Every ER has its regulars--those patients who return multiple times for a multitude of complaints. Sometimes their complaints are easy and minor, yet other times their complaints can be quite concerning, demanding our full attention. Regardless, that familiar face and voice can become quite a mainstay to a typical ER day. Depending on the patient, these repeat visits, over and over and over, can be the stuff that can sink an already hectic day. Or, remarkably, elevate it.
With multiple visits to an ER, then, a patient can learn the ropes of how our system works, using it to their advantage. For example, what are our busiest times? Most of our regulars know not to come in the evening, especially on a weekend or Monday night. Which doctors are working? They learn quite quickly which ones are more generous with the pain medications. Which nurses will be available to lend them an ear and a sympathetic nod of the head? Which case managers can get them free rides home and complimentary prescription refills? The list of "inside information" can be exposed and manipulated quite easily in the right hands.
We even get frequent "anonymous" phone calls, answered quite brilliantly by our secretaries, asking for the name of the currently working physician. "Umm," the phone caller starts, "my family doctor told me to come to the ER right now. But I'll only come in if Dr. Smith is working." "Well, sir," the secretary will say, "if you are sick enough to visit the ER, I don't think it would really matter to you who is working." "But can you just tell me who is on?" To which our secretary shakes her head as she answers. "I'm sorry, sir, but I can't give that information out." The first click of the phone never seems to come from our end.
So walking into Room 12, I was quite prepared to see one of our more frequent patients, a pleasant, middle-aged woman with chronic abdominal pain of five years. Unfortunately, she is very susceptible to alcohol-induced pancreatitis and hasn't yet mastered her drinking problem. As a result, her abdominal pain and drinking issues keep her in a perpetual state of requiring our ER services. The more she drinks, the worse her abdominal pain becomes. The worse her pain becomes, the more she drinks (to dull the pain). A vicious cycle of dependency, for sure.
I smiled at my patient as I walked into the room. "Hello, Ms. Tinnell," I said, extending my hand, "how are you today?" I paused, before adding, "I haven't seen you in a few weeks!"
The patient's face lit up. Obviously, I thought to myself, I must be one of the docs generous with the pain medications. Ms. Tinnell looked worn-out, very sallow, and just overall miserable. She was holding her belly, despite her happiness to see me.
"Hi, Doctor," she said, "I'm glad you are on today. I'm hurting real bad here, sir."
"Was it your drinking again?" I asked, cutting to Ms. Tinnell's chase. She nodded her head in the affirmative. "Ms. Tinnell," I said, "how do you expect to get better if you don't want help with your drinking problem?" We had been over this time and again, but she didn't want any offered services for her abuse issues. That said, I sure couldn't leave a patient like Ms. Tinnell suffering, either. Despite bringing all of these problems on herself, I still needed to address her pain issue.
After finishing the interview, I performed an exam. Leaning in to listen to her heart, I smelled her staleness, her sleep--that scent of just rolling out of bed in two-day old clothes. It was a smell I abhorred. "Ms. Tinnell," I said, "are you taking care of yourself? It smells like you haven't showered in a few days. Have you been binging again?"
"Oh, no, Doctor," she assured me, "I just had a couple last night to help with the pain. That's all." I looked closely at her disheveled self as she tried to sell me her line, shaking my head "no" as she spoke. "Okay, okay," she said, after watching my reaction, "you are right. I've been drinking for three days straight."
"Well," I asked, "what are we going to do about this? I want to help you but I'm not sure how I can. Are you willing to be admitted for your pain?" She nodded "yes." I continued. "Are you willing to talk to someone this visit about your drinking?" Again, she nodded "yes." "Good, Ms. Tinnell," I said. "I will order up a work-up, give you some IV fluids with nausea and pain medication, and start working on admitting you to the hospital, okay?" I had no doubt her chronic pancreatitis had been exacerbated by her drinking.
Once again, she nodded "yes" to me.
And then, Ms. Tinnell reminded me of how frequently she comes to our ER. "Um, Doctor," she said, before I could step out of her room, "can you get me an extra pillow?" "Ms. Tinnell," I said, "you know how hard it is to find an extra pillow around here! I'll look, but I doubt I will find one." She continued. "Then how about some extra blankets. And not those regular ones, either. I want the warm ones from the toaster oven." Those warm blankets were usually saved for trauma patients, to keep them warm as we undressed them to closely examine their injuries. "Okay," I told her, "I'll have one of our aides run a few down to you." She continued. "And Doctor, do you know if the pudding you have today is lemon or chocolate? Your chocolate pudding doesn't sit well with my stomach." Oh, the cafeteria pudding is now my fault? I chuckled to myself. "Ms. Tinnell," I said, "you and I both know you won't be eating anything for a day or two, not until we get your pancreatitis under control."
Finally, the big question that I knew was coming. "Doctor," she asked, "what are you going to give me for pain? You remember that the one that starts with a "D" works best for me, right?" "Yes, Ms. Tinnell," I answered, "I know the dilaudid (a morphine derivative) helps you the most with your pain." She was only going to get half of her typical dose, though, to start with, since her renewed energy in making all her requests was quite impressive to me.
I stepped out of the room, but not before I heard Ms. Tinnell giving her nurse explicit instructions on where and where not to place the IV. "Honey," she was saying, holding up her left arm, "they always get one here. Are you new here? I don't think I've seen you before."
I stepped out, shaking my head. This patient obviously felt right at home with us.
Twenty or so minutes later, I walked back into Ms. Tinnell's room to check on her as well as explain that her pancreas enzyme levels (amylase and lipase) had returned from lab and were quite elevated, signifying, for her, a flare-up of her pancreatitis. She was not alone in the room.
"I feel much better already, Doctor," Ms. Tinnell said, before I could even approach her bedside. "That "D" medicine works great!" I smiled at Ms. Tinnell as I walked up to her guest, and older gentleman, who was sitting in the room's corner. "Hello, sir," I said, "may I ask who you are?" I was not going to share any of her private information without knowing his identity. "Oh," Ms. Tinnell answered, "this here is Johnnie. He's my new boyfriend." I held out my hand to Johnnie, shaking his. "Nice to meet you, Johnnie." Johnnie smiled, revealing his sparse, yellow-stained teeth. He appeared quite comfortable, sprawled out in the room's only chair, covered with one of the hospital blankets that Ms. Tinnell must have chosen to share.
I walked back to the cot and stood . "Ms. Tinnell," I said, "your pancreatitis is flared-up again. I called the medical doctors and case management. They are both going to be in to see you quite shortly, okay?" She nodded "yes," again. "We'll admit you like we planned." A part of me thought maybe, just maybe, she was going to back out of her admission, since we made her more comfortable and eased her pain. But she didn't.
As I stepped away from her cot, preparing to leave her room, Johnnie grunted. It was a signal to Ms. Tinnell. "Oh, yeah," she said, "I hope you don't mind that Johnnie is using the oh-two." I looked from Johnnie's nose, where two nasal prongs hovered in their silent swishing, and followed the clear plastic tubing that led to the oxygen hook-up on the hospital wall. It was set on two liters. Until this point, I hadn't even noticed that his tubing wasn't hooked up to the green tank that sat behind his chair.
They both must have followed my eyes as I took in the scene. "Yeah," Johnnie said in a low, rumbling voice, "I need to save my oh-two since I'm running low."
This was a new one for me--a patient's visitor hooking himself up to the hospital's oxygen. Not the patient, but one of their visitors! It gave a whole new lever to the phrase "make yourself at home." I shrugged at the both of them. "I guess it would be okay," I answered, "since you are only going to be here a few more minutes. When you go upstairs, though, you'll have to check with your nurse before you hook up to any more hospital oxygen."
Again, I started to walk out of the room. Before I could, though, Johnnie had cleared his throat yet again. I turned around, now growing a little impatient. "Yes?" I asked him. He looked to Ms. Tinnell. "I ain't gonna ask him," she said to him, "you have to." "What is it, Johnnie?" I asked.
"Well, do you have an extra chair that I can put my legs up on while I'm waiting here?" Um, no. Sorry, Johnnie, I thought to myself as I shook my head. He continued. "Then do you have an extra pillow and more warm blankets?" "Johnnie," I spoke, "we don't have any more pillows. I looked. And those warm blankets are for trauma patients. We gave you three between the two of you--you don't want to take any more in case someone really injured needs them, right? We'll get you some regular blankets if you want them." He looked at Ms. Tinnell before speaking a final time. "Well, then, how about some pudding or a turkey sandwich? Nobody's even asked me if I want coffee or something to eat yet." The words were spoken with entitlement dripping off every syllable, not as a question.
It was obvious Ms. Tinnell had shared the secrets of our system with her new boyfriend. Ughhhhh! And to top it off, right before walking out of the room, Ms. Tinnell did her own little throat rumble. "Doctor," she said, looking quite comfortable lying in her cot, "the pain is coming back. Can I have more of that "D" medicine to help me?"
According to Ms. Tinnell's nurse, the requests from their room continued throughout the entire ER visit. "Do you have any extra tooth brushes?" "Why won't channel 68 come in on the TV?" "Can someone get me some reading magazines from the waiting room?" Imagine a typical hectic ER day--the noise, the crowded hallways, the prehospital sirens going off, the commotion, the incessant phone ringings, the scurrying staff, the enormous traffic of patients coming and going, the arrival and departure of ambulance after ambulance. Now, imagine getting called into the same room repeatedly for such above issues.
I am quite fine with helping someone, anyone, in need. It's what I signed up to do, what any of us in medicine do, really. But, between Johnnie and Ms. Tinnell, I was feeling, once again, that our kindnesses and our system were being taken advantage of. It appears to be a growing problem with emergency departments across the nation as we struggle to redefine our roles in our changing medical world. Despite the pressure from administration and patient satisfaction surveys, there will always be patients and families that we simply cannot make happy. I felt we had gone above and beyond providing for our patient and, especially, for her visitor. But where is the endpoint?
Right before Ms. Tinnell was transferred to her medical admission room, the nurse approached me. It seemed Johnnie was upset that our case managers couldn't provide him a free taxi ride home. I shrugged my shoulders at her, exasperated.
"It looks like Johnnie is just going to have to find his own way home, I guess," I said. The nurse smiled, adding, "Or make himself at home...in our waiting room."
I could only hope they had some extra pillows out there.
As always, big thanks for reading. I hope this finds you all well...