As our hospital administrator emphasizes the importance of high patient satisfaction scores and “pleasing every patient every time,” I’m really becoming disenchanted with emergency medicine. He’s getting his directives from the hospital board and being pressured by statistics on some web site that only administrators look at, so it’s tough to blame him, but this medical system is really heading the wrong way fast.

Patient #1:
A 18 year old female is brought in by her mother complaining of lower abdominal pain. She’s doubled over while she’s walking. After the nurse gets the history, she hands the patient a gown and tells her that she needs to get undressed for the exam.
“I’m not getting undressed for you. You’re all stupid here.”
“We’ll if you want the doctor to try to help you, you need to get undressed and put the gown on.”
Then the patient’s mother says “Honey, why don’t we start by putting the gown on?”
The patient replies “Why don’t we start by you shutting your f***ing face?”
Then she whips open the door and leaves.

Patient #2:
A 22 year old female also complaining of lower abdominal pain. She is accompanied by her sideways-hat-wearing pants-on-the-floor boyfriend. Urinalysis was normal, so I explained to her that we needed to perform a pelvic exam to look for other causes of the pain.
Boyfriend immediately chimes in “Yo! Ain’t nobody looking at my woman’s s*** but ME!”
I looked at the patient. “Do you want me to do the exam?”
She shrugged her shoulders and said “I guess so.”
Then I told boyfriend that he needed to wait outside. He pulled his pants up, puffed out his chest, and left.
The patient was ultimately discharged with diagnosis of an ovarian cyst.
Following day, the nurse manager finds me and says that boyfriend came back to her office and wanted to know my name because he was going to sue me for raping his girlfriend.

Patient #3:
Drunk guy brought in by police after beating up his girlfriend. He was fighting with police, so he was cuffed and escorted by a couple of officers. When he got to the ED, he was still fighting and threatening the staff, so he was put in 4 point restraints. Then he started in on one of the officers.
“You won’t be able to keep me in these things forever, you know. I’ll get out. When I get out, I’m going to find you, throw you up against your police car and [sodomize you].” The term that he used was too vulgar to post.
He could see that he was getting on the officer’s nerves, so he kept it up.
“Yeah, maybe I’ll even let your chief watch. I’ll enjoy every minute of it hearing you scream like a b***h, too.”
All the while the officer just stood there until he was secured in restraints. I don’t know that I could have stood there with this guy talking like that to me and not done anything.

There were other similar encounters. They all took place within two days. All of these patients will receive patient satisfaction surveys. I doubt any of them will be “pleased” as our administration desires.

Treat a judge like this and you get thrown in jail for contempt of court.
Treat an employee this way and you get sued for harassment or sexual discrimination.
Treat an average person on the street like this and you get a fist in your mouth.

When people can come to your place of employment and treat you like a piece of toilet paper – yet your continued employment depends on pleasing “each one of them every time,” it’s time to think about whether to continue practicing medicine.

A grandfather brings in his 14 year old grandson because the boy hurt his wrist … for the second time in two days. The first time he was  brought to the emergency department, x-rayed, and was diagnosed with a Salter Harris Type I fracture. He was put in a splint and sent home.

This time, he was wearing the splint, fell while walking, and had more pain in his wrist. There wasn’t really any point tenderness or deformity on his exam, so I explained that we weren’t going to change the management and we didn’t need to repeat an x-ray because even if there was a small fracture, he was already in a splint.
The grandfather argued with me for several minutes because he felt the patient needed an x-ray to make sure there was no fracture. I finally got fed up trying to reason with him realized that my diagnostic skills leave something to be desired and just ordered an x-ray.
The patient and grandfather had to wait another hour to get through the line waiting for x-rays.
After the x-ray came back as normal … like I was saying, he’s already in a splint, so we aren’t going to change the management. Continue taking the ibuprofen and see the orthopedist for follow up.

“He wants a cast on his arm,” remarked Grandpa.
“I beg your pardon …”
“You need to put a cast on his arm. He wants a cast.”
“No. Sorry. We don’t put casts on in the emergency department. He has a splint to protect his wrist from injury. You need to see the orthopedist for follow up and he’ll decide whether he wants to put on a cast. That’s not something we do here.”
Then the patient chimes in.
“I want a cast NOW!”
“We don’t put casts on in the emergency department. Your arm will be protected until you see the orthopedist. The nurse has your discharge papers.”
“I’m not leaving without a cast!”
“Why do you want a cast?”
“I just DO. I want a cast NOW!”
“I’m not going to argue with you. We don’t put casts on in the emergency department and you aren’t going to get a cast put on today. It’s time for you go home now. Have a nice day.”

I left and went to see another patient, hoping that the patient would be gone by the time I was done.
Ten minutes later, I walked out of the other patient’s room to see that this kid had backed himself into a corner by the exit door, was holding onto a wheelchair, and was loudly stating “I … want … a CAAAAST!”

We called security.
Several security guards then lifted the patient onto the wheelchair and wheeled the patient out to the front of the hospital. The grandfather went to pull the car up to the door.
Then the patient jumped out of the wheelchair and started running down the street.
Grandpa pulled up in the car, rolled down his window and said “I’m not dealing with him when he’s like this. He gets out of control. You’re going to have to call the police and transfer him to a psychiatric hospital.”

The police had already been called and apprehended the patient a block away. He punched one of the officers, was put in handcuffs, and tried to bite another officer. Guess where he ended up.

Back in the emergency department – psych room.

There, the patient threatened to kill himself and everyone else in the room. He was dropping F-bombs left and right and was trying to hit and bite the staff. It didn’t take long for the patient to be put in four point restraints, and then to receive 5mg Haldol and 2mg Ativan. Funny that he didn’t complain of his wrist hurting any more.

Six hours later, we still weren’t able to find a psychiatric hospital willing to accept a violent child. Either they only took adults or they didn’t accept violent patients. The grandfather wanted to leave, but was told that he needed to stay with the patient since he was a minor.

During one of the times I went in and re-examined the patient, the grandfather looked at me and sneered “None of this would have happened if you just put on the cast like he wanted.”

I just smiled. After all, Grandpa would soon be receiving a survey to rate my clinical competence in the care of his grandchild and I do want to receive all “excellent” scores, you know.

Saddest part of the whole encounter was that one of the phlebotomists used to babysit the patient when he was younger. She said that the patient was normal until he started being put on psychiatric medications for attention deficit disorder. Now he was on four psychiatric medications and had been in and out of psychiatric hospitals for emotional outbursts such as this one.

But at least he was able to focus his attention.

If you’ve ever tried to insert an intravenous line before, you know how difficult of a task it can be with a child. Adults usually have thinner skin and most of the time have (not always) less fat on their arms. Infants and toddlers have lots of pudge on their arms and seeing a good vein is usually difficult and often impossible. The nurses who are really good at starting IV lines – the ones that everyone in the hospital calls in a pinch – have their little tricks for getting IVs in place.

Often the veterans know that you can’t always go by sight. Sometimes veins are deep enough below the skin that you can’t see them, but you can feel them. When the hospital staff ties the tourniquet around your arm and starts prodding you with their fingertips, they’re seeing if they can feel any of the veins. Almost like the way a safecracker feels for the tumblers in the safe to drop when turning the dial.

When the veins are especially difficult, one trick that many providers use is to remove the fingertip of of the index finger of one of the rubber gloves, put a little betadine (disinfectant) on the exposed finger tip, and use that finger to palpate for a vein.

A mother who worked as a phlebotomist at another hospital (and who was badmouthing that hospital to our staff) brought her young child in for evaluation of a high fever. The doctor working that night ordered some blood tests and some IV fluid. One of our best nurses pulled the finger off the tip of the glove, put a little Betadine on her fingertip, and began palpating the pudgy kid’s arm. Immediately, the mother whipped out her cell phone and started texting someone.

No one thought much about it until the child’s grandmother called the emergency department and said she received a text message that the nurse was performing an “illegal procedure” by pulling the fingertip off of the glove.

Fifteen yards, repeat first down.

The nurse was trying to avoid poking your kid a couple dozen times before having to insert an intraosseous line. Next time, we’ll keep the fingers on the gloves. No problem.

Sometimes we just can’t win.