Monday, April 09, 2007
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?