My First Time

I remember my first inpatient experience well. The patient is burned into my mind as a constant declaration of the ignorance that I held entering the clinical aspects of medicine. To be honest I found this person disgusting, repulsive, and inhuman. A perception that I did not wish to have betrayed to my superiors or my patient.

This feeling was uncomfortable and appaling. Over the last 2 years I’d been indoctrinated with the ideals of the “ethical physician” and the “professionalism” I must inculcate before meeting real patients. Despite the many fantastic thoughts and discussions we as a class had entertained, these forums, as well meaning as any, were utterly useless upon this first meeting.

Homeless, IV drug addicted, and crippled with disease, the patient came to us earlier that morning while I oriented to the inpatient wards. Upon entering the room I beheld a haggard, disheveled, and desperate form. Reeking of a filth known only to years of hardened drug use, I realized and withheld the primordial urge to retch and vacate the room.

“A full history and physical.” was the task charged me by my senior resident. "You will need to get a full H&P, write it out, and present it to me later today along with a differential and plan." Considering I'd never done a full blown physical, I knew I would need at least an hour with this patient and was not looking forward to our prolonged encounter.

Even though the intern was finishing up his H&P when I entered, I had to revisit every last detail already procured. The patient, clearly upset over this obvious intrusion, deferred several questions, cursed my stupidity readily, and resisted any attempts at a full physical. The anger inherent in the eyes was penetrating. Trust was not given nor expected, just more hurt, and he wished to inflict it before receiving.

Over the next week and a half “my patient” grew more tiresome. Pre-rounding was endless, useless, and ultimately absurd. The only information gathered was from forcing myself on the chest wall, abdomen, back, and head in order to elicit the heart sounds, breath sounds, and other physical tasks requisite of me after questioning the lethargic night nurses for overnight events.

Once able to hold a semblance of conversation, my patient soon withdrew from everyone and became mute. On one occasion I found my senior yelling in exasperation as she attempted to get consent for treatment. She no longer rounded unless the attending requested – leaving only the intern and I looking after the patient in the early mornings. The hate emanating from those eyes was palpable. We all felt it.


Regardless of the hate, the battles, and the apparent lack of concern about their declining condition the patient did not leave. Eventually a surgeon at another hospital agreed to fix the problem, and they were thankfully transferred off our service.

A month later, while on surgery, I heard a coarse, rough, and demanding voice yelling from a room.

“NURSE!” it boomed out of the darkened room. Despite the days of silence, I still instantly recognized it as my former patient’s.

My first instincts were to walk away and ignore the voice. I was no longer on this service and thus, not responsible for this patient anymore. However, for reasons still unknown to me, I walked into the room.

Upon my entrance I felt the same misgivings I had previously. There the patient was, improved in some ways, but in others very similar. I wondered if the reasons for another hospitalization were due to drug use and thought quickly about the cost of treatment they’d received that would surely never be collected.

I informed my former patient that I was not the nurse, but would let them know they were needed. Then, turning to leave, I said as calmly as I could:

“I hope that you’re doing everything you were asked to get better. A lot went into your care to get that surgery and I don’t think you realize how hard it was to get that taken care of…don’t blow it.”

I then walked out. A part of me felt vindication – speaking out against the wretch who hated those trying their best to improve a hopeless life. However, another piece of me knew that my innocence of doctor-patient politics had been forever lost. The urge to “want to help those in need” had been challenged and clearly weakened. By saying what I did I had only perpetuated its decay, amongst both parties. Despite knowing that I should have remained silent, I felt the need to let this person know were tried for them. We worked hard, against a system designed to hinder progress and I was upset by their seeming displeasure of my team's daily work.

This patient still haunts me. I’ve not seen them since, but I frequently think of them. I did not hate this person, but I entertained such desires at times. In my innocence, as a 3rd year medical student, fresh on the hospital wards, I wanted my patients to want to be helped. Furthermore I hoped that they would appreciate our efforts. Unfortunately I learned that it’s not that simple and patients, like those caring for them, are people first and foremost. Some are just better than others.

ER Abuse

Scalpel has been talking about the pain scale and pain-seekers recently. Reading these entries got me thinking about a trip I had to an ER during med school and the lasting impression it left with me.

Between 1st and 2nd year I had a research project that fell through. Since this occurred late in the year I decided to just get a job and work over the summer. I don’t really like research anyways and my Orthopeadic frenzy had significantly subsided so I didn’t feel research was absolutely mandatory at that time.

I returned to work for the company I’d been with prior to med school and was given a job in the backroom where I would stock and pull items for the salesfloor. This entailed some heavy lifting which aggravated my back already damaged from poor weight lifting during high school. I began taking Aleve in the mornings before arriving to work in order to move better and decrease the stiffness I was appreciating in the morning. This seemed to be working well until 4 weeks into the job.

One Saturday morning I awoke with a great deal of pain. I found that I had a significant amount of trouble getting out of bed and walked bent over since straightening caused a great deal of discomfort. Some NSAIDs and attempts to stretch out my back resulted in little improvement. Deciding to rest my back, I laid down for a period of time, hoping for a “miraculous” improvement. Instead my decreased range of motion and pain only increased.

I found that I couldn’t stand up at all. In fact, trying to walk resulted in me crying out briefly a rather nasty curse and falling to the floor. Wife found me crawling on the floor, unable to get out of this position, heading to the living room to sit. She decided that there was something very wrong and that I needed to go the ER. I resisted, thinking it weak and pointless; after all this wasn’t an emergency – right?

She persisted and I finally caved. The ride to the ER was torture, with every bump knifing through my back. In order to decrease the pain I was in the fetal position the whole ride. On arrival I tried to get out of the car, only to fall on the sidewalk from the pain. Wife ran in and found a volunteer who brought out a wheelchair. Humiliated, I again resisted, but eventually had to sit and be wheeled into the ER. They wouldn't let me crawl.

The staff was courteous and quick (not very busy at that time of day), but I continue to feel that they thought me a druggie. I rated the pain a 5/10 since I didn’t want the stigma of being a “seeker” and tried to be as helpful as possible in relating my history, but when everyone who wants drugs mimics this kind of pain I just knew they were talking about the “drug seeker” with lower back pain in room 12. It was frustrating to know that I was in very serious pain, had fought seeking treatment, and just wanted to be able to walk without severe shooting pain, but that because of parasites in society I was most likely considered an addict.

After some x-rays, a perfunctory exam by an NP (I wasn’t even taken seriously enough for an MD to waste his time on), and a shot of narcotic in the ol’ butt, I was discharged to follow up with my doc.

The narcotic and muscle relaxants worked wonders, allowing me some increased motion, but I was unable to return to work. An MRI done later per my PCP showed osteoarthritis of the lumbar spine with small herniations. I was informed that the kind of work I was performing was out of the question with my back and physical therapy was eventually needed for me to regain my normal mobility.

Now, I tell this story not as a lesson to be learned for all ER docs. Rather it is the reason that I find so many of the patients I’ve seen - who claim 10/10 pain, want Lortab or Dilaudid since they have “allergies”, and abuse our system - completely abhorrent.

It is the reason I decided to opt out of Emergency Medicine. I was just too jaded. It is because of patients like these that those who truly need the services of the ER are often initially considered addicts. It's because of asshole patients, cyring wolf constantly, who abuse our system that ER's are practicing defensive medicine. It's the reason I think ER's should get a free pass for all frequent flyers who they don't believe who present with an actual problem. You weren't believed? Too fucking bad!

Past

Oh, wait...that's passed! I guess my mediocre education and inability to think beyond what I've read just showed its ugly, narrow-minded, and racist head.

Or so I was told something like that by a stain on American culture patient today and her family. BTW: it's called a shower... take one!

Anyway, just wanted to say that I received my USMLE Step 2 CK results today. I passed. 98th percentile! Remember when I was freaking out last month? God what a waste of energy that was.

Mining for Gold

“How’s your pain today, Ms. Drugseeker?”

“It still hurts like hell!”

“How’d you rate it?”

“Same as yesterday, a fucking 10! God, why don’t you give me anything?” Her eyes demonstrate a clear desire for pain meds; desperate and conniving as is often seen in connoisseurs of opiates.

“We are giving you pain medications. We aren’t going to increase the dose at this point as you've yet to gain any relief over several days.” I lie to the patient. Really we know she’s full of it and we’re planning on taking her down, giving something for her iatrogenic constipation, and giving her the boot.

I proceed to complete the requisite physical check which includes the patient jumping with “pain” each and every time I touch around her left chest. Oddly enough every test performed to this date has come back negative. Wonder of wonders. She doesn’t have ACS, an MI, or any other problems - except drug addiction and vagrancy. I’ll be glad when she’s outta my hair.

I learned quite early in my 3rd year of training that some patients need a place to stay, some need a bed and a meal for the night, and others just want drugs and use the hospital for these purposes. Things that I knew already, but never quite understood how it was that they were able to manipulate the system so well. I've seen the scams and read about others. Oddly many are very similar, but unique with the person involved.

Ms. Drugseeker will receive a bed because she is middle aged, has abused her physical and psychological health for years, ingests varied amounts of drugs which she obtains by doing unmentionable acts, and has not seen a regular physician since Nixon was in office. An abnormal EKG results and labs will most likely surface, relegating the on-call team to take on this freeloader in a useless search for the etiology.

The patient stays, getting a bed, free food, free healthcare, free drugs, and a place for her hubby to sleep as well while the doctors, nurses, and medical students try to not think about the waste of money this person has become. Hubby remains sedated throughout the process until he hears they're being "evicted". Then he suddenly is concerned about his wife's condition.

Unfortunately for our society this is an all too common occurrence. Many private hospitals won’t take them and will either give a quick drug cocktail and/ or street the druggie. Then the charade plays out all over again, at another ER, another clinic, wasting the same taxpayer dollars; but nothing can be done because god forbid if the constant abuse of heath resources by a parasite might actually lead to the discovery of some illness. Then the lottery is in town.

Hell, we might find gold in them thar hills…so wouldn’t it be a shame to not go looking at the same or slightly varied complaint for the upteenth time while knowing full well that you‘re most likely not going to find anything other than someone who can only tolerate a “D“ drug? That’s what a litigious society has constructed for our kids.

Personally this abuse pisses me off. If we’re going to ever have a healthcare system that has any potential to become universal this exploitation has got to stop. Personally I like the idea that people have a certain amount of points that they can use. Use it up and your done for the month, year, etc. If you’ve been diagnosed with a legitimate disease that will increase your healthcare use then you receive additional points.

This would reduce the overuse of ER’s for minor ailments, reduce the ICU stays with ridiculous attempts to prolong lives already long lost, and might just curtail drug seeking abuse. Of course there's a lot to be desired from this plan; it won't define what an actual "emergency" is, it won't create jobs and decrease poverty/ addiction in many abusers, and it won't take care of the illegal immigrant crisis. But I like it in it's infancy.

Till then the exploitations will continue, the drug seekers shall refine and perfect their lies, the viral URI's will get treated with antibiotics at 3am, illegal immigrants shall continue to invade ED’s for each and every complaint to avoid INS troubles, and my taxes and health insurance premiums will continue to increase.

Not For Me

When did I discover it wasn’t for me? Basically a question often asked of me by underclassmen regarding my deviation from Emergency Medicine (of which I’m still VP of the interest group – when are the elections already?). Essentially I can honestly and without delay state that the time was during my Internal Medicine rotation.

I liked IM enough. I figure I could be a rather great internist because of the knowledge aspect and the detective work that goes into managing patients. I really enjoyed that part of Medicine. The problem that I had, however, was that I didn’t like the patients.

And not just the patients, I didn’t like the type of patients we mostly catered to: poor, underserved, homeless, etc. The “scum of the earth” as some might put it. I thought about these patients and how most of them came to us from the ER. I evaluated the prospect that I would have to deal with these kinds of patients on daily basis many times over for year and years. And I knew I couldn’t do it.

It just wasn’t in me. I would have burned out incredibly fast had I decided to enter this field of medicine. Partly because I think many of these social parasites shirk their responsibilities and trust in others to do everything for them while continiuing their immoral behaviors. I can’t remain humble and self-less to people that I can’t even stand to talk to or interact with in some semblance of humanity. For that reason I knew EM was not for me and I believe that these patients would be better off without me as their “primary care giver”.

Parasites

The way some people carry-on you think they were royalty. In a hospital that caters towards the indigent and uninsured I see a great deal of unwillingness in patients to help themselves out of their dire situation who will, at the drop of a hat, threaten to leave for a better hospital. They don’t like what’s happening here and they want better care. In short they feel entitled.

But here’s the thing: these other hospitals that these tragic patients want to have their care transferred to won’t see them. They’ll kick their asses straight out the door should they try and walk-in and they sure as shit won’t receive them as a transfer. Why? No ability to pay for services rendered.

So instead this hospital accepts these patients, hemorrhaging money by the millions each year in order to give the extremely poor a place to receive equal and fair treatment. Because of the huge financial pitfalls there are areas where we suffer. We don’t have the newest, most expensive, and most advertised machinery or treatment options. Instead patients receive quality care with methods proven to work. And all at almost no expense to themselves (since we all know they’re not paying for anything anyway).

Despite these efforts and the obvious level of gratitude that should be inherent in these people I often see them ungrateful. Upset at the conditions they “perceive” in a place that’s never out of the red.

“I’m going somewhere else. They’ll take better care of me.”

“You don’t know what you’re doing. Over at (huge research hospital with lots of fancy and expensive new equipment) I’d get this test done. I’m outta here.”

“I’m leaving AMA. I don’t care what you say. Some doctor out there will take me and care for me without insurance and a stable income.”

I hear these lines or variations everyday. Trying to explain to a patient who has not had a job in over 5 years, drinks 12 or more beers a day, smokes like a chimney, and has absolutely no means of paying for services for his congestive heart failure, kidney failure, and rectal cancer that no doctor in town will touch him other than those currently seeing him is just futile. They don’t get it. They don’t want to get it. All they want is a handout and feel entitled to the services and care received by the best insured and wealthiest in society.

I guess it’s the delusional aspect of many of these patients that got them where they are in the first place. Believing that someone will always take care of them, trusting in the fact that Uncle Sam will never stop giving them money or food or clothing. Ensuring that they’re not responsible for their own damn care – ever and behaving like spoiled children with surrogate parents. Why else wouldn’t they think they can get that new drug, fancy treatment, or costly surgery with little to no cost to themselves? It’s how they’ve been living their entire life.