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Life In The ER: Never Judge A Book By Its Cover

The ER is a highly effective bottom-filter for society.  When you work in the ER you are in daily contact with the worst that mankind has to offer: addicts, sociopaths, criminals, and the many many varieties of personality disorders with which a loving God has imbued humanity.  I say this not as condemnation: they are my people.  I know them and accept them for who they are.  I am here every day to serve them in their various needs, from the heroin addict who is dropped off blue and apneic to the homeless guy who just wants his unwashed feet looked at.

One of the refreshing features of many members of the lumpenproletariat is their candor regarding their habits.  Sure, it’s by no means universal, but it’s entirely common for me to ask someone quite directly: “Do you use meth?” and have the patient respond in the affirmative and without the least trace of self-consciousness expand on the degree and nature of their drug use.  The hardest question for me to learn to ask without blushing was “do you ever have sex for money or drugs?” (And yes, I do ask that of both men and women, when it seems potentially relevant.)  But people on occasion forthrightly admit that they turn the odd trick to support their habit.

I have a good bullsh*t detector, because often enough you need to ferret out the real story, but sometimes I get lazy because so many of the patients I see are so open and honest about their vices. The mores of some of these folks are amazing to me.  I see the fifteen year-old in the ER for her threatened miscarriage and I elicit the following information from her: she smokes; she drinks on occasion; she uses marijuana regularly, but avoids meth because she tried it and did not like it; she has has three sex partners this year.  And during the course of the interview, the child’s mother is sitting next to the gurney without batting an eyelash at the horrific information so freely laid out.

Had that been me when I was fifteen, I would not have needed the services of a physician, but a mortician, because just one of those admissions would have caused my mom to simply kill me where I sat.  But to a certain segment of the lower-middle class, these lifestyle choices are mundane and unexceptional. So it was with some pleasure that I saw a young lady recently with some gynecologic discomfort.  She was pretty, well-groomed, polite and charming.  She did not smoke.  She did not ever use drugs.  She reported that she was still a virgin. (And yes, I pressed her on the point; she was quite clear that she had never come close to having sex.)  She was extremely bashful about the pelvic exam, but tolerated it with good grace.  The nurse and I left the room and remarked to one another about now nice it was to see a “good girl” in the ER for once.

I liked her — this was the sort of patient that you really want to help and it makes the shift a more pleasant experience when you are able to make a difference for them. Since she was in some pain and needed an ultrasound, I ordered her some pain medicine: Toradol.  It’s a non-narcotic pain med which is quite effective.  It is also notorious among drug-seekers for causing “allergies,” the most common allergy being the adverse reaction of not getting one high.  The nurse was back in three minutes: “She says she can’t take Toradol.  It doesn’t work for her.”That’s odd, I thought, Where the hell has a girl like her had Toradol before?  And is she playing games with me? I ordered her a conventional narcotic and went to do a more detailed chart biopsy.

The first thing that struck me was the fact that she was on clonazepam (an anti-anxiety med, which happens to be popular among the drug-seeking set).  I was busy and had missed this on the initial cursory chart review.  Her visit history was more concerning.  She had never been to our ER before the midpoint of last year, but had visited twelve times since then. As time went on, more and more red flags started popping up: increasingly aggressive demands for more pain medicine; refusal of the ultrasound because she was in “too much pain”; escalating dramatic manifestations of the severity of her pain; and the complete lack of any findings to explain her symptoms.

She also started splitting: buttering me up quite shamelessly while verbally abusing the nursing staff.It all culminated in a world-class meltdown when it came time for discharge.  Narcotics were of course at issue, but she by this point had developed a litany of grievances against myself, the “bitch nurse” and every other health care provider she had ever interacted with.  She screamed and railed and was ultimately escorted out by security.  The nurse and I shook our heads in disbelief at how stark the contrast was between the charming young woman we had met four hours ago and the shrieking demon we had just discharged.

“So much for your ‘good girl,’ Doctor Shadow,” the nurse acerbically commented. At this point my partner, a wise old doc who has been working in the ER since I was three years old turned to me and said, “See, Shadow, it all goes to prove the point I have been making over and over for years: when you are working in the ER, you can never be too cynicalIt’s a logical impossibility.”  I ruefully conceded the point.  Guess I need to get my bullsh*t detector recalibrated.

*This blog post was originally published at Movin' Meat*

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One Response to “Life In The ER: Never Judge A Book By Its Cover”

  1. Edwin Leap says:

    Dear Shadow,

    An excellent post. I see it over and over; some of our more effective sociopaths are positively charming and delightful, even beautiful, until the nuclear bomb drops when no narcotics are forthcoming.

    The problem is, some folks will read this and make the ridiculous assumption that you’re ‘burnt-out.’ And yet, no one outside of the emergency department, psych wards or detox centers are seeing these patients with regularity. Private docs simply fire them as patients. But when we find them difficult and try to explain to the world of erudite readers what the world of the ER looks like, we’re branded cold, heartless, angry and irritable.

    It’s maddening, but the truth hurts. Sometimes, one simply has to be a prophet of doom, speaking what we see and what we know as information and warning to a world all too willing to believe the best of the worst, and the worst of the best.

    Keep the faith!

    Edwin Leap, MD, FACEP

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