So I had a good day at work

[The White Coat Investor]

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[Ex-44E3A]

every ED doc and nurse I have worked with during these occassions has basically told me to suck it up and get over it.

**** on that.

If it's some out-of-his-mind drunk guy, that's one thing, but if they're nothing more than a misanthropic knucklehead who thinks they're going to throw their weight around in my department, they're in for a surprise.

I utilize my law enforcement colleagues to the fullest extent possible. I take care of them, and they return the favor by taking care of us. Anyone alters one of my scripts, they go to jail (felony). Anyone takes a swing at one of my people, they go to jail too (felony).

Bad behavior is perpetuated whenever peope tolerate it.

And for the record, God help the idiot who punches a nurse, and I'm not referring to retribution from me... I'm talking about retribution from the other nurses. There was this one crackhead who got himself clinically "stabilized" by half-an-ER's worth of nurses after he punched one in the head. Until that day, I didn't even know they made foley catheters bigger than 18F. Turns out, they go up to 28F in size (yes that's right... 28 French... I've seen smaller ewald tubes).

Kathy Bates has nothing on some of the nurses I've worked with over the years.

 

[IgD]

What happened to "do no harm" to the patient?

 

[deuist]

What happened to "do no harm" to the patient?

I'm no ethical theorist, but I would imagine that once the patient takes a swing, he's no longer your patient.

 

[resxn]

I'll say this, it is nice to call a patient to attention (if you outrank them that is) if they are indiscriminately berating one of your staff inappropriately. I did that once. Felt good to have the authority to do it too.

Made him stand at attention for 5 minutes to calm down, then took his entire history and physical while he stood at attention--one of the nice parts of just having to evaluate an ear infection is that it did not require him to move.

Then I made him write a letter of apology to my staff or I threatened I would accompany him personally back to his supervisor and explain the entire interaction.



It was a nicely worded letter.

 

[Ex-44E3A]

My first post was tongue-in-cheek (did you miss the "Misery" reference, IgD?), but there was a clinical pearl in it. For those of you who missed it, I'll be more plain:

For the record, I'm not a big believer in punitive medicine. The things your medical knowledge enable you to do to a patient could turn a truly retribution-driven physician into one of history's darkest sadists... personally, I don't want to venture onto that slippery slope.

On the other hand, you need to find out what's making the patient so nuts... assaulting ER staff is not something a normal, rational person does. Combative behavior generally falls under the "change of mental status" category, and the differential is wide.

Urosepsis?
Hypoxic?
Hypovolemic?
ICH?
Did they injure themselves in the subsequent fight?

You really need to treat these patients as a medical emergency. Like a trauma patient (and they may legitimately have become a trauma patient, depending on how hard they fought), a cautious physician gives these patients the full workup, including multiple IVs, and fingers and tubes in every orifice. If they continue to fight against the restraints, they may need chemical sedation or even iatrogenic paralysis and intubation to prevent rhabdo or sudden death.

Plenty of police departments have been burned after fighting an out-of-his-mind suspect, and simply throwing him in the back of the cruiser. If you assume he's just a thug and throw him in cuffs, you may find him dead a short time later. It's a foolish physician who allows his staff/security to swarm, subdue/restrain, and throw a violent individual in a bed, and doesn't seek a medical cause for their behavior. If it all turns out negative, then fine... send his stupid a** to jail. However, it's axiomatic in the ER that the one time you ignore a potential medical cause, or call bullsh*t ("he's just saying he has chest pain so he doesn't get arrested"), is the one time he'll have an MI and die on the way to jail.

I don't believe in punitive medicine (can't speak for all of my nurses), but I do believe in thorough medicine.

 

[R-Me-Doc]

So I found out medical privileges (his, not mine) can be taken away, including the ED (barring life threatening emergency, of course.) Very interesting. All it takes is a letter from me to the hospital commander (which was sent within the hour.)

.

This is a nice idea but my experience has been that in reality it doesn't work too well. I've seen this attempted a few times (have tried it myself, in fact) and I can tell you that at best all you have done is bought yourself a little time. Because military hospital medical staff turns over pretty rapidly, there is no "institutional memory" for things like this and these people invariably manage to weasel their way back into the system. Also, especially in the ER setting, there is no way you can comnpletely keep people out; all they have to do is show up at your triage desk and say some magical phrase like "chest pain" or "worst headache of my life" and you are obligated to evaluate them, whether it's the real problem or not. EMTALA applies in the miitary, too.

X-RMD

 

[Ex-44E3A]

Note: I wasn't being tongue-in-cheek about sending violent, assaultive idiots to jail... you just do it after the workup.

 

[met19]

All right, the ratio of negative posts to positive ones is getting too high again (I know, its my fault, I killed that one with the slideshow.) So I thought I'd post something nice. I had a good day at work today. Let me tell you the best part. As a civilian emergency doc I was obligated to take care of everyone, no matter how they treated me or the staff. Well today I have a guy come in making inappropriate gestures at my triage nurse and berating her with vast quantities of profanity. After he was seen by the resident I spoke with him for a few minutes during which time he informed me he was going to be filing a complaint and suing me (because I asked him if he heard things others don't hear). On his way out the door he went back by triage to berate the nurse some more.

So I found out medical privileges (his, not mine) can be taken away, including the ED (barring life threatening emergency, of course.) Very interesting. All it takes is a letter from me to the hospital commander (which was sent within the hour.)

Another interesting patient was a 65 year old retiree with a cocaine problem who wanted to clean up and so came in asking to be checked in for detox. Apparently, if he had gotten Tricare Prime he would have been eligible for that, but since he only had Tricare for Life, he was only eligible for outpatient treatment. He ended up going to a civilian hospital where they would take him because medicare apparently reimburses quite well. Go figure. You'd think if you didn't do coke the first 50 years of your life you wouldn't be very likely to take it up in retirement.

If anyone else had a good day, feel free to chime in, it'll help fight the depression.

sounds like i have some nice things to look foward to post deferral.

to keep in the spirit of good posts......
had some sweet interviews for EM....and my flights out of NYC have been even leaving early (usually I just hope for them to be on time instead of an hour or two late!)