There are certain patients who push your buttons and cause you to lose your cool. It’s up to you to anticipate these triggers and come up with a plan to manage their care with compassion and poise.
All my attempts to delve into the shallowness of epistemological relativism and to grasp objective and universal truths seem to have flopped. Viewing my fan mail versus hate mail, it is clear that the more down-to-earth suggestions are what people want. As one reader put it: “Don’t give me any crap by Bonhoeffer and Kant. Give me something that I can use in my next shift.”
To that end, I’d like to give you some techniques for recognizing when you have been either emotionally or intellectually hijacked and you are no longer in control in your own emergency department. Believe me, patients can play you like a violin, whether you like it or not.
Oh, you think it doesn’t happen to you. Yeah, right. The staff, the patients, even your own children are masters at twisting your emotions and responses. I tell people all the time to write down those incidences or activities which make them the maddest. Then whenever they see those things appear in the department, to be on their guard. You are set to be intellectually hijacked. You need to understand your own list of “hot buttons.” You need to know when you’re about to be captured, hauled off, sucked and blown out the other end of the emergency department.
In this world, there’s really only one thing we can hope to change, and that is ourselves – our own behavior. So let’s be aware of all the situations where a perfectly intelligent and caring emergency clinician can be made to do some really ridiculous things and lose control of the primary principles of decision making. Here are some hot button issues that we all confront, we all need to know about and we all should have a plan for managing.
The Drug Seeker
Drug-seeking behaviors either imagined or real is by far the greatest trap for emergency personnel. The reason we need to understand our feelings is not just for the patient but for ourselves. Too many “drug-seeking patients” can turn what otherwise would be a good shift into a nightmare. Know when you’re falling apart. The greatest contributor to this problem is the emergency staff itself. “That piece of crap is here again looking for a fix” has been said to me many times by the staff as I’m about to enter a well-known patient’s room.
Now you have two problems: Convincing the nursing staff that the patient deserves a proper evaluation and, if necessary, real treatment in which they feel you are “feeding the bears.” You need to focus yourself and get it right. Repeat headache patients, low back pain patients and all other chronic pain syndrome patients deserve a real evaluation just as if it was their first time. In headache patients, carbon monoxide poisoning, meningitis and subarachnoid hemorrhage are still in the list. In low back pain patients, perispinal abscesses, midline disks and aneurysms still need to be considered. Don’t be controlled by outside forces into giving half-assed medical care. Focus, focus.
Mr. 11/10 Pain
The next group of people who push your buttons as well as your limits are those who state: “Doctor, I have a high pain tolerance.” What does this mean? They are trying to impress you with the severity of their situation. The more irritating subset of this group of patients are those who state that on a scale of one of ten, their pain is an eleven. This often produces a mini lecture/scolding from the healthcare provider on the fact that there has never been an eleven. Let me just state that I hate pain scales. I don’t know who really invented them and I understand fully that no patient understands them. No one intrinsically knows what a seven or a five even is. If they need more pain medicine, I give it. The real danger is not the pain in the patient but the irritation in the providers. Stop it. Stop it now. Don’t lecture people on the pain scale. It isn’t their fault that it was invented by some deranged administrator. Emergency doctors tend to be tough guys and gals from the wooden ship, iron men school of personal commitment. And such wimp-like personalities tend to trigger negative responses in all of us. Just be aware.
A variant of the pain scale is the whiner. Everything to them is being done wrong. The nurse hurt them with the IV. “I’m cold. Can I have a sandwich? Can I smoke a cigarette?” Anything sound familiar yet? Steady the course. Respond as best you can. Sometimes when the patient knows you are taking them seriously, the level of complaints and confrontation actually descends.
I actually see emergency personnel say to the patient: “You get one, count them. One complaint, that’s it.” I know you want to say this but you can’t. They get to tell you whatever they want. It’s your job to prioritize what you’re going to do tonight with each one of these so-called problems. The corollary is the mixture of major and minor complaints and noncritical concerns. The fact that they have both the worst headache of their life and an itchy red spot on their left foot that they’ve known about for years do not really seem to us to go together. You may be the only doctor that they have ever felt comfortable in talking to about this problem.
Here’s the approach. At least look at it. Then you can talk about approaches for care which can be employed but not necessarily tonight. Offer to note it in the chart for the primary doctor and this at least provides a painless way to wrap up what otherwise could be a long story. Nonlife-threatening complaints are always difficult for emergency physicians (your own family understands this).
The Unfixable Medical Problem
The unfixable medical problem is the natural predator of the emergency clinician’s soul and the sapper of his or her energy. The ambulance arrives from the nursing home. You pull the sheet back on a 92-year-old patient who is emaciated and in contractures, hasn’t spoken for two years and smells of feces and urine, to say nothing of the calcified Foley and feeding tubes. Your face drops. You feel weak. You keep wishing you’d gotten that dermatology residency. Before you seriously consider hemlock, define the goal: What’s the question on the table? Emergency people don’t like things they can’t fix, period. Before a minimum $20,000 workup is commenced, find the people, the players, also known as the family and find out what they actually want. Don’t assume they’re looking for everything to be done. Patience is key to solving this conundrum.
This is a country that doesn’t know how to die. Americans are the only people on the planet who believe that death is optional. Redefine success in these patients as having had an honest discussion with all the parties involves. Chronic, poorly-defined, ubiquitous medical problems are our new albatross. Your emotions at that time and how you deliver the message to the family will determine whether this will be a successful or unsuccessful interaction. Take pride in having delivered some honesty. We are in an age divorced from tradition, history and purpose. We are trained for usefulness and a market economy given to fulfill-ment through technology. This is the moment you realize science does not answer the big questions. You can at this moment do both this family and the wider society more good than you can ever imagine by being honest in our limitations as a profession.
The Patient with Poorly Defined Ailments
Next, we all confront patients who have complaints which are not easily translatable into medical-ese. Not everything has an ICD10 code. Poorly defined is too often synonymous with undefinable. Late at night you wish you had picked up the two-inch laceration chart as your last case to end the shift. Nondescript areas of “tingling” are the worst. They don’t fit a dermatome or a peripheral nerve distribution. They have no real periodicity or any particular action or inaction that provokes them. Like the patients, my family frequently has these types of complaints. When you admit you have no idea what it is, they are both angry and disappointed and conclude that you are an idiot of a doctor. Never open up with, ‘I don’t know.’ You know lots of things. You know they’re not about to die in the next ten seconds. You know it’s probably not total occlusion of the blood flow to the arm. Open up with something you know. That reassures the patient. I know now to use the term “irritative neuritis, probably of a viral nature.” How can you be wrong with cold compresses and reassurance?
My wife once inquired of me concerning a dysesthetic area on the back of her hand. After visual inspection, I made the unforgivable mistake of saying: “I don’t know.” She immediately impugned both my intelligence and medical skill: “What do you mean you don’t know? You give all those talks and write those books on neuro and you don’t know?”
“Well,” I said, “it’s cancer.”
“It’s not cancer,” she retorts.
“Then I don’t know.” Now she is really mad.
“If I were a patient, you would ask me questions.”
“Have you had this before?”
“Yes,” she said.
“Well, you’ve got it again.”
Clearly another mistake. Go with the nonspecific neuritis response – how wrong can you be?
The Patient Who Calls for Reinforcements
The last area which threatens the healthcare professional’s pride and raises ire are challenges to your direct competence. It may be subtle, even non-intended, but when they say: “Call my doctor,” all manner of negative thoughts can go through your mind. You are tempted to say: “I know that idiot and he won’t have a clue.” I know you’ve thought this because so have I many times. Instead, I take it now as a compliment that they want me to be more involved in their overall healthcare. It’s okay. I often on the phone renew an old acquaintance with a doctor I may not have spoken with in years. I can secure follow up and I win a friend for life when I tell the primary doctor that they don’t need to come in or admit the patient. Trust me, calling the patient’s doctor has its upsides.
A much tougher challenge to your authority and position on the healthcare team is when they say: “But how do you know, doctor?” Now you have to explain why the internet does not have all the information and certainly doesn’t know about you the patient who is sitting in front of the provider. All your diplomatic skills are required. It tends to be the more intelligent patients who ask questions. A little non-condescending conversation goes a long way in winning you a friend and admirer. We often forget that candor is appreciated by patients and their families. The internet suffers from too much information and way too much opinion and putting this in some perspective for the patient is definitely required. It is most required that we take this time when we are not going to do a test or not going to write for an antibiotic. Patients want to hear your thought process.
Sometimes with difficult patients just a compassionate interaction is more important than what is actually done. It’s like tourists in Times Square. It is not for the sake of a picture that a selfie is taken but for the sake of the taking. The desire is not for a captured image but for the captured self. They achieve through the lens what they cannot achieve through themselves: a moment in which the object penetrates both their body and soul and changes them in some way according to their value structure. It is this interaction, this magical laying on of hands that may be the most important part for the worried well in our society.
“Thanks,” they say. “I feel better now.”
Editor’s Note: Dr. Greg Henry’s iconic column, Oh Henry, will conclude with a final essay in the December 2016 issue of Emergency Physicians Monthly. Want to send Dr. Henry a parting note about his column? Email firstname.lastname@example.org and we’ll pass it along. Look for a collection of Dr. Henry’s work to come out later this year.