Another HUGE melt down, this time, a
35 year-old female with dental pain and the enabling administration.
The patient’s medical complaint was
a long convoluted history of dental pain for more than a month and why she was
in the emergency department versus seeing a dentist, blah, blah, blah, blah,
blah. On exam, not that it mattered, because as mentioned many times, over and
over and over, these dissatisfaction complaints have nothing to do with
healthcare but everything to do with EXAGGERATED UNREALISTIC EMOTIONAL
EXPECTATIONS. Nonetheless, the physical exam revealed a number of teeth missing
and the rest of them had cavities, erosions, fractures and/or all of the above.
Overall, just very poor dental hygiene, to critics, that is NOT being
judgmental but a diagnosis and even more reason why the medical complaint was
not an emergency, not that dental pain is an emergency ever.
“Here are your discharge
instructions,” I said to the patient, which included follow up with a dentist
and Pen VK (antibiotic).
“What am I getting for pain?” the
“A dental block, which will last 2-4
hours, and also take ibuprofen or naproxen as needed for the pain,” I said,
which she had agreed to when I saw her initially. However, by the time I put
her discharge together, gathered the necessary equipment for a dental block and
returned to perform the dental block and discharge her the patient had changed
“Are you kidding me?” the patient
“Ah, no,” I answered. Did I mention
the patient was crying the entire time about how bad the pain was during the
history of present illness, review of systems, physical exam and the discussion
of treatment, follow up and why to return to the emergency department? She was.
And maybe that was why she agreed to the dental block initially as I doubt she
did not hear me mention the dental block. Anyhow, then I suddenly had her
attention as her crying had come to a sudden halt. However, it seemed, if not
obvious, that she had not heard anything I had said. Although I believe it was
selective listening, as I was not convinced her lack of hearing my instructions
was because she had cried the entire time when I initially saw her. As I found
it ironic that when she did not hear what she sought all the crying stopped.
“I want to see someone else who is
going to give me something for my pain,” she yelled, again, no longer crying.
“Sure you can. You can see a
dentist. Or, you can check in again,” I replied.
“I want to see someone NOW(!) who is
going to give me something for my pain,” she yelled back, again, no longer
“I am going to do a dental block to
take of your pain away right now. That will help with the pain and will last
for 2-4 hours. Then take acetaminophen, ibuprofen or naproxen, as needed, for
the pain. Because what is going to help your dental infection are antibiotics
and not pain medicine,” I added.
“I know my patient rights. I want to
see someone else,” she yelled back.
“I agree. You need to see a dentist.
Or, you can check back in after I discharge you,” I said.
“NO!” she yelled at the top of her
lungs. “I want to see someone who is going to give me pain medicine NOW!” she
yelled at the top of her lungs some more.
“No ma’am. That is not how any of
this works. You are discharged and you need to follow up with a dentist or you
can check back into the emergency department,” I said.
“NNNOOOO!!!” she continued to yell
at the top of her lungs and I walked away.
In the past, when patients asked for
another provider or “a second opinion”, as their patient rights dictate, I
would tell them that was what the follow up was for, to make sure they were
doing better and/or a second opinion. Sadly, healthcare administrators did not
like my answer stating I had misunderstood the patient’s request at that moment
as it was a customer service issue and not about follow up or about “a second
opinion”. Oh, really? Sounds like placating and NOT healthcare to me.
Therefore, in order to keep my job, I decided not to get involved with patients
seeing some else or a “second opinion” at those moments. Consequently, when a
patient says they want to be seen by someone else I just tell them to go check
in again. It bottlenecks the already overcrowded healthcare system, but again,
customer satisfaction is NOT about healthcare and instead solely about customer
retention and profits. Not to mention, it is not fair to add to other
providers’ census JUST because a patient did NOT get what they wanted. So, if
administrators do not care about overwhelmed systems then sending one more to
the waiting area to check in, again, will not matter.
At the nurse’s station I asked the
clerk to call security to have the patient escorted out. Oh. Did I mention it
was 5:30am and the dental clinic on campus opened at 7:00am?
Yes, every weekday, the dental
clinic takes the first 20 patients as walk-ins and the line starts to form at
about 6:00am. Did I also mention this dental pain with the long convoluted
history had been going on for more than a month? Yes, more than a month. And,
and, the unconvincing part of the physical exam was that when the patient was
distracted the dental and intraoral exam was unremarkable other than poor
dental hygiene and multiple chronic dental issues but nothing that looked
acute. Yet, I had to fix it now and why I offered her a dental block. But
Of course the charge nurse then got
involved after all of the screaming down the hall. Unfortunately, the charge
nurse wanted to point out that the patient had an opioid contract. Although I
understand the administrative “position” of opioid contracts and I know the
charge nurse was on my side I shared with the charge nurse, “It does not matter
to me if the patient has an opioid contract or not. She [patient] does not need
opioids for her dental pain. And, even if she didn’t have an opioid contract
she still does not need opioids.”
“But if she has an opioid contract
we can tell her we are not supposed to give her opioids,” the charge nurse
“I understand,” I said, “but the
issue is not that I am ‘not supposed to give her opioids’ because of her
so-called contract. The issue is she does not need opioids for dental pain.
Thus not that I am ‘not supposed to give her opioids’ but that I am NOT going
to give her opioids. Not to mention, what would be your argument then if she
did not have an opioid contract and she insisted on opioids when I cannot find
reason to prescribe them? Whether her or anyone else.”
That said, again, knowing the charge
nurse was on my side, although not what I was looking for as when these
incidents occur it is not the moment to seek out companions and why I always
take full ownership of these moments and try not to involve others. I also knew
the charge nurse was not suggesting that opioids are ONLY for patients without
opioid contracts. With that said, I do NOT entertain opioid contracts. DO NOT.
DO NOT. DO NOT. And I do not for a number of reasons but here are a few:
-Providers create opioid contracts
because they are incapable of telling patients, NO! That is not I. I do not and
will not hide behind opioid contracts to tell patients no. The answer is no not
because you have an opioid contract thus I “cannot” prescribe them to you. The
answer is no because I, me, I, do NOT find a reason to prescribe you an opioid.
Of course, some will say why not pick your battles. This being a battle someone
else has already battled for you and all you have to do is point to the pain
contract as to the reason why you “cannot” prescribe them opioids. No, that is
not I. When I say NO it is because I said NO and not because your mother said
NO. I take ownership of my decisions rather let others do that for me.
-Administrators support opioid
contracts so those patients can be written off as problematic without affecting
the organization’s satisfaction scores if the patient complains. That is not I.
Not to mention, bad stuff happens to bad people too. Even a drug-seeking
patient may have a condition in which they may need a narcotic temporarily. Is
it still denied because of their pain contract? Pain contracts are nothing
about doing the right thing but instead are a slippery slope.
-The ONLY thing opioid contracts do
is LABEL people. My narcotic prescribing habits are limited and why I NEVER get
caught up in those issues and NEVER have reason to look up patients in
prescription banks. How is that possible? NEVER have I seen a drug-seeking
patient whose pain complaint was for anything I would consider an opioid for,
like a fracture. Instead, drug-seeking patients, more common than not, have
medical complaints for which I do NOT prescribe opioids, like headaches, dental
pain, abdominal pain or musculoskeletal and joint pain being the most common. I
do NOT prescribe narcotics for any of those thus I never have those issues with
drug-seeking patients. Drug-seeking patients might get upset but I do not get
caught up in the drama of having to look up patients in prescription banks to
influence me on whether or not to prescribe narcotics.
Those being a few of my reasons as
to why I shared with the charge nurse, “It does not matter to me if she
[patient] has an opioid contract or not she is discharged.”
The charge nurse, again, who I know
was on my side, went to inform the patient of her [patient] disposition.
However, now security, with their impotent conflict resolution and aggression management
policies, had become
the patient’s shining armor advocate telling the charge nurse the patient
“only” wants to be seen by someone else. The charge nurse then comes and
repeats the patient’s request to me.
“I know already. She told me. And
why I told her to go check in, either with the dentist or in the emergency
department again,” is what I shared with the charge nurse. Unfortunately, by then
I had an agitated tone as security got involved in what is not in their job
description, to undermine the nursing and/or medical staff.
However, to everyone’s disbelief the
patient does not really “only” want to be seen by someone else. Instead, the
patient “only” wants what she wants and who she sees for that does not matter
at all to her. And to get what she wants the patient is manipulative and
because her strategy did not convince me now she is laying it on, and laying it
on thick, I must add, to anyone that will listen. Because, to the patient, it
does not matter if it were the security guard who gave her narcotic or
housekeeping for that matter, as either would suffice the patient’s drug-seeking
behavior if either were possible. On that note, maybe I should have given
security the patient’s chart so that security could evaluate, diagnose, treat
and disposition the patient. As if that was all the patient really wanted, to
“only” be seen by someone else. What a missed opportunity?
Because if so that this patients
“only” wanted to see someone else I would be willing to prove my point—that
they are not interested in seeing anyone for that matter and instead just want
what they want and who they get it from do NOT matter to them. To prove that
point I would put a bowl of opioids in the waiting area, along with a stack of work
absence notes (the notes being for a different complaining demographic—but that
is another story), from where those seeking those items could just grab a fistful
and go about their business without seeing anyone as it would keep them from bottlenecking
the healthcare system. Because if those complaining, or better yet, yelling, drug-seeking
patients wanted to be seen by someone, anyone, not a single opioid would be
missing from where they were placed.
And by the way, to critics, drug seeking
behavior is an actual ICD-10 diagnosis and not about being “quick to judge” or
judgmental. But that too is another story.
Did I mention, after security
interviewed the patient the officer came to ask me what had gone “down”? Does
it really matter? Why do we waste resources on these patients? Security and I
have other things to do rather wasting our time, money and effort on patients
with EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS. For me, that includes
seeing patients who value, trust and appreciate us for the care we give. For
security, I was not aware hospital security was Scotland Yard or Columbo for
that matter. This is not about us versus patients. This is about a patient
abusing the healthcare system. And not any system or industry but a system and
industry that is genuinely dedicated to looking out for their well being.
But NOOooo! Now I have to answer to
security as to why the patient is complaining. Are you FREAKING kidding me!?! I
DO NOT know why the patient is complaining. Go ask the patient complaining as
to why she is complaining. My job is to evaluate, diagnose, treat and
disposition patients and NOT to figure out why they are complaining. That’s the
job of administrators who side with patients and why I leave that placating to
administrators and I move on to the next patient.
But now, I guess, it is the job of
security too, to placate to complaining patients.
My stand, although it has been my
Achilles’ tendon, has been and continues to be to dismiss
those who annoy us. Dismiss the rude, the entitled, the
abusive, the demanding and outsiders who have taken us down the wrong tracks.
Why? Because by dismissing those who annoy us it
frees us to focus on those who value, trust and appreciate us for the care we
give. However, although difficult for others, as it is not worth the risk of
losing their jobs, on this we must stand in solidarity and not waiver. Otherwise those who annoy us will not change their
behavior as long as they can find tolerance elsewhere. Thus why when security
and administrators placate to those who complain the cycle continues.
As for security, am I above them?
ABSOLUTELY NOT! NEVER have I believed or suggested that. Not above security,
not above the charge nurse or advocating nurse, and not above complaining
patients either. Actually, I am not above anyone for any matter. However, do I
really have to rehash the entire exchange with security? Not to mention, some
administrator will be by shortly who will want me to tell them what happened as
well. But for those who want my answer this is it: I saw the patient. I
evaluated the patient. I made a diagnosis. And, most significant I formulated a
treatment, follow up and discharge plan. Unfortunately, unlike 99% of patients
I see, this patient, this ONE patient, did not agree with those plans. Because
of that, and only because of that, the patient wants to see someone else. But
not “only” someone else but instead someone else that will agree with whatever
the patient’s EXAGGERATED UNREALIST EMOTIONAL EXPECTATIONS are. Expectations, I
must add, that have nothing to do with healthcare. Note, the patient is NOT
complaining about my evaluation, diagnosis, follow-up or discharge. The patient
is ONLY complaining about my choice of analgesic. Not to mention, when
encouraged to check in to the emergency department again the patient balks.
Why? I have no idea. However, what about these reasons, all speculation, but
bear with me as I point out some of the obvious.
-The patient agrees with everything
except my choice of analgesic, a dental block and NSAIDs.
-The patient does not want to see a
dentist for whatever number of reason.
-The patient does not want to go
through the waiting again.
-The patient does not want to take a
change that who ever picks up the chart next might have the same prescriptive
practice as I of no opioids for dental pain.
I am sure there are many more reason
or not as to why the patient will not see the dentist or check into the
emergency department again. But whatever those are those interested in the
reasoning, as I am not, must ask the patient.
Nonetheless, security wants details.
“Read the chart!” I didn’t say that, as I know security cannot read the chart
as that would be a HIPPA breach for the patient but damn.
Anyhow, now security is not an ally
of mine but of the patient and I am okay with that as everyone wants to be the
patient’s advocate because I guess I am NOT.
However, I will say this, and for no reason other than to
point out the ridiculousness of such position of other. It is appalling that I
am trusted to care for the ill and injured, men, women, child, infant and the
unborn. Yet, when I dismiss those who tread on us I am no longer trusted but a
monster. A monster enablers have determined is inappropriate and why enablers feel
compelled to coddle those who tread on us. Sadly, the enables do not stop there
but they also seek others to do the same for them under the membership card of
My position as to when others suggest, or better yet tells
me, to pick my battles. Picking your battles is NOT only the mantra of those who have NOT
fought battles but more so it is a position of convenience. Because anyone who
has fought any battle will tell you how inconvenient that is and it is that
inconvenience and sacrifice which gives worth to the battle.
On that note, I never solicit anyone’s support, although it
would be very much appreciated. I do not solicit anyone’s support as I am well
aware of the wrath, which includes losing everything as I have so many times,
from being on the “wrong” side, as defined by others, of these skirmishes. That
being something I never wish onto others nor will I put them in such jeopardy.
what is meant by “a monster” or “rude” is that I am conceited, standoffish and
confrontational because I do not allow others to define me, push me around or
walk all over me than I will wear that label proudly. Because as long as anyone
is a welcome mat who defends and coddles those who are inappropriate those who
are inappropriate will not only walk all over you. The inappropriate will also
wipe their shit-caked feet on you as well. Because of that I always stand in
solidarity with those I share a
shift with, even those who are undermining, as I will not allow outsiders to
Nonetheless, the endpoint to this
debacle was to just have the patient check in again. But NOOOoooo!
Now security, the dissatisfied
patient’s “NEW” advocate, involves the nursing supervisor, an administrator.
Why? Because the patient does not want to hear it from the charge nurse either
after the charge nurse informed the patient she was discharged. So now
security, the patient’s “NEW” and supreme advocate, dismisses the charge nurse
as well in what security must believe is in the patient’s best interest.
Now the nursing supervisor asks the
attending physician to see the patient. I, of course, or at least of course in
my mind, came unglued telling the nursing supervisor, “There is no reason why
the attending needs to see that patient.”
It’s not like the attending sees patients
who are in agreement when I discharge, transfer or admit them. This is not a
pulmonary emboli I am negligently discharging. This is not a misdiagnosed
necrotizing fasciitis I am negligently discharging. This is not an abdominal
patient I have overdosed with opioids and despite the patient’s respirations
are six per minute I intend to discharge after given the patient a single dose
of narcan. This is not a patient with a penicillin allergy I intend to give
Bicillin IM to after consenting the patient to the risk of anaphylaxis shock
and potential death.
Nor is it because of my incompetence
or breach of duty. Nor is it because I might cause injury, disability or death
to the patient. Nor is it because of my prejudice, alcohol or drug addiction. Nor
is it because I am unreliable or cannot be trusted. Nor is it because I
undermine those I work with.
It is none of those. Instead, this
big brouhaha and the reason the attending is being asked to get involved is ONLY
because the patient complained. And for the same reason, or lack there of, an
alliance has formed to advocate for the patient over my desire to discharge her
to follow up with a dentist.
Having said all that, one would hope
intervention was solicited for any of the negligent other reasons listed above
but it was not. Not that the intent here is to point fingers but instead to
point out, that the above-mentioned conditioned have been discharged by others,
both physicians and non-physicians, only for those patients to return with
significant complications. Complications that could have been prevented if
“so-called” patient advocates were looking out for outcomes and the safety of
healthcare workers and patients rather concerned about dissatisfied customers.
However, to those misfortunate cases the administration simply says, “Those
incidents were system failures and are being handled.” Oh really? System
failure? Yet, when patients or families complaint about healthcare workers
because that healthcare worker did not cater to EXAGGERATED UNREALISTIC EMOTIONAL
EXPECTATIONS those incidents are not system failures but the individual
healthcare worker’s character flaws. On top of that, those complaints from
patients and/or family are taken at face value as to whatever those who
complain make up is the truth and no reason for those incidents to be thoroughly
However, as I shared with the
current director, as long as those negligent healthcare workers are not on the
customer complaint radar those providing poor care are not dismissed. A comment
the director did not appear too comfortable with yet did not dismiss.
Nonetheless, this dental pain patient is not a sentinel event about to happen
or even one of 40,000 annual medical errors in healthcare about to happen
either. So then why does the attending have to get involved with this patient?
Oh, for the sake of saving an
unsatisfied “customer”. Got it. It’s called “customer recovery”.
“Why can’t the patient just go line
up at the dental clinic or check in again [in the emergency department] if that
is what she wants, to be seen again,” I ask the nursing supervisor.
The nursing supervisor firing back,
“You no longer matter.”
WHAT!?! I no longer matter. Really?
That was the answer from the administration. I no longer matter. Really? Aww!
My ego. I no longer matter. Maybe I should go home then. I thought.
I “NO longer matter”. That is an
interesting one. Never heard that before. Not to mention, when the patient
seeks litigation against me, do I still NOT matter? How interesting! A “NEW”
paradigm. If you want to matter you have to stay off the patient complaint
radar. Oh! Okay! Got it!
More interesting is the fact that
despite the number of these melt downs and ALL the drama they involve at every
place I have worked at nothing ever changes as the end result is the same as
well, me being fired or being asked to resign.
Strangely enough, despite me knowing
the administration will side with patients and families I am still amazed that
administrators continue to side with petulant, unreasonable, angry and demanding
patients over those of us who are not only vetted extensively but more so are
permitted to provide care to the masses, the ones who do not complain. More
ironic is the fact that of ALL the masses seen it is those with EXAGGERATED
UNREALISTIC EMOTIONAL EXPECTATIONS who remind me as to how expendable we are.
Expendable not because of a bad patient outcome as those healthcare workers are
given the benefit of the doubt and a risk versus benefit assessment is
conducted and rarely are those healthcare workers dismissed. Yet, we are
expendable, without discussion I will add, because we will not bow or cater to
the whims of others. That comment not to play the victim card but to point out
that it makes NO sense, at least to me. And even worse that administrators
would say, “you no longer matter” to those caring for the masses who did not
complain. I am sure any satisfied patient would
agree that those who do not bow do matter.
If I recall correctly, that same
shift I admitted three patients and transferred another two or three and
discharged a number of them all of which were appreciative and satisfied yet
the administration says I “no longer matter”. Huh!?!
Nonetheless, after the nursing
supervisor’s plea to the attending to see the complaining patient I had
discharged the attending asked the nursing supervisor to have the patient check
into the emergency department, if the patient’s desire was to be seen in the
emergency department again.
Oh, wait, where did I hear that
before? That a rhetorical question as I have no expectations of attending
physicians in supporting me for any reason as we work independently and neither
of us owes the other anything. However, it is a breath of fresh air when
someone supports you in that manner. Having said that, I do not find it
appropriate that my patient load is being thrown onto the attending physician’s
lap as the attending has their own patients to see. I also do not appreciate it
when the attending is asked to pick up patients I have already seen as I feel
that I have let the attending down.
It is obvious that I “no longer
matter” because when I made the suggestion 30 minutes prior it was
inappropriate. Yet, the attending says the same thing and the nursing
supervisor leaves with her tail tucked between her legs to tell the patient the
choices were to either check into the emergency department or follow up the
dental clinic. The same patient the charge nurse and I told the same thing to,
to check in again or follow up in the dental clinic more than 30 minutes
before. But NNNNOOOOOOooooo! So now it was the nursing supervisor telling the
patient to check in if she wants to be seen again and it was fine. Huh?
Although never been the case, not
that I am aware, I am just curious what the administration says when the
patient declines to be seen by the attending. Oh wait, that is a story from the
book. A patient who demanded I find her a surgeon after I called her surgeon
and her surgeon declined to see her before her scheduled appointment. I, of
course, said, “No” to the patient’s request that I find her another surgeon.
However, at the patient’s insistence and because of her inappropriate behavior
the attending physician in the emergency department at the time called the
hospital’s medical director, a surgeon, who accepted and catered to the
patient’s demands. Thus the patient was admitted, as she had demanded.
Nonetheless, with regard to the
dental patient, now the dynamics had changed. Somehow, during the same shift, I
went from seeing patients and dispositioning them on my own, to include
admissions, transfers and discharges, to “no longer matter”, to what I said
more than 30 minutes earlier, in the patient’s best interest, he-he (that’s a
laughing he-he), and now back to being able to see the next patient. To top it
all off, now the administration was okay with the patient checking in, again,
for the same medical complaint. However, again, as well, the administration had
no qualms with the patient bottlenecking the system. Not to mention, just a moment ago according
to security and the administration, it was I who was being bombastic and
inappropriate when I asked the patient to sign in again. Huh?
WHY? What had changed? NOTHING!
Oh, wait a minute, there was a
difference, the nurse practitioner “no longer matter[ed]” but the nursing
supervisor could not say the same to the attending. Not an issue of mine but an
issue of the nursing supervisor as I do not get caught up in the politics of
administrators as patients seek help from healthcare workers and not administrators.
So the patient checks in again and
without any additional drama, I must add. Despite I said the same to the
patient more than 30 minutes before, to check in again. But at the time the
patient yelled, “NOOooo!” and demanded to be seen by someone else as if I were
a monster and should not be allowed to make such suggestions to patients.
That’s okay, it was obvious security
and the nursing supervisor thought the same as the patient, that I am a monster
and should not be allowed to make those suggestions to patients. But now it was
attending who made such bombastic and inappropriate suggestion and no one
thought the attending was a monster. Not the administrator and not the security
officers. So now the same words, check in again, MUST be okay. Oh. Okay. Once
again I am reminded where I stand in the line of things.
So the patient checks in and is seen
again, not by me and not by the attending, but by the fresh provider who just
came in at 6:00am and who immediately discharged the patient without any
pushing back. Why? Anyone?
Yes, the patient was given a
prescription for opioids for her dental pain. Whatever! Again, had security or
the administrator done the same, just given the patient some opioids, the
patient would have been out the door a long time ago.
Just to be clear, my issue is not
with drug-seeking patients but about the difference between appropriate
healthcare and accommodating the EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS
of the few.
I am okay with patients complaining
that their EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATION were not met rather
bowing to poor healthcare because of placating.
I hope the security officer and the
nursing supervisor are not patients some night, not because I would dismiss them, but because that will be very
awkward, considering I “no longer matter” to them yet I am the one seeing them. Although, they may request to be seen by someone else and if so I will discharge them as well after telling them to check in, again.