Recently, we were presented with a typical frequent-flying crackhead who had the usual litany of complaints. The specific details don't really matter; I'm sure you know the type. Apparently one of the nurses on duty had some previously unpleasant experiences with this particular individual, and she seemed none too thrilled about her assignment. I, on the other hand, had never seen the patient before.
This patient was a bit irritable and paranoid, but there was neither obvious evidence of danger to self or others nor anything particularly abnormal on the examination. As I was charting my notes, I could hear some animated discussion coming from the room. The nurse was finally able to obtain some blood, but she was unable to start the IV. After I reviewed some of the previous records, I decided that I didn't necessarily want this patient to have an IV anyway, because I saw that on a previous visit the patient had eloped from the ER prior to disposition. So I ordered an IM injection of a sedative, which the patient agreed to accept, grateful that there would be no more IV attempts.
But the patient didn't want the nurse in question to give the injection, because the patient was now afraid of her. She tied the tourniquet way too tight on purpose, the patient claimed, and she was less than gentle with her multiple IV attempts, purposely "jabbing the needle into the bone." Unfortunately I still had a few other patients to see, and I really didn't have time for any nonsense. Whatever, I'll try to find a different nurse to give you the shot.
"Oh no you won't!" barked the clipboard-carrying nurse administrator who had been lurking vulture-like, eager to plunge her beak into the carrion this situation was becoming. "This
nurse is assigned to the patient, and she is the only nurse that will be involved. The patient isn't allowed to change nurses, especially after being so abusive and uncooperative all these times. We're not going to play these games."
Fine, I said. I don't care who gives the shot, or really if the patient ever even gets the shot. It's not really an emergency anyway. I'm just waiting on the blood tests and trying to make the patient a little more comfortable and less agitated so everyone
can chill out a little bit.
Of course the patient refused the shot from the "mean nurse" and continued to be angry and upset. A battle of wills ensued, in which each of the opponents tried to exert their dominance over the other. The patient used whatever ammunition was available, primarily the power to hit the call bell and to be generally defiant and rude. The nurse countered with her unwavering authority and adherence to policy. For example: the patient was claustrophobic and wanted the door to the room open. The nurse took it upon herself to be the door Nazi and kept closing the door, smugly quoting government regulations and patient privacy considerations.
Was this nurse really such a true believer in the closed door policy that she consistently applied it to all patients in every situation? No, she was just using the policy as a stick with which to poke this particular patient. There were some raised voices from both corners and a couple of visits from security, but nothing really exciting or disturbing. After they eventually tired of the battle, the nurses came to me for resolution of the problem.
"What are you going to do about this?" they asked.
My job is to diagnose and treat emergency medical conditions. Based upon my initial assessment, I determined that some tests were indicated, and my disposition will be based upon those results. If the patient wants to stay and be treated, then we should treat the patient. If the patient wants to leave, then I'm not going to stand in the way. I've got a couple of sick patients I'm dealing with right now, and the fact that this patient is annoying and doesn't want to follow your rules isn't high on my list of priorities at the moment. I'm not going to do anything that would make this situation more unpleasant than it already is, if that's what you're asking. I've been in that room three times, and I've been able to verbally calm the patient down each time. I recommend that you try to do the same instead of agitating the patient further.
I'm all about supporting nurses, but I will never support their blind adherence to bullshit policies and regulations, and I don't like it when they seem to purposely antagonize patients. I admit that I'll probably be less inclined to tolerate any misbehavior from this patient after a couple more visits like this one. But in this case, I couldn't shake the feeling that we all could have handled the situation better.
UPDATE: IF you want to know more about crackheads AND you need a laugh THEN go here
Labels: nurses, patients, perception, questioning authority