The Lady on Elm Street

One of our least favorite frequent fliers individuals well known to our facility is a very large lady (over 400 pounds) for numerous non-emergent complaints. In fact, she utilizes the town ambulance service several times per week for her free taxi ride transport to the ER. On one less than joyous occasion, the ambulance stretcher malfunctioned, causing this plus sized lady to plummet to the ground. Never mind that two of the EMT's sustained injury. Now, when the ambulance is toned out to a medcal call at number x Elm Street, an entire batallion of responders is activated. Self preservation. In addition, if transport is required, there is call service who sends a bariatric stretcher. More self preservation, as well as shielding the town from a lawsuit.

Once her care is completed (usually some minor dressing change, an xray of a wrist, elbow, knee, ankle from fall, or abdominal pain that she suffers from chronically) she is ready to go home. On the return trip, she invariably asks for a taxi voucher. The local taxi service is reluctant to take her because she rarely wears more than a nightgown and robe, her fuzzy pink (or used to be pink) slippers that smell like pee, and she leaves the back seat of the cab a mess. Since the single cab company knows the address, there aren't many who are willing to risk their backs to heave her out of the cab. We don't have the authority to give the cabbie a whopping tip, but usually they deserve it; consider it combat pay.

Sounds like this lady is a pretty sad case, doesn't it? That because of her size we are reluctant to provide care? Consider her problems her own fault? Don't care that she has nobody to care for or about her?

Wrong.

So wrong.

We have all tried so hard with her; most of the doctor's have had caring heart to heart chats with her about how dangerous her weight is for her health, discussed options ad nauseum, services, alternatives, health promotion. The Talker has spent hours with her; Cindy Lu Hu has spent hours with her; Gil has spent hours with her; Cripes has spent hours with her; even Bobo has spent hours with her. Her response was to lodge a complaint against each and every one of them because they discussed her weight.


A.


Complaint.


How can you help someone manage their health by ignoring (forgive me) the elephant in the room? Can't be done.

Kerry got written up because she tried to arrange a home health aid. Why? It was none of her business what her home was like; never mind that she smells like a goat. Kerry did it out of concern for her well-being and she was repaid by getting a complaint. So has Sherry who has seen her as a home-care patient. So has Mikki. So has our boss, Jane. Jane had this little gem to share:

"I was putting ornaments on the Christmas Tree in the waiting room and I dropped one of them. It landed on the floor and shattererd. The Lady from Elm Street was sitting in the waiting room and said to her companion (with whom she had managed to get a ride for an outpatient blood draw), "Did you see that? She threw that at me! It's lucky we didn't get cut! I should complain"

I gave her a steely glance and said I hope you are kidding, in a deadly voice.
She backed down and said she was. "



I learned that there had been no less than 20 complaints over the last two years; she must have Patient Services on speed dial.

We all know how this will end.

She will have need of care for a life-threatening issue when she calls 911.

More likely, one day EMS will find her dead in her house.

Today's Last Patient of the Night.....

....was 22, had no insurance, had presented 16 times in the last 8 months for the Holy Trinity of Pain Complaints* and wanted oxycodone for menstrual cramps.

Um.

No.

*migraine, dental pain, back pain

When Spidey Sense Kicks In

The patient had presented with mid-lower back pain, more in the flank area, rated as maybe 4/10. He felt a little uncomfortable. His BP was a little high, heart rate in the 80's. Dr. CindyLou Hu pounded on the area but the patient said nah, that doesn't hurt, it feels like it is DEEP inside. Hmmm...

Back pain? or something worse?

Dr. CindyLou elected to do a CT instead of sending him home with pain meds. It showed a HUGE dissecting aortic aneurysm (click here to read about it). This would be a bad thing, but there are two types.

One type requires surgery like, yesterday; if it ruptures, it's all over. The other can be treated conservatively with medication. It was an overnight shift so CT's are read remotely by an on-call radiology service with whom the hospital contracts; I believe they exist in bunkers somewhere, perhaps in Antarctica, or in rainforests, possibly connected with the Dharma Project and sharing office space with Keebler Elves while alternating searches for Sasquatch and the Loch Ness Monster. Normally there is a little bit of a lag for readings (hey that happens during the day as well). Fortunately this guy had the NOT IMMEDIATELY FATAL type and was admitted to Higher Level of Care Medical Center where he did well.





As Dr. Cindy Lou and most nurses would say, sometimes you just gotta go with that gut feeling. Not all BAD THINGS slap you in the face and say they are a BAD THING; but experience helps, and sometimes the patient just can't say for sure what is going on beyond (and this includes parents regarding their kids), "there is something that just isn't right".





I once had a 38 year old with nausea who said he just didn't feel right; except he LOOKED like he was going to die, literally, right in front of me. An EKG confirmed that he was having the BIG ONE. Some nurses never develop that sixth sense that prods immediate action, but most do. Gotta trust that Spidey Sense.

A Comment on Drug Seeking Behavior

A while back I had the predictable response from one of my posts about drug seeking individuals; the respondent took issue with my attitude and begged me to consider that all patients with chronic pain complaints are not, in fact, drug seekers. My response:

"Yes, but why are you out of meds? Surely with a chronic painful problem you would make it a priority to contact your provider well in advance so you DO NOT run out; this is what reasonable individuals do who are taking responsibility for managing their health care. "I've run out of my meds and haven't had time to contact my doctor" is often how individuals seeking narcotics present to the ED. This is not to paint everybody with chronic pain issues with the same brush, I am merely pointing out why you may be treated like a drug seeker when you say you have run out of meds. You must understand that most of us working in emergency departments see the same individuals all the time with the same chronic complaints; most of these patients could be well controlled with medication if they are diligent. But that is my point, so many want only the narcotics. Their histrionics and constant drama suck the life out of us and take us away from legitimately sick patients. No, not everyone is a carbon copy, however when 9 out of 10 individuals with these chronic types of pain issues IS a carbon copy perhaps you can begin to see the problem".



For example:



Today a gentleman arrived with a complaint of "Getting a Migraine". No headache, but you know, he says, I've had these visual "bubbles" for a whole 20 minutes now and that's how it starts. He has had 25 ER visits in 2010 for pain-related complaints; most were without trauma, and those that involved a fall, lifting furniture, banging his thumb with a hammer were all without clinical findings. Of course the majority were for the Holy Trinity of pain complaints: Back Pain, Migraine, and Dental Pain. Amen. He had been prescribed 15 Percocet for 10 of those visits, 10-15 Vicodin for 6 visits, and Ibuprofen for 3 visits. He declined a dental block for two visits and just took the antibiotics.



Another well known individual with many, many visits for back pain always has the same story; my doctor is not available. In 18 of the last 19 visits, he has arrived at 5:15 pm ALMOST TO THE MINUTE. Of course his PCP's office is closed at that hour. He asked for oxycodone without the acetaminophen, which is oxycontin pretty much and very powerful stuff. He claimed that the Tylenol hurt his stomach; note that for 19 out of 19 visits he received a prescription for percocet. The ER physician informed him that she never prescribes pure oxycodone in the emergency setting and wasn't about to start now.



Both of these cases involve individuals with chronic pain issues who have either not been up front with their physicians about how much medication they are taking, or are simply lazy. Lack of planning on your part does not constitute an emergency.

Welcome to the Dark Side, Bobo

Apparently, Dr. Roboto has thrown in the towel, conceded my cynical superiority, and has decided if you can't beat 'em, join 'em.



Yep. He's rolled over and realized that I'm no pushover, have no respect for him, could care less if I am fired and, more importantly, my sucky attitude toward him has spread to the other nurses. Pied Piper rulz; no one has called him Dr. Roboto in weeks, we now all call him "Bobo".

Oh, Bobo is still going full tilt on the rapid door to doc. But, if the nurses are busy he will greet the patient at the ER door and see them before they are triaged. Great! Now you're beginning to understand teamwork! I am a powerful ally, but a formidable opponent as he has discovered. I have caught him trying to make jokes, along with uncharacteristic human emotion, an occasional eyeroll, and actually CHATTING with nurses. I told him, as he considered having one of us give a constipated individual and emergency enema, that there was a special place in hell for ER docs who order either ear irrigations or enemas in the ER. The son of a bitch actually laughed and didn't order it. Another social lesson well learned (or he is at least on the right combination of meds), but my work is not yet complete; now I just need to get him to talk to his clavicles a little less as he does occasionally backslide on that issue.
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I rarely work with Mikki, and had an opportunity to do so with her today on an infrequent day-shift appearance on another busy shift in which we ran our little legs off. Everyone got hydration, labs, meds and instructed in how to collect a sample of the alleged diarrhea that a many had claimed to have experienced for days, which somehow mysteriously resolved upon arrival to the ER. We had Dr. Cripes today, which was a happy bonus. Gotta love him. Working with Mikki is a trip because she has been very insecure in the past, and frequently looks to me for...I don't know, courage, leadership, approval-whatever. She gets better all the time though, I'm happy to report. I tell her the cool kids like her and not to worry about what Second in Command says or does, because she is unhappy, unliked, and uncool. Who needs her?

I had been given a yellow pen with a duck head that lights up and quacks when you push it on the noggin; very annoying, but I LOOOOVES me my ducky pen. It goes well with my yellow scrubs; the yellow submarine in da house.

I emitted a cheerful "quack" with my pen as I greeted Mikki and Cripes. "Hey, what's with the duck", Cripes asked. "It annoys Bobo, what could be better?" I asked.

"I used to be a wreck when you and I had to work with Bobo", Mikki said. "I'll never forget the time you said you wouldn't respond to anything he said unless he called you by name and looked you in the eyes".

Cripes and I laughed. "That was also the day I told him he was needy. And because he took the time to write 'suture set, 1% lidocaine, 4-0 nylon, normal saline, Zerowet and set up for sutures' on an order sheet which took 4 times as long as it would have for him to just do it, I put 1/2 the wrong stuff up on purpose".

"I wanted to disappear", Mikki cringed.

"Nurse Passive-Aggressive on the job that night?", Cripes grinned.

"Yep, guess you will never have to meet her since you are pretty much the pinnacle of ER physician role models. We all change shifts so we can get to work with you".

The highlight of the day was that my boss told me that I would be receiving the first raise of the new year since my anniversary date is January 4. WOOT!