Monday, June 14, 2010

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?

20 comments:

Chrysalis Angel said...

I feel bad for poor Kathy.

(Have a safe trip.)

Laanykidsmom said...

Our daughter started having seizures at age 6 and was officially diagnosed with epilepsy a few months before turning 7. As her mom, I am her biggest advocate and watchdog, but if I ever become like that mom, lock me up! Our daughter takes anti-seizure meds twice daily and should she need to conitnue this into adulthood, her health will be her own responsibility, although I am sure as her mother, I will never stop worrying or wanting the best care for her. Hovering and answering questions for her when she's 30? I better not!

Winking Doll said...

We get such controlling behaviour rather regularly in Singapore. Unfortunately, management and the work culture (it's a private hospital) tends to bow down to patients/NOKs who raise hell, so it becomes a recurring pattern on their future admissions.

I am in the Paediatrics, so parents have an "excuse" to provide information regardless of the child's age. Some parents seem to think that their treatment demands should be met, although our professional assessment of patient says otherwise. It can be an annoying situation. Then again, IMHO such controlling behaviour often extends beyond just treatment demands (e.g. demand to jump queue for private room).

E.g. Recently there was a case that should rightfully belong to High Dependency Unit but is nursed at ward levels. Ostensibly it was for the hospital's compassionate image in catering to the parents' budget issue. However, it results in overloading the ward nurses with HDU work in a busy ward short on trained staff.

The child was admitted because of infection from a previous ventricular shunt inserted at an overseas hospital. The mother was obsessed with the patient's temperature, because she wanted to keep the child afebrile to have a ventricular shunt inserted sooner and to prevent seizure. The child was still suffering from on-and-off low grade fever, and we followed our nursing protocols.

One day the temperature spiked from afebrile to 38.2 degC (100.8 degF) in-between an hourly temperature monitoring. The patient's mother was verbally nagging and blaming the nursing staff non-stop (especially me since I was in-charge of his medications that shift) for not monitoring him more frequently (on-demand) and not giving him the anti-pyretic while he was afebrile. She was demanding that I give paracetamol STAT via NGT, while I was preparing the patient's STAT IV Albumin drip order at his bedside. I finally told her to "I am handling a very important treatment for your child, please can you give me a few moments of peace to ensure that this goes correctly?"

The mother screamed "You cannot talk to me like this!" and repeated her broken record of why because of our treatment that her son is now having "high" fever. [Note: her son came in due to an infected shunt inserted overseas and had been febrile on-and-off since admission.]

The mother never paused for a moment to let me focus on her son's more important STAT Albumin treatment. I hit my tolerance limit. I told firmly her that we have our protocols for managing a patient's fever, especially in preparation for operation, we don't want to mask any underlying infection and we were handling her child as per protocol. She disregarded my explanation and still raised her voice and continued to blame us. Finally, I told her that if she is not happy she could lodge a complain. That I was there to help her child get well, if it were for her, I won't care either way. I continued with my work while her husband spoke to her in their language (presumably telling her to tone down), and then she continue running her broken record in a lower volume.

When the patient's consultant came, we informed him of the incident details after he reviewed the patient. Fortunately for me, this consultant was fair to nurses. He returned to the patient's bed and told the mother that we the nursing staff are competent in our work and had been doing her family a huge favour in cost savings by treating her child at the ward. She had been privileged to received such good nursing care at low cost (and free doctor's consultations). However if she insists on demanding interventions her way, he will re-assign the patient to HDU and she will have to foot the full bill.

That lecture bought us some peace for a while. I was glad the consultant was the one who dealt with the parents. Sadly, I am not confident that my hospital management would have been so supportive of its nursing staff.

littlepretendnurse said...

I have many reasons for working the night shift. One that gets reinforced time and again as I now spend 4 hours every shift on evenings (there are downsides to 12 hour shift) is the family!!! We had a 80 something year old patient on a small unit one time that had a daughter from hell. She constantly name dropped and DEMANDED that her mother get her medicine the way she wanted it given. Most of it made sense. Until she demanded the colace to stop the diarrhea. Oh and she brought in a few of the medicines for our hospitalist to look at. Along with a med to stop the stools there was a bottle of colon cleanse. Yup she was giving her mother a medication to cleanse her colon while giving a laxative and an anti-diarrheal. {face-palm}

The other incident that comes to mind is this. Up on the floor we have semi-private rooms and sometimes the roommate can provide very valuable information to us. Telling us that the patient is trying to climb out of bed or is vomiting or whatnot. The problem is when the roommate starts dictating the care we provide. We have had a couple of situations where we have had to change rooms of one of the patients because the (and I must believe well-intentioned or I will really go crazy) roommate was being a little too obnoxious.

So long story short
I have been there, I feel your pain!!!!!

tracy said...

Such a sad and frustrating post on both sides.
And one i can "relate" to, on many levels. Just two...

Having had 3 seizures in the distant past (don't even like hearing or writing the word...Magical Thinking, anyone?!)

And...a controlling mother...i love my mom...but....you know.

Many thanks, Dr. Jim.

Stephany said...

That mother sounds like one of Dr.Grumpy's! http://drgrumpyinthehouse.blogspot.com/2010/06/attention-patients.html

Hopefully, Kathy wasn't keeping one of those polite smiles on her face, pretending all is OK, while being manipulated by her mother. Time for mom to stop being part of her "treatment team" is what I think.

Stephany said...

That should read, one of Dr. Grumpy's patients! (he's a neuro-doc)

Attention Patients-The emergency room is for EMERGENCIES!!!

Kate said...

When I had meningitis (didn't know it yet) I was so grateful that my mother was there with me. I was terrified on top of being violently ill. I'd been to the ER twice and been sent home with migraine medication when I finally asked her to drive three hours to come with me. I knew I needed help and I knew I wasn't well enough to advocate for myself. Three hours later, I was admitted. And they finally knew what was wrong with me. She wasn't mean, but she sure wasn't letting them discharge me one more time without finding out what was wrong.

SeaSpray said...

You handled it so well...on all fronts!

Cathy said...

This reminds me of my room mate I had, in a semi private room, at the cancer center following radical surgery. Bless her heart, she was so well intentioned that it was not possible for me to get angry at her, although it was totally nerve wrecking.

She was an older lady. Following my surgery I was NPO for days until bowels sounds returned. This included ice and water. One day when my Onc.surgeon walked in and found the water pitcher had been filled and placed on the stand right at my bedside (even though I had not drank any of it)he grabbed the table and slid it completely across the room. I was NPO for 4 days following this surgery.

On the morning of day 3, Jessi (my room mate) decided she would go on a hunger strike until they gave me something to eat.lol...its comical now but it was not at the time.

She refused her meals the entire day. The nurses talked to her and I did too. I explained to her that I knew it would be a few days before I could eat and it was ok, I wanted her to continue eating her meals. She would have no part of it. She told them to feed me and then she would start eating again. I was still sick enough that this was all very upsetting and soon I was crying. I wanted her to eat. Jessi was still refusing to eat.

The end result is that I was moved across the hall into a private room. We told Jessi as soon as I moved that I would be eating a BIG meal for dinner that night. She started eating again. I'm sure this was not a good day for the nurses assigned to Jessi, or to me, for that matter.

terri c said...

Ha, you should be a hospice doc!! Death is a good thing to trigger control issues and sometimes friends and family become quite adamant about treatment as a way to cope with a terrible loss, and probably a very HABITUAL way at that! I remember one lovely patient who had a family member that insisted on continuing glucose checks and wanted the patient only offered sugar-free snacks, and all manner of stuff like that, even though the patient was going to die and just wanted to enjoy some ice cream and some pudding while able. The family member also wanted immediate response to requests for things like blankets, repositioning, etc., and I remember one time having to tell the family member that a nursing assistant would be in the room as soon as possible--but it would take a few minutes. There was steam coming out of the family member's ears. From behind the family member the patient moved to get my attention, and gave me an ENORMOUS wink, knowing exactly what was going on. I winked back and waved to the patient as I left, causing the family member to wonder if I'd lost my mind I am sure.

Texas reader said...

I think Kathy was planning how she would mix her mom a few cocktails then smother her with a pillow that night and THAT is why she was smiling.

Milo said...

i am so sorry... but my mum treated me that way my whole life. i somehow managed to smile too. it felt like i was being suffocated by her. the moment i stood up to her, she kicked me out of her house. somehow i survived... but i feel much better now. at least i know if i am smiling it is for real and is coming from the bottom of my heart.
i wish that daughter all the best too.

love, Milo

Stephany said...

And then there are blog authors who describe ER's like this, in an ER status of a severely disabled child, and the rest of us can just stop complaining.

Anna said...

Jim as much as you want to make everyone happy, there is always someone. Looks like mother was fed up with Kathy's disorder, and tried to cut corners. Jim thanks for sharing, this is one good lesson to us. Anna :)

Peter said...

Hi! I wish I had a dollar for every pillow that went missing during my time in ED. Then maybe I'd be a millionaire.

Having shares in a pillow company may be even better than shares in BP at the moment.

Take Care,
Peter

Katie said...

Haha... I have a similar story but it's a traveling story rather than an overprotective parent story. Although, we call my parents Chopper One and Chopper Two because of the way they hover...

<>< Katie

Persephone's Maiden said...

I have a nasty feeling that's what my sister is going to be like in another 10-15 years. I managed to break away from the controlling relationship that our mother tried to clamp on me and as soon as I was out of her clutches, I became the most hated, villainous daughter on the planet.

My sister, OTOH, puts up with it, probably because as a reward she's showered with gifts--new laptop, brand new car, designer clothes and jewelry. But she's going to be 21, has never held a part time job in her life, does not have her driver's license so our mother drops her off at the university where she attends classes. They argue with her professors. They do her assignments.

She is so smart and talented and she's never going to live up to her potential because she's been stunted. She's never had control of her own life, and she's probably not going to. I can totally see our mother doing this Goddess forbid if my sister ever ended up in the hospital.

Granted, this might not be the case with the woman in your story...but the similarities give me chills.

Slave of Allah said...

Grea...

Slave of Allah said...

owhh..