Who Am I Treating?

Occasionally, as difficult as some patients may be to treat in the ER, for whatever reasons, that difficulty may be nothing compared to the stress and negativity brought to the encounter by their accompanying family members or friends. People who "know the patient more than they know themselves" and don't hesitate to try to dictate the course of therapy for the patient.

Don't get me wrong, I appreciate a family's or friend's input greatly. In fact, I welcome it. Sometimes, even, they can be a greater source of the patient's history than the patient himself.

But...sometimes the support person can be totally and completely obnoxious and abrupt in how they choose to communicate with our staff. "Demanding" is a word I hear often. They just know that the patient needs two pillows. Three warm blankets. A new pair of footies. A turkey sandwich. Some ginger ale, not orange juice. The patient likes to lay on their left side, not their right. They need this and this and this test, but not that one. Oh, and by the way, where do they go to get their parking ticket reimbursed for free parking?

I recognize that sometimes this is simply a vain attempt by the visitor to have some sort of control over an uncontrollable situation, sure. A spouse trying to make her sick husband comfortable. A parent trying to ease their child's pain. A best friend trying to step-up to ensure proper treatment. I fully understand all the reasoning behind these situations. More importantly, though, I respect and applaud their advocacy.

Unfortunately, though, sometimes a visitor's intentions can be detrimental to the patient, if the patient is an adult, is coherent, and can easily verbalize their problems and symptoms by themselves.

I was sitting in my hallway seat, several months ago, when I observed the triage nurse escort two women to Room 27. One woman appeared to be in her sixties, the other in her thirties. The older woman appeared irritated, grumpy almost, while the younger woman was smiling and walking alongside the older woman. Neither appeared in any distress.

Within minutes, the patient's name appeared on our computerized list of waiting patients, so I clicked on it. Surprisingly, it was the younger woman who had checked in as the patient.

I walked into the room to find the younger woman sitting comfortably in the treatment cot, a gown draping her thin frame, a smile still on her face. The older woman, who by now I assumed was the patient's mother, sat in a chair under the corner TV. She was still scowling.

I approached the patient first, my hand extended. "Hello, Ms. Brown, I'm Dr. Jim. Nice to meet you, maam." She extended her hand and we shook. "Hello," she returned, meekly. From the corner of the room I heard the other woman speak. "And I'm her mother." I left the patient's side and walked up to the mother, my hand still extended. The mother eyed my hand for several long uncomfortable seconds before finally extending her own. "Nice to meet you, maam," I added after our handshake.

I went back to the patient's bedside. "Ms. Brown," I started, "what can we do to help you today in the emergency room?"

And before Ms. Brown could even begin to answer, her mother started in. "Kathy has a seizure problem and we are due for our yearly neurology appointment and thought we would come here to get everything done."

"In the ER?" I asked. "Yes," said the mother, continuing. "She needs an EEG, an MRI, and you may as well just call the neurologist down to see Kathy as long as we are here. That way, we won't have to waste a day going to their office."

I turned back to Kathy. "Kathy," I said, "how long have you had a seizure disorder?" From the corner of the room, I heard her mother answer. "Since she was seven." I continued focusing my full attention on Kathy. "And Kathy," I said, "have you been having an increase in seizure activity?" Kathy nodded her her head "no" while, again, from the corner of the room, her mother piped-in. "No, it's just time for her annual check-up." Again, I kept my focus on the patient. "Kathy, has there been any changes recently to your anti-seizure medications?" Again, as Kathy nodded "no," I heard the familiar, interrupting voice. "Eight months ago, the doctors increased her dilantin, but otherwise she has been on the same medicines as always."

I had finally had enough. "Kathy," I asked, holding my index finger up to the mother, requesting her to wait, "are you okay to answer my questions? Or is there a reason your mother keeps answering for you?" Kathy looked at her mother to me. "No," she said, "I guess my mother just always likes to be in charge." From the corner of the room, the mother yelled out, "I do not, Kathy."

I looked at the mother and cocked my eyebrow. "What?" she asked, "I haven't been answering all of your questions." "Yes, maam," I assured her, "you have." Her scowl deepened. "I appreciate you trying to help, maam," I said, continuing, "but this is what we are going to do. I am going to ask Kathy all of my questions and then, when I finish, I will give you a chance to add whatever you want, okay?" She dismissed me with a roll of her eyes and a shrug of her shoulders.

So, I had two problems on my hand. A mother who wanted to interrupt my history-taking with every question addressed to her daughter. And, a mother who wanted an extensive work-up and consult that, unfortunately, wasn't going to happen the way she had hoped for her daughter.

Well, I guess it was just one problem, really. A vocal, demanding mother.

After I finished my interview with Kathy, who did a fine job of telling me about her history, I looked toward her mother. "Do you have anything you'd like to add, maam?" She just "humphed" at me and remained quiet. I proceeded with a physical exam that was completely unremarkable.

The triage team had ordered some baseline blood work and some medication levels on Kathy and, after those results were posted, I went in to speak to the women.

"Well," I said, "I have good news. All of your blood work has returned satisfactory. Including your anti-seizure medication levels."

Kathy gave me a grateful smile as her mother spoke up. "But what about her EEG and MRI and neurology consult? Aren't you going to get those done now?" I explained to the mother that those tests, as well as Kathy's neurology appointment, had already been scheduled and that I wouldn't be able to provide those tests through the ER. Not without an emergency concern. And, trust me, there was no emergency concern.

"But," the mother said again, speaking up, "Kathy hasn't been feeling well recently. I want all of those tests done now. We'll wait for the appointment, if that helps."

I assured the mother, again, that Kathy had a great exam, great blood work results, and would need to move forward as planned by her neurology team. In all honesty, I told her, I wouldn't even be able to get this requested workup for one of my family members, unless it was a new-onset seizure or the patient was in status (a seizure that won't stop).

"Kathy," I asked the patient, "are you okay with everything?" "Of course," she answered, sincerely, "I didn't want to come today. Mom thought we could get everything done early so we wouldn't have to waste a couple days next week."

Out of courtesy, I did call the resident on the neurology team to make them aware of this patient's treatment in the ER. They whole-heartedly agreed with our ER approach, reiterating that this patient would need to keep her outpatient appointments.

I discharged this patient to home, knowing that there was no way I was going to make this mother happy. As they walked out of Kathy's treatment room and down the hallway, I noticed that Kathy still was smiling, while her mother maintained the scowl that prevailed during her time with us.

I had to wonder to myself how Kathy maintained such a happy state. I hope her smile was genuine.

The best I could hope for, I guess, was that Kathy, and not her mother, would get the hospital questionnaire. And that she would get some good results from her non-emergent, outpatient-testing, too.

If only we could just make everyone happy...

As always, big thanks for reading. I hope you all had a great weekend. Although I'm traveling for work the next few days, the next post should be on Wednesday, June 16. See you then...anyone with similar stories to share?