have become superstitious regarding compliments at work. Being an ED physician, “thank-yous” are certainly few and far between. Most of the time if someone approaches me from an administrative position or from another department with the opening line “do you have a minute?” or “do you remember that case?” my defenses go up immediately. Other ED physicians I have spoken to say they have the same reflex. It is rarely good news. Emergency Medicine is like being a race car driver. You are on a high-speed track and will eventually be stuck in the pit or hit the wall. Complaints and patient care issues are inevitable when facilitating care of a high volume of patients, usually under highly stressful conditions, often fatigued, while handling a wide range of patient acuity. So, I was ecstatic this past week when an administrator provided a back handed compliment. He stated that he had recently been contending with patient complaints in regards to the care provided by my colleagues and added that it had been a seemingly long time since anyone complained at all
about me. I should have known at that point in the conversation that I was a doomed!
The shift started simply enough. The full moon outside should have been my additional warning. I had gone to my computer station, cleared out charts that needed to be completed, and printed up the nurse’s sheet for the first patient of my shift. As I was standing at my computer terminal, to my left I overheard the voice of a very animated woman conversing across the desk to a nurse. I printed up the nurse’s sheet for the first patient of my shift, assured that by the time I came back she would be gone. When I returned to my work area, I noticed the increasingly boisterous woman still in the same spot, sandwiched between the suture cart, the desk, and me, such that she was essentially on top of me. In an attempt to be polite, I let her finish her discussion for several generous minutes. I attempted to focus on my documentation and execute a few orders. I found it increasingly difficult to concentrate with this woman’s voice echoing from such a close distance. I finally turned to her and cordially explained that I would appreciate it if she continued her conversation a few feet down at the other end of the desk. She suddenly lashed out at me. “You are rude and inconsiderate!” “This is the worst hospital I have ever been at!” I tried to explain that this was my work area and explained I had to protect the patient data I was working with as required by law. She would hear nothing of it. I, on the other-hand got to “hear” all of “it” from the nursing supervisor twelve hours later! Apparently, the woman in question later contacted the offices of nursing administration to complain. The woman made it clear to the supervisor that she felt that I made the presumption that she was “white trash,” as she stated “because I didn’t have time to do my hair!” Not only that, but this woman actually recommended that I be slapped for making her feel that way. -And this was just complaint number one of the evening.
I wish I could say that my night improved much after that. The shift consisted of multiple patients brought in by police in handcuffs, crisis patients needing immediate psychiatric intervention, with several being exceptionally violent. I let the few less complex patients linger in the fast track area just to stabilize the escalating psych patients and appropriately manage those that were medically unstable. My plan was to subsequently move on to see some of the non acute patients in fast track.
I prepared to see a young woman with back pain and printed the nurse’s note. Figuring this would be an easy case, I quickly reviewed the triage information. Vitals all looked good and the narrative discussed how she walked from the waiting room down the hallway and into the room without difficulty. I then decided to take a quick look in our chart records to see if she had presented to the hospital in the past and if there were any further helpful details in her history regarding today’s complaint. Multiple presentations were present for dental pain and ankle pain, with prescriptions being provided every week or so for Vicodin and Percocet. I was suspicious but was going to give her the benefit of the doubt. I introduced myself from the doorway and immediately noticed an absolute discrepancy in her movement as compared to the triage note. She was ambulating with overt difficulty to such a degree that she could have doubled as a female version of Lurch from the movie The Addams Family. Her movements were all slow, exaggerated, with hesitating motions, wincing and moaning. I obtain her complaint history and performed the physical examination. Subsequently I explained I wanted to get a few tests. I reassured her that based on the lack of risk factors for bony pathology, I expected the result would be a negative workup and most likely the diagnosis of lumbar strain. I added that we could most likely manage her well with some muscle relaxants and anti-inflammatories until she could she her doctor the next day.
“I’ve tried those, and they don’t work,” she responded.
I offered her a generous IM dose of Toradol, explained it’s benefits, and recommended subsequent doses of muscle relaxants as well. She scoffed at my suggested plan of care.
“You can see your primary doctor in the morning for further workup if we find no significant pathology tonight.”
“Can’t you give me anything stronger?” She asked.
I explained my concerns for the freqeuncy of presentations over the last several weeks, including multiple prescriptions for narcotics. I impressed once again that the discharge plan with Toradol would be effective and her primary doctor’s office could proceed with further management the next morning. The next few minutes consisted of the patient trying to convince me that my plan of care would not work because every medication I recommend was not strong enough. I finally had to excuse myself and proceed to other patients.
A few hours passed and the x-ray order column never lit up as completed on the computer terminal for this patient. I wondered what had happened.
The nurse’s narrative said it all. “The patient refused the x-rays and left.” Furthermore, I was rude and called her a drug addict! While I did express concerns regarding the frequency that she had presented and received narcotics, the words “drug addict” never were uttered. Fortunately, during the patient’s stay she did provide a urine specimen for a drug screen. As I reviewed the result, I noticed that the patient was positive for opiates despite her claim that she was not taking any medication at triage. Do I believe I said anything in an even remotely rude manner? No. However, I then imagined yet another complaint for me to address with administration on the horizon.
Things continued along the same vein for most of the evening. It was as if the forces of darkness were out to squash what good graces I had left with that mighty administrative complement.
Several patients who were regulars with psychiatric histories were “holds” in the department. The nurses were approaching me with requests for pain medications for several of these patients. At one point, without my mentioning a patient’s name, I verbalized at the work station to a nurse how I didn’t want to write for any pain medications for one particular patient as I wanted a chance to reassess her. I explained without mention of identifiers how this particular patient is frequently in the ED for various complaints and has multiple psychiatric issues. For whatever reason, I immediately afterwards seized the opportunity to show a newly hired nurse nearby how to pull up old records on our chart documentation program. I proceeded to show her without verbally mentioning any names or identifiers, how to pull up old records using a patient for which she was the primary nurse. Several minutes later, this same nurse approached me a few minutes later stating “You know, that lady in room K thinks you were talking about her! I apologized to her for you!”
Great! I new I was in trouble.
I reviewed the nurse’s notes and scanned the last several presentations. Sure enough, this woman had a psychiatric history as well as a substance abuse history.
Entering room K, the patient laid into me. “I have had a problem but it is taken care of!” I explained that I had not been speaking about her and she overheard a partial conversation not related to her at all.
“Miss, I don’t think I have ever seen you before. I only now accessed what is documented in your old records.”
I further explained that, as such, there was no way I therefore could have been referring to her. At the time, she seemed satisfied. Care was rendered appropriately. Nevertheless – a complaint was filed. While only a conversation was held without any identifiers at normal voice modulation at a designated work area, administration was alerted to a HIPAA violation complaint.
So there you have it…. I’ve become superstitious.
While I have had a black cat for years, along with a house number that happens to be 13, I never gave credence to superstition in the past. For now on, if I dare ever receive an administrative complement again I am going to immediately see if I can switch shifts with someone. Clearly such a happening is a sign for an ER physician that the forces of darkness are out to get him!