A Nice Person

Big thanks to all of you who reached out to make sure I am okay. I am. In fact, I have just finished a long string of overnights, the kids have successfully adjusted to the new school year, and I have a week off! I'm better than okay... Now, after a hectic but fun summer, I hope to get back to my regularly scheduled postings. Thanks for your concern and patience, friends.

The nursing staff gave me ample warning about the mother of my next patient, a nineteen year-old female with right upper quadrant abdominal pain. Supposedly, the mother had squealed her car into the front parking circle of our ER entrance, jumped out while leaving the car run, and hurried into the waiting room, abruptly cutting to the front of a line of eight patients waiting to be registered.

"Help! My daughter broke her leg and she's in my car bleeding!" the mother yelled, prompting our triage nurse and techs to grab an available cot and rush out to the car.

Disappointingly, our team did not find this woman's daughter, as she had screamed, lying in the back seat with a bleeding broken leg. Instead, what our team found was a young lady, mildly uncomfortable, sitting upright in the front passenger seat of the car. The daughter had gall bladder disease and had just eaten a fatty meal that she shouldn't have.

Sue, our triage nurse, confronted the mother alongside her car while the techs took the cot back into the building and returned with a wheelchair for the patient. "Why would you possibly come in screaming lies like that? Your daughter doesn't have a broken leg? She has abdominal pain!"

The mother, unapologetic, said, "I knew you guys would come running a lot quicker if it was a broken leg." Sue, who has been a nurse for nearly thirty years, simply shook her head. "I've never seen such a thing before," she had said to me, "and I hope never to again."

Sadly, though, the mother's startling behavior didn't end there. After finding out that her daughter would be third in line to be evaluated by the triage nurse, behind two other patients who were deemed more ill and waiting longer, she showered a tirade of obscenities not heard from the mouth of a sober person in quite a while. When that didn't get her daughter moved to the front of the line, she began to threaten "to sue."

It tells you about the state of affairs in medicine when an angry patient or family member threatens to sue and nobody really flinches at the threat. Most in medicine have become immune to the fear that threat once elicited.

When her threats to sue were disregarded, the mother finally threatened to call an ambulance service to pick up her daughter from our waiting room and transport her around the corner of the building to the ambulance entrance bay where, according to her, her daughter would "be guaranteed a room right away."

"Listen to me," Nurse Sue said, addressing this mother again, "you have the right to do whatever you want. But calling the ambulance does not guarantee your daughter an immediate room. In fact, the triage nurse back in the main ER may decide that your daughter doesn't need to be seen immediately and send her back out here, and then she will need to start the whole process of registering again."

The mother decided to not call the ambulance service. Ultimately, after several hours of waiting, in which time she continued to be quite rude and disruptive as well as consulted by a patient advocate, the nursing supervisor, social services, and security, her daughter was finally placed in Room 27, where I stepped in to see them.

I walked into a tension-filled room where mother and daughter did not appear to be enjoying each other's company. I approached the patient, an embarrassed-appearing young woman with straight shoulder-length hair. She seemed quite comfortable sitting upright in her cot. "Hello, Lindsey," I said, extending my hand, "I'm Dr. Jim and I'll be taking care of you today." Lindsey took my hand lightly into hers, barely gripping back my welcome. I then turned to the mother, hand extended, to introduce myself to her but, before I could speak, she started explaining herself.

"I'm sorry for my behavior today," the mother said, "but I didn't want my daughter to wait a long time to be seen. I really am a nice person, you know." From so many years in the ER, I have learned that if you have to explain you are a nice person, you might not be so nice.

"I understand from several people that you have been quite unhappy since you arrived to our ER, maam," I said, addressing her head-on, "but if you want to apologize to anyone, apologize to our triage team who appropriately followed the guidelines of our system in approaching your daughter's care."

"I just don't understand why a sick patient would have to wait two hours to be seen," she continued, while her daughter hushed "Stop, mom," at her.

I'm not sure why I did, but I explained that there was currently a five-hour wait for several non-urgent patients. I also explained that we had been busy dealing with multiple unstable, critical patients who, as long as her daughter's vital signs and exam were stable for our triage team, needed to be treated on a more emergent, immediate basis than her daughter. "Our system is designed to treat the most critical patients quickly," I added, "but that doesn't mean we aren't on your daughter's side--we want to help her as well."

After clearing the air somewhat, I reviewed with Lindsey her history of gall bladder disease and the meal she had eaten prior to developing her pain. Pain which, incidentally, was now gone. After a stable exam, we repeated a round of stable vital signs. Finally, upon review of all of her labs, I went in to explain our plan with the patient and her mother.

"Lindsey," I said, focusing on her, "you are currently pain-free. You don't have a fever, you have stable vital signs, a pain-free physical exam, and normal lab work. In essence, I think you aggravated your gall bladder to spasm with your fatty meal and now it has calmed down." Lindsey shook her head in agreement. "So," I continued, "I talked to your family doctor and made you a surgical appointment in two days. Is that okay?"

"No," the mother blurted in, demandingly, "I want Lindsey to have her gall bladder taken out today and be done with this." I looked from the mother back to Lindsey. "Lindsey," I repeated, "are you okay with my plan?"

"Yes," Lindsey answered, clearly relieved, "I cheated on my diet today and paid the price. I don't want surgery, anyway. Unless I really, really need it."

"Then don't come complaining to me if you get another attack," the mother said snidely to her daughter.

"Listen, Lindsey" I said, "I will write you for some pain medication if you get another attack. And watch what you eat. Clear liquids for the next 12-24 hours and then slowly advance to a bland diet. Otherwise, the surgeon will help you through this, okay?"

The mother huffed. Lindsey smiled her approval. I quickly went back to my station to get her discharge instructions ready. It was futile to try to please this mother. Couldn't she see we invested more time placating her than treating her daughter?

As I typed out the discharge instructions, I heard the mother's voice at the nurses' station. She must have followed me out of the room. She was apologizing again, attempting to save face with our staff. "I really am a nice person," I heard her repeat to the nurses.

Just maybe, I thought, she was saying this out loud to convince herself. I had to fight myself, though, from sharing with her my favorite quote, by the genius Ralph Waldo Emerson: Who you are speaks so loudly I can't hear what you're saying.

Sadly, we all heard loud and clear what this woman was saying.

As always, big thanks for reading. I hope this finds you all well. Be back Friday...