Monday, April 09, 2007

Scapegoat?


Like every ED, the one where I volunteer has its share of frequent flyers, patients we see several times a month, if not more often. Many, although not all, frequent flyers are the chronically homeless, often substance abusers who also have other psychiatric issues. Because patients with this profile consume far more than their share of social-service and hospital resources, several cities, including Washington DC and Seattle, have begun offering them free housing with no requirement that they become clean or sober. (To qualify for the program, recipients must have proven unable to maintain recovery.) While such programs are controversial among people who object to handouts, they're reportedly much less expensive than letting this population stay on the streets.

There's no such program here, although we certainly have our share of these individuals.

During a recent ED shift, I had a pleasant chat with one frequent flyer who always greets me with hugs and expressions of affection. I sometimes see this patient several shifts in a row, but I haven't noticed any ill will from staff.

Halfway through that shift, another frequent flyer -- someone I'd somehow missed meeting until then, but who was very well known to the staff -- arrived via ambulance, and I heard one of the nurses, within earshot of the patient, saying loudly, "Dammit, why doesn't he die? He's a worthless human being! He deserves to die!" That nurse told me that this patient has run up a staggering bill at the hospital. The hospital will never see any of that money.

We all know that the healthcare system is broken, but I've never seen a nurse being so hostile to a patient, even one who can't pay. Within minutes, another nurse was equally hostile to the patient. I assumed that the patient must have done something even more awful than running up a huge bill: assaulting staff, maybe? But he wasn't restrained, and nobody seemed unduly worried about violence. The security staff obviously knew him, but were laughing; a cop who'd come in with another ED patient obviously knew him, but greeted him warmly. "Hey, how you doing? I haven't seen you in a while. You doing better?" There was no indication of why a medical professional would have loudly wished him dead within his hearing.

I was bullied and called names a lot when I was a kid, and I'm also a kneejerk liberal, and I'm also a Parable of the Nations Christian, somebody who actively looks for (and usually finds) Christ in the "least of these." All of this means that the quickest way to get me 150% in your patient's corner is to condemn that patient as a worthless human being. Think red flags and bulls.

So I settled in for a good long talk with the patient. He told me about finding a friend's dead body in combat, and mourned the fact that he'd had to kill people he felt didn't deserve to die. He told me about the deaths of people in his family: he felt responsible for several of these deaths, and even when he didn't feel responsible, he told me that he wished he'd died instead, that he'd prayed to God to take him instead, because his loved ones who died were better than he was. Everything he told me about his past involved acute survivor's guilt, and I had to wonder what role the nurse's comment had played in that.

He also told me that the Holy Spirit loved me, that I was "God's good daughter," that I was a healer. He tried to give me something he was wearing as a gift; I explained that volunteers aren't allowed to accept gifts, but that the real gift was that he'd wanted to give me a gift, and that I thanked him for that. We prayed together. He clung to my hands, often squeezing them so tightly that they hurt.

The first frequent flyer, who was being discharged, came along and stopped to say hello to my patient and to wish him luck; they clearly knew each other. My patient took the other patient's hand and prayed aloud for God to protect him. When the first frequent flyer had left, the patient took my hands again, and told me that he was in a lot of pain, but that I'd made him feel better.

I said, "God loves you. Do you know that?"

And this patient who'd been talking so eloquently about God and Jesus and the Holy Spirit fell quiet. After a minute, he said, "Are you sure? I've done a lot of things wrong."

"Yes, I'm sure. We've all done things wrong. God loves all of us."

And then the nurse who'd called him worthless showed up, saw me holding his hands, and snapped, "He has [horrible communicable disease #1]! Wash your hands after you talk to him!"

The patient was clearly hurt by the comment, which he shouldn't have had to hear.

After our conversation had ended, I washed my hands in the meds room. I'd have done that anyway, since I always wash my hands after patient contact, but I have to admit that I gave myself an unusually thorough scrubbing. The nurse came in, glared at me, and said, "He also has [horrible communicable disease #2]!"

"That's not transmitted through casual contact," I said.

"If you're bleeding, it is!"

"He wasn't bleeding," I said. I thought, but didn't say, And if he's so freaking contagious, why isn't he on contact precautions? "He was in combat; did you know that?"

"No, he wasn't in combat! He was lying to you! He's a liar!"

The nurse left. A minute or two later, a doctor appeared and said, gently, "Our friend hasn't done military service."

I've been volunteering since late 2004. This is the first time a doctor has gone out of his way to tell me something. A few are friendly, and I've been around long enough that almost all of them, even those who aren't actively friendly, will at least acknowledge my presence. But ED physicians, for obvious reasons, keep unnecessary motion to a minimum. For a doctor to walk from where he's been standing to somewhere else, to communicate with a lowly volunteer, is huge.

"How do you know that?" I asked.

"I know. I've been in the military. Several of us have. We can tell from how he talks about it that he's just making up stories."

"Okay," I said. (I'd wondered about some of his stories myself, but wasn't about to accuse him of lying.) "But look, all I know is that he's carrying around a lot of pain. The pain's real, even if he's making up false stories to explain it. It's not the kind of pain you can help him with, but I can. That's my job."

The doctor nodded. There may have been some grudging respect there. I took a breath and said, "And I have a problem with saying that patients are worthless people who deserve to die."

The doctor said, gently, "I'm not saying that," and walked away.

All of this happened at the end of my shift. I woke up the next morning fretting about it, wondering what in the world the patient had done to invoke such overt nastiness from two nurses, not to mention a physician's expenditure of energy to discredit him. I'll probably never know.

And I'm still wondering: can it really be that massive bill? The bill's horrifying, as much for what it represents -- the breakdown of American healthcare -- as for the sheer number of digits, but would a nurse take that so personally, however horrifying it is? Or has this patient become a scapegoat for the medical staff's frustration with a broken system, the target for all of their rage about too many patients and too few resources?

25 comments:

  1. It could be that he's a scapegoat. It could also be that he's burned a lot of bridges. I'm not saying that he deserves to be treated as unworthy, and certainly no one deserves to be called that - ever. But just as the system can break people over time, other people can too. Perhaps the first fifty times he came to the ER, this guy was treated with respect and concern and the friendliness that the other "frequent flier" received. Maybe his lies became bigger and more exploitative - perhaps he's taken people in and betrayed their trust. Given the strain of the ER, it's more than possible to push nurses and doctors too far. Do you know if he has a history of addiction? Of asking/begging/demanding medications? Of accusing people falsely, saying hurtful things, or losing his temper? Has he ever been sexually or physically inappropriate to the staff? Perhaps you caught him on a "good night," when other times he's raging and horrible.

    None of these things make him worthless, nor do they justify the nurse's comments in which she wished he were dead. But they may explain why he receives such treatment when other "frequent fliers" don't. He may have pushed people too far too many times, and since they, too, are only human, they may have snapped.

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  2. Thanks for your comment, Alexis. I don't know the answer to most of those questions, and I wondered, too. It did seem evident that I must have caught him on a good night, but it also seemed odd that the only justification the nurse gave for that comment was the patient's bill. The conversation with the doc certainly indicated that this patient has a history of tall tales, if nothing worse -- but so do many other patients who don't get treated that way. And if he'd ever been a security risk, the security guards would have warned me away from him (as they've done with other patients), instead of finding me a chair so I could sit and talk to him.

    So I'm left with the feeling that the pieces I was able to see don't quite add up.

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  3. As a one time shelter chaplain I've seen lots of folks like your frequent flier. I'm sick to death of hearing people complain about their cost to the healthcare system. If the system allowed all people to receive the care they need in the appropriate manner and at the appropriate time--NOT the ER!--their bills wouldn't be so high. But it's easier to blame the person rather than work to change the system. So I'm delurking to say this. Thanks for keeping this blog

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  4. Thank you, thank you, thank you for seeing the human in him. And then acting upon that.

    Compassion fatigue is a very real thing. That ED staff was demonstrating it, and whether it all intentionally or accidentally came to bear on this particular patient - perhaps you will never know.

    But they got to see you in action, and whether or not it registered, it's there in their brain pans for reflection and their own healing. I'd say that was powerful group therapy, since it generated reactions from nurses and a physician - maybe horrific, but at a level that is now above their radar.

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  5. Maggie: Thanks for delurking!

    N=1: That's a very positive way to look at it, and I hope you're right!

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  6. Ya know what? The man may have been lying through his teeth. He may have burned bridges with some of the ER folk.

    But that night you allowed God to love this man through your touch and your heart, that was not a lie.

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  7. Perhaps his intent was not to discredit the patient but just to give you more info that he had. He believed the man was not in the military and perhaps wanted you not to naively accept every word this man said as gospel. The way you reported this doctor as speaking - gently- it doesn't seem as though his intent was to discredit the guy but to help you.

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  8. Surgeon: Thank you!

    Maria: Yes, I think you're right; but the question remains why it was so important for me to know that he was lying. I've dealt with plenty of other patients who've been unreliable narrators; in the work that I do, emotional content and patterns are often more important than factual data, anyway. And the issue of military service had no immediate bearing on his medical case: medical staff have sometimes asked me to try to suss out if a patient may have been battered, for instance, in which case the facts do have immediate relevance. But this stuff was ancient history, so why was it important enough for a doctor to seek out a face-to-face meeting with me?

    Unless he thought the patient was going to try to use me to get church charity or something. Maybe that's it.

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  9. My curiosity is now in overdrive - what's so different about this guy that everyone felt the need to warn you? What makes them so angry with him? I would like to believe that the medical staff have some basis for their comments, even if the comments were inappropriate......

    As much as I wish the nurses had chosen better words (if they felt the warning necessary), I really want to understand their purpose.

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  10. Anonymous8:29 AM

    As a self confessed knee-jerk liberal I doubt you will understand this. As a wounded veteran with two prosthesis and as an ER trained P.A. I would not have been as nice to this guy as the Doc you mentioned.
    His lying about military service and holding dead buddies would not only disrespect my service but denigrate the ones who did die. We have these liars come in my ER often. Luckily in the ER I work in we can bounce them right out.

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  11. Alexis -- My curiosity is on overdrive too! Especially since some people who interacted with him (security guards, the cop) were kind, so he hasn't created that kind of anger in everybody.

    Anon -- Had he been lying about military service to try to portray himself as a hero, I'd agree with you 100%. That emphatically wasn't what he was doing, at least with me. He was expressing enormous grief over the costs of war to everyone it touches. Even if this is a lie, I'm more inclined to see the lie as a symptom of mental illness than as disrespect. People with delusions believe them.

    As for the bouncing -- you can bounce people out of your ED for lying about their pasts even if they need emergency care? If somebody came in having an MI, you'd put him back out on the street for lying about military service?

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  12. Anonymous11:46 AM

    Thanks for holding to your beliefs...I have no idea if this man was lying or telling the truth, but by treating him as a person, and showing God's love, you have planted a seed that cannot be taken away. Thank you for being kind.

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  13. Deirdre2:48 PM

    I've noticed a tendancy in medical institutes to feel anger towards patients that do things we don't like, like lying and manipulating. Many of these patients are drug users or people with psychiatric issues. I think this reflects a lack of awareness about those diseases which can easily be confused with moral offenses. Drug users lie and manipulate, it's part of the disease, it's part of the person's survival mechanism. It isn't personal and deserves to be met with the same compassion we feel to other symptoms.

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  14. Anonymous3:51 PM

    It's nice that you volunteer in the ED. I respect that. But believe me when I say you are, quite simply, in no position to judge the ED staff. A few hours of volunteering a week lets you meet some poor homeless people and chat with them. Ten years of dealing with their fake MIs, drug seeking, lies and/or sexual harassment for 5 days a week tends to whoop the knee-jerk liberal right out of you. When you have to sit there and waste your life, page by page, documenting this guy's 5th fake heart attack this year because he knows you're powerless to stop him from abusing the system, then you can talk to us about why we don't provide service with a smile for him. Until then, he's getting "treated" at taxpayer expense so he's still not doin' too badly.

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  15. Anon #1: Thank you.

    Anon #2: I think Deirdre's comment speaks well to yours; you're also assuming that you know what this patient's history is; and even if you're right, why didn't the nurse tell me all of that, instead of only complaining about the bill?

    Also, there's a big difference between "service with a smile" and loudly telling someone that he's a worthless human being who doesn't deserve to live. Do you consider that professional or appropriate behavior? If you were in an ED, would you feel safe or comfortable if you heard a caretaker talking that way to another patient, let alone to you?

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  16. I have not worked in an ER but I did work in a General Relief Agency. I told my supervisor one time that the job was drying up my milk of human kindness. I had to be on guard to not let that happen. In a medical setting it is all too easy to forget patients humanity.

    I think the nurses remarks were made because there is an atmosphere in that ER that allows those kind of remarks to be make. I think it might be a good idea for you to have a conversation with the nurses and ask them directly what was going on. Was this behavior out of character for them or are they prone to treating patients as objects or diseases instead of people.
    I expect you may need to be chaplain to the staff as well as the patients.

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  17. Excellent point, Knomad; thank you. There are a few challenges to being a chaplain to the staff, though: one is that it's very difficult to have any extended conversation with them (this is also true, but to a much less severe extent, with ER patients). And the second is that, much like one of the anonymous commenters on this post, I think many of them see me as a clueless volunteer who can't possibly understand the pressures they're under (and to a large extent, of course, that's true). They value me as someone who can help calm down patients, but whenever I'm taking up their time -- instead of doing something to save it -- I become a nuisance.

    I've had some run-ins with this particular nurse in the past, and I can definitely see signs of stress. I doubt that any long conversations would be welcome, but at the very least, I'd like to find a way to ask, "Have you had a vacation lately? Any chance of taking one soon?" This individual's showing some major signs of burnout, obvious even to a clueless volunteer.

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  18. I suspect you may not be so clueless. You sound like a very good observer of human behavior. Burnout is a very real hazard for nurses and other helping professions.
    It may be that only a someone she recognized as a colleague or a supervisor could get through to her that her behavior was inappropriate.

    I expect all you can do is model acceptance.

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  19. Anonymous1:17 AM

    Just a thought here...you say off-handedly that the medical system is broken...how so? How is the medical system broken? Why are people crying about the medical system being broken; what are the signs and symptoms of it being broken?
    Is it the wait times to see a doctor? Is it the cost of seeing that doc? What is the criteria for claiming the disfunction?
    I personally don't think the system is broken; I feel the users of the system are broken. Nobody uses the medical system properly. Nobody uses common sense any more. Everybody is quick to abdicate their health care to somebody in a white coat.
    If we continue to proclaim that health care is "broken"; then we will get socialized medicine. If we educate the users on the proper use of the medical system; then we can continue with what we have.
    Oh, and DON'T tell me about the 'po foolk that aint got no health insurance. ANY hospital that receives medicaid or medicare MUST treat them thar 'po folk. Yep another unfunded federal mandate!!!
    Steve

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  20. Knomad: Yes, I suspect you're right.

    Steve: The system is broken because the ER is the only place where care is guaranteed for everyone -- which means that it becomes overburdened with patients who really need primary care, but who can't get it anywhere else. (My primary physicans don't accept Medicare or Medicaid patients, even though they could provide much more cost-effective treatment than an ER can.) If an affluent mom takes her kids to their pediatrician when they have ear infections, she's being a good parent; if an indigent mom takes them to the ER for the same reason, she's showing a lack of common sense?

    The problem with lack of access to affordable primary care is that some people will go without any care at all until they really are in an emergency situation.

    "Nobody" is a very big word. I've visited with literally thousands of ER patients over the last two-plus years: very few of them were "abdicating" their health care. They were at the hospital because they wanted to get better. And the people in the white coats are supposed to take care of them: that's their job.

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  21. Beloved, that's a painful set of circumstances for you as the Chaplain (and you know that for me the fact that you're not paid, and in that sense Volunteer, doesn't change the fact that in that time and place you were the Chaplain).

    You've gotten some good comments. I would only add that you need to ask. Ask the nurses involved, certainly. I'm really interested (in a forensic sense) in the comments about communicable diseases. Those exchanges suggest two things: first, they were trying to protect you (whether you needed it or not is another issue), from biological infection, and perhaps also from "psychological infection" - getting sucked in by a manipulative patient. The fact that at least one nurse focused on infection in an environment where universal precautions are second nature is striking. Has this person been sharing needles, or engaging in risky behavior without proper protection or "informed consent?" Has this person used this story (and for the moment whether it's confabulation or distorted memory isn't important) to get secondary care outside the ER from staff or from other volunteers? Now, I've been at this a long time, and could speculate all day. You'll just have to ask; but the elements of the outbursts speak of danger and personal loss, and their interest in protecting you.

    Also, don't underestimate the importance of those who have served distrusting the patient's stories of service. Those who have served feel strongly about folks who pretend to have served or who amplify their service; and family members of those who have served can feel even more strongly. In these days of active combat, has the nurse served? Who does the nurse know who has served? Who has the nurse lost who has served? Again, these could be important in caring for her.

    You might also ask others who clearly know the person. Check with the Security staff who know and treated the person differently. Check with staff chaplains to see if they know the person. Not only will this informtation help resolve your current moral/professional questions; they will help you care for all involved if the person shows up again while you're there.

    In the meantime, you are right to appreciate the patient's humanity. You're also right to consider that God can hear the prayers of the sick, or lost. Thanks be to God, trusting that prayer is heard isn't - can't be - a function of the "worthiness" of the "pray-er." And if he's mentally ill, remember God's concern, well remembered by the pre-Enlightenment church, for the mad.

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  22. Thanks, Marshall; all of that's very helpful.

    I was struck by the concern about infection too, particularly since the patient wasn't on precautions and had physical contact with the other frequent flier -- whom, to the best of my knowledge, no one warned.

    I'll do my best to find out from staff what was going on; but, as I've said, it's very difficult to have anything but extremely fragmentary conversations with them.

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  23. I think the anger comes from, in part, the feeling of impotence on the providers' part -- a feeling of not knowing how to help some of these frequent fliers. Add on top of that the negative feelings that are projected on to us from folks who repeatedly abuse themselves by drugs, not taking care of themselves, etc, and it is easy to see how the compassion fatigue develops.

    Yet, it doesn't excuse a healer saying or doing something that is designed to be hurtful to a patient.

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  24. Anonymous3:27 PM

    A few observations:

    1.) That nurse was inappropriate to suggest that this patient, or anybody, should die. It's not his/her call.

    2.) It was also inappropriate to inform you that he suffered from any specific medical condition. A suggestion that you wash your hands or avoid contact should be enough.

    3.) My experience with volunteers is that they are restricted in their patient contact. This includes some of the things that your post suggests you may be engaged in: counseling or offering spiritual guidance. Of course, it can be a thin line between simple conversation and therapy.

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  25. Anon -- Thanks for your observations! Re volunteer restrictions: I'm a volunteer CHAPLAIN, so spiritual guidance is sort of the point. Mostly, though, I just listen, as I was doing for this patient.

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