Refusing to treat murderers

[GeneralVeers]

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I treat them all the same.. you have to. I have taken care of the rich, the famous, the poor, the drunk, the homeless. When I walk in the room I treat them all with respect.. how the rest of the visit goes depends on them.

I can agree with that statement. If people are respectful, honest, or not demanding then I will generally do my best to help them in any way I can.

If they lie to me, become verbally abusive with me or staff, or are trying to game the system I have a low threshold to throw them out.

 

[K31]

When treating prisoners, I never ask why they are in prison (acutally, usually jail when I see them at the county hospital). I don't see how it's relevant to their care, and it helps avoid issues like in this thread. Things like how long they've been in prison and how much longer they will be there I will ask, as well as social history questions that might lead to me finding out why they are incarcerated (drug use, etc.).

However, I'm having a hard time coming up with a situation where it would be relevant to their treatment for me to straight up ask them why they are in prison.

 

[turkeyjerky]

When treating prisoners, I never ask why they are in prison (acutally, usually jail when I see them at the county hospital). I don't see how it's relevant to their care, and it helps avoid issues like in this thread. Things like how long they've been in prison and how much longer they will be there I will ask, as well as social history questions that might lead to me finding out why they are incarcerated (drug use, etc.).

However, I'm having a hard time coming up with a situation where it would be relevant to their treatment for me to straight up ask them why they are in prison.

Really? I usually ask just out of curiosity.

 

[EM2BE]

Really? I usually ask just out of curiosity.

I do sometimes as well...if I'm in the mood / have time for conversation (people I get are jail, usually check up prior to jail or they will go to another hospital if they are in prison...so usually not a big deal in comparison). Had someone with a house arrest bracelet on the other day. I usually find out about those before I see them because they ask for a note for proof they were seen and were there.

 

[Apollyon]

Really? I usually ask just out of curiosity.

Yikes - I would much prefer just not to know.

 

[chimichanga]

Yikes - I would much prefer just not to know.

agreed.
for me, it's just not my business...

Used to work in a place that stamped the payer source on the front of the chart. So everyone knew who was on Medicaid (MediCal, AHCCCS, etc.) and who had commercial insurance.

IMHO, it made a tangible difference on my and others' (docs and nurses) perception of the non-commercial insurance patient, and how they were treated.

Admittedly, when I saw MediCal stamped on the chart, I formed an opinion. I saw other nurses, staff, and docs make the same value judgements, based on nothing more than insurance or lack thereof.
The same applies to whichever (non clinical) "issue" you become aware of (jail status, deadbeat dad status, or pick any of your choosing.)

It's all moot (clinically)

Sure, they are abusing the system, and it royally blows, but, knowing that stuff, or thinking that it actually matters, clouds our judgements.
So, anymore, I don't ever want to know that stuff, and I don't ask.

No, I'm not a doc, but have seen us all be guilty of it. (myself a the top of the list)

I know that docs have these same feelings (we've discussed this ad nauseum on slow ER nites)

Worked UCSD where, on any given night, (seemingly) half of SD County's jail population was in the ER...Can't remember one time, in my 20+ years in the ER, of why they were in jail mattered, or changed the course of treatment.

Sure, the story/history of why they're in front of you is important, but the reason they were sent up the river,does not dictate, or have any bearing how you guys clinically treat them.

 

[SDEM2012]

Wow, I'm surprised by some of the comments on here, especially in the transplant situation (which, IMO, is completely different than the question posed by the OP).
Usually, at our hospital, it's an American who is completely noncompliant and on the transplant list while the super compliant illegal immigrant with a dependent young family and two jobs is the one who is sentenced to dialysis for the rest of their shortened life (even though it costs taxpayers way more).

Before anyone goes crazy, I'm not arguing that illegal immigrants SHOULD get organs in the US, I'm just saying that it's usually not the evil scenario people are painting on here.

 

[Pinner Doc]

I think we're all responsible for the personal choices that we make. Addiction or not, the decision to use them, and then not get off of them is a personal one. It's inappropriate to make bad personal decisions then go to a hospital and say "please fix up the consequences of my bad decisions, so I can go out and make more bad decisions".

Please see Atlas Shrugged for complete details.

Some words of wisdom I like to live by: "Whatever you do, don't congratulate yourself too much, or berate yourself either. Your choices are half chance. So are everybody else's."

 

[Pinner Doc]

I treat them all the same.. you have to. I have taken care of the rich, the famous, the poor, the drunk, the homeless. When I walk in the room I treat them all with respect.. how the rest of the visit goes depends on them.

Some middle ground it looks like many of us can agree with. 👍

 

[learss]

Your job/duty as a physician is to heal, not judge. Withholding care because of an individual's past actions is disgusting and immoral. Before you apply to medical school, take an ethics class.

 

[gutonc]

Your job/duty as a physician is to heal, not judge. Withholding care because of an individual's past actions is disgusting and immoral. Before you apply to medical school, take an ethics class.

Alternatively, just don't go to med school. Pretty sure there are a million or so MBA programs begging for somebody with "ethics" similar to the OPs.

 

[Lilpip]

Alternatively, just don't go to med school. Pretty sure there are a million or so MBA programs begging for somebody with "ethics" similar to the OPs.

Talk about being judgmental huh? Half these comments have been more sarcastic comments giving advice about what I should do with my life based on a 5 sentence question than a simple answer to a legal issue. But no, no you guys don't judge anyone right?

 

[learss]

Talk about being judgmental huh? Half these comments have been more sarcastic comments giving advice about what I should do with my life based on a 5 sentence question than a simple answer to a legal issue. But no, no you guys don't judge anyone right?

Ok, here is the legal answer: Intentionally refusing to treat a patient which leads to their death is murder.

From The People v Klvana
Murder is the unlawful killing of a human being, or a fetus, with malice aforethought. Malice may be expressed or implied, and implied malice is present when no considerable provocation appears, or when the circumstances appending the killing show an abandoned and malignant heart.

Second-degree murder based on applied malice is committed when the defendant does not intend to kill but engages in conduct that endangers the life of another and acts deliberately with conscious disregard for life. An essential distinction between second-degree murder based on applied malice and involuntary manslaughter based on criminal negligence is that in the former, the defendant subjectively realized the risk to human life created by his conduct, whereas in the latter the defendant's conduct objectively endangered life, but he did not subjectively realize the risk.

 

[BushDoc20]

Heres some advice: Physician heal thy self and grow a thick skin and do the job .....your pre-med you've had no experience .....don't ask don't tell that bloody simple.

 

[Apollyon]

See, I thought that, basically, 1st degree murder was a pre-planned, intentional killing of John Doe, whereas 2nd degree was that you intentionally planned on killing someone, but without a specific victim in mind. Then again, in NY, "murder in the first degree" is if you kill a police officer or judge or prison guard. I don't know in which states the felony murder rule has been abrogated by statute ("felony murder" is when, through your action or inaction, while you are committing a felony, someone dies, even if you were not planning on it - you are still guilty of murder, not manslaughter), but wiki has a page on it.

 

[chapaquito]

I am in disbelief of the member who started the first question of this ,it is childish,silly
question,give to the Cesar what belongs to Cesar and to God what belongs to God,if
you are a Doctor then think as a Doctor,act with ethical nature as a Doctor be in an
ED floor or in any other place in the hospital,the patient that comes to the ED needs your intervention a a Physician not as an Attorney. I do not know how can the Senior Member of SDN did not stop already this ridiculous opinions.Shame on yhe people who think otherwise.😡

 

[Lilpip]

I am in disbelief of the member who started the first question of this ,it is childish,silly
question,give to the Cesar what belongs to Cesar and to God what belongs to God,if
you are a Doctor then think as a Doctor,act with ethical nature as a Doctor be in an
ED floor or in any other place in the hospital,the patient that comes to the ED needs your intervention a a Physician not as an Attorney. I do not know how can the Senior Member of SDN did not stop already this ridiculous opinions.Shame on yhe people who think otherwise.😡

Who defines what a Doctor "should" think? Is a Doctor a pre-listed set of opinions that must be followed to an exact formula? "Shame on the people who think otherwise."

Since we're doing quotes here: "A man chooses, and a slave obeys." I simply believe that there should be the choice. And if everyone is as much a paragon of virtue as they say, then there would be no change in anything. Right?

 

[BushDoc20]

you are only a man who chooses if you started your own practice...we as doctors are slaves...we obey orders from senior physicians and the on- duty attending! you are a mere sporn in the the cycle of medicine...you don't have an opinion until you're and attending....suck it up and don't ask questions about the person, just treat and discharge

 

[Lilpip]

you are only a man who chooses if you started your own practice...we as doctors are slaves...we obey orders from senior physicians and the on- duty attending! you are a mere sporn in the the cycle of medicine...you don't have an opinion until you're and attending....suck it up and don't ask questions about the person, just treat and discharge

As the overwhelming response has stated the law says there is no choice. You must treat the murderer even if he is dragged in by the police themselves who witnessed him gun down their fellow officer. Whether I have my own practice or not, there is no choice. Don't ever NOT ask questions if you ask me. That's living without thinking. Obey your superiors, but always have your own opinion and question. That way you don't end up saying "But I was only following orders" in the end.

 

[learss]

Who defines what a Doctor "should" think? Is a Doctor a pre-listed set of opinions that must be followed to an exact formula? "Shame on the people who think otherwise."

Since we're doing quotes here: "A man chooses, and a slave obeys." I simply believe that there should be the choice. And if everyone is as much a paragon of virtue as they say, then there would be no change in anything. Right?

I can't believe you quoted a video game to make your point. Seriously? You have a choice if you withhold care: be sued, go to prison, or both.

 

[Lilpip]

I can't believe you quoted a video game to make your point. Seriously? You have a choice if you withhold care: be sued, go to prison, or both.

Gandalf (you know the wizard from the imaginary story as well) got quoted earlier on, I figured anything was game. And that isn't really a choice, that is a demand backed up with punitive action. "You will do X or face Y consequences." That is what is offered.

 

[BushDoc20]

*facepalm* how about actually listening and learning from those that have been in the industry ...because it is a fact of "if you do X you will face Y consequences"

 

[Lilpip]

*facepalm* how about actually listening and learning from those that have been in the industry ...because it is a fact of "if you do X you will face Y consequences"

Exactly. I am saying that that IS what the current option is. Right now "if you do X you will face Y consequences." That is not a choice. That is a demand. You will treat this murderer, who will go to prison (hopefully) and waste years of resources, or you will go to jail/lose your license. I can't help but feel you are not reading what I'm saying. It isn't a choice if you've got a gun to your head (career) so to speak.

I'm not arguing you are wrong about the law, that is the law. The initial question was resolved long ago, the sheer amount of judgmental responses was starting to make me a little down so I figured I'd defend myself.

 

[umz]

Exactly. I am saying that that IS what the current option is. Right now "if you do X you will face Y consequences." That is not a choice. That is a demand. You will treat this murderer, who will go to prison (hopefully) and waste years of resources, or you will go to jail/lose your license. I can't help but feel you are not reading what I'm saying. It isn't a choice if you've got a gun to your head (career) so to speak.

I'm not arguing you are wrong about the law, that is the law. The initial question was resolved long ago, the sheer amount of judgmental responses was starting to make me a little down so I figured I'd defend myself.

You still don't understand how there is no way for you to know if someone is actually a murderer when they get to you in the ED? Would you rather murder an innocent patient once in order to prevent your "waste [of] years of resources," or save that one innocent patient along with 100 murderers?

 

[learss]

Alright quick question popped in my head earlier today after watching COPS. Say a man shoots and kills let's say an officer. Man is also shot but survives and is taken to the hospital. Would an ER surgeon be FORCED to treat the man?

Please don't quote the Hippocratic Oath as an answer, if you ask me more "harm" is being done if they leave that operating room alive (just an opinion so pay no heed). I'd gladly go to hell and back to extend the life of any regular Joe, but I don't know if I could sleep knowing I helped a murderer, who best case scenario rots in prison, worst case gets out early just to hurt others again.

So just curious if you can put your foot down on something or if you are forced to be a slave to that Oath. I'm pre-med and this thought scared the hell out of me.

A Trauma surgeon is not forced to work on a "killer", they are just doing their job, which is saving lives.

BTW are you going to put your foot down before you bring them in the OR for a exploratory laparotomy or while you are performing a urgent thoracotomy in the trauma bay?

"Slave to the oath"?
Why are you interested in medicine?

 

[Lilpip]

You still don't understand how there is no way for you to know if someone is actually a murderer when they get to you in the ED? Would you rather murder an innocent patient once in order to prevent your "waste [of] years of resources," or save that one innocent patient along with 100 murderers?

Police drag the guy off the ground after he's done shooting, throw him in the ambulance and escort him to the hospital. I'm talking about a situation where there is no speculation. Never once did I mean to include your purse snatchers or random prison inmates in this hypothetical situation. I mean your smoking gun, we just watched him do it murderer. People throw around all the time the stories about the innocently convicted that are placed in jail. The same could be said for the guilty let off due to a technicality, who go back out and kill/harm again. It happens on both ends because the justice system is not 100% perfect.

I'll say it again because I know people will stop reading mid way through. This guy did it, everyone saw him do it, and there are police that were friends with the fallen officer trying to get at him. You save him, now best case scenario is legal system works and they get three square meals a day, and worst case is he gets off and does it again one day. It happens.

 

[Lilpip]

A Trauma surgeon is not forced to work on a "killer", they are just doing their job, which is saving lives.

BTW are you going to put your foot down before you bring them in the OR for a exploratory laparotomy or while you are performing a urgent thoracotomy in the trauma bay?

"Slave to the oath"?
Why are you interested in medicine?

That's like saying a lawyers job is to prosecute/defend. Or a chemical manufacture's is to make chems. What if they get an order for something that in the long run does nothing and can pose a threat to the general population? Most likely turn the product away. They don't just make whatever is on the list. I don't believe a job can be summarized as simply as that. I've been called naive and that my thinking is black and white by others in the forum, but the thought that people exist to just do law, save lives, or grow food seems black and white to me.

As it stands I don't put my foot down because I want to keep my job and get tossed the occasional person I take pleasure knowing is walking around again. That's why I'm interested in medicine.

 

[Xerxes1729]

Who defines what a Doctor "should" think? Is a Doctor a pre-listed set of opinions that must be followed to an exact formula? "Shame on the people who think otherwise."

Since we're doing quotes here: "A man chooses, and a slave obeys." I simply believe that there should be the choice. And if everyone is as much a paragon of virtue as they say, then there would be no change in anything. Right?

Medicine is a profession. It's a term that has been watered down over the last half century to the point that it is barely distinct in connotation from "job". At one point, however, the professions - medicine, law, and divinity - were clearly distinct from other vocations that a person might pursue. Those who pursued them professed to have a special body of knowledge that set them apart from others. Because of this, society grants professionals rights that are denied to other citizens but they are in turn expected to hold themselves to a higher standard of behavior than laypeople.

We like to complain that no one respects us, that we're just pawns being pushed around, or, apparently, that we're slaves. Brief reflection reveals that this is clearly not the case. As physicians, we enjoy a state-sanctioned monopoly on the practice of medicine, and people trying to violate it can be subjected to criminal charges. This has made us among the wealthiest people ever in the history of mankind. Patients may not always be pleasant, but they place an enormous degree of trust in us. They let us cut open their skin, put needles in their spinal canals, shock them with electricity, and even give them drugs that stop breathing and cause paralysis. Perhaps even more extreme, society allows us to deprive people of some of their most basic rights. Based solely on our say-so, patients can be chemically and physically restrained and held for several days, with no recourse and no appeal. That's a remarkable power, and so while we're quoting fiction, "with great power comes great responsibility."

The fact that we can do all of these remarkable things is contingent on us holding ourselves to certain standards, one of which is that our treatment of patients is not affected by any judgements we might make about who they are or what they've done. People who are sick shouldn't have to worry that their suffering will be compounded by the judgement of their physicians. Do we always achieve this ideal? Of course not, but we still should try to.

 

[umz]

I don't know why I'm still trying to explain this... Unless you actually saw this murder take place, there is no way for you personally to know what happened. Taking someone's word for it is not knowing the truth. For instance, what if a cop caught another cop having an affair with his wife. In a rage, he murders the guy. Blames it on some repeat offender and tries to kill him to cover himself. Doesn't succeed, and the "murderer" is brought in to your ED. Further investigation proves that the first suspect, that you saved, was not guilty.

 

[Rendar5]

Police drag the guy off the ground after he's done shooting, throw him in the ambulance and escort him to the hospital. I'm talking about a situation where there is no speculation. Never once did I mean to include your purse snatchers or random prison inmates in this hypothetical situation. I mean your smoking gun, we just watched him do it murderer. People throw around all the time the stories about the innocently convicted that are placed in jail. The same could be said for the guilty let off due to a technicality, who go back out and kill/harm again. It happens on both ends because the justice system is not 100% perfect.

The justice system is not 100% perfect, so I'm not sure how you think that your judgment is perfect enough to execute a murderer via neglect of medical treatment. Did you see the murder happen? do you know if the murder was done because the dead officer was sexually assaulting the wife at a traffic stop? or because he was hearing voices in the midst of a psychotic break?

What if the guy was already convicted with a smoking gun by a jury of his peers, and is sentenced to jail for X number of years or for life, who are you to disobey their judgment and execute someone not put on death row?

What if the guy is on death row? Who are you to impede the viewing of the execution by causing it to happen ahead of time? what if the victim's family is awaiting the execution to achieve closure? You just assured them that they would no longer have the closure that they desired.

 

[StevieStud]

You do your best, so somebody else has a chance to do their best.

You do your best, so somebody else has a chance to do their best. That is all you can do. You don't get to decide or judge. Just do your best treating the patient and move on.

 

[Apollyon]

You quoted...yourself? What, was that for effect?

 

[theseeker4]

I'll say it again because I know people will stop reading mid way through. This guy did it, everyone saw him do it, and there are police that were friends with the fallen officer trying to get at him. You save him, now best case scenario is legal system works and they get three square meals a day, and worst case is he gets off and does it again one day. It happens.

So it is better to murder someone who hasn't been tried, hasn't had a chance to defend themselves, because they MIGHT be released and cause harm in the future? I don't care what you hear the person did, or how many cops say they KNOW the guy did it, you have no first-hand knowledge, and witnesses can and often are mistaken about what they see.

Even if there is certainty that this guy killed a cop before being shot himself, what if the cop was being cheated on by his wife with your patient, and the cop, seeing him on the street, decides to take matters into his own hands. The patient happens to have a license to carry a gun and defends himself against an unjustified attack. If you let him die, you just killed someone who was justifiably defending himself.

Sounds far-fetched, but it is probably more likely than you having absolute certainty about anyone's guilt or innocence in the minutes after a crime is committed.

 

[turkeyjerky]

You quoted...yourself? What, was that for effect?

Lol! Man this is getting good

 

[GeneralVeers]

Basically the justice system is not 100% accurate, so if someone is a "murderer" and found guilty by their peers, we should discount that? Hell, let's just let everyone off of death row, and better yet out of jail because we can't be 100% perfect all the time!

 

[Conjuctiva]

You guys are coming up with WAAAYYY too many highly unlikely scenarios. It's more likely that the cop killing gamgster was just that, A FREAKING COP KILLING GANGTER, not that the gangster was cheating with cops wife and killed him out of self defense.

Your imaginations are too far fetched.

 

[Lilpip]

I don't know why I'm still trying to explain this... Unless you actually saw this murder take place, there is no way for you personally to know what happened. Taking someone's word for it is not knowing the truth. For instance, what if a cop caught another cop having an affair with his wife. In a rage, he murders the guy. Blames it on some repeat offender and tries to kill him to cover himself. Doesn't succeed, and the "murderer" is brought in to your ED. Further investigation proves that the first suspect, that you saved, was not guilty.

That was another scenario, not an explanation. I will ask for the sake of it, what would your opinion be on the matter then if you were at the scene and saw it firsthand? Treat or not?

I hear "you're not the jury" time and time again when on the subject, and the same question arises. Who/what is a jury to decide anything? It is simply a random gathering of people who 1) do not all want to be there and 2) in all probability don't want to send someone they don't even know to jail/death. They weren't at the scene, they didn't even see an aftermath. They get whatever evidence is left after all technicalities have been brushed away. Is it any better of an idea to have Aunt Julie from down the road, who takes several weeks to make a decision as simple as what color to paint her new door in the fate of a man? Aunt Julie isn't going to want to know she helped sentence a man to death. Get enough of those people on a jury and you've got a recipe for a case of groupthink.

As Xerxes said above (extremely well written post by the way, enjoyed it 🙂 ) society grants physicians the abilities to restrain patients for days if need be. Now what do you think the initial reaction was to that bit? Probably aghast, "You mean they can hold me against my will?!" Eventually it has integrated itself into the norm for the profession. When proposed, I'm sure there was plenty of "that is not our place" said among one another. Society changed and offered new freedoms, and those freedoms have been used responsibly. Whose to say in the next 200 years that society couldn't change again?

If a lawyer gets his client he knew did the crime off, and that guy goes back out and hurts another then that weight is on the lawyer. He had the choice to turn the client away. Now if laws were enacted that mandated every lawyer must take on every client that walks in the door, that weight is lifted and any responsibility shift to the age old maxim, "I was just doing my job." The role of lawyers would then shift to something more sanctimonious, praising their dedication to the defense of the public.

A physician has a fallback when their decisions are made. We can go through patient after patient knowing that we "just did our job". If society changes and allows him new responsibilities, would the freedom not be worth it? Those that used it would deal with whatever the result was, as would those that didn't.

Just the other side of the coin. I get where the other opinions come from here. And I agree on points such as the patients need to trust us. Some won't ever trust us, and others warm up eventually. People can be stubborn about doctors, for example my father was stupid enough to actually believe doctors would come harvest organs early if you were an organ donor.

 

[Rendar5]

You guys are coming up with WAAAYYY too many highly unlikely scenarios. It's more likely that the cop killing gamgster was just that, A FREAKING COP KILLING GANGTER, not that the gangster was cheating with cops wife and killed him out of self defense.

Your imaginations are too far fetched.

as is the imagination of some criminal with a known smoking gun showing up in an ED and the details of the murder made known to the staff.

 

[EM_Rebuilder]

Repeat after me: You go into medicine to heal. Not to judge.

Someone went into this line of thinking above, but it's a slippery slope. "if it were up to me, i wouldnt treat the fat people/smokers/insert whatever here who had heart attacks. why heal them? so they get better and then just keep smoking and staying fat and wasting health care dollars and taking up hospital beds for people who really need them? its never ending - let them kill themselves. waste all these resources on people who just end up killing themselves?"

Obviously we are all indivduals and have our own personal political, relgious, etc etc viewpoints (and often physicians are very vocal about their said opinions). I think as a physician all the above must be checked at the door and have a truely equality treatment of people... rather its a 14 year old with a botched abortion, someone that just shot and killed your best friend/cop/neighbor/family, someone whose family you dislike, etc.

If these are not checked at the door, your life will be more difficult to deal with on a day to day basis... espically in EM where you deal with people you probably would not normally associate with and might go out of your way to avoid on the streets and sit in your easy chair and cuss their viewpoints.

 

[8654Marine]

The key is to ensure your personal feelings do not interfere with your professional judgement.

We are all different and have varying viewpoints. I accept that.

But as a physician, you have to behave and perform according to the standards of care: medically, ethically, and legally.

You can think and say whatever about whomever, but your professional conduct must pass the sniff test.

They are patients, not smoker, diabetics, black, poor, drunks, murderers, etc...

I know, I know, ask me the same question at 0300 on a Saturday night after the 9th drunk MVA who comes in swinging...

 

[CommunityED]

The one and only time I refused to treat someone was a spitting belligerent guy with multiple swastikas tattooed on him. My grandfather and Uncle had numbers on their arms and I couldn't do it. Luckily I was at a shop with 3 other docs on at the time (including the ex navy seal gun nut who took him)

 

[deleted65604]

Below is my patient list from the night shift I worked 2 nights ago:


Futile
63 yo deaf, blind, dialysis, brief chest pain. Just got cathed and stented 2 days ago. Normal EKG and enzymes. Asked to go home immediately. Refused waiting for repeat enzymes.

72 year old with endometrial cancer, presents with chest pain- I find widely metastatic metastasis to abdomen and chest. I admit for pain control and work-up. They will be discharging to hospice for poor prognosis.

Jail
61 year old guy with perfed cholecystitis. Happens to live in jail.

Alcohol
25 yo drunk driver going to jail for drunk driving. Scalp laceration. I put in about 15 staples and sent to jail after normal CT.

23 yo drunk going to jail here for medical clearance after evading police and subsequent dogbite.

54 yo alcoholic with chronic abdominal pain from alcoholic gastritis. Drank over a pint of vodka and now has pain.

61 yo homeless fall-down drunk who has been kicked out of every shelter in the city for bad behavior. Last got kicked out of Catholic Charities for urinating on a Bible. Wants ativan to "help him withdraw." Numerous admissions to detox.

Illegal drugs
29 yo meth user with hepC. Abdominal pain of unknown etiology. Menses ultimate diagnosis (denied vaginal bleeding, but was obviously menstruating on physical exam)

47 yo meth/heroine/cocaine user here for chest wall pain after rib injury and previous normal chest x-ray. Admitted for overdose after given pain meds for labial abscess (she uses labia to shoot up for the pleasant genital sensation. Tweaking like mad and needs "strong pain meds." Was on pain contract with PCP, but got booted off because she tested positive for meth. Has totally fallen off the wagon recently.

Prescription drug seeker
33 yo male with chronic abdominal pain. Just moved into town. 2 CTs in past 2 weeks. Seen in ER 4 different visits with an uneventful admission to hospital with final diagnosis of abdominal pain. Normal EGDs, labs, and even porphyria work-up. Wants prescription for something stronger for abdominal pain (asks for dilaudid IV and an oral prescription as that is the only thing that ever works. )

47 year old with 17 visits to ER in past year for back pain/tooth pain. Won't turn down volume on TV, just wants vicodin. Tends to come in by ambulance.

Other
63 year old nurse from upstairs with needle stick from a HIV/HepB/HepC negative patient. Not emergent. (Why can't the hospitalist get paid to see these ridiculous patients?)

60 yo female with chronic paraplegia. Low mechanism fall, chest wall pain. x-rays normal and out the door.

Person Who Needed Me, Wasn't an Alcoholic, Illegal Drug User, Seeking Narcotic Prescription Drugs, or in Jail
36 year old with peritonsillar cellulitis, white count of 20 despite amoxicillin for strep. I admitted because he was dehydrated and could not swallow.

 

[deleted65604]

I helped 3/14 patients. An infection in the throat, an infection in the gallbladder, and some staples in a drunk kid's head.

We act as the safety net for the nation. The government mandates that we be take care of all comers. We are like rescue crews trying to catch people before they hit the ground while crossing the chasm of life. For now, we are well paid, and OK with being there. As time goes on however, if the pay goes down, and our biceps start burning, we will increasingly start getting @#!*% off at the people that are throwing themselfs off the chasm (alcoholics, drug users). For them, it has become a game "Look at this guys...WEEEEEEEEEEY!!!" Some of the idiots use our safety net as a trampoline, mooning us as we tell them to get out of the way so that we can take care of the next potential faller. An increasing number of people we run and run with the net, catching them at the last minute and saving their life for 3 seconds right before they thank us, walk away from the net, only to drop dead despite our soft, cushiony net (80 year olds on dialysis, 70 year olds with widely metastatic cancer).

The murderer pushed somebody over the edge, then fell himself. His lack of deservedness is just a drop in the ocean that is our futile task.

The government is starting to see the futility of our efforts, and are going to simply force us to use worn out nets, give us less rest and pay other, slower, weaker, but cheaper rescuers. Society will then face a choice..."Reliable safety net? Or allow "undeserving" to fall to their death?

At least, that is what my last shift made me believe.

 

[GeneralVeers]

👍👍👍👍

Not sure that the hippocratic oath was ever intended to cover most of these people. If someone has no involvement in their own care and in fact doesn't want a patient-doctor relationship, then the oath doesn't apply.

Just because we are supposed to help the sick and poor doesn't mean we need to be doormat for every amoral *****hole who comes in by ambulance for toothpain.

I call it as I see it, and I kick these people out.....without their vicodin.

 

[UnderwaterDoc]

Do I form my own preconceived notions about these people as they come in? - yes, for sure, I think we all do whether we want to admit it or not.

Will that prevent me from treating them? - no it won't.

In our current society and with the current laws in place we simply have no choice, we are stuck seeing everything that walks in through the door, choice is a luxury we do not have. However I still have my own opinions and my own way of thinking ,no law changes that.

 

[docB]

Do I form my own preconceived notions about these people as they come in? - yes, for sure, I think we all do whether we want to admit it or not.

Will that prevent me from treating them? - no it won't.

In our current society and with the current laws in place we simply have no choice, we are stuck seeing everything that walks in through the door, choice is a luxury we do not have. However I still have my own opinions and my own way of thinking ,no law changes that.

Good point. I would take this farther and say that the "preconceived notions" I develop are what people come for. I look at a chest pain and quickly decide if I think it's high or low risk for cardiac, belly pain and decide if it's likely an apply. I look at others and decide if they are likely to be there for drugs or other secondary gain issues. This is not unethical. It would be unethical and would cause harm to do otherwise. For example if I am reasonably sure that someone is drug seeking radiating them with CTs and subjecting them to the possible complications of additional workup is the wrong thing to do.

As Veers mentioned these folks defy the easy categorization of people looking for actual medical diagnosis and care. The secondary gain patients really stretch the boundaries of medical ethics and morality.

 

[Xerxes1729]

As Xerxes said above (extremely well written post by the way, enjoyed it 🙂 ) society grants physicians the abilities to restrain patients for days if need be. Now what do you think the initial reaction was to that bit? Probably aghast, "You mean they can hold me against my will?!" Eventually it has integrated itself into the norm for the profession. When proposed, I'm sure there was plenty of "that is not our place" said among one another. Society changed and offered new freedoms, and those freedoms have been used responsibly. Whose to say in the next 200 years that society couldn't change again?

But when we sedate and restrain patients, we are doing it within the context of traditional medical ethics. We can only do so if a patient's behavior is such that he is an imminent danger to himself or others. If someone has just bought a gun and is suicidal, then we are justified in placing him on a psychiatric hold, because his behavior and mental state place his life in danger. If someone smokes three packs a day and has a triple-digit BMI we are not justified in hospitalizing him against his will (for smoking cessation and weight loss) because although his behavior endangers his life, it does not do so imminently. When the issue is danger to others, we are justified in acting when the patient is actively trying to harm others, such as throwing chairs at the staff. However, a patient whose own death is imminent after being shot by the police cannot possibly represent an imminent threat to anyone else.

The other important distinction is that when we do these things, we do them in the context of the traditional principles of medical ethics, beneficence and non-malfeasance. We are doing them to help a patient, to preserve his life and well-being, when he is in such a state that he lacks the capacity to do so for himself. Even when restraining someone to prevent him from harming others, we have to do so in a manner that is safe for the patient - we can't hogtie people or sedate them to the point of respiratory depression without support and monitoring.

If you're going to advocate for allowing physicians to deny life-saving treatment to presumed criminals, what punishment would you propose for those who do so and are shown to have been wrong in their assessment that the patient was guilty? If you refuse to care for the cop-killer who turns out to be an innocent bystander, whose role was confused in the chaos of the scene, and he dies, what is your responsibility?

 

[TrumpetDoc]

I am with the don't ask ppl. Less concerning my part.
Although, most (hopefully all of us) of us worked busybtruam centers and we got the "cop killer, the "spouse killer", etc. "
I HATE these ppl but I suck it up and just do what I am trained to do.
If they have to come in, they come in. If they have CP and risk factors, and I blow it off an not prop. rule them out as I would the "regular" guy and they have an event after the fact, "I" am toast. That's all there is to it.
I do sometimes use a line I learned from a mentor to the effect of; hey guy/gal, I don't know why your are in x situation, but I am here to see to any immediate life threats, and stabilize you do you can defend or answer for whatever you need to...b
I document really well and and only pray that the system does right.
Maybe if and when I go to law school. (a definite possibility) I must say I can affect the outcomes of the legal part.
Until then, they are just one on my list.
I do feel s***** to be honest, sometimes...but it's just part of the job a I see it.


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