Sunday, June 24, 2012

Dr. Douchebag: A Tale of the Emergency Department

A doctor's perspective on abusive patients in ER. By J.M. Baruch. Originally from the Hastings Center Report. Reprinted from Medscape.

Two gun shot wounds," the emergency medical technician says, breathing fast, the summer night pouring down his face. "One in the right flank, one in the right thigh."

"I don't want to die, doc," pleads the victim, whom I will call Mr. Smith. His vital signs are stable.

"This is the trauma team," I say. "We're going to take good care of you, but we need to ask lots of questions." I press my stethoscope to his chest. "Can you take some deep breaths?" I listen for the airy hollow of a punctured lung but am calmed by the hum of normal respiration, even as his alcoholic breath warms my cheek—or so I believe. He denies drinking, but this is one of those overnight shifts when everyone—motor vehicle crashes, chest pains, depressions, confused grandmas, even rashes—has thrown back one or two.

Once inside, we palpate Mr. Smith's neck, chest, back, abdomen, and muscular extremities. "Does it hurt here, and here, and here?"

He doesn't answer us. Now he acts annoyed and bothered. "Call my cousin," he says.

"Sure," I say, "after we make certain you don't have an injury that needs immediate attention."

"And you are?" he says.

I'd already introduced myself, but I know what he means: Who am I in the hierarchy? "I'm the doctor in charge," I tell him.

"Good," he says. "Go call my cousin."

"First things first," I say.

"Hey, douchebag," he says, his voice hardening. "Call my cousin."

I pretend the comment was what he might, on reflection, consider a regrettable slip of the tongue. But his head arches off the stretcher and his eyes meet mine. "Now, douchebag."

I feel the heat of the trauma team's averted gazes. I say nothing, but inside, I grasp at explanations. He's been popped with two bullets. Maybe he's scared, anxious, emotionally shocked. Or he's a thug, a power-fiend, and now he's vulnerable. He distrusts authority. Perhaps he is drunk, his tongue greased.

He refuses intravenous fluids, blood draws, x-rays. "Let us take care of you," I say, proffering shared control, thinking he'll soften up and participate. "You don't want to die, do you?"

"I'm not afraid of dying," he says, despite his plea on arrival. "Listen up, douchebag. Are you calling my cousin or what?"

I swallow hard. The ache in my stomach will ease somewhat when I find time to eat my tuna sandwich. But the frustration feels bottomless—untouchable and undeniable. "What gives you the right to talk to us this way?" I finally say.

He stares me down. I tear the blood pressure cuff from his right bicep.

"I'm not fighting you. Many patients are waiting to be seen. You're free to go if you want."

He stares at me. "I'm calling my lawyer!"

"Good luck. We'll dress those wounds before you leave."

Afterward, I neither swelled with satisfaction nor sighed with relief. Justice hadn't been exacted. I felt empty, drained of emotion. It was that word: Douchebag. It's important to avoid euphemisms, or a vague term like "expletive." I've been called worse in my career without flinching. It was the way he said it, with his riveting eyes.

The emergency department might be the only sphere of human exchange where one party—patients (and sometimes family)—are permitted to insult, threaten, and even spit at the very people on whom they depend for help, while the offended parties—physicians, nurses, and other health care providers—must not only tolerate the abuse, but treat their tormentors. Although only a minority of patients are difficult, still, you cannot practice emergency medicine without being skilled with, and tolerant of, difficult patients. The challenges they present are shared equally by ED nurses, midlevel providers, and staff. The wide range of people and behaviors populating our practice contributes to a distorted normative standard: uncooperative, vocal, demanding, drug-seeking practitioners of various self-destructive and illegal habits. Yet I found this patient difficult beyond these familiar and forgivable ways.

The specialty of emergency medicine was built on pillars of "egalitarianism, social justice and compassion"[1] and the demand for expert services for the poor and uninsured in society.[2] This ethos was shaped into statute with the Emergency Medical Treatment and Active Labor Act, which codified the principle that any patient who comes to an emergency department must be screened for a medical emergency. EMTALA translates as a patient's right to care—a justified claim on the time, expertise, and, I believe, the empathy of the ED staff.

These moral and legal obligations situate the ED at a boundary where hospital and community blur. The responsibility and challenge of serving marginalized patients who are ignored or discounted by a dysfunctional health care system drew me to emergency medicine. In practice, however, this ideal has been tarnished by those patients who make you feel foolish for caring, who think the right to emergency medical service implies a right to treat the ED staff as their servants. When such patients act out or say nasty things, I'm often at a loss for how to respond. How much tolerance is appropriate? Are certain behaviors so inexcusable that they supersede our responsibility to patients? When the drunk spits at me as I try to examine him? When patients punch staff? When one tosses a bedside urinal, filled to the brim, at a nurse? Or takes the meal just served to her and chucks it on the floor? Are we truly expected to construct empathy out of this?

I've been hearing similar sentiments with greater frequency, usually from physicians—beginners and veterans alike—whom I respect for their skills and compassion. It's strange, but the most empathic, sensitive physicians seem to be the ones to fray at the edges.

Some authors have called for emergency physicians to reaffirm their commitment to their patients and their practice with a virtue-based ethic, "to treat each patient with unconditional positive regard," and respect each one with "common courtesy, sincerity, and willingness to help."[3] These ideals and virtues serve as a moral lighthouse for me when the appropriate action, belief, or emotion feels lost in the fog. But are these duties absolute? Are they too tidy for a health care system that leans on EDs to shoulder the consequences of its shortcomings?

Crowding is a critical problem facing our nation's EDs; Mr. Smith wasn't the only patient there that night. Between 1997 and 2007, patient visits to the ED increased 23 percent nationwide, from 95 million to 117 million.[4] And yet, during the past two decades, approximately a third of hospital-based EDs have closed their doors.[5] Health reform is expected to drive the newly insured to the nation's EDs, since their access to primary care is complicated by both physician shortages and practices that limit Medicaid patients due to the low reimbursement rate. Patients are also sicker on arrival, having delayed medical care until delay is no longer an option.[6] Troublesome individuals disturb fellow patients and undermine the opportunity for efficient, accurate, and sensitive treatment. Moving beyond professional considerations to health policy, the national conversation on spending and resource allocation cannot ignore on-the-ground obstacles to excellent care.

Does the ED's collective duty to greater numbers of patients demand a revised ethos of tough love for extreme cases of misbehavior? Can we ask these patients to leave without legal recourse after extending genuine, compassionate efforts to participate in their care—barring evidence of a medical explanation for their toxic comportment or a mental illness that puts them at risk of harming themselves or others? Consider this sign posted prominently in ED waiting rooms: The emergency department is a community resource. We are honored to do everything within our power to help you. But behavior that interferes with the care of other patients, or that is insulting or threatening to the health care team, will not be tolerated.

How insensitive and unprofessional was I to ask a man with two gunshot wounds to leave? He was uncooperative, obstructing his care and that of others, but those issues did not earn him an exit pass. It was personal. His insults violated some unwritten social contract. Yet any justification feels flat and petty. The burning in my chest is gone; the certainty that gripped me seems silly.

Fortunately for me and Mr. Smith, the account above is not really what happened, merely what I wished I had done at the time. I did care for a man with potentially critical wounds, a nasty attitude, and an affinity for the word "douchebag." He forcibly pushed hands away when we tried to examine him. Efforts by staff to assuage him were met with insults. He denied drinking, but his blood alcohol level was high. Only after he was medicated to make him sleepy could we provide the care he needed. In the end, he escaped major injuries. We never heard "thank you." The last time he called me a douchebag, I was made sick by what I wanted to say back to him. Upholding my professional duties and virtues did not fill me with honor, and my self-restraint was not a source of pride.

But by writing about this—using the imagination as a moral testing ground—I have gained a clearer and more sensitive impression of the event. That said, if empathy is the capacity to imagine oneself as another, or to project one's personality into another's life sufficiently to feel and understand the other person's feelings, then this creative exercise has not fostered empathy for Mr. Smith. But narrative serves as an ideal medium for wrestling with intense incongruity: a patient insults the very people trying to help him, and a physician finds himself on empathy's chilly ledge. Consider the novelist John Gardner's thoughts on the value of fiction: "[It] helps us to know what we believe, reinforces those qualities that are noblest in us, leads us to feel uneasy about our faults and limitations."[7]


Lynda Halliger-Otvos said...

The amount of abuse that you ED workers put up with is unconscionable and i wish there were a way for you to be compensated for what you have to deal with every day. Unbelievable to me how someone can be ugly to the same people that are trying to help her/him... I just don't get it on any level.

Thank you; all four of my ER visits have been amazing and I have been blessed with good care providers and wise minds to help me get the correct treatment every time. Many thanks for what y ou have learned to do. it may be the hardest job in medicine.

Mark p.s.2 said...

I was thinking, being shot, you might feel some pain?
When I am in pain, I am not rational.
When I am in the mild pain of hunger I am very grumpy and can be insulting.
The doctor himself in the story complains he had not the time to eat"my tuna sandwich".

girlvet said...

are you actually defending abuse? I don't care what kind of condition you are in, you do not have right to abuse people. Period.

Anonymous said...

I work as an RN in a very busy urban ED, and I thank you for eloquently expressing the moral quandary that emergency medical staff experience daily.

Anonymous said...

I'm not defending abuse, I can't imagine the situation where I would call someone a douchebag. I'm also sure this particular patient is not a nice person.
I do, however, have one thought.
The man asked/demanded that his cousin be called. The physician, instead, said "First things first" and essentially denied that.
If I was the patient, and that was my firm desire, I wouldn't have been pleased either (although I would have been more polite about it).
If, instead, the physician had said "Please may I finish your exam first, I am worried about you - then I will make sure to call your cousin" maybe he would have gotten a better response. Letting the patient make his own choices, as is his right, rather than trying to force the physician's will upon him. People, in general, don't like being forced/dominated.
Now, if he was so drunk as to not be able to make rational choices, I suppose that might not have helped.

Mark p.s.2 said...

"are you actually defending abuse?" Defending ? no. Explaining that someone who is shot, is in pain. The person would then have little control over themselves. The effects of pain change the patients ability to think rationally and if you can't think, you can't act civilly.

girlvet said...

Guess what this patient has a punctured lung, probably bleeding into his lung folks. His breathing is the first priority of the MD, not his flippin' cousin.

girlvet said...

I see people every day in serious pain and guess what they don't act like assholes. This guy was an asshole plain and simple.

Anonymous said...

And it should be the physician's first priority. But it appeared to not be the patient's first priority. And if he's in his right mind, he still gets to choose - even if he's making a stupid choice. People make all sorts of stupid choices. The physician can hopefully persuade (not force) him to make the right decision here.
But sure, in addition to that, he probably is an asshole.

Marissa said...

Well, no. Patients don't get to decide when they don't fully understand the consequences - even when they're in their right minds.

girlvet said...

thank you

Adam Gill said...
This comment has been removed by a blog administrator.
Anonymous said...

Then the physician needs to explain the consequences to him so that he does understand. Not that hard "You may have a punctured lung. If I call your cousin before I check you out and maybe fix that, you could die". And he still can choose. You do have the right to refuse any medical treatment.
Don't get me wrong, I'm sure I wouldn't like the guy either. But trying to force people doesn't gain their trust, and may bring out more "asshole" in them.

Anonymous said...

"Force" people? The man was bleeding out. What, was the doctor to allow this deluded jacknape to die because he (the patient) wasn't competent enough to realize his dire straights (and no doubt get sued by his family)without even a touch of protest?

There is no excuse for this patient's behavior. Given his response, no amount of TLC or appeasement would have helped the situation. Why? Because I see the same situation occur in my ER everyday. I see physicians, PAs and Nurses play the same situation out from different angles and you know what? It changes nothing. "Gaining their trust" does not work with the untrustworthy.

In such a situation, we do our duty and cover our collective asses.

Eileen said...

I really do not think that calling his cousin should be either the job or the priority of the doctor. This is a hospital not a hotel - if you want that sort of service then you need to pay the costs of a hotel concierge staffing. It was bad enough he expected a highly trained member of hospital staff to do something like that. To be so rude whilst doing it is even worse. I don't imagine a police officer would have been any faster or more helpful about it either.

There is enough complaint on blogs about the stories told that make nurses and doctors react like this hypothetical situation. If those who don't meet it think they would be better at empathy after such abuse on a continuing basis and object - then let them do the job. And see how they feel.

Anonymous said...

No, there is no excuse for his behavior, I never said there was.
But, adults do have free will, he obviously wasn't that bled out (yet) that he was confused, or incapable of making decisions.
Should you let him bleed out if he refuses treatment, and wants to talk to his cousin instead? Maybe so. Natural selection??? Or let him call his cousin, then treat him once he passes out - since he can't make any decisions then.
The part I react to here is the idea that because the medical folks are right, they should override his decisions. They are right, I don't disagree at all. But, overriding other adults competant wishes is a slippery slope.
Again, if he's too drunk to be rational, that doesn't apply.

girlvet said...

So okay lets call the cousin. Take time out for that. Meanwhile the guy goes down the toilet. He dies. Guess who his family will sue?

Anonymous said...

I'm sorry in an Emergency situation you do need to use judgment and possibly override the patients decision. I do get a laugh at how a patient who is shot can be considered in his "right mind" I am assuming that the people arguing for the patient here have been shot before and know that it is a very calm situation no stress at all.

Anonymous said...

I can only go on the written description of events. The guy was portrayed as looking daggers at the physician, and saying "call my cousin". Sounds calm to me. He refuses particular treatments, and they respected that right.
If they said he was thrashing around yelling wildly "call my cousin, call my cousin" then I'd probably have a different opinion.
Just because someone is hurt doesn't mean they aren't in their right mind, and can't make a decision. But - yes - being hurt, they certainly might not be in their right mind to make a decision.
But - the physian was SO offended. If someone is "crazy" - out of their mind - why be offended? They don't know what they're doing. You wouldn't (I hope) be offended by a schizophrenic in a psychotic episode or anything right? So if he's not competant to decide for himself, then you're being offended at an incompetant person who's not in their right mind?
Or... you're so offended because he is a nasty idiot, and does know what he's doing. But then, he's competant and has the right to make his own (stupid) decisions.
OK, sure, I understand the fear of being sued. But should that mean "Do whatever you want regardless of what the patient says?" That's a slippery slope.

Anonymous said...

the fact that he's drunk means he is not competent to make his own decisions at that point... I can just see the judge saying to the doc and all the nurses that were there, "you allowed a drunk man to tell you to stop treatment when he was bleeding out? Was he really in the right frame of mind to make that decision?" then they all lose their licenses and their means of life all because of one drunk idiot

Anonymous said...

Well they decided he wasn't too drunk to refuse some treatments. Wasn't that wrong too then?
If he's not competant, I'm fine with that. But it doesn't sound very clearcut from the story.
I suppose where the line is isn't always clear. But somewhere, there is one.

Snarky RN said...

He was only (theoretically of course) wanting to talk to his cousin so he could get his alibi straight......let's not kid ourselves......Ghetto Ghetto DOES.....***Signed your friendly "burned me once shame on you, burn me five million times, shame on me...ED nurse**

Anonymous said...

You're probably right on that one, I wouldn't argue.
The thing is - there are very few situations where you have control over another adult. Police officer. Jail guard. Medical personnel. I can't really think of any others (maybe there are some, but I haven't had enough coffee yet to think of them).
So anyone who does have that control has to be held to an incredibly high standard.
If you start making the judgements - this guy isn't nice/is an idiot/is ghetto, I'm smarter than he is and I know better, I will choose for him against his will... OK, here's a corporate lawyer, now there I'll do what he says... how do you choose? Where is the line where you decide this is such a "bad" person, he doesn't have the right to make his own choices. Hence my "slippery slope".
Honestly, though, I'd support being able to say "You're free to leave, go somewhere else if you're abusive towards me". No, I don't think people should be abused, if the patient is competant. Unfortunately, you can't.
I suppose being yelled at by crazy people/drunks is part of the deal if you choose to work in the ER though.

Anonymous said...

There is no "slippery slope" in this case. These are sound clinical judgements based on obvious evidence and clear medical guidelines (and a clear understanding of the legal ramifications of actions and their consequences).

Furthermore, whether or not a person is competent, NO ONE has the right to abuse anyone else. Even a psychotic must be corrected if they abuse staff (and in fact, state hospitals with sizable psych units have staff specially trained to educate such individuals).

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