Monday, July 28, 2008

And Since Then I've Hated Myself Just a Little Bit

I am consistently in awe at the succinct beauty of C.S. Lewis' writings. Something I recently read by him raised this point,

"...we must hate the bad man's actions, but not hate the bad man. For a long time I used to think this a silly, straw-splitting distinction: how could you hate what a man did and not hate the man? But years later it occurred to me that there was one man to whom I had been doing this all my life--namely myself. However much I might dislike my own cowardice or conceit or greed, I went on loving myself. There had never been the slightest difficulty about it. In fact the very reason I hated these things was that I loved the man. Just because I loved myself, I was sorry to find that I was the sort of man who did those things..."

It has caused me to reflect on a recent incident from a few nights ago has been gnawing at me. I keep coming back to it in my mind, seeing myself react more quickly, with more confidence and ease, with strength. Like those times when you think of a really good comeback or joke but the moment is long past and you're just left to burn and smolder in your thoughts of inadequacy.

This 30 something woman in tight jeans, heels, and handbag has been coming in for her late night dose of IV therapy. She's suffering from a case of pyelonephritis. I am sure it is unpleasant and irritating to be sick to have to drag yourself to the hospital thrice daily, (two times to Ambulatory Care during the day, and once to the ED late at night) but I believe that this does not excuse her behavior in the slightest.

Each night when she comes in she harasses the nurse who must work at a slow jog to keep up with the IV therapies, the evening meds of the admitted patients, the call bells, the pukers, the criers, the poopers. It is the 'non-acute' side of the department which means you can forget a break all night and you can also forget getting to do anything fun (like assisting with reductions, sedations, intubations, chest tubes, etc). This woman will complain about the fact that she has to sit in a chair (a chair that just happens to go into full recline but I guess that is beside the point), because really she "deserves a bed". She demands blankets. No, HOT blankets. She needs juice. She needs a new IV site because this one is really bothering her.

One night the nurse actually accommodated the early site change and thus subjected the entire department to the womans wails, screams, and sobs while the new IV was put in. And I mean SOBS. There were tears rolling down her cheeks I-kid-you-not. I even went over to see what was going on and to see why one of my colleagues had clearly snapped and decided to shove bamboo slivers under someones nails that evening instead doing her job.

But no. It was just our little pyelo getting a #22G catheter in the arm.

So I am on the dreaded 'pit' side the other night. And I am dealing with the usual 10-pt-per-nurse ratio and I go to flush her IV with normal saline while we wait for her repeat blood work to come back to see what the plan for the next day will be. While I am hooking up the syringe she points to how badly her skin is doing, how the site is clearly not working and that it needed to be changed. Since 250mls of cipro had just gone into that supposedly "non working site" I was unconvinced but assessed the area anyway. Her skin was slightly puckered from the op-site but looked pink, healthy, and non-infiltrated underneath. I explained that it was the taping job and not the signs of a faulty site.

When I went to flush the line she almost knocked me over as she reached around to grab her hand in pain, screeching. The saline was going in with no resistance and again I noted no signs of infiltration or an interstitial loss. She demanded that it be taken out otherwise she wouldn't sleep that night.

Remembering back to the antics the night before I told her that since we'd been having such a hard time getting IV's in her I was less than willing to pull out a perfectly good site. I added that I was certain it would not go over well when she returned the next day without a saline lock in place (I was really trying to save this faceless RN unknown to me at the ADC program that kind of a start to her day...faceless RN if you ever read this blog you can thank me anytime).

I wrapped her hand up and went to tend to the patients in the department that were actually quite sick and in need of attention (in a non-pathological way). Like, for example, the woman in bed 6 with gross hematuria and the guy in 5 with hepatic encephalopathy.

As I am on the other side of a curtain nearby doing a quick EKG on a patient that had seemed to have vagaled but just wasn't coming around in a timely enough fashion for my liking, I had to listen to pyelo ranting at a just-below-yelling-decibel-level:

...yeah they have me in a hucking chair in the middle of the hucking I am NOT in a hucking bed I am sitting here in a chair! Yeah I told her to take it out and she wouldn't...because it is so hard to start a hucking IV on me!! Yeah, they are so hucking brutal down here...they are waaay hucking better in ADC...I just cannot believe the hucking treatment I am getting....I don't even hucking know what the huck I am waiting for...this stupid hucking antibiotic isn't hucking working anyway!....

And on and on and on she went in a similar fashion. I could feel the anger rising in me. I felt my face beginning to flush and my heart rate starting to rise.

Why was she allowed to pollute our emergency department with her sense of entitlement, her anger and her foul language? Why was I feeling so incredibly offended by her mouth? I used to be a basketball referee for crying out loud! I've been called every name in the book in front of hundreds of people and I had never taken it this personally.

Why was the person who was the least in need of emergency care in the entire department allowed to rudely and inappropriately disturb patients and family members with dissatisfaction over her care?

Because I didn't do a thing about it.

Ugh. It makes my stomach turn a flip every time I think back to it.

Why didn't I walk over to her and say, "please turn off your cell phone, as you can see there are signs everywhere restricting their use. Also, please refrain from using such offensive language. If you are not happy with your care here please feel free to be seen at XYZ emergency which is about a 10 minute drive away. Thank you and good night".

I am so angry with myself for cowering away from the confrontation that would have spared my other patients, family members, and colleagues from her ridiculous (and totally unreasonable) ranting.

And I am also unhappy with myself for hating this woman who was sick and clearly has other issues than her pyelo or she wouldn't be acting out in the way that she did.

I have been thinking of ways I will deal with these things in the future, how I will handle them more pro-actively. How I will learn to "hate the bad man's actions but not hate the bad man". How I can try to see those poor qualities in myself and change them; the sense of entitlement, the impatience, the desire for attention.

And how I will let go of this, move on , regrow that thick skin I once had, and keep smiling.


Anonymous said...

If you figure it out, please let me know.

I enjoy your blog, btw - keep up the good work, and good luck in Med School. I started med school in my (late) 40's, I have some appreciation for what you will be going through.

Albinoblackbear said...

Thanks Fidel, glad you enjoy the random ramblings. :) Great to hear about other people who took the plunge later in life! Cheers.

Bostonian in NY said...

No PICC line on Ms. Pyelo?

In my experience (limited though it may be), people come to the ED with expectation that their medial problem is as much of an emergency to everyone else as it is to it little Ms. Pyelo or the gangbanger that got himself shot in the ass and is now lying prone for 6 hours until you can get a bed upstairs or the drug seeker that says he has chest pain for his 2 mg dilaudid 3 nights a week. What gets me are the demented LOL's that come in and become combative and yell help while you have to restrain them...breaks my heart.

Whatever you would have done would have been thrown back in your face by her the next 10 or so times she comes in for her IV cipro. The ED is where attention craving people flock to take advantage of caring, self sacrificing people that work there!!

Rogue Medic said...

Bostonian in NY said...

"Whatever you would have done would have been thrown back in your face by her the next 10 or so times she comes in for her IV cipro."

Maybe, but how do you know if you don't try something. Good point about the PICC.

Is there a way to isolate her, at least a little bit, from the rest of the ED patients? She is there as much for the attention as the medical treatment. As long as she is having her need for attention satisfied, she has no reason to change.

The method of not paying attention to her has to be appropriate for her, her condition, the environment, and the staffing.

Things that might work include: delaying start of treatment until she behaves, if she acts up after the start of treatment, can it be stopped, or slowed without affecting her care? Can you keep her in the waiting room longer? Is there another annoying patient she can be placed next to? They may conspire, but that is likely to keep them quiet for at least a little bit.

Does she receive any pain management? I have no problem with delaying or denying pain meds to a disruptive patient. They are compounding their own pain. Drugs are not the only part of pain management that we use, the non-pharmacological ones can be as effective as the pharmacological ones, when used appropriately.

Only speak to her when you need information for documentation, she is a glutton for attention, if you deprive her of that, she might behave a bit better. Pretend you are dealing with a 2 year old throwing a tantrum, but without the 2 year old's good behavior. How would you deal with that?

Since she is coming in for regular treatment, can she be required to sign a contract that specifies what acceptable behavior is and what penalties are applied for breach of contract? Pain management doctors do this with patients who have a history of drug seeking, drug abuse, selling their meds, . . .

Their are many possibilities, but you are in the best position to figure out what will work. Talking with the rest of staff, including the doctor, is important. If you are not all together in your approach, she will play you against each other.

You could bring in your ukulele and try to sing like Tom Waits. Maybe if you make her laugh, you find the human underneath the porcupine.

Albinoblackbear said...

BINY- Thank you for the comment, it has gotten me thinking and has fueled a post of its own...but in the meantime, regarding the PICC...

Normally I would agree, however in her case, I don't think it would be the best choice for a few reasons...she is on short term therapy (most likely a week--tops) and she has fabulous superficial veins. It is not that she is a difficult start in the traditional sense, it is that she has been demanding they be changed and then has a MELTDOWN when it happens (hence me kiboshing that plan the other night).

Also, I think it would likely just feed into her pseudo-Munchausen personality to have a specialized procedure that requires more attention from staff (and thus everyone around her).

IMHO the risks of PICC insertion outweigh what benefits we could maybe see from it (i.e. it mostly being done to save us having to go through more IV starts) and she would likely find problems with the PICC and want it changed anyway!
Therefore more wasted resources, more catering to crazy lady.

Call me jaded and undereducated (I am sure that I am both) but those are my thoughts on that matter. ;)

More to follow in response...

Rogue- Thank you also for all the suggestions. Your comment reminded me of something I heard a doc say the other night at work, "hey I can order the pain medication but how much of it hits the floor while the nurse walks to the bedside is entirely at her discretion".

I was (naively) shocked! I must admit! All the other nurses just chuckled but my jaw actually dropped. lol! I have done some 'bending' shall we say of orders in my day but I have never never never thought of withholding pain meds. I would rather have a snowed a-hole than a howling-in-pain-real-or-imagined a-hole. She was only getting acetaminophen anyway...

I like the isolation idea, the quiet room (which is usually reserved for prisoners when they come in with guards) would be perfect. I wouldn't have thought of that...hmmm...yes...take away the audience. I like, I like.

I did talk to the staff and asked the doctor to 'make her go away' which he did by telling me to d/c her. :)

Though he didn't put her on PO meds which would have been the best (albeit not as medically prudent perhaps).

And it is a good point about playing the staff against each other (which she was). I have worked with enough borderline personality disorders on the crisis unit to see those folks coming a mile away (the gut rot feeling I get around them actually is the dead giveaway--true fact).

And HEY are you callin' my sweet mandolin a UKULELE??

Watch it! Them's fightin' comments!!! ;)

Rogue Medic said...

When dealing with a patient in pain, there are a variety of methods of dealing with the pain. Especially if the pain is partially due to the patient's exaggerated gesticulation. Withholding pain medicine in exchange for cooperation, cooperation that would benefit other patients, is not unethical, in my opinion.

They will get pain medicine when they behave in a civilized fashion. I am not referring to the screaming in pain and foul language due to something that is extremely painful. I don't know many people who have not heard and used foul language. The easiest way for me to manage that is to manage the severe pain.

A manipulative semi-Munchausen's jerk (not at all redundant) does not deserve the same consideration about pain management. Although I would be happy to snow that patient - more for the benefit of the other patients and staff, than for the patient's CRAP score.

Isolation-wise, you do need to be able to keep an eye on the patient to make sure she is not doing anything dangerous, getting up and falling, pulling out the lines, . . . . These are all things she could do in the middle of the ED, but she has more time to do them in isolation.

I am too ignorant to recognize the differences among a banjo, a ukulele, a guitar, and a mandolin. I am certainly not qualified to make judgments about the quality of the instruments. Musically, I am only qualified to listen and keep my mouth shut.

Bostonian in NY said...

Not to nit pick on the details, but if she truly had pyelo she would have been on a longer course of abx. Perhaps she was d/c'd after 5 weeks of treatment with central access. I know that my deparment would stick one in if it was more than a week of therapy just to save everyone the trouble of dealing with her. I don't know the whole story, so I'll refrain from speculation and sharing my thoughts on nephrology.

But I think there's a bigger picture problem:

She is not an ED patient!!! Your nursing resources should not be used for her in the first place. She should have had a PICC in with a visiting nurse to show her how to use it twice and a follow up to have it removed instead of taking up a chair, an hour of your time and a week of your patience. Personally, I would have written for another week of abx just to put the PICC in and save everyone the trouble. The fact that it became your concern at all was due to the misappropriation of your time by a doc that you've never met in a situation that sucks.

Common sense is the Rx for most of medicine's ailments...too bad the people at the top don't have much of it.

Bostonian in NY said...

addendem to above:
-I think the major benefit to the PICC is that she'd be at home, avoiding the nastiness/hassle of the ED and she'd be a much happier person. Sometimes convenience for the patient is overlooked as an important benefit which can raise barriers to royally piss off every nurse in a mile radius while she bitches into her phone. Board-wise you may be correct in the indications for a PICC, but practicality wise why would you send someone like that to sit in an ED for IV abx every day for a week?

As a side note: pyelo is a pretty legit medical diagnosis, versus the usual Munchausen type production of symptoms (fecal wound infections/fake cancer). For your step ones in a couple years: she comes across as a somewhat histrionic'll know it when you see it.

Albinoblackbear said...

Rogue--Sorry, I didn't mean to imply that what you were suggesting was unethical. It just had never occurred to me. I think your point was well made and I agree.

BINY--*hands up* OK OK I concede. You're right. (Wow! I can say that to a male! lol)

"She is not an ED patient!!! Your nursing resources should not be used for her in the first place."

BINGO! Couldn't agree more. In our ED we actually have an ER RN that is assigned to ONLY IV ABX on evenings (when the planets align and there is actually a full staff load working, which is never hence me agency nurse working there) because of the large volume that come through the dept. It is insane and a terrible use of resources, space, time...but that is the problem with t.i.d.

They get the two daytime doses at ADC but then have to come to the ED for the 2300h or 2400h dose (there is no homecare late at night for non palliative folks in this region).

And yes, you're right (that's twice in one night now...I must be tired) about the histrionic personality. Much more accurate overall diagnosis...when I referred to her pseudo-Munchy it was in regards to her gross exaggeration and attention seeking behaviors (yes--more histrionic) not that she was faking a pyelo for attention.

What I should have said were her total cluster B traits which were apparent from the get go. I used to work in a 6 bed lock down acute psyche ward and 8 bed crisis unit for over a year before I switched into full time ED. Which was, I think, part of the reason I was so pissed with myself for how I handled the whole situation. I used to know how to diffuse these things and deal with this stuff but I haven't worked in those trenches in almost 5 years and like anything else, if you don't use it, you lose it.

So I stand corrected.

Nit picking good...keeps me on my toes. Between you and Rogue I feel like I need to have 4 recent journal articles on hand now before I open my big mouth!


No really, I enjoy it. Thanks to both of you for the comments.


Bostonian in NY said...

I really need to stop posting comments after 13-14 hours in the hospital dealing with surgeons and sick people...they're making me anal retentive and nit picky.