for the plantar ulcer on his, already, partially amputated foot, which he has no sensation secondary to diabetic neuropathy.
 
All that, because, as he said, he has “other things to do.” Oh, by the way, did I leave out he had not been taking his blood pressure medication for the past three days either? And why? Because “I forget”, he said. Really? You forgot. His blood pressure—187/107.
 
—So do not tell me I lack compassion!
 
-41-year-old female with a large abscess needs admission. It just happens she is a single mom with a 12-year-old son who happens to be present with her. When a patient is admitted besides it being a prescription for nursing care it is because the patient is not able or willing to care for themselves and they need others to care for them. In other words, patients able or willing to care for themselves do not need admission. It really is that simple. So, if unable to care for themselves, how are they going to care for a dependent child when the adult is a patient? Simple, they cannot and neither can the hospital staff.
 
As if not enough, the patient’s abscess was going to need surgical debridement. In other words, she would be under an anesthetic.
 
What’s the big deal? Others thought. Why can’t the child stay with the parent? Have people not learned from Michael Jackson’s death? People die while under anesthesia, to include while under procedure sedation. It may not be a common occurrence but what if(!) this parent were one of those unfortunate statistics and dies while under anesthesia? Then what becomes of the 12-year-old child? All because the patient did not have family or friends in town that could care for the minor and because of that some more caring and compassionate healthcare worker thought it would be innocent if the child stayed with the parent, who was now dead, in the hospital. NO! The child needs a temporary guardian while the parent is a patient in the hospital. Yet, for some reason everyone else thought I was making a mountain out of a mole. Really?
 
—So do not tell me I do not care!
 
-8-year-old with petechia only on his face, which I must add was very impressive. On that note, the differentials of that phenomenon are very limited and it just happens to include strangulation. By no means can I pin point that was the case with this child but nonetheless it is a differential which is concerning. Not to mention, I must also consider the consequences of such differential and why I discussed the case with the attending physician without revealing my concern. A conversation that was as if it came from the same brain as the first concern the attending had was strangulation and suggested I call the children’s hospital to discuss the case with one of the emergency department attending physicians there. So I did, and again, without expression of my concerns the first differential from the attending at the children’s emergency department was strangulation as well.
 
That being the common mention, it is not a differential that could be ignored even if all three of us were wrong. With my concern and the opinion of two attending physicians, one of them a pediatrician, I contacted the police to file a report and I also consulted Children Protective Services.
 
During my conversation with the police officer I expressed the parent’s chief complain, the history of present illness/injury, the findings from my physical exam, my conversation with the pediatrician and lastly my concerns. Then, after listening to what I had to say the police officer asked me, “Have you done this before?”
 
Done what before? I thought and asked the police officer, “What does that mean?”
 
“Nurses, a lot of times overreact about these issues,” the police officer said.
 
“Oh really?” Not what I said but what I thought. What I said instead was, “Would you ask that of a physician? Would you have told a physician, ‘Physicians, a lot of times overreact about these issues’?”
 
“Ah. Ah. Ah. Not what I meant,” the police officer said.
 
“Okay, so lets say that I am OVERREACTING, what is the worse harm I could cause to the child by asking someone else to investigate the possibility that a child has been harmed?” I asked the police officer.
 
The police officer simply saying, “I will go interview them.” From there we went our separate ways.
 
For those who have not read the book I will share that I have had very few, if any, positive interactions with police. Not that it matters but just being transparent.
 
On that note, I also shared with the police officer that I do healthcare and not investigate crimes and I just did not want to return a child, or anyone for that matter, to those abusing them.
 
By the way, I am always available for anyone who wants to abuse others. Come look for me—but I digress.
 
Something else I wanted to share with the police officer was, “So Mr. Police Officer, can you then please enlighten me as to why this child would have petechia covering ONLY his face? NOT to mention, I just spoke to the attending pediatrician at the local children’s hospital emergency department. That was an emergency medicine board-certified pediatrician at the children’s hospital in our nation’s sixth largest city and NOT a pediatrician who is a friend or even a cousin, for that matter, and much less not WebMD either. Yet, the pediatrician, too, listed strangulation, as the first differential diagnosis as well despite the pediatrician did not know I had already ruled out the other six differentials he mentioned.
 
Oh! But then, maybe, just maybe, the police officer was referring to the volumes of OVERREACTIONS that stem from healthcare. Like that of all the 50-year-olds who complained of chest pain and we refer them to a cardiologist, who then takes them to the cath-lab only to diagnose them with GERD. Maybe that was what the police officer was referring to when he said that nurses OVERREACT. Yet, no one ever questions that volume of patients with who we OVERREACT all the time with. Well, maybe this police officer might have, as he questioned if I was OVERREACTING about this child.
 
Really? I could only hope it was as simple as taking an abused person, child or adult, man or woman, to a cath-lab somewhere so that we could run a catheter up their groin to see if they were being abused or exploited. I truly wish it were that simple.
 
Nonetheless, after the police officer’s interview with the parent in the emergency department the officer tells me that the suspected abuser, not a suspect I cited as that is way outside of my scope but the suspect the patient’s parent cited, was a good person, goes to school, works, everyone loves him/her yada yada yada.
 
Oh, what a great person one would think. Yet, because of my lack of experience, I guess, I suggested to the police officer, “Huh? Didn’t everyone say the same thing about Ted Bundy? A law student who just happened to be good looking and charming they said.” A comment the police officer had no rebuttal to, as he kept quiet.
 
Later the Child Protective Services investigator came out and interviewed the parent in the emergency department as well. That investigator then followed them home, after the patient was discharged, to do an in-home investigation. Was that really necessary at 2 am if the suspicion were so low? But then I wouldn’t know as I am not a criminal investigator and much less a police officer.
 
Despite choosing not to know what the outcome was, as I prefer not to EVER second-guess myself and the rational as to why I do not follow up on patients, even if I OVERREACT, I would not have changed anything. To include NOT backing down after the police officer implied that I might have OVERREACTED. And if I OVERREACTED, GOOD! I am glad I OVERREACTED! Especially since I OVERREACT so often!
 
–So do not tell me I do not care!
 
Actually, Mr. Police Officer, here is the patient you should have questioned me for OVERREACTING and I would have agree with you, I OVERREACTED!
 
-66-year-old female with CAD, MI and CHF who has had left arm pain for a week. On exam I shared with the patient it is very likely her arm pain was arthritis. However, based on her history a cardiac work up was initiated by the provider who saw her chart before I got to interview and exam the patient. Having said that, I cannot say how surprised I was when her Troponin came back elevated, three times above normal. Because of that alone she had to be transferred in order to be seen by a cardiology, a service not available at the hospital I work at and I shared that with the patient.
 
Still believing it was her arthritis I unapologetically shared with the patient that I could not dismiss the elevated Troponin. “I do not take risks with patients,” I said to her and added that even if the elevated Troponin were in a patient without her comorbidities that other patient would still have to be seen by a cardiologist.
 
Without objection the patient thanked me over and over for taking care of her and looking out for her best interest to which, of course, I replied, “I take care of everyone I see, even if they push back and do not want me to take care of them.”
 
Her answer, unsolicited I might add, “You are a good person.” Which caught me by surprise but to which I replied, “Thank you. Most of us are.” Meaning, as I did not to go into detail, most on the planet are good people and it is unfortunate that the few bad people are the ones who capture everyone’s attention, that being another conversation.
 
A week later, the just-mentioned patient’s spouse was the patient and he was accompanied by her in the emergency department. At first I did not recognize her as I do not follow up on patients and as if not enough I also purge my brain after every encounter. On top of that, I do not engage family when they are present unless it is absolutely necessary. Nonetheless, she obviously remembered me as she stood up from her chair and she reached out to shake my hand as I walked into the room. Shaking my hand she said to me, “Thank you so much for taking care of me…after a few test they said [her shoulder pain] was arthritis.”
 
“I am glad to hear that. If that is okay?” I replied. She smiled and said, “It’s better than having another heart attack. Thank you so much.”
 
Again, I do not take risks with patients. Just like the 8-year-old with petechia, I-do-not-take-risks-with-patients. I do not.
 
Will I remember that patient if I saw her? Absolutely not. However, I will recall her story and whether I remember her physically or not that does not mean I discount her or others with similar history and symptoms. As I mentioned to her, “I take care of everyone I see.” And I will take care of her and those who push back again as well.
 
—So do not tell me I lack compassion.
 
-48-year-old male I have seen a number of times in the year that I been working here. And every time I have seen him he has been intoxicated and most of those times he is just looking for a place to sleep to which I always say, “This is not a hotel.” Having said that, there have been a number of times during which I have seen him when he needed medical attention of which he was not aware.
 
One of those nights he was so intoxicate all he complained of was that his joints hurt. Well, it was a cold night and likely his joints did hurt. However, that night I noticed his wrist was deformed and he whimpered on palpation. When I asked him what happened to his wrist he told me he had a ground-level fall “some days ago” but had not sought medical attention for it.
 
The x-ray revealed an impacted comminuted intraarticular fracture of his radial head and a comminuted intraarticular fracture of his distal ulna. The two were closed fractures, however, made for an unstable wrist joint that would require internal orthopedic fixation, which we did not have at our facility so he had to be transferred to a facility of higher care. Done!
 
Surprisingly, this gentleman is not homeless, as he has a place to live, but like he has told me a number of times, “I was hanging out with my boys.” So rather than stay home and drink he slips out of the home he shares with his family and goes on these drinking binges. Nonetheless, one can easily say his joints hurt because he is outside, in the cold.
 
On a different visit, he came with the same complaint, “My joints hurt.” That too was a cold night and I reminded him that the emergency department was not a hotel but also asked him if anything was different since he was in the emergency department last and he mentioned he had been at another hospital due to bleeding from esophageal varies.
 
On that note, I shared with him, “You are killing yourself. You have family to live with yet you insist on hanging out with your boys. What have your boys done for you? Nothing. Your boys are just wasting your time and you are wasting your life hanging out with them.”
 
I then did my hasty physical exam but still head to toe. I look through his scalp for injuries, I looked in his ears for blood or insects, I asked him to open his eyes while I made sure they worked, I looked in his mouth to see if he was dehydrated, I pushed on his shoulder, arms, wrist and hands to see if they hurt. His right wrist, although repaired, it was permanently deformed. I pushed on his abdomen, and it hurt everywhere, just like it has every time I have seen him, but other than that there was nothing new. I pushed on his pelvis, hips, thighs, knees, lower legs, ankles and both his feet and nothing hurt more than ordinary.
 
I then asked him to sit up, which he struggled, and I listen to his lungs and heart. Afterwards I said, “Okay, you can lay back down.” I then asked him, because of his abdominal pain and his recent esophageal bleed, “Have you been throwing up any more blood?”
 
“No,” he nodded his head.
 
“Have you seen any blood in your stool?” I asked.
 
“No,” he nodded his head.
 
“Any black stools?”
 
“Yea,” he whispered.
 
Not expecting that answer I asked him again, “Has your stool been black?”
 
“Yea,” he whispered again.
 
“Well then I have to do a rectal exam to check,” I said to him before I went to get a guaiac card for the exam.
 
Guess what? One, the stools were jet-black and tarry. And two, the guaiac was so grossly positive, the positive blue obliviated the jet-black color from the stool specimen underneath.
 
“Guess what sir? You are bleeding again and we do not have gastroenterology here so I have to transfer somewhere they do,” I said to him.
 
“I do not want to be transferred,” the patient said.
 
“I do not have a choice. Unless you want to die I have to transfer you,” I replied.
 
“But I do not want to be transferred,” he griped back.
 
“Listen to me, if you are trying to kill yourself that is your problem and I do not have a problem with that. However, if you come here it is because you want help. If you come here and I see you I am going to do a physical exam, every time. That is what I do. I make observations and I answer questions. I help others. If you do not want to be helped, DO NOT come here or to any other emergency department because that is what we do, help others. If you were not intoxicated and you did not want to be transferred you can refuse and you could leave against medical advice. However, you are intoxicated [like almost 400mg/dL] and because of that you are incapable of making appropriate decisions so I have to make that decision for you. If when you sober up. And you are capable of making appropriate decisions. And you want to leave against medical advice you should mention that to whoever is taking care of you at that time. Keep in mind; although you might not appreciate it, we are trying to help you stay on this planet. And you would have to agree, that in regard to your health, we have done more for you than you have done for yourself and a whole lot more than your boys have done for you as well. Having said that, if you do not get this taking care of you will die.”
 
He said nothing more and was transferred to an unknown outcome, because, again, I do not follow up on patients. (Note: The same patient was in the ER this week, more than a month after the last time I saw him.)
 
These patients are better known as “frequent flyers”. It does not matter to me the number of times these patients come to the emergency department, something I mentioned in the book. I will see them a hundred times a day if they show up on my shift and I will see them no different than if it were the first time I saw them. The bottom line is if their condition is not emergent they will be discharged, regardless if it is cold outside or they are intoxicated. On the other hand, and no different than any colleague, if these “frequent flyers” have an emergent condition they will be taken care of as anyone else. For me, my issues have never been with “frequent fliers”. Instead, my issues have always been with those who have EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS! “Frequent fliers” or not.
 
So do not tell us we have “compassion fatigue” as no one tires of helping others. That is classic junior high school CRAP that only suggests that we cannot hang! By attributing it to patient care healthcare administrators and pundits purposely deflect it from the real reasons we fatigue, the idiotology [sic] policies that have taken healthcare down the wrong tracks.
 
Now, those are the real reasons we tire. Those are the real reasons why so many have left our ranks. Those are the real reasons why so many warn others to think twice before a career in the most rewarding and gratifying industry, healthcare.
 
So please, do not tell us we are fatigued of helping others because even if we only had to help those who do not care for themselves or of those who will forget by tomorrow the good we did today we would still NOT fatigued of helping others. Instead, what we are so tired of, and not fatigued of but OH(!) SO(!) tired of, is the CRAP that we have to put up with to keep our jobs.
 
–So do not tell me I do not care.
 
-27-year-old female who did not look good and was toxic. Despite that she was yelling at the top of her lungs because of her pain. “Ma’am, yelling is not going to help in any way,” I said to her. “What the f*&k? I am in a lot of pain,” she fired back. “Ah, watch your mouth. I am not using that kind of language with you and you will not use it with me or anyone else here either. We are here to help you and it will be so much easier to help you if you act appropriately,” I said to her.
 
From what I was told the patient had started off on the wrong foot. The moment she walked into the emergency department she did not hit it off well and the fact that I was next to see her is never good either. Because for the most part I would have to say that those before me are the most accommodating and if I am the chosen one at the end of a bumpy road it rarely, if ever, suddenly becomes a “Kumbaya” moment. Was it the patient’s inappropriate behavior or her life style as to why she was not getting alone with others? I do NOT care and why I always caution colleagues, “Bad stuff happens to bad people too.”
 
What I did know was that the patient was septic after an elected abortion that had gone bad and wherever she had the abortion was not a place she could return to and why she was in the emergency department.
 
Nonetheless, after IV fluids, antibiotics, analgesia, antipyretics, antiemetics and an admission she was much more appropriate, appreciative and even apologetic to those helping her.
 
–So do not tell me I lack compassion
 
-41-year-old female, the impetus for this blog and the patient the nurse asked me to “Be nice” to. A patient I was seeing after her intimate partner beat her. For what reason, I DO NOT CARE(!) as there is no reason, NONE whatsoever, for anyone, ANYONE, to assault anyone else. Unless, invited to do so as I have offered some of them that when ever they have the urge to assault innocence they should come look for me. But none of them have taken me up on my offer as those who assault innocence are cowards, but that is another story.
 
Anyhow, this patient, as so many in her situation, feared for her life. And she feared so much that when I offered to notify the police for her she declined and said she would leave despite me telling her she was in a safe place.
 
Sadly, now that I write that statement, after the fact of course, it makes me pause. Is it really a safe place? After everything I know about the safety of healthcare and the obvious increase of violence directed towards healthcare workers I am not so sure she was in a safe place or that I could protect her if I needed to. This paragraph bothers me. It really does. Especially after the fact as the current concern of the lack of safety in the emergency department did not enter my mind then.
 
Nonetheless, to the nurse’s credit, although not how it came out at the time, the former was what the nurse had tried to convey that the patient did not want to file a report with the police. I get it. However, I hoped then, and hope every time that I see those assaulted that I can change their mind. As it is not only a step in the right direction but it is part of the healing process and in their best interest, as well. Having said that, if a patient declines they decline. However, in no way does that change my desire to want to help them and much less does it influence my desire to want to protect them or look out for their best interest.
 
–So do not tell me I do not care.
 
-29-year-old female who was psychotic and having a hard time with suicidal and homicidal ideations projected by auditory hallucinations. Although she was in a heighten and labile mood, one moment she was appropriate, another moment she was crying and at a different moment she was laughing, none lasted long before she was elsewhere and none were aggressive and why I thought I would let her sit while waiting for a behavior health counselor to come assess her in the current mood(s).
 
No problem! In less than an hour the assessment was made by the counselor; who found the patient not only a threat to self and others but the patient was unable to make appropriate decision thus the counselor submitted a petition for involuntary inpatient treatment.
 
Not so great! Those involuntary inpatient petitions can take days and even weeks before the patient is transferred. Fortunately, this patient was doing well.
 
Ah! Spoke to soon. It was not long after I sat that patient’s chart to the side when the patient began to make demands and behave inappropriately, prompting the sitter watching the patient to ask for security to assist with keeping the patient in the room.
 
In domino fashion, the nurse asked me to sedate the patient as the patient was escalating and could hurt herself and/or others. Of course, I have no reason to second-guess the nurse. However, before throwing a bunch of medicines at the patient I have to assess her as that was not how I had left her. As expected, the nurse was right and the patient’s behavior was escalating. Let’s see if the patient will take her medicines, which she has not taken in two-weeks and why she was psychotic, and the patient agreed to take her medicines. However, when I asked the patient to sit on the gurney while the nurse went to get the medicine the patient decided she would challenge me. And with both closed fist, palms out, above her head she stepped into my space and lowered her fist to strike me. Unfortunately, for her, she did not know those gestures never go well with me.
 
As she swung down at me I caught both her fist in my hands and was walking her back. Unfortunately, unknown to me, the security guard had entered the room and I guess the security guard thought he should grab the patient’s legs while I was walking her back. Well, that set off the patient and she tried to kick the security guard. Unknown to the patient, when I am at work I stand in solidarity with the colleagues I share the shift with and that includes security. So when the patient tried to kick the security guard my immediate reaction was not to see if the security guard was okay. Instead, my immediate reaction is to overwhelm and overpower the patient, or family, who is being inappropriate. So I scooped up the patient’s 170 lbs and forced her forehead to her knee, a wrestling move known as a “cradle”, and with the same momentum I threw her and me onto the bed while still holding the cradle until others showed up.
 
Now, while I have everyone’s attention, if a patient or family directs violence toward those I share the shift with or me I intent to overwhelm and overpower that person. Having said that, and to be clear, my intent is never to hurt them but instead to subdue that person until that person either submits or security or police show up to take over. Again, just to be clear and before I get accused of being “a MMA brawler”, my intent is to defend those I share the shift with and myself until security or police arrive. And then I just walk away as I have nothing to gain from the incident. Adding to that, and to make something else absolutely clear, if the patient or family viciously attacks me criminal charges will be filed against them, regardless if the state I find myself in defends healthcare workers or not, as so few of them do but that is another story. And charges will be filed regardless of the patient’s or the administration’s justified reason for the violence, end of story.
 
On that note, I intend to press charges against ANY administrator who attempts to conceal the incident or interfere with me filing said charges.
 
Anyhow, moments later, at the alert of the sitter, additional staff came into the room. Among them was the patient’s nurse with the patient’s p.o. medication, which the patient still agreed to take while we continued to hold her down.
 
Unsure if the patient had swallowed the pill I asked her to open her mouth to ensure she had swallowed it. Well, I am sure others have already figured out what happened next and I should have known better as this was not a community patient who I was certifying had swallowed her TB medicines. Instead, this was a psychotic patient who was very agitated that we were holding her down.
 
Surprisingly, the patient did open her mouth and I could see she had swallowed the pill. At the same moment I realized, and I am sure others reading this too, I had made a mistake as the patient closed her mouth only to spit at me. Except, to the amazement of others, I was one nanosecond ahead of her and as she spit towards me I yanked my head back and turned to the left. The spit completely missing me but sprayed everyone behind me and they were all upset.
 
After that I asked the nursing supervisor, who was helping to hold the patient’s torso, if he could find a head net to put over the patient’s face to keep her from spitting on others. I also asked the charge nurse to grab the 4-point restraints and asked the patient’s nurse to give the patient Haldol 5mg, Benadryl 50mg and Ativan 2mg, all IM.
 
Once restrained and given her medications the patient was left with the sitter. To my surprise, 30-minutes later, the patient was still spitting into the head net that covered her face and she was still trashing and fighting the restraints. So I ordered another Haldol 5mg IM and only then did the patient sleep for the last 5-hours of the shift. At the end of my shift I transferred the care to the oncoming provider.
 
Twelve-hours later, I returned to work and the patient’s care was transferred back to me. Within the first hour at work I was able to visit the patient who seemed to be appropriate but she continued to hear voices that were edging her on to kill herself and others.
 
From just outside the door to her room we talked and she specifically asked why I picked her up and threw her in the bed and had her tied down, the night before. My answer, “You were being inappropriate and you were a danger to yourself and others.”
 
She then asked, “Is that going to happen again?”
 
“As long as you are appropriate and cooperative it will not happen again. But the moment you become inappropriate or a danger to yourself or others it will happen without hesitation. So if you feel like that again, getting agitated, you need to let us know so that I can get you some medicine,” I said to her and she agreed.
 
Some two-hours later, the patient’s nurse mentioned the patient was becoming agitated so I went to check up on her and she was. “Ma’am, sit on the bed,” I asked her and she did. I then said to the patient, “I asked the nurse to bring you some medicine that will help you settle down and help you sleep. Do you want to take it as a pill or do you want it as a shot?”
 
“As a shot,” she said. Done and she slept the rest of the shift.
 
The next night the same, another series of shots and she slept the rest of the shift. By the forth night she was asking to take the medicine by mouth and she would sleep the rest of the shift. By the fifth night she looked happier and was no longer having homicidal thoughts but continued to have suicidal ideations and she still awaited admission somewhere.
 
For those who do not know, it is very common for these psychiatric patient’s to spend days, if not weeks, in emergency departments across the nation while they wait for an inpatient behavioral health bed to become available.
 
On the fifth morning, at the end of my shift, I transferred the patient’s care only to find her still there when I returned four nights later, except her care had been transferred to the attending who had been caring for her for the days I was gone. Surprisingly, the patient remembered me and as I walked past the new room she was in her smile caught my attention. When I looked over she waved at me so I turned around and went to her door, with the sitter sitting outside, the patient said, “Hi.”
 
And I asked her, “How are you doing?”
 
“Better,” she replied with a big smile on her now radiating face.
 
“I am glad,” I replied.
 
It was the same for two more nights, except every night she looked better, happier and her smile was even bigger than the night before.
 
After the third night in a row, the outgoing provider reported the patient was reevaluated by Behavior Health and was found to no longer be a threat to herself or others and was discharged to follow up with her Behavior Health provider. Good for her.
 
I do not hold patients in psychotic crisis accountable for their actions, as they do not pose appropriate judgment or competence. Again, my intent is to help others, especially those most vulnerable.
 
—So do not tell me I lack compassion.
 
-47-year-old female who had a LOTTTT of drama and when I decline to cater to her drama she must have taken noticed and fired back, “We are not going to get along…get me someone else who is more caring…”
 
Really? More caring because you sprained your ankle, please!!! Not what I said but that was what I wanted to say. Instead, I asked the patient directly, “Ma’am, are you drunk or on drugs?” A question that neither startled the patient or the family with her as if the behavior were her regular every day dramatic behavior.
 
And although her injured ankle was no different than the uninjured ankle the patient refused to stand on the injured ankle stating she could not bear weight. That, despite I did not appreciate any bone deformities, tenderness or crepitus when I palpated while the patient was distracted and those findings, or lack thereof, were how I documented in the chart. Not to mention I had to document extra as I had to justify the unnecessary treatment. Because although the findings were unremarkable I could not get her to bear weight and she refused to attempt to bear weight so I put her in an orthopedic boot and discharged her to follow up with orthopedics in the next 5-7 days if her pain had not improved.
 
Guess what? After all the drama, the patient apologized for her, as she said, “inappropriate behavior…I was just in a lot of pain.”
 
“You do not need to apologize Ma’am as my intent is not to get you to apologize. My intent, and that of those here, is to help and we can do that much easier when you are appropriate. I am glad you are feeling better,” is what I said.
 
However, I found it most interesting that she was feeling much better after getting Ibuprofen 600mg less than 30-minutes earlier. So I shared with her that if she done the same, taken ibuprofen prior to coming in she may not have to come to the emergency department to begin with. She agreed.
 
That aside, I did not know that besides being an anti-inflammatory analgesic that Ibuprofen was even better for drama-titis. Who knew?
 
—So just because I do not let others walk all over me does not mean I do not care or that I lack compassion.
 
Having said that, I get it. I understand. And just so the world knows, I am on the side of every one of these patients, regardless if they complain or not, or are appreciative or not. I want to help them. I realize that sounds cheesy. I also realize it does not fit what others think of me. However, I am not bothered by what others think of me. I am me! And although that might not be what others want me to be or not to be I know my desire is to help others. However, that desire does NOT grant anyone power over me and much less should it embolden any of them to believe they can walk all over me. Those who allow patients or families to do so under the pretense that healthcare worker are their to serve patients only set a bad precedent for patients who believe healthcare workers are punching bags. NO! We are NOT anyone’s punching bag. Not of patients. Not of families. NOT of administrators either.
 
On that note:
 
I wish I could convince your parent that you do not need to be held down and stabbed just so that you can get intravenous fluids when you can so easily take fluids by mouth. But your parent’s mind is already made up. And whether she read it online or heard it from her neighbor you are going to get an IV as I cannot convince her otherwise. By the way mom, just so you know, cranberry juice does not cure urinary tract infections either. That study was debunked decades ago.
 
I wish that you would believe me that I do not want you to lose your leg. I realize you do not think we know what we are doing but somewhere you must believe so because why else would you come back for us to help you. But then maybe, just maybe, you have realized that we have done more for you than you have done for yourself.
 
I get it. You are an adult and will make bad decisions. And between you and I, only you will have to live with your bad decisions. I just wish you thought of your children first.
 
I understand that it seems like an OVERREACTION and even an inconvenience. However, you brought your child to me and I just want to make sure that he is safe, that’s all. I would do the same for you, mom, and for you too, Mr. Police Officer, if you were the patient. So why do you question me when I am looking after the most vulnerable of us. I could only wish those abused knew that I was no their side and that if they made the simplest attempt to let me know that they needed a hand I would match their courage to fight their evil.
 
I did OVERREACT but it was in your best interest. Imagine if I was wrong and it wasn’t arthritis and you were having a cardiac event. In that sense, sometimes being wrong is a good thing. I am not sharing this with you because you doubted me. I am sharing it because some police officer might question me as to if I had done this before.
 
I know you are here to sleep but this is not a hotel and every time you come I will not take you for granted nor will I blow you off. And although I know about you, as I have seen you a number of times, every time you come I am going to see you as if I had never seen you before and treat you like I would treat every patient I see and that includes me doing an assessment. On top of that, I cannot, and will not, apologize for looking out in your best interest. Having said that, if I do not find anything, I am going to discharge you back outside as I have so many times before, regardless how cold, figurative or literal, you or others might think that is.
 
I simply pick up the next chart in the rack and in that sense I have no control if I pick up yours. Having said that, I know that regardless who picks up your chart you medical condition will be treated appropriately. Regardless as well, we know that bad things happen to bad people too. However, just because you talk to others like that on the street it does not mean you will talk to me, or anyone I share the shift with, in that manner, even if you are septic or in pain.
 
I cannot tell you how bad I want you to get you out of your abusive relationship. On top of that, I also want to tell you that none of us need a partner to navigate through life but that is not my place. Having said that, if you insist on a partner, and I understand, you do not deserve to be abused in any manner by anyone and neither does anyone else.
 
Of all the patients we see in healthcare you are the most feared, as psychiatric patients you are the most volatile, the most dangerous and the most violent. Yet, you are the most vulnerable of all. Because of the latter, I do not hold patients in psychotic crisis accountable for their actions, as they do not possess appropriate judgment or competence. On the other hand, that is not a pass to those who do possess appropriate judgment and competence yet viciously attack me. To them, regardless if patient or family, criminal charges will be filed against you and that is regardless if the state defends healthcare workers or not and regardless what the patient’s or the administration’s justified reason for the violence was. On top of that, although it should be to no one’s surprise, I will press charges against ANY administrator who attempts cover up, interferes or aid and assists anyone who viciously attacks me. I would hope other healthcare workers held the same position.
 
Lastly, I know you might be overwhelmed because of illness, injury, uncertainty, pain, fear, powerlessness or whatever else troubles you. But your sprained ankle is not the end of the world. Actually, even if you amputated your leg or you had to have ten feet of colon removed due to cancer it still would not be the end of the world, as you are still alive. Regardless, neither gives you a pass to be inapt with those trying to help you and that is regardless if you are intoxicated or not. As none of us are your punching bags even when you are scared. Now, if being alive with a sprain ankle is not your desire, then guess what? As long as you are an adult with appropriate decision-making capability and competent than you know that stepping off the planet is not a difficult task. Otherwise let us do what we do best, help others.
 
After all that, please, just because I do not let others walk all over me, DO NOT tell me to “Be nice” and much less assume that I do not care or lack compassion.
 
Having said that, although none of those above expressed dissatisfaction, I know the ones below did, if not to administrators at least to me or by their actions.
 
-45-year-old female who when asked, “What brings you to the emergency department?” Unleashes a barrage of medical complaints, Headache…no wait…a bump on my eye…no wait…dizziness…no wait…a bump on my eye. None of which I was impressed with and much less was I impressed with her laissez-faire way of presenting her medical complain. Not that there is a manner in presenting medical complaints but this patient acted as if it were a game as she and her family laughed about her flip-flopping between her chief complaints. This was not a child either it was a 45-year-old adult goofing-off as if it a joke.
 
Of course, I have to interrupt, “Ma’am, what was the one thing that made you come to the emergency department tonight?” Otherwise, who knows how long this circus would have gone on?
 
The patient firing back, “Are you a police officer? Because I feel like this is an interrogation.”
 
“No Ma’am, I am not a police officer.” If she only knew how far fetched it is for me to be a police officer or the law in any manner but that is another story. However, I did feel like asking if she was hiding something but instead finished my answer with, “I am here to help you.”
 
Although those words were not rehearsed now that I have written and read them I find the sequence somewhat comical—but I digress.
 
The patient fired back and I doubt she noticed the sequence of the words as she just said, “You don’t look like you want to help me. I am going to go somewhere else where they will help me.”
 
“Okay,” I said and walked out of the room and grabbed the next patient’s chart and went to see that person who was very appreciative that I was able to help.
 
-28-year-old female whose medical complaint was the so common yet so vague, “I am bleeding from down there.”
 
And to which I just as often always ask, “Down where?” This patient was having vaginal bleeding in the first trimester of her first pregnancy. Because of that some will comment that my question as to where the bleeding was coming from was insensitive and I might agree. However, one, I cannot document in the chart “bleeding down there”, two, if I could document such ambiguity there is a lot down there to be bleeding from and each is a different diagnosis and treatment plan. However, women are not alone in this ambiguity. Men say the same thing, “I am bleeding down there.” “Okay, down where?” I ask. Now, is it still insensitive when I ask men the same thing? Because they too are embarrassed, they say.
 
Not to mention, when I ask patients if they are sexually active I do not leave it as a yes or no question as sexual preference could make a significant difference in the treatment of the same diagnosis and why I ask. Believe me, I could not care less as to who or what you are dating or which witch is which.
 
The same goes as to where you are bleeding from. I get! You are embarrassed to have to share with others that you are bleeding. Wait until I start asking you why you are bleeding, especially if you are bleeding from down there.
 
Not to mention, I am going to ask you in front of your family and friends, as it was you who thought it was a great idea to have them join you in the room knowing why you were there. If you are so embarrassed to share with a stranger who could not care less and likely you will never run into again, why did you think you could share the same in front of family and friends? As I am sure you must have known I was going to ask you those embarrassing questions.
 
On that note, I truly could not care less where down there you are bleeding from or why. But I need to know for the purpose of assessment, differential diagnoses, diagnoses and treatment plan. Otherwise, what you do down there or anywhere else for that matter is no business of mine.
 
I understand! Patients do not see it as we do. Fine. But if so than patients must think we share their stories with everyone. And if they think that then why do they come to us with their medical problems? Simple. Because they know we will help them and most significant to them because they know we will not share their stories with others, that’s why. So I do not for one moment believe the naïvetés or the sudden onset of embarrassment.
 
Anyhow, prior to me going to see the patient I was told by the off-going physician, after someone mentioned that the patient was back, that the patient had already been seen and was diagnosed with a fetal demise and discharged home some four hours prior.
 
After getting past the initial, down there as to where the bleeding was coming from, the patient mentioned that, “Nothing had really changed.” Essentially the patient came in because she kept bleeding although not more and not less but the same as before. After what the patient shared with me we had an extensive discussion regarding the findings, expectations and why she needed to return to the emergency department. The same talk I have with these patients when it is I who bears their bad news.
 
Knowing how significant a fetal demise is I make the effort of sharing with these patients that the results was not any one thing that any one individual did. I then reinforce that by stating that a female egg and a male sperm come together only to divide at absolutely incredible speeds and against incredible odds to make a viable fetus. Unfortunately, sometimes that process gets disrupted somewhere thus a fetal demise. However, I again make the point that it was no one person’s fault in any manner or at any time.
 
However, although this patient did not mention it I could tell she was having a hard time coping with the idea that she had lost her pregnancy. And worse, that she had to carry a dead fetus inside of her until she passed it. I get it. And, believe me, I feel your pain and I feel bad for you. I wish somehow I could help you keep your pregnancy but there is absolutely nothing I can do. I am on your side and I always feel bad when I am the bearer of such bad news, “You have a fetal demise.” But there is nothing I or anyone else for that matter can do. I know. I know. Some would say I can hold your hand and maybe even hold you in my arms and I do not mention that as mocking but that is not me. On that note, not only do I believe but I am sure that the last thing you want from me right now is for me to be pretentious and insincere with you.
 
Nonetheless, when I initially walked in the room the patient was already in a gown and after our extensive discussion I asked her to wait until I found a chaperone in order to do a pelvic exam. Surprisingly, when I came back to the room the patient had changed back into her clothes and stated that I had made her feel stupid and she was sorry she was the inconvenience before she walked out. I was shocked as my intent was never to have her apologize and much less for her to feel stupid and as I tried to share that with her but instead she said, “Leave me alone.” So I did and she walked out.
 
-23-year-old female with a headache for five days told me she had come to the emergency department, “To get something stronger…” because what she had been taking from over-the-counter “…was not working.”
 
Again, I am a simple person and not a smart-ass, although some might disagree with the latter, but I really am a simple person. Anyhow, just like I do not know, or assume, what is meant by “bleeding down there” I do not know, or assume, what is meant by “something stronger”.
 
The exception would be if you walked in with a closed jar of Ragu spaghetti sauce, which is always a pain in the ass to open. Then, and only then, as you passed me the jar and you said, “I need something stronger” will I understand, or assume, what you mean by needing “something stronger”. Other than that I have no idea what is meant by “something stronger” and much less when patients ask for “something to knock me out”. Because although I might be able to knock you out it is very likely I will go to jail and I am sure that is not what was meant.
 
Anyhow, as those following these blogs might have already speculated, my reply never goes well. “What does that mean by ‘something stronger?’” I asked.
 
“I want to see someone else,” the patient’s parent fired back.
 
What? My head snapping back. Where did you come from and why are you in this conversation? I must be having a nightmare or maybe something I ate is causing me to have a nightmare. I thought. Nonetheless, after recovering from that ambush I said, “Ah, no. You are seeing me.” Not to mention I just walked into the room and the parent, of an adult patient, not the patient mind you, but the parent, again, the parent of an adult patient already wants to see someone else.
 
“I know my rights and I am entitled to a second opinion,” the parent of the 23-year-old patient injected. Again, yes, the parent, of a 23-year-old said, “I know my rights…” What rights? The parent is not the patient. The patient is the patient. I do not have a problem with the parent wanting to be the patient’s advocate, although this patient was more than capable of caring for herself. But if you are going to advocate for someone the least an advocate can do is advocate for the person they are advocating for and not for themselves by saying, “I know my right…” but you are not the patient.
 
Anyhow, my rehearsed answer to that being, which no one likes, “You are right. You are ENTITLED to a second opinion. HOWEVER, that second opinion is not from another emergency department provider or until you get what you want. You get a second opinion by following up with your primary care provider or at another facility.” Yeah, it never goes well.
 
Anyhow, after that dust settles the parent mentions for the patient, “She has not eaten or slept in five days either.” Okay, let’s go down that road as well, although I am not impressed with the patient’s presentation as she does not look ill and much less toxic or lacking in sleep or starved, although a bit difficult to assess under her well applied facial make-up.
 
Anyhow, so I asked, “So in the five days that you have had this headache, not eaten and not slept have you gotten medical attention before today?”
 
“No,” the patient and parent said. Oh, now I am working in an echo chamber. Huh? How annoying.
 
“So if you have not sought medical attention before today. What was different today?” I asked.
 
“I thought it would get better,” the patient said. Oh, the all to common “I thought it would get better” answer. Interesting. As that all to common answer varies from after a few days to a few years. Nonetheless, it is a common answer. It is hard to believe its not an original answer.
 
However, what I wanted to ask further was, “What part did you think would get better, the headache, the lack of appetite or the insomnia?” But instead I held off knowing it did not matter.
 
After completing the history of present illness and a physical exam I mentioned a treatment plan, which included a steroid but the patient declined and agreed to other medicines. However, despite that the parent seemed apprehensive about the whole plan she did not object, more to come from that I know.
 
Okay, time for discharge, again, I was neither impressed nor convinced with the patient’s presentation. Having said that, and as mentioned, I was expecting more to come and at discharge the parent pushed back. “She is not better,” the parent injected, despite I was not speaking with her but nonetheless she added, again, “I want to see someone else. I know my rights.” Really? I thought we been through that already.
 
The patient adding, “You did not give me a steroid!”
 
What? I am being tag-teamed. No problem. I got this. Don’t get tangled up with either one of them and just keep blocking until you can get one clean shot. Got it. “You declined the steroid when I offered it,” I replied. Not that I thought she needed a steroid but as an olive branch I offered it at the beginning and she declined it and now she wants it. Grrrr!
 
I know critics reading this will rally behind the patient as well. Now I am being triple-teamed. “Holy cow hooves,” as Robin would say. I think. But to critics, the absence of a steroid was not the issue not to mention it was declined when offered initially. Nonetheless I said, “Okay. I can add a steroid.” Barely getting the words out of my mouth, “One steroid coming up.”
 
And getting out of the room as I fought the opposing forces the patient fired back, “I don’t want it now!”
 
What? Almost like stopping a vinyl record by lay your hand on it everything came to a screeching halt. So, let me get this straight, you call me out on the steroid, which I agreed to and even told you and your parent that both of you were right although not really. Yet, because I did not fall to my knees to beg for forgiveness after a careless moment now that I offer it you do not want it. Is there a camera somewhere?
 
“I want to see someone else,” now the patient joined the campaign of recruiting the attending to get involve. Interestingly, the parent knew the attending by name and the parent knew that the attending was present in the emergency department as well.
 
“I am going to discharge you and when you follow up you can see someone else and get your second opinion then,” I said. By discharge I meant both of them, the patient and the parent who wanted to be the patient.
 
Moments, wait, not even moments, nanoseconds later, the patient’s nurse asked me if the attending could see the patient and I said, “There is no reason why the attending needs to get involved with a patient that has been rightfully discharged. Now, if you thought I was discharging the patient inappropriately then absolutely you should object but that is not the case here.” Now, I get the nurse’s advocacy and even knew the nurse was on my side and that she was only trying to keep her job. So I do not blame the nurse for being an advocate and most definite not for trying to keep her job.
 
Unfortunately, the nurse, again, trying to keep her job asked the charge nurse to intervene and so the charge nurse asked me the same, “Would you mind if [the attending] saw the patient?”
 
“I do mind,” I said to the charge nurse as well and added some other words. However, it all fell on death [sic] ears as no one listened or cared as to what I had said and the charge nurse asked the attending to get involved anyway.
 
The attending later sharing with me, and as a professional I listen but shared with the attending it was not my place to question the attending’s practice, but a steroid was given. A sleep aid was also dispensed for the patient despite she had a refill for such in the pharmacy, as she had a history of insomnia, yet she had never accessed the sleep aid during the hours that the outpatient pharmacy was open, 8am-10pm, that is 14-hours, 7-days a week. Yet, somehow, the patient had not found enough time in the last five days of her insomnia to stop by the pharmacy to pick up her refills for both her insomnia and migraine medicines.
 
Not to mention, after five days of headache and insomnia, of which likely one let to the other, the patient had not sought medical attention, despite having a PCP. And when I mentioned such, not seeking medical attention before I saw her, the patient fired back that I had not asked, although for my practice it is common I ask patients if they had sought medical attention before I saw them. And that is the case even if the illness or injury were a minute old, I still ask.
 
I did ask because I recall both the patient and the parent said, “No.” And I thought they were annoying as an echo chamber.
 
So now I am told, that during that prior medical attention the patient was given “something stronger” and somehow in five days whatever that was it was already gone. Huh?
 
Anyhow, after the steroid everything was calm. But I offered a steroid too and it was declined before it was mentioned that I had not offered and declined again after I offered it a second time. I guess the adage is that “The third time is a charm.” But what the hell do I know as I do not agree with adages, especially the one that states that “The customer is always right”.
 
Again, somehow I got it wrong or I do not listen as patients tell me. But I do listen. I listen so intensely I can recall the entire interaction, almost word for word days later. So I do listen. Some of them are so fascinating that I write them down. Not so that I do not forget but in hopes that others will read them. So then what is it? What is it that I keep missing?
 
Afterwards, long after the dust had settled, the attending mentioned to me that the patient’s parent had asked if I had been in the military, as if that mattered. Not to mention, the charge nurse served in the military too, yet, no one questions him on that. Nonetheless, the attending share with the patient’s parent that I had serviced in the military and I do not have a problem with that as I am proud of my service, and the men and women before me and those who have followed.
 
However, I thought I would share with the attending an unrelated story that a different charge nurse had mentioned to me some weeks ago. That was that someone called the emergency department and asked, “Is that Mexican PA [Physician Assistant] there tonight?” Meaning me, I guess, although I am neither, not Mexican and not a PA. Anyhow, I mentioned to the attending, “Next time they call they will ask, ‘Is that MILITANT Mexican PA there?’”
 
Great! Because although I was in the military so are a number of others working here. Yet, that I know, they are not asked or asked of others if they were in the service.
 
On that note, it is not the first nor will it be the last time I been or will be asked if I was in the military but I do not believe that is neither here or there. Having said that, I been asked by many about my military service, to include by those who were appreciative of the care I provided them. Some of them even have shared with me that they or a relative was or is in the military and some have thanked me for my service. Not that it matters to me but yes I was in the military. Having said that, my time in the service is not something I come out and share. However, neither is it something I hide from as I am very proud of my service and even more proud of those I served with, those who came before me and those who went after me, as there is NO GREATER WORK FORCE than the men and women of our armed forces. NONE! Not even healthcare workers although they are a close second-place.
 
After all that I have list here to show that I care and that I am compassionate I must add that after all these years in healthcare, since 1983, its still bothers me when I have to share with a patient they have a mass in their brain, in their lung, or anywhere else. That they are having a stroke or a fetal demise. That they will never use their dominant hand again. That they have bacterial meningitis or a bleed in their brain. That I am not sad but angry that they are in an abusive relationship whether a child, an adult or an elderly. And that list of those bothersome diagnoses goes on and on and on.
 
I DO care and I AM compassionate and those are not just my words as many patients and their families have mentioned the same and so have nurses. Yet, despite those unsolicited remarks some healthcare workers still feel compelled to want to coach me to “Be nice”. When I really do not need to be told to “Be nice” as I have a long history of caring and being compassionate. However, I understand the worries of colleagues since I do not cater to exaggerated unrealistic emotional expectations as most of them, if not all of them, do. If for any reason, just to keep their jobs. Yet, I do not fault them for that. Despite I refuse to compromise my integrity and much less let anyone walk all over me. However, that does not mean I am superior to them it only means that I am not inferior to anyone. But to those who think I am inferior when it comes to caring or being compassionate I share this anonymous quote with them,
 
“My brain has no heart. My heart has no brain. So when I speak my mind I seem heartless and when I do from my heart it seems thoughtless.”

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