The Asshole

I‘ve been called an “Asshole” by a patient two days running now. I guess I have to reluctantly plead guilty in the first instance. The second, I’m not ready to admit it yet.

Here’s how the calls went down.

***

The first was for a diabetic, altered level of consciousness. 40-year-old man lying in bed with glazed over eyes, cool, clammy skin, no idea what time it is, but he knows he’s an insulin dependent diabetic. His sugar on finger stick is 35.

There are a few different theories on how to treat conscious diabetics with altered mental status. Some medics like to give them orange juice and something to eat. I tend to prefer to go ahead and put a line in and give them the D50 and just take care of the issue. Officially in our protocols, the line is defined by “alert with intact gag reflex.” “Alert” is somewhat open to interpretation. Now obviously every medic is going to have a line they draw between their decision to give juice or to give D50. Where another medic draws the line is not as important to this story as this patient is right on my line. I decide to pop a line in. I’d rather just take care of the issue and be done with it than going through trying to get him drink and then waiting for his sugar to gradually come up to a point where he can competently refuse transport, which is what most of diabetics do when they come around. By most diabetics, I am talking about the young, independent insulin diabetics who occasionally drop their sugar when they forget to eat and who have been through the whole ED rigmarole on other occasions and just do not want to be transported.

I put the tourniquet around the man’s arm, spot a vein in his AC and no sooner have I put the needle into the skin, then the man swings his arms and says, “I’m not going to the f-ing hospital. Don’t you stick me with an IV.”

Now I am annoyed that I have now missed the IV on the only vein I could see, so instead of doing the smart thing and saying, “Nobody says you have to go to the hospital,” I start reasoning with him in a way that he cannot understand. I am trying to tell him that while he cannot refuse right now because he is not competent, in a minute after I give him some sugar and make him competent, he can then refuse.

It of course goes right over his head, and then he punches me and calls me an asshole.

Things can get out of hand so quickly.

I grab his arm to keep him from punching me again and the cops then grab him and start yelling at him and everyone is yelling at everyone else. He is screaming “I know my fucking rights. Just let me drink some coke.”

There is an open can by his bedside which his roommate had tried to pour in his mouth before our arrival and he manages to break through and then pours half the can on me and himself as he tries to chug it. I find myself hindering his efforts to drink it because I am still pissed that he clocked me, messed up my IV and spilled coke on me.

In the back of my brain unable to get through is a voice that says, “Hey, if he can drink, let him drink, maybe he isn’t as altered as you thought.” The other voice is saying, “He can’t talk to you like that. Christ, he hit you, if he’s alert, he’s going to jail. You give him an IV and give him sugar, he doesn’t have to go to jail. He hit you because he was altered.”

With the cops yelling at him and me with a good hold on his arm, and him calmed down just a little – maybe the coke did it — I quickly stick in another IV and push in half an amp of D50 and within another minute, he is apologizing for his behavior, and I am saying that’s okay I have seen worse, and he agrees to eat, refuses to go to the hospital, admits he overslept, says he is a brittle diabetic and should take better care of himself. His sugar is up to 200 now. Etc, etc, we get the refusal.

Outside, I apologize to the officers for not handling myself better. I shouldn’t have antagonized him at first. But what I am really thinking is I walked a fine line between providing the right care and committing assault. Something about it just didn’t feel right. I think what happened is in the course of the call, he went from being not alert to being alert, he crossed my line himself, maybe due from the Coke his roommate had poured in his mouth kicking in, supplemented by the Coke he poured in himself, and I wasn’t nimble or ego-free enough to change my course of action. It became about me versus him, rather than me versus appropriate medicine. I think next time my line between IV D50 and giving the patient a chance to drink some juice to see if he can drink it okay has moved closer to the juice side.

***

The second patient who called me an asshole had a history of chronic pain — back pain, sciatica, fibromyalgia, migraines. You name it, if it had to do with pain, he had it. This is an old patient for me. I used to take care of him years ago. You’d find him one day in bed, unable to move, complaining of pain all over, and acting almost stuporous and then the next week see him out bare-chested showing off his nearly full body tattoos as he mowed his lawn.

Now he says he takes Darvocet, but his new doctor recently reduced the dosage. He tells me he hasn’t had any pain pills for a week. I ask to see the Darvocet bottle but it is nowhere to be found. He has his other pill bottles — pills for hypertension and gastric upset — but no Darvocet bottle.

I ask what happened to the pills his doctor gave him last week, but he won’t answer my questions. He just closes his eyes and moans. If he lowered your dosage, you still should have some pills, did you not refill the prescription? Did you lose the pills? Did you take too many? No answer. He can answer other questions, but not these. I ask why we aren’t going to the hospital he normally goes to, and he won’t answer that either.

Admit anything to me – you were in so much pain, you took six a day — just don’t refuse to answer my questions when you are competent to answer. I am here to help.

But he won’t answer. Whenever we get on a touchy question, he just moans and closes his eyes.

I should just say “whatever” and transport him BLS and let the hospital deal with him, but I keep up asking the questions, my tone getting harsher and harsher. I am clearly starting to get pissed.

He finally opens his eyes, looks right at me, and no slur in his speech, says, “You’re an asshole.”

“If you are alert enough to recognize that I am an asshole,” I say, “then you are alert enough to tell me what happened to those pain pills.”

I am into pain relief. I have no problem with being taken by a drug abuser if it means denying someone with legitimate pain relief. I fully understand the devastating effects of chronic pain, and how it can turn otherwise normal, upstanding citizens into drug seekers out of fear they will not have enough medicine when they need it. My bonafides are solid on this issue, but he is getting no inch from me because he will not be straight with me. “You can answer. You want me to help you, answer the questions. What happened at the other hospital and what happened at your doctor’s office. Where are the pills he gave you? Tell me a believable story.”

He won’t look at me. The volunteer riding with me sits across from me looking at me like I am being so mean to this man. I feel like saying, “Go ahead, call me an asshole, too. I know that’s what you are thinking.”

I give my report at the hospital, and then leave. This morning when I go back, I ask what happened to the man and I am relieved to hear they concurred with my impression. The man was abusing prescription drugs, doctor shopping and when he was told he wouldn’t be getting any medicine, he stormed out of the hospital.

***

I’ve done two calls today and both patients have thanked me afterwards. I do admit to trying t
o
be extra nice today.

Even though I was right about the man with chronic pain being a drug seeker, in retrospect now, I think I was an asshole to him, too.

And no matter what, I don’t ever have a right to be an asshole to a patient.

12 Comments

  • nickopotamus says:

    Isn’t it better to act like an asshole and get the treatment right, rather than er on the side of niceness and get it wrong – in this case, he can’t drink his coke, or things go downhill before it can take any effect. And the way he apologised afterwards suggests that he didn’t genuinely consider you an asshole – I imagine this has happened before to the chap, and will happen again.Oh, and most of the volunteers over here are just as mean as the professionals 🙂

  • Gary says:

    A good rule of thumb is to use the least invasive treatment possible. If the patient can eat and drink enough to get his mental status back up, then that’s the way to go. It often takes a few minutes to determine this by trying to get the patient to eat. It’s usually worth it, though. We don’t have to transport patients even if they’ve had an IV and D50. Still, I prefer not to do that if I can just feed the patient. In the second case, you were completely right. The fact that he called you an asshole indicates that he knew you were doing the right thing, not what he wanted you to do. The volunteer probably hasn’t seen enough to know whether you were right or mean. Then again, in this business you can be both. Gary

  • Witness says:

    My line with diabetics is their level of consciousness, not their mental status. If they’re awake enough to mumble, they’re awake enough to swallow a tube of glucose. Obviously that’s not always the case, but that’s the rule of thumb I employ. If they’re completely out, then of course they get a line and a glass tube of sugar.As for the second patient, I think you did the right thing.

  • Chris in SE TX says:

    Here’s my $0.02 on the 2nd case:Many medics and doctors find it easier to just appease a drug seeker and get them out. I think if more of them would confront the patient and refuse to provide what they seek, the problem would start going away. Those people would stop going to the EDs, stop calling ambulances.I am increasingly tired of people abusing the system and letting me, the tax payer, pay their bills….I think you did well….

  • AlisonH says:

    Re the second patient, I think you very much did the right thing: you not only confronted him straight on just how he so much needed to be, but at the same time, you refused to give in because you cared about him personally. That’s a powerful combination. That combination is what gives people something to hold onto later if they do decide–at some point–that they want to change. You had more power for good in that situation than I think you had any idea of, even if you didn’t get to see it.

  • Rogue Medic says:

    You are being too hard on yourself. I don’t think either patient was right.The diabetic seemed to become more alert after being stuck with a needle. If that leads to reassessing and determining that he is now able to protect his airway, while eating or drinking, so much better. I am a fan of Gary’s approach of “A good rule of thumb is to use the least invasive treatment possible.” Just because I have ALS tools, does not mean I need to use ALS treatments.For the other guy, I am with you on pain management, but you summed it up perfectly with:“If you are alert enough to recognize that I am an asshole,” I say, “then you are alert enough to tell me what happened to those pain pills.”Being mean, the way I interpret it, has more to do with my intention, than the result. Starting an IV, that causes a lot of pain, is not being mean, but it is hurting. Starting an IV in the most painful way possible, when there are practical alternatives, is being mean.Some of what we do inflicts pain. That does not make it mean, at least not in my eyes.

  • Herbie says:

    An asshole you are not. You had to remediate sticky situations, and it’s quicker and safer to start the line and give the D50. He’ll get over it.And the drug seeker. I know the feeling. I have no sympathy for them.Remember, one thank you outweighs 10 FUs.

  • PC says:

    Thanks for all the great comments.While each case we encounter is different, I do agree with Gary’s philospohy of the less invasive the better, although I have not always followed it. It is a major factor to consider in every case. With particular regard to hypoglycemic diabetics, I need to weigh the drawbacks of the IV — infection, tissue necrosis if the dextrose infiltrates, possible needlestick if the patient becomes combative with the quicker resolution of the problem.On the second patient, I guess where I am critical of myself is not that I did not treat the patient’s pain, but that my questioning, once I had identified him as a drug seeker, eventually crossed the line from trying to get the information I needed to badgering. He pissed me off and I kept hammering him because I was pissed, where I think a better man, once they’d figured out he was drug-seeking, would have just backed off, transported without a further word, and left it at that.Sometimes in the past — I don’t do it nearly so much anymore — I would find myself being rude to a patient who may be abusing the system — calling for an ambulance when they didn’t need one, not calling their doctor when that course would be more appropriate or even the patients feigning unresponsiveness to gain symphathy from family or friends. Now, I find it easier to just put them on the stretcher and take them in.Maybe they should be scolded, but I find that shouting at a patient tends to just wear me out and put me in a worse mood.Thanks again for all the comments,PC

  • rookie bebe says:

    Love the post, but not commenting on the pts or their calling you an asshole. I’m commenting about your student. Were they EMT and not real experience, or a medic student and still not very experienced? I doubt they were looking at you in disbelief. Okay, maybe a little. But as an EMT and medic student doing my hours, I have to say that student was soaking it all in. Watching you, knowing it’s okay to confront the drug seekers, knowing you don’t talk like that to everyone, and learning it’s okay to keep questioning patients for the sake of the right Tx.

  • Anonymous says:

    When I finally lost it one night and lit up our regular drug seekers (and made him walk next to the stretcher all the way to the truck), he called and complained.The upside of being a model employee at a small company is that when known system-scamming douchebags call and complain about you, management doesn’t believe them. End result? A note was added to his profile in our dispatch system that I wasn’t allowed to pick him up anymore. Oh, darn, no more 1am trips to pick him up off the same spot on the floor with his med list and medicaid card in hand!

  • pozzo says:

    Everybody freaks out at some point, and anyone with any mettle will look back later and see it clearly, honestly, and say, “What was I thinking?” It’s not a big deal. We’re constantly put in unstable situations with irritable people in unfamiliar environments. And every job is a little different. Freakouts happen. Think about the treatment. Evaluate what you did. Take a deep breath. And move on. That’s it. Good post, by the way.

  • davisemt says:

    I just moved into a new system. Although it is private ambulance. Fire has a medic on every engine. I am guessing they live by the rule “go big or go home” They constantly place 16s on people who only need meds. and go for the EZ-IO in almost any unconscious pt. That is being an asshole!I have no idea how I am going to survive these egos.We all have rough days, rough patients. You were only human, you gave the right care in my mind, and for god sakes you are allowed to get annoyed occasionally too. Living and learning every day!

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