Step back and start over

Every doctor has had this patient.  You know the type?  The type that has an actual illness, or had one in the past, and now there is no evidence of anything active, but the patient shows up at the ER every other week, and knows the system enough to use the perfect buzzwords to get admitted?   The one who’s always complaining, but you don’t believe them.  The one who somehow managed to call 911 for an ambulance FROM the hospital room when their Dilaudid took more than 5 minutes?  The one where you make an ultimatum: if you need that much narcotic medication, you can’t eat.  And then watch how quickly the pain med requirement decreases.  The one who is so sincerely wanting help while inpatient, only to be completely lost to follow up when discharged?

And let me just take a quick aside here: so, for a short while, the brilliant minds at my hospital thought it was a good idea to invent something called “Code help,” where a patient could pick up the phone in their room and call this “Code help” if he was feeling ignored by the nurses, and there was a problem evolving.  This would essentially trigger a rapid response team to show up.  Brilliant use of resources!  What could possibly go wrong??

Anyway.

We’ve all had that patient.  More than likely, the patient initially had real pain, but somehow, now has perceived pain or is malingering in order to manipulate the system for narcotics.  Also more than likely, there is some psychiatry involved there, because no one who is “normal,” and note that I am using quotes, would display this type of behavior.  There is either a bipolar depression, or a personality disorder, or even just good old polysubstance abuse muddling the whole picture.  You probably highly dislike this patient, although you know that’s transference, and you really shouldn’t be forming personal opinions about patients at all, and especially based on your short term interaction in the hospital.  But you just can’t help it because the patient has so few redeeming qualities.

Every admission, you probably get paged a few times a day with inane complaints from this patients, ranging from the wrong diet order to demanding an increase in Dilaudid (watch out for the code help!), and you are so sick of it, and so is the nurse who is paging you, but she has to, and together you roll your eyes and throw your hands up in the air, like, how the heck are we going to get this person out of here??

And on and on it goes for those multiple admissions.

Until one day, you show up in the morning to discover that this patient has been moved to the ICU overnight.  Flummoxed, you find the hospitalist to find out what happened, because just yesterday, you two talked and the hospitalist told you, the consultant, not to bother seeing the frequent flier because things are status quo and there is nothing to do.  Just the same old battle over Dilaudid and diet.

Turns out, the patient had been complaining like always, and finally, feeling backed into a corner by the patient and the nurse, who is tired of constantly answering that callbell and ignoring her other responsibilities, the hospitalist orders a repeat imaging study.  There was a normal one on admission just a few days ago, and no new finding is expected.  But…  instead, a frantic radiologist calls to report massive amounts of free air in the abdomen?!

(That’s bad, by the way.  It means one of the viscera, a hollow organ in the belly, like the stomach, or the intestine, has blown a hole in its wall, and now, air, poop, juice, acid–whatever the contents–are leaking out into the abdominal cavity.  That’s bad.)

The patient looked alright, but seeing as how bad the imaging study was, a surgeon comes, and as if on cue, the patient shit the bed.  I use that term, figuratively, of course.  I mean crumped, crashed, suddenly got a lot worse.

So, by the time morning came, an intubation, an emergency surgery, initiation of big-gun antibiotics, and several pressors (medications to make sure the patient’s blood pressure doesn’t get dangerously low) had been started.  And the situation was still tenuous.

Imagine the shock and the guilt you feel suddenly?

This is why you don’t cry wolf!! You say to the hospitalist.  THIS IS WHY you don’t CRY WOLF!

Though, arguably, the problem probably occurred in the last 12 hours of the hospital stay, and would have happened regardless – there was a normal study on admission after all…  And thank god complaints weren’t ignored too long and there really wasn’t a delay in diagnosis or treatment… But still!  Such misjudgment doesn’t feel good.

All I’m saying is, the transference, annoyance, and distrust of the patient are normal human reactions to past abusive behavior, because that’s what the patient’s behavior was: abusive of the system.  Our judgement can be clouded by feelings.  Our clinical judgement is also greatly affected by what has happened to us and the patient in the past.  “Have you had it before?  Well, you got it again!”  Same old, same old.  We must remember that medical and psycho-behavioral conditions CAN co-exist in one individual, and most likely, you will have some trouble telling them apart when the patient presents.  But we must be cognizant of that fact, and when things are not adding up, we must be able to step back and start over.  Otherwise, time to call it quits.

*note: details have been changed to protect patient privacy.  See disclaimer in the “preamble” section.