I‘ve been called an "Asshole" by a patient two days running now. I guess I have to reluctantly plead guilty in the first instance. The second, I’m not ready to admit it yet.
Here’s how the calls went down.
***
The first was for a diabetic, altered level of consciousness. 40-year-old man lying in bed with glazed over eyes, cool, clammy skin, no idea what time it is, but he knows he’s an insulin dependent diabetic. His sugar on finger stick is 35.
There are a few different theories on how to treat conscious diabetics with altered mental status. Some medics like to give them orange juice and something to eat. I tend to prefer to go ahead and put a line in and give them the D50 and just take care of the issue. Officially in our protocols, the line is defined by "alert with intact gag reflex." "Alert" is somewhat open to interpretation. Now obviously every medic is going to have a line they draw between their decision to give juice or to give D50. Where another medic draws the line is not as important to this story as this patient is right on my line. I decide to pop a line in. I’d rather just take care of the issue and be done with it than going through trying to get him drink and then waiting for his sugar to gradually come up to a point where he can competently refuse transport, which is what most of diabetics do when they come around. By most diabetics, I am talking about the young, independent insulin diabetics who occasionally drop their sugar when they forget to eat and who have been through the whole ED rigmarole on other occasions and just do not want to be transported.
I put the tourniquet around the man’s arm, spot a vein in his AC and no sooner have I put the needle into the skin, then the man swings his arms and says, “I’m not going to the f-ing hospital. Don’t you stick me with an IV.”
Now I am annoyed that I have now missed the IV on the only vein I could see, so instead of doing the smart thing and saying, “Nobody says you have to go to the hospital,” I start reasoning with him in a way that he cannot understand. I am trying to tell him that while he cannot refuse right now because he is not competent, in a minute after I give him some sugar and make him competent, he can then refuse.
It of course goes right over his head, and then he punches me and calls me an asshole.
Things can get out of hand so quickly.
I grab his arm to keep him from punching me again and the cops then grab him and start yelling at him and everyone is yelling at everyone else. He is screaming "I know my fucking rights. Just let me drink some coke."
There is an open can by his bedside which his roommate had tried to pour in his mouth before our arrival and he manages to break through and then pours half the can on me and himself as he tries to chug it. I find myself hindering his efforts to drink it because I am still pissed that he clocked me, messed up my IV and spilled coke on me.
In the back of my brain unable to get through is a voice that says, "Hey, if he can drink, let him drink, maybe he isn’t as altered as you thought." The other voice is saying, "He can’t talk to you like that. Christ, he hit you, if he’s alert, he’s going to jail. You give him an IV and give him sugar, he doesn’t have to go to jail. He hit you because he was altered."
With the cops yelling at him and me with a good hold on his arm, and him calmed down just a little – maybe the coke did it -- I quickly stick in another IV and push in half an amp of D50 and within another minute, he is apologizing for his behavior, and I am saying that’s okay I have seen worse, and he agrees to eat, refuses to go to the hospital, admits he overslept, says he is a brittle diabetic and should take better care of himself. His sugar is up to 200 now. Etc, etc, we get the refusal.
Outside, I apologize to the officers for not handling myself better. I shouldn’t have antagonized him at first. But what I am really thinking is I walked a fine line between providing the right care and committing assault. Something about it just didn’t feel right. I think what happened is in the course of the call, he went from being not alert to being alert, he crossed my line himself, maybe due from the Coke his roommate had poured in his mouth kicking in, supplemented by the Coke he poured in himself, and I wasn't nimble or ego-free enough to change my course of action. It became about me versus him, rather than me versus appropriate medicine. I think next time my line between IV D50 and giving the patient a chance to drink some juice to see if he can drink it okay has moved closer to the juice side.
***
The second patient who called me an asshole had a history of chronic pain -- back pain, sciatica, fibromyalgia, migraines. You name it, if it had to do with pain, he had it. This is an old patient for me. I used to take care of him years ago. You’d find him one day in bed, unable to move, complaining of pain all over, and acting almost stuporous and then the next week see him out bare-chested showing off his nearly full body tattoos as he mowed his lawn.
Now he says he takes Darvocet, but his new doctor recently reduced the dosage. He tells me he hasn’t had any pain pills for a week. I ask to see the Darvocet bottle but it is nowhere to be found. He has his other pill bottles -- pills for hypertension and gastric upset -- but no Darvocet bottle.
I ask what happened to the pills his doctor gave him last week, but he won’t answer my questions. He just closes his eyes and moans. If he lowered your dosage, you still should have some pills, did you not refill the prescription? Did you lose the pills? Did you take too many? No answer. He can answer other questions, but not these. I ask why we aren’t going to the hospital he normally goes to, and he won’t answer that either.
Admit anything to me – you were in so much pain, you took six a day -- just don’t refuse to answer my questions when you are competent to answer. I am here to help.
But he won’t answer. Whenever we get on a touchy question, he just moans and closes his eyes.
I should just say “whatever" and transport him BLS and let the hospital deal with him, but I keep up asking the questions, my tone getting harsher and harsher. I am clearly starting to get pissed.
He finally opens his eyes, looks right at me, and no slur in his speech, says, “You’re an asshole.”
“If you are alert enough to recognize that I am an asshole," I say, "then you are alert enough to tell me what happened to those pain pills.”
I am into pain relief. I have no problem with being taken by a drug abuser if it means denying someone with legitimate pain relief. I fully understand the devastating effects of chronic pain, and how it can turn otherwise normal, upstanding citizens into drug seekers out of fear they will not have enough medicine when they need it. My bonafides are solid on this issue, but he is getting no inch from me because he will not be straight with me. “You can answer. You want me to help you, answer the questions. What happened at the other hospital and what happened at your doctor’s office. Where are the pills he gave you? Tell me a believable story.”
He won’t look at me. The volunteer riding with me sits across from me looking at me like I am being so mean to this man. I feel like saying, "Go ahead, call me an asshole, too. I know that's what you are thinking."
I give my report at the hospital, and then leave. This morning when I go back, I ask what happened to the man and I am relieved to hear they concurred with my impression. The man was abusing prescription drugs, doctor shopping and when he was told he wouldn’t be getting any medicine, he stormed out of the hospital.
***
I’ve done two calls today and both patients have thanked me afterwards. I do admit to trying to be extra nice today.
Even though I was right about the man with chronic pain being a drug seeker, in retrospect now, I think I was an asshole to him, too.
And no matter what, I don’t ever have a right to be an asshole to a patient.
