Got this email the other day from one of the veteran attendings in our program. Seemed to be some sound advice so I thought I’d pass it on.
Folks: We had a recent M&M where a very obnoxious patient demonstrated a classic case where the ED doc needed to step back and reassess, and not get sucked in by the absolute idiot he was trying to help. I hate these cases with a passion, and it will often get the best of anyone. Clearly the patient was a first class pain, with many reasons to truly hate him, but the situation was not handled ideally. This is EM in its most difficult scenario. No one knows what we put up with, it’s degrading, and insulting, but that’s life in the ED. I often succumb to the same mentality as happened here, but I have also seen the result in court.
Briefly, my understanding is that the patient was uncooperative to the point of essentially impossible to deal with. He was disruptive to the entire ED, demanded pain medicine, threatened and insulted the staff, but was offered only Tylenol/motrin. He refused proper xrays. He was escorted (thrown) out of the ED, refusing a sling, when he became totally unbearable, and showed up with a dislocated elbow the next day, still so obnoxious you wanted to shoot him. The single xray that was taken suggests a dislocation. There is no chart notation that a serious elbow injury was considered.
This patient is a nightmare, but 2 years from now the only thing that will be heard is that the doctor refused to give a patient with a dislocated elbow proper pain medicine so he could cooperate, and then they threw him out of the ED without making the correct diagnosis of a limb threatening injury. If he were psychotic drunk or drugged, all the worse for the doc since the poor patient was unable to comprehend his situation, and the doc needed to do that for him. Not my take, but that is what will be presented if this becomes an issue.
The patient was a perfect example of a “good riddance” approach. You are a jerk, insulting, and threatening, so get out of the ED, with copious chart notes documenting the patient’s bad behavior. “I told the patient he could lose that arm if he did not let us examine him, and he understood, and was not drugged or drunk” would be a great chart addition. In the heat of documenting the patient’s absurd behavior, that medical aspect was lost.
Perhaps there is nothing that could have been done differently, but cooler heads need to prevail.
1. Give even jerks proper pain meds or sedation if needed for evaluation. It’s only 1 med, not 100 percocet to go.
2. The diagnosis on the chart should be “probable fracture/dislocation of the elbow”, If you are right you are a star, if you are wrong, no one cares, you were being careful.
3. Get another Doc on the case, bow out of this one. “offered another physician to the patient” is warm and friendly charting.
4. “I told the patient he had a bad injury and could return anytime if he changed his mind” is a nice gesture.
5. Document the LACK of drug/alcohol effect, or psychiatric disease.
I am glad I was not the doc on this one, but I have been in the past, and made the same mistakes.