A Little Bit of Sole

The other day I really stuck my foot in my mouth, although it was kind of necessary to counter future embarassment.

I had picked up a new chart, and went to go find my new patient. When I went to claim my patient on the whiteboard (unfortunately we are soon switching to a computerized tracking program), I noticed that the patient was actually in a different room than the one listed on the chart. Patients often get relocated if the room isn't quite clean yet, so I went to the room listed on the whiteboard. Instead of finding a middle-aged male, I walked in on a topless female. I apologized and ducked out.

My second attempt was in the room originally listed on the chart. Nope, that was an octogenarian male, and clearly the wrong room as well. At this point, I threw up my hands and consulted the charge nurse. He had no idea where this patient was, so he called up the triage nurse, who also walks the patients back to their rooms.

"Didn't you see my stickey?" he asked.

"Um, no."

So, the triage nurse flips around through chart and finds a small 2x2" yellow Post-It note. It reads: Patient wants to be called [insert female sounding version of a male name here].

"Um, ok, so what does that mean?" I ask.

The triage nurse just rolls his eyes at me and mouths the words "he looks like a girl."

This isn't helping matters. The patient's chief complaint is hematuria, or blood in the urine, so it makes a big differnce whether or not they have male or female anatomy. I have already observed what are obviously augmented breasts, so there's no getting around asking what other sort of surgeries the patient has had.

Finally, I develop a game plan. I go into the room, and act like I think registration has made an error and marked the patient as a male instead of a female. He says no, and after a lengthy discussion, he explains that other than breast augmentation, he hasn't had any sex change surgeries. Although I think I may have alarmed him at first, I think he probably found me to be concerned and attentive in the end.

I was explaining my technique to the charge nurse later and he said, "I can't believe you did that." When I asked him how he would have handled it, he said he would have asked the patient when their last menstrual period was. Maybe I'm wrong, but that seems a lot less diplomatic way to bring up the issue.

While nobody likes to be asked what sex they are, sometimes you just can't tell. I think it's better to be direct rather than to end up with a male in the stirrups or asking all sorts of unnecessary questions. And in medicine, gender totally matters. Workups revolve around it, so there's no excuse for ending up in court saying, "Well, I didn't get a pregnancy test because I thought she was a dude."

On Diplomacy...

I have been working overnights lately. It has been especially painful lately with the flow of waiting room traffic being steady ALL NIGHT LONG. Why, oh why, would you check in at 3 am with a complaint of foot pain FOR A YEAR?

To make things worse, I have been dealing with contractors lately... another particularly painful practice. My driveway is in horrible condition, and the "highly-recommended" person I called three weeks ago, finally bothered to show up the other day. Unfortunately, my driveway is too narrow for him to negotiate with his paving equipment. This has since sent me into a frenzy of phone calls, trying to get people to come out and give me an estimate because I would really like this taken care of before winter. So, to add to my already toasted Circadian rhythm, what sleep I do get during the day has been interrupted by random dudes calling me back or showing up at my door.

Having some experience in customer service in the past, I pride myself on being able to remain calm when dealing with your average jerk. The other night, this particularly difficult woman came in at 4 am, and I just wasn't going to deal with any nonsense. First off, she wouldn't narrow down her complaint. First it was nonspecific tremors, then the list expanded to include chest pain, left ring finger pain, and tongue pain. The "tremors" she was talking about involved her rhytmically flapping her hand on her chest. However, when she answered my questions, the flapping stopped, and only resumed when she remembered to start it back again.

Suddenly, she began demanding Valium. It turns out that someone has just been giving her this medication for over a year, without having diagnosed anything. Apparently she has now ran out. Oh, and prior to coming in by ambulance? She drank 2 inches of vodka.

I told her straight off that I couldn't see any reason to give her Valium, that I would like to workup her chest pain and other problems, but currently I had no reason to give her that medication. At this point, she refused any blood draws, stating that she was Jewish, and it was against her religion.

I went to enter her orders in the computer.

At that point, the nurse came in and told me that the patient was screaming and cursing. So, I went back to the room, where I was told that she was going to, "F***ing sue you so hard, you won't know what hit you." I again told her that I wouldn't be giving her any Valium, but that it was important that we make sure that her heart was ok.

At this point, the attending walks in, and the patient starts screaming at him that I am calling her a liar. I reiterate that I don't disbelieve that she had tremors, I just don't see any reason to give her that medication.

The attending and I talk privately, and he explains to her that the Jewish religion is opposed to autopsy (which sadly we will not be performing), but that blood draws are typically ok. So she agrees to the blood draw, and he compromises to 1 mg of Ativan, on the condition that she stays for evaluation.

Ten minutes later, she's screaming again at the staff, so I offer her another dose, and explain to her that she can just hit her call button rather than coming out and yelling obscenities.

Five minute later, she's demanding: a warm blanket, jello, and the "head doctor". The attending stalls on going back in there and thankfully she yanks out her IV and walks out. Everyone was silently rejoicing. I think she would have walked out much sooner if we hadn't caved to her demands in the first place. I just don't have any patience for people demanding medications without wanting to be evaluated. Even more annoying is that when people walk out, apparently social work has to contact them at home and ask them if they want to come back in. I'm pretty sure I know what her answer will be!