Moments of internal struggle in the ER

I walked into Room 22 to find a very interesting patient who presented to our ER with complaints of abdominal pain and associated nausea and vomiting.

The patient sat on her cot with her pant legs rolled up above her knees, refusing, according to her nurse, Gwen, to put on a treatment gown. Her left leg hung in the air, her ankle crossed over the knee of her right leg. Her feet were bare and dirty. Nestled in the crook of her left hip, resting on the cot, was a worn bible, opened to the first page of The Book of Genesis. As Gwen was trying to obtain a better history, the patient was obviously ignoring her, giving all of her attention to the her bible.

Or so I thought. I walked into the room and introduced myself to this patient. She briefly flit her eyes up at me several times. Finally, after gaining her approval, she steadied her gaze on me and extended her hand. We shook. Gwen, meanwhile, seemed to have gotten an even colder-shoulder than before, as the patient turned her back on her to give me her undivided attention.

With her gaze on me, I absorbed this patient’s features. She had dirty-blond hair pulled away from her face. Long, thready, frazzled dreadlocks started at the crown of her head and were gathered behind in a bulky ponytail. Her eyes were piercing blue and, quite honestly, unsettling. High cheekbones, clear skin smudged with some dirt, and thin narrow lips accented her prominent nose. Her hemp clothes were worn and faded, tattered almost, and, like her skin and bare feet, smudged with dirt.

She was in her early twenties.

“Hello, Rose,” I said with a warm smile, “what brought you to our ER today?”

Her voice was husky yet quiet. “I ate some fish yesterday and I think it was rotten.” She went on to explain that she, at the time, wondered if the fish was “not good” because it had “a funny, pink color to it, like salmon. And” she confidently added, “I know my fish–it wasn’t salmon.”

“Where did you eat this fish?” I asked her. She blatantly ignored my question, which made me wonder if it was from a clean site or a garbage can.

She continued, however, to explain that since eating the fish, she had vomited three times later that evening and once this morning, prior to coming to our ER. “I feel better now, though,” she said. She hesitated before continuing. “I’m feeling well enough for a cup of coffee and a sandwich, even.”

And there we go–the main reason why Rose was in our ER. She was hungry.

It turned out that she had already asked Gwen for some food and coffee and Gwen had put her on hold. “Rose,” Gwen had explained, “we need the doctor to see you and get some of your blood results back before we can give you anything to eat.” That explained the snubbing of Gwen. I had to smile, since Gwen was an extremely compassionate, cognizant nurse.

“Rose,” I said, looking her in the eyes, “is this the real reason you came to our ER? Are you hungry?”

Rose stared at me as I visualized the cog wheels in her brain churning. Finally, she spoke. “Um,” she started, “I came here because I ate some bad fish. But now I feel better. So yeah, I guess so. I was hoping, I guess, that you guys would be able to give me something to eat.” As she spoke, she held my gaze. I appreciated her efforts at honesty.

Gwen looked at me with her knowing smile. I looked back to Rose. “Rose,” I said, “I need to perform an exam and, since the triage nurse ordered some blood work, I need to review your results and make sure they are all good before we can let you eat. You understand this, right?”

Rose nodded her approval. With Gwen at bedside, I performed a thorough exam of Rose. Everything checked out well. Specifically, she had no abdominal pain on exam. I walked out of Rose’s room and reviewed her stable vital signs and her stable blood work on my computer station.

As far as I was concerned, we could now feed Rose.

Which presents the dilemma we sometimes face in the ER. Frequently, we get unfortunate patients that present for reasons other than emergent medical care. It might be a drunk, homeless person, refused for the night by the homeless shelter for his alcohol abuse, who is looking for a place to sleep. It could be a patient who is looking for free prescription vouchers to get his medications renewed. And, in Rose’s case, it could be a person simply looking for a meal, a cup of coffee, a warm blanket, or some companionship.

As far as I am concerned, we should extend ourselves, as long as it doesn’t take away from providing emergency care to those in dire need. And, as long as our efforts are appreciated. Is a bed free? Go ahead and lie down for a short while. You’re hungry? Let’s see if we have any pudding or turkey sandwiches for you. Your cold? Here is an extra blanket for you from our trauma blanket warmer. Free vouchers? Well, I see those cigarettes and iPhone poking from your pocket, so we’re not going to be able to help you with that tonight. Sorry, but I can only go so far.

With these acts of kindnesses, though, I understand the flip of this coin. You set yourself, your ER, and your staff up for repeat visits by these patients who come to expect these kindnesses every time. And, as a result, they keep coming back and coming back and coming back. Sometimes clogging the system. Eventually, these kind acts are no longer appreciated but, rather, demanded. We’ve all seen this happen. And it’s at this moment when our thought process changes.

With Rose, she had only been to our ER once before so, after Gwen and I agreed, she received a full meal, some warm coffee, some foot slip-ons, and a social service consult prior to being discharged. She was gracious for everything, which helps the cause. And it was our pleasure, really.

However, there are repeat offenders whose visits to our ER number in the fifties and hundreds. Seriously. And, unfortunately, these handfuls of patients are the ones who can ruin it for the others.

The ER presents many moments of internal struggle where, as an individual working there, you have to review and examine your moral fiber and essence. This is one of those struggles for me. I wish we could accommodate every single person’s needs, but that is unrealistic. So, I’ll just continue to provide on an individual basis. And, hopefully, these kind acts will be appreciated and not abused and demanded.

To feed or not to feed … that is the question.

StorytellERdoc is an emergency physician who blogs at his self-titled site, StorytellERdoc.

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  • George Anderson

    Dr. Pho,
    What you have demonstrated in this post is the value of Emotional Intelligence training for all healthcare professionals.
    The good news is that those physicians who are mandated to take coaching for “disruptive behavior” are now learning EQ which should have been offered in medical school.

    Thanks so much for your work.

  • paul

    providing food is fine. but it is frustrating that tax dollars, insurance premium dollars, etc go into paying the big facility fee tacked on to her completely useless level 4-5 ED visit her workup will generate. would you have fed her and skipped the bloodwork if she just showed up asking for food? or would you have done your Medical Screening Exam and turned her away after excluding an Emergency Medical Condition?

    i once had a guy come in and when i asked him why he came he said “oh, i don’t have any complaint. i just want a note to get the day off of work.” it was a chaotic morning in the ED… honestly, i was thankful he didn’t waste any more of my time by coming up with reasons for me to launch into unnecessary tests.

  • Steven Reznick MD FACP

    You showed compassion and understanding and acted as a professional and a healer. The profession should be very proud of you. !!!

  • gzuckier

    In fact, having inquired about a similar conversation I overheard in the next bed on my last ER visit, I learned that they stock a number of premade sandwiches in the fridge each day for the predictable number of such encounters. (This being an inner city hospital in a small, impoverished city).

    This was followed by the ER doc issuing a voucher for a taxi ride to theh homeless shelter, which apparently are kept in stock for the same reasons.

    Reinforces the conclusion that trying to separate “medical care” from the other aspects of these folks’ life is an exercise in empty semantics. And at that, they’re probably less crushed than the folks who are still trying to make a go of it, trying to maintain some sort of family/home life with a single parent minimal wage salary in some scary neighborhood, for whom the concept of taking an afternoon off work to transport their kid to the doctor via public transit for a probably inconclusive visit which will likely result in only a referral to a similar visit to a specialist represents a degree of difficulty we just don’t encounter outside of action movies.

  • Molly Ciliberti, RN

    “If you have done this to the least of these you have done it unto me” I am an atheist, but I remember and try to keep those words at heart. Thank you for being a healer with a compassionate heart.

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