When I went to discharge my pain-seeking patient yesterday, I picked up her chart and saw a sealed envelope taped to the chart addressed to me. "For Dr. ____ Only" it read. I wasn't sure what to expect, but what I pulled out were four stapled sheets of notebook paper, both front and back filled out, and consisted mainly of a list of grievances that the patient felt had been committed against her since her thoracotomy two weeks ago. Mostly, she was furious that I'd called an "MD" (her name for the pain specialist) who was "disrespectful" and "power hungry" and did nothing to try to help her pain (as she believes a pain specialist's goal is the comfort of the patient). She also described the increased "suffering" she endured from not being able to talk to me over the weekend (it was my weekend off) and accused me of forgetting our "good relationship built on trust." She felt I put my trust in the wrong person (the pain specialist), and in her words, "I suffered since you left me and in my book and most others that is not very thoughtful practice." My mental response when I read that part: What. The. F***.
Maybe she thought that she was speaking to me as one health professional to another (since she used to be a NP, apparently) and used plenty of medical terminology in her letter to emphasize that, but to me this seemed more like the ranting of a crazy person. I don't blame her for writing a letter and putting all her thoughts on feelings on paper; hadn't I done the same throughout junior high, high school, and college when I kept a journal? But this was definitely something else. She also included a list of medications she needed for home, including Valtrex (which she didn't even NEED anymore since she got 10 days of Valtrex in the hospital for shingles) and my favorite, "Dilaudid 2 mg IV q3." She claimed that she had received IV Dilaudid at home in the past, but I find that extremely doubtful. I vented to several of my colleagues about what to do, and they told me not to give her narcs at all and get her out. The problem: I knew this woman, and if I didn't send her home with scripts for narcotics, she'd throw a fit, and that's the last thing I wanted. My number one goal was to get her OUT.
When I went into her room to see her (with the nurse, of course), she initially didn't make eye contact me and said, "Did you read my note?" I said yes, then added that I'm sorry I wasn't there over the weekend and added, "It was my weekend off." She said that she understood that doctors need time off, then went on about how offended she was by the pain specialist when he tried to cut her off IV meds. I made no move to be friendly during her one-sided complaining; I kept my arms crossed like I meant business and I think she read into that. When she asked if I'd be writing her all the medications she requested, I said, "I'll take care of it." She was particularly insistent about getting oral Dilaudid, saying that she needed it for "several weeks" but I wasn't about to do that. I wrote her for a two week supply of pain medications; if she wants more, she'll either have to go to the ER or go to the pain specialist, which I doubt she'll do since she hated his guts. She even asked if she could have an extra dose of IV Dilaudid before she left, but I pretended not to hear her and the nurse quickly removed her IV and said it was time to go. Fortunately, the patient was mentally ready to leave, and she left without a fight.
Today a lot of us in the nurses' station couldn't stop talking about how much better things were now that she's gone. I, for one, am more cheerful and don't dread that particular floor anymore. I did put her note in the chart and it has been scanned and is part of her permanent record. If she ever returns with drug seeking behavior or tries to get me in trouble, I'll gladly show her note to the CEO or whoever else wants to see. Let them read that note and see exactly what state of mind she's in. She's batshit crazy, and I can only hope that I'm never on call whenever she returns. The two weeks she was my patient, I felt like my soul was being sucked out day by day. Now I can get some of my sanity back.
Tuesday, November 20, 2012
Saturday, November 17, 2012
Master Manipulator
One of the biggest challenges I've found with being an attending is learning to deal with drug-seeking patients. I had plenty of those throughout residency, but I was protected because I didn't have a DEA number and therefore couldn't write prescriptions for narcotics. If they needed pain meds, I just said, "Talk to my attending" and left it to the attending to decide whether or not to write for narcs. Now I am the attending, and I have to deal with these narc seekers directly. Sometimes it goes well, other times not.
For the past two weeks I've had to take care of a patient (who, incidentally, used to work as a nurse practitioner before she was injured in the line of duty in Iraq) who was transferred to our hospital for a thoracotomy for a persistent pleural effusion (no CT surg at the other hospital). I'd heard from the EMS reports that the patient was a big-time drug seeker and that the other hospital was glad to be rid of her. That should have been the first indication that the patient would be difficult. She had the VATS and had two chest tubes placed. Most people are simply placed on a PCA Dilaudid until the pain improved, but not her. In addition to the PCA Dilaudid (which she rarely used), she was also getting 1-2 mg Dilaudid IV q3 prn, and then she "begged" the CT surgery team to give her a basal dose on the PCA since she was waking up in pain. There were many times when I tried to wean her off the PCA (at least the bolus), but she'd always cut me off, saying that it was "unethical" for a patient to be in the hospital in so much pain and that she needed to be comfortable so that she can undergo physical therapy and do what she could to get better.
Finally last Monday her chest tubes were pulled, and I can reinitiated plans to wean her off Dilaudid. The plan was to discharge her on Friday. She didn't really make a fuss when I stopped the bolus and then the PCA (she wasn't pressing the button much by then anyhow), but when I tried to stop the q3 Dilaudid, she argued with me, saying that she "needed" the Dilaudid while she was in the hospital. "When you're ready to let me go, I'll be fine with the pills," she said, "but while I'm here, I want to be as comfortable as I can be." Any attempts I had to try to wean her would lead to 30-45 minute conversations/arguments which I don't have time for, so previously I let her have her own way. Then the patient said she didn't want to go home on Friday b/c she didn't feel "safe" being alone especially with the Fortune-1 race in town, and that she was going to go home on Monday instead because "my insurance will cover my stay." That was the last straw. Finally I took a partner's advice and asked a pain specialist to see her. He prescribed her with a Fentanyl patch, discontinued her IV Dilaudid, and cleared her for discharge on Friday. I was told that right after he left her room, she frantically called her nurse asking to speak with me. Fortunately the nurses protected me and told her I was gone for the day, and I did all her discharge paperwork in hopes that one of my partners (who was covering for me since I took Friday off) would be able to discharge her in my absence.
It didn't work. I'd told my partner to write the discharge order and be done with it, but instead she got sucked into another 45 minute debate as my patient listed all the reasons she couldn't go home on Friday, but then agreed to go home on Saturday. See, that was crafty on her part, because Home Health doesn't go to patient's homes on weekends, and the patient needed Home Health. In agreeing to leave the hospital on Saturday, then saying on Saturday that she can't go home until Monday because that's when home health shows up, she essentially bought herself a weekend stay. I was pretty furious when I called her nurse and got this info; I was hoping not to have to deal with her this coming Monday.
But it looks like I will have to deal with her on Monday, but I'll be damned if I let her manipulate me into staying another day longer. It's pathetic to see how a former medical professional like herself became a drug-seeking manipulator, but I'm through with playing her games. She goes Monday, no matter what.
For the past two weeks I've had to take care of a patient (who, incidentally, used to work as a nurse practitioner before she was injured in the line of duty in Iraq) who was transferred to our hospital for a thoracotomy for a persistent pleural effusion (no CT surg at the other hospital). I'd heard from the EMS reports that the patient was a big-time drug seeker and that the other hospital was glad to be rid of her. That should have been the first indication that the patient would be difficult. She had the VATS and had two chest tubes placed. Most people are simply placed on a PCA Dilaudid until the pain improved, but not her. In addition to the PCA Dilaudid (which she rarely used), she was also getting 1-2 mg Dilaudid IV q3 prn, and then she "begged" the CT surgery team to give her a basal dose on the PCA since she was waking up in pain. There were many times when I tried to wean her off the PCA (at least the bolus), but she'd always cut me off, saying that it was "unethical" for a patient to be in the hospital in so much pain and that she needed to be comfortable so that she can undergo physical therapy and do what she could to get better.
Finally last Monday her chest tubes were pulled, and I can reinitiated plans to wean her off Dilaudid. The plan was to discharge her on Friday. She didn't really make a fuss when I stopped the bolus and then the PCA (she wasn't pressing the button much by then anyhow), but when I tried to stop the q3 Dilaudid, she argued with me, saying that she "needed" the Dilaudid while she was in the hospital. "When you're ready to let me go, I'll be fine with the pills," she said, "but while I'm here, I want to be as comfortable as I can be." Any attempts I had to try to wean her would lead to 30-45 minute conversations/arguments which I don't have time for, so previously I let her have her own way. Then the patient said she didn't want to go home on Friday b/c she didn't feel "safe" being alone especially with the Fortune-1 race in town, and that she was going to go home on Monday instead because "my insurance will cover my stay." That was the last straw. Finally I took a partner's advice and asked a pain specialist to see her. He prescribed her with a Fentanyl patch, discontinued her IV Dilaudid, and cleared her for discharge on Friday. I was told that right after he left her room, she frantically called her nurse asking to speak with me. Fortunately the nurses protected me and told her I was gone for the day, and I did all her discharge paperwork in hopes that one of my partners (who was covering for me since I took Friday off) would be able to discharge her in my absence.
It didn't work. I'd told my partner to write the discharge order and be done with it, but instead she got sucked into another 45 minute debate as my patient listed all the reasons she couldn't go home on Friday, but then agreed to go home on Saturday. See, that was crafty on her part, because Home Health doesn't go to patient's homes on weekends, and the patient needed Home Health. In agreeing to leave the hospital on Saturday, then saying on Saturday that she can't go home until Monday because that's when home health shows up, she essentially bought herself a weekend stay. I was pretty furious when I called her nurse and got this info; I was hoping not to have to deal with her this coming Monday.
But it looks like I will have to deal with her on Monday, but I'll be damned if I let her manipulate me into staying another day longer. It's pathetic to see how a former medical professional like herself became a drug-seeking manipulator, but I'm through with playing her games. She goes Monday, no matter what.
Thursday, November 1, 2012
A Day in the Life...
Now that I've been working for over a month, life has settled into something of a comfortable routine. In some way, since the hospitalists work independently of each other (unless we're on call), I am my own boss. I set my own hours, decide when to come to the hospital and which patients to see first, and leave when my work is done. Most days I come to work between 6:30am - 7:00am in hopes of finishing earlier (so that I can get out of the hospital sooner), but if I worked a 5-10pm call shift the night before and didn't leave the hospital until 11:30pm, then I'll usually come to work later, like 7:30a.m. (try to give myself at least 5.5-6 hrs of sleep a night). Or if I need to be somewhere by 4 pm and I have 15 patients to see, I'll come at 6:00 a.m. to give me plenty of time to work. No one ever yells at me for being late, and no one tells me how to practice medicine. I just hope that I know what I'm doing.
In the mornings, depending on how high or low my census is, I can usually expect to get some extra patients who were admitted overnight. Or, if one or two of my partners has decided to take the day off, their patient lists are split amongst the rest of us. The only rule regarding taking days off is that 10 hospitalists have to be present on any given day, so some partners use this to their advantage (i.e. take every Friday off). I once took a day off to attend hospital orientation, but since I got out in 4 hours, I ended up taking back my patients and working a regular day anyway. This is why I try to come to the hospital early; yesterday I ended up with four new patients on top of the others I already had. My "desired" patient cap is 15, so as long as my census is less than 15, I can almost always expect to get new patients every morning.
The general rule is to see the ICU and IMC patients first, and since the IMC is on the top floor of the hospital, proceed with gravity rounds. I usually stick to this rule, but there are times where I will skip a floor (i.e. if the patient's a rock) and go to a different floor where I know I have pending discharges to do. We try to discharge patients as early as possible, and those take up a LOT of time (paperwork plus dictations). I once spent almost an hour dictating a patient who'd been here for a month and miraculously survived everything that got thrown at him (GI bleed with simultaneous MI, gastrectomy, post-op CVA, etc), and that delayed time in seeing other patients. On a good day I can see 4-5 patients in an hour if they're not too complicated. The ICU/IMC patients usually take up a good 30-40 minutes per visit.
Food is free for physicians in the hospital (awesome perk!), and is usually not that bad. I've even stopped making my own breakfast of oatmeal and eggs b/c I can get the same at the hospital (plus extra fruit and bacon I wouldn't otherwise eat....) The menu has both healthy and greasy options, though my biggest weakness so far is helping myself to a chocolate chip cookie for dessert at lunch. I never ate cookies in residency b/c I had to pay for them (which I refused to do), but when the cookie is free, then all that goes out the window. So needless to say I've gained some weight. =P
Overall, more good days than bad on this job. Can't complain about that one =)
In the mornings, depending on how high or low my census is, I can usually expect to get some extra patients who were admitted overnight. Or, if one or two of my partners has decided to take the day off, their patient lists are split amongst the rest of us. The only rule regarding taking days off is that 10 hospitalists have to be present on any given day, so some partners use this to their advantage (i.e. take every Friday off). I once took a day off to attend hospital orientation, but since I got out in 4 hours, I ended up taking back my patients and working a regular day anyway. This is why I try to come to the hospital early; yesterday I ended up with four new patients on top of the others I already had. My "desired" patient cap is 15, so as long as my census is less than 15, I can almost always expect to get new patients every morning.
The general rule is to see the ICU and IMC patients first, and since the IMC is on the top floor of the hospital, proceed with gravity rounds. I usually stick to this rule, but there are times where I will skip a floor (i.e. if the patient's a rock) and go to a different floor where I know I have pending discharges to do. We try to discharge patients as early as possible, and those take up a LOT of time (paperwork plus dictations). I once spent almost an hour dictating a patient who'd been here for a month and miraculously survived everything that got thrown at him (GI bleed with simultaneous MI, gastrectomy, post-op CVA, etc), and that delayed time in seeing other patients. On a good day I can see 4-5 patients in an hour if they're not too complicated. The ICU/IMC patients usually take up a good 30-40 minutes per visit.
Food is free for physicians in the hospital (awesome perk!), and is usually not that bad. I've even stopped making my own breakfast of oatmeal and eggs b/c I can get the same at the hospital (plus extra fruit and bacon I wouldn't otherwise eat....) The menu has both healthy and greasy options, though my biggest weakness so far is helping myself to a chocolate chip cookie for dessert at lunch. I never ate cookies in residency b/c I had to pay for them (which I refused to do), but when the cookie is free, then all that goes out the window. So needless to say I've gained some weight. =P
Overall, more good days than bad on this job. Can't complain about that one =)
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