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]