Sunday, April 27, 2008

Sue Me

Ethics be damned, I finally did it. I worked the overnight recently and one of our executive class frequent flier patients showed up in the waiting room at 2am. Dr. Deborah Peel (the patient) was, evidently, prepared for the fact that our ER cocktail lounge had been closed for a bit so she tanked up prior to arriving. Her chief complaint was that she was "really going to do it this time", as in, she was really, honest to goodness, no kidding and no reversies, going to off herself.

All she had done toward that end was polish off the better part of a fifth of Old Grandad with some valium as a chaser and yank out stitches one of my colleagues had placed in her wrist (very superficial wound) the week earlier. Apparently not happy with how quickly she had been brought back to a bed she 'fainted' out in triage and when I was called to see her in the room she had the "I've just seen a ghost" stare and was very good at it. Just as an aside I could well have said that it appeared that she had just had an encounter with the 'numinous', which is my favorite new word, but let me go ahead and tell the rest.

After I jammed a Q-tip most of the way past her turbinate (nasal passage) and she persisted with the stare I gave her narcan and she woke up a bit. Turns out narcan does occasionally have an effect on severe alcohol intoxication and this woman did not have opiates on board so that was interesting. It took about two minutes to figure out that she wasn't going to die within the next 5 hours so I felt a lot better. I ordered tests and meds and went to the next patient.

The next patient had his face mangled by a big dog. The patient and his girlfriend were extremely nice and I really enjoyed helping them out. The repair took me about 45 minutes and I had big flaps of facial skin to realign and the lip to put back together in two places.

As I was actually doing something worthwhile with the dog bite guy the aforementioned woman kept yelling that no one was doing anything for her pain. Debbie (as I call her now) denied being in pain when she 'woke up' so that, along with the fact that she was as drunk as Cooter Brown made it inadvisable to giver her pain meds. She would not leave her nurse alone though. Finally the nurse had to act so she came to me and I nodded conspiratorialy before she said anything.

ME (within earshot of drunk lady): "Wow, it sure sounds like she's hurting, better give her something strong... Why not try 650mg of paracetamol, but tell her not to take it unless she wants to sleep because it's so strong (wink, wink)".

NURSE: "Oh doctor! Are you sure???"

ME: "I think it will work and I think she needs it".

Paracetamol is tylenol (as the Brits call it). The patient asked what the pills were, she was told they were paracetamol and would make her sleepy etc... and like a good patient she swallowed the tylenol and promptly went to sleep.

Ethicists would probably say I abused my authority and engaged in deception. I don't agree as tylenol is a pain medicine and I would argue that I was setting the patient's mind up for successful treatment. In fact, I would argue that I was using CAM and that it worked like a charm.

The dog bite guy did well and he and his wife winked at me knowingly when the snores started from the adjoining room. CAM rocks!

59 comments:

  1. This comment has been removed by the author.

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  2. Well, you are making a believer of me, maybe CAM works after all.
    Nah... it's the bone in the nose, the dodo bird feathers and the skull on a scepter that hold the power, isn't it?

    If positive thinking helps healing, then you triggered that feeling and it worked.
    Really, your role was to make Ms Peel better, and you did just that.
    How you got there is irrelevant.
    I think it's brilliant. Next time she comes (because she will) she'll ask for paracetamol straight away. :-)

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  3. Paracetamol is good, but you should consider prescribing my favorite medication: Placebatrol (hydroglucose chloride).

    Very few side-effects and it can be repeated several times in increasing doses.

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  4. Having worked in the ED for 10 years I've always wondered what would happen if there was a standard protocal for the pain patients. A standard protocal such as two liters of fluids, toradol, and benadryl. Let them sleep for an hour. Then if they continued to c/o pain; admit them to the floor for pain control.
    I wonder how long it would take for the "street" to find out that "homey don't play those games no more"!!!

    Steve

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  5. CAM rocks!

    Well of course it does, 911. That'sa what I've been trying to tell you! Now sit still and let me Reiki your dome...

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  6. You rock! I was thinking, way to work that CAM. You know I use it on my kids all the time. Kisses on owies, and bandaids if there's any blood. They have amazing psychological effects on a kid's pain.

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  7. Amy: You're right. This absolutely works in kindergarten. Ice packs and bandaids could probably cure cancer if grownups believed in them as much as 5 yr. olds.

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  8. Devorrah: "Ice packs and bandaids could probably cure cancer if grownups believed in them as much as 5 yr. olds."

    Me: Isn't most of what we do just an ice pack and a bandaid anyway? Patient comes in with headache. We give her dilaudid. Patient goes home. We didn't fix the headache. We hid it. The more time I spend in medicine the more convinced I am that our job is to pat people on th head and tell them they will be alright and let their body heal itself. I mean this in a good way. i need that pat sometimes, too.

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  9. "The dog bite guy did well and he and his wife winked at me knowingly"

    911: I'm done with winking at doctors, after my recent turn in the ED...

    Braden: Well,I guess it depends on the problem. If the patient has a staph infection, she needs more than a pat. She needs drugs AND a pat. Point well-taken, and I largely agree.

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  10. I used to often give my 4 year old son his "Placebo medicine" to help him sleep. It was a big spoonful of water, he later started asking for his "water medicine" before bed, and it sure did wonders to keep him in his bed at night. Well, except for the days he sleepwalked, but that wasn't really his fault and unfortunately the water medicine did nothing for that at all.

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  11. Is it me or are the word verification things a lot more difficult to see lately? It took me a bunch of tries to get it right and my comment wasn't nearly interesting enough to warrant all that effort!

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  12. Just like those old commercials used to say. "A mind is a terrible thing"

    perhaps ethically it would have been a problem if you gave her only saline, but you gave her a pain reliever.

    Nice!

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  13. If placebo is effective 50 percent of the time, why would it be unethical to give saline? Many other touted "drugs" are less effective than that. Intent and result are many times separated, not only in medicine.

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  14. You say 'ethicists would disagree', but the thing is, they are 'armchair philosophers' who are usually in the role of 'Monday morning quarterbacking'...they are not the ones personally dealing with these very difficult situations in the middle of the night when all hell is breaking loose. Practice and theory are often two very different things, esp when you start trying to apply absolute 'shoulds' to real world problems such as this.

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  15. 'cat (and anonymous),
    if your experience is anything like mine you had a nattily bearded PhD ethicist in med school, who smelled of pipe smoke and dressed like a reject from 'starsky and hutch', wax poetical for an hour or two about our atheistic yet sacred duty to never prescribe placebos. i can't remember the tortured reasoning but i'm fairly sure he had never come close to having to take care of dr. deborah peel before. 'cat, i see that you have a post started. let me know when it's going up so i can avoid stomping on it.
    cheers,
    me

    ps 'cat, call me soon, eight irons in the fire right now, interested in your perspective. email works too.

    pps RADGIRL, yes, it seems the verification letters are getting trickier. blogger must be getting spammed a lot. if YOU ever have any problems let me know.

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  16. We put substances and devices into patient's bodies to change the way their bodies work. We also put ideas (including expectations of therapeutic success) into patient's minds for the same reason. We do it because it helps the patient. Isn't that the reason the patient came to us?

    Yeah, I know, very patriarchal and elitist. I should go and wash my keyboarding fingers in lye as penance. However, what I wrote is still factually correct.

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  17. Our CAM people would call this 'activating the body's potential for self-healing'. It's not the 'placebo effect' it's 'self-actualization'.

    Awesome. I don't agree that this is in any way unethical; you're prescribing standard first-line therapy for pain and helping the patient make best use of it. Elegantly done.

    PS, I wouldn't use Toradol. Last thing I need is an ornery patient with a creatinine of 3. And I've seen it happen with one dose.

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  18. You didn't lie, deceive nor prescribe a placebo. You gave the name of the pharmacologically active drug, that it was for pain, and that it may make the patient sleepy (because the "pain" was relieved of course!!). If she read into it that it was a narcotic, that's her deal, not yours.

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  19. I'm definitely having problems with the spam filter too. I thought it was just me getting dumber. Sometimes it takes me 3 tries before I get it right, and I'm an EXPERT on the alphabet.

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  20. To lie to a patient to relieve the patient's symptoms is bad?

    Why does the patient present to you?

    For relief of symptoms, not for truth.

    I am not a fan of telling lies to patients, but sometimes that is what is best for the patient. Horribly paternalistic of me, but safer than giving a drug with more significant side effects potentiated by the alcohol and benzodiazepine already in her system.

    Besides, as has been pointed out several times, you did not lie.

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  21. 911 Doc, great work. You are a HEALER, I say. You would think that smart ER docs like yourselves would come up with more drugs, like toradol, that sound so much better than they really are. Let's see here...

    Smashatrol
    Dilaudicaine
    Benzominaphen
    Morphazole
    Hydropivicaine

    I bet your pain in the ass at 2 am would love to get their grubby little paws on one of those babies!

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  22. Absolutely marvelous strategy and I applaud your intellect!

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  23. Hey, I'm going to go anonymous here because I don't want it to be connected to me, but my name starts with an "R" and ends with an "adgirl".

    I think I finally get your fear of being sued. I ALWAYS have a million kids here playing even when we don't invite any of them over. I don't send them away because what's a few more. Well, I'm done being the neighborhood babysitter.

    A kid fell off his own bike the other day in our driveway and last night his dad came over to tell me that his fingers are broken and they are going to sue us. I didn't know the kid was here because he was just riding his bike and the kids in our neighborhood (minus my own) run free and have no parental supervision.

    As soon as he feel, I ran over and helped him wash off his fingers because they were scraped up. I bandaged him up and put ice on his fingers. I asked him who his parents are because I don't have any idea where he even lives and asked him if he wanted me to call them to come get him. He said he was fine. This was on FRIDAY. He stayed a few more hours and happily played.

    Last night (Monday night at 9:30 pm) his dad came over and asked what happened to his kid because he had just had him at the ER and his fingers were broken. He wants to sue us. Are you fucking kidding me?????

    I get it now. The world is sue happy and it sucks. SO I babysit your kid every fucking day even though no one ever asked me if it was ok, and when he falls and I try to help him you sue me? This is what is wrong with the world. And I totally get your frustrations with society now.

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  24. Dear "Anonymous": I am SO sorry. I've never been sued, but had a near-miss with a friend's child: I had a bunch of friends over (playgroup), and our kids were all under 3 (yeah, we were tired). Moms, babies and toddlers were hanging out in the pool, and one Mom just didn't notice that one of her twins was under the water, quietly slipping to the bottom... Fortunately I noticed, and he was fine. That was it for the pool, even though we had a fence AND motorized cover. My ex-husband is also a lawyer, and we put the house with the pool on the market within the week. The same thing had just happened to me best friend, while her husband, a radiologist, was supposed to watching the baby (who ended up in the hot tub--at least Dad knows CPR)
    My house is the neighborhood hangout too, as I live near a school and I have food. At least I knew all their friends and I knew where they were (under my nose getting help with their homework). It's still a good thing.
    As for the douchebag who is suing you, I don't know what state you're in, but this is an issue of comparative negligence (we use that in CA). What are the proportional levels of causation/negligence here, the good Samaritan who helped an apparently abandoned child who was injured, or asshole who lets his kid run wild with no supervision? It all comes down to whether you acted negligently, comparing your conduct against the conduct of a theoretical "reasonable anonymous person" just like you. A scary letter should make this go away. If you don't already have an attn., ask for references from friends and family, or call your local bar assoc.
    Email me or go to my blog anytime, and I'm really sorry you're being sued.

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  25. Sad to say, the best defense is still a good offense. Those parents were putting YOUR children at risk by failing to supervise them, and the little bugger exposed you to his nasty blood, endangering you and everyone in your household, the little trespasser. If people were nice, I was nice in return. if not, let the games begin...

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  26. radgirl,
    i know it's not in your nature but here's what i would do. i would inform the father, especially if the kid was riding without a helmet, that you had no idea that he was riding in your driveway, there was therefore no implied consent for you to watch or supervise his child, and besides that you are concerned about his child's well being given that he was unsupervised so you are going to do the right thing and call child protective services to do a 'welfare check' on all his kids.
    end of story.
    me

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  27. lofty,
    i love those names! my favorite real drug name is 'sublimaze' for fentanyl. awesome.

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  28. Let us know how it goes, Radgirl. Good luck. I'm guessing this will go nowhere, that the Dad is a hothead.

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  29. shit likes this gets under my skin and i can't let it rest. here's a suggestion. go to a porn store and get the inserts out of all manner of gay porn mags. sign him up. done. no fingerprints! and now that i mention it i did not recommend this and i mean it merely as a joke. do not commit mail fraud! something along these lines though... oh, it would be delicious.

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  30. We had a tiny language barrier, so I'm not positive he actually knew what he was threatening. It was an asshole thing to do, but I think maybe he doesn't have insurance? And was hoping we'd feel bad and offer them money? And when it didn't work out like that he got flustered and said things he didn't mean?

    The part that makes me the most mad is that now my daughter can't play with her friend because there is no way in hell I will let the kid near our house again even though he did nothing wrong. And that we live near a jerk that would threaten to sue a neighbor that he didn't even know that has been feeding his kid snacks and watching him for free for months when no one else seems to be paying any attention to the kid.

    I'm thinking since he waited 3 days to bring his kid to the doctor, the chances of him actually suing are small. Waiting to see is the sucky part.

    That gay porn thing is great, but I don't even know the guys name. Seriously. He came over and yelled at me while I was in my pajamas and never introduced himself. I almost never think bad things about anyone, always see the good in people but this guy is on my shit list. Even if he never sues us. Explaining to the kids what the word "sue" means and telling them they can't have any friends over unless I know the parents sucks.

    A few more things like this and I think I will be as bitter about the state of human nature as you all are sometimes!

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  31. oh radgirl you are a bright light shining in a dark world! maybe a flaming bag of dog poo on the front door and a ring-and-run?

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  32. On the suing thing, when my daughter broke her arm last year, (jumping off the couch in our living room), the insurance company not only called to ask if there was anyone we could sue for the medical costs, they sent a form that I had to sign, swearing it happened in our house.

    I know people who got sued because a teenager scaled their fence, when they were out of town, and broke his leg. The teenager's parents did not want to sue, but they couldn't stop their insurance company from doing so.

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  33. Don't ever get mad at me, 911!

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  34. anonymous-you are scaring me! But part of our homeowners insurance covers that kind of stuff so I guess it would be ok even if that happened. It would make me livid, but I guess as long as the kid gets taken care of (and never comes near our house again even though he is a sweet little boy) I would be happy.

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  35. A lot of times it seems like parents get mad and lash out when confronted with evidence of their own negligence or bad parenting.

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  36. My insurance company was desperately looking for someone to sue after my idiot son fell off a cliff. Sue me for failure to use birth control!

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  37. devorrah,
    don't worry, with me bark <<<<< bite.

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  38. You're bark is less than your bite?

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  39. I think he's saying it's the other way around.

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  40. I hate our letigious society. Not to stress you out Radgirl, but be careful. Sometimes the biggest lawsuit threats come from outside our borders. I lived in Tucson for the last 4 years. Recently we had a case where some illegals crossed into a property on the border. The property owner "captured" them at gun point and called the police, I believe. The illegals sued him, and the judge awarded them his ranch. It sucks that lawsuits govern behavior, and make human decency virtually impossible in many instances.

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  41. SORRY,
    failed math

    bark >>>>> bite

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  42. Just one of those things my math > my English. And my silliness > crankiness. :-)

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  43. Amy,
    You see why I left the law. By the way, Amy and Radgirl, don't drink sodas. I've just been diagnosed with osteoporosis (only in my lower spine), and I'm only 45. Osteopenia in the rest of my spine. I'm taking drugs (Actonel) to treat it, and I'm having trouble with the drugs (that's the only reason I'm commenting during the workday). Soda is bad for your bones, and I've been drinking a lot of Diet Coke since I was about 10. Shit. I'm off to the Dr. now...

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  44. What if I drink soda/pop and take calcium supplements? I am supposedly at higher risk of osteoporosis because of my super suppressed TSH level (.03) and also because I have small bones to begin with. I don't drink alcohol, I don't do drugs, I need my pop/soda!

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  45. I know, I feel the same way too. Calcium supplements didn't help me, and I've always taken them, as I'm a vegetarian. I too am in good shape, average weight, and I don't even have small bones. My last boyfriend said we wishes he was as muscular as I am. And here I am. My ortho surgeon said it's the soda, as I'm such a good girl health-wise. It doesn't even run in my family. Ask your doctor (that's what I"m supposed to say, right?)

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  46. richter,
    do not post here again. you are banned. follow my advice delivered in our private email exchange. best of luck to you but your posts will be promptly deleted here and if you make any threats on this blog, like you just kind of did, i will call the police and have them arrest you before you know what hit you.

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  47. Fuck fuck fuckity fuck! The dad just rang our doorbell again. He wants us to call our insurance company and said we need to pay because his son is having surgery. What an ass. I get that homeowners insurance is for this reason, but once we file a claim, our insurance will go up, our claim free discount will decrease and we will have to pay our $500 (?not positive because we have never had to use it before!) deductible. This is what being nice gets a person. I have taken care of this kid outside and fed him snacks for months! The dad can rot in hell for all I care. I still love the little boy, but there is no fucking way the kid will ever be allowed on our property in his lifetime. I feel mostly bad for my daughter because she loves this kid. Is it possible to get a restraining order for a 7 year old? Because I think that's the only way we can keep him off our property!

    My husband travels all the time and I am sort of afraid to be alone here when he keeps ringing my doorbell to "talk". I live in a nice neighborhood! What the hell is going on????

    What's the scoop with Richter? I think I missed that drama!

    I apologize for taking over your comments with all my drama today!

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  48. anon,
    get a lawyer's advice. call DCS. fire with fire now. enough of the shit. call the police and get a restraining order. lawyers? please help our good friend.

    richter is banned for reasons that should remain private.

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  49. Just a minute, let me go back and read your initial post--just got back.

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  50. I don't think you need to be scared at this point, unless your gut tells you otherwise. You're right, though. this is what homeowner's insurance is for, so let them take over--they don't want to pay either. I used to work insurance defense, I know.
    Call your insurance company and let the insurance adjusters sort it out. They have lawyers for that purpose. My Dad ran an insurance adjusting company, so he did this for a living. It doesn't sound like the guy is bringing a civil action, so I'm not sure you need a lawyer yet. I would NOT go over there yourself to tell him to keep his kids off your property--I would write a letter pronto, keeping a copy of course. I would tell him that you will file trespassing charges against his kid if he is on your property. It's important to make a "paper trail" and keep a written log of all encounters. I don't think it's likely a judge will issue a restraining order at this point, as you have to exhaust other reasonable measures first. You also want a witness to any interactions you have with this guy. I would get a TRO if the kids won't stay off: You don't even need a lawyer for that--it's pretty easy: Abused women do it all the time (forms available at www.nolopress.com). I would probably prefer to let a lawyer handle it, though, for the intimidation value. But this is just my opinion, I don't practice any more, and I don't carry malpractice insurance. So don't sue me! Any more ideas, anybody?

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  51. And don't panic: this is everyday stuff for insurance companies and lawyers, and they are there to fight this guy for you. The kid was on your property, even if you didn't know it, and there is an implied duty to know what's going on on your property, especially if this family has established a habit of letting the kid come over.
    Please try not to worry. I'll include you in my prayers, and try to let the wheels of justice/insurance do their work.

    Take care, and I hope this helps. Seriously, my Dad constantly staked out, confronted, shook down and dragged into court assholes like your neighbor all the time: You're not alone, and the there are plenty of assholes on your side as well (-:

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  52. Devorrah-I'd never sue you. In fact that is what makes this all so baffling to me. I wouldn't sue anyone unless they purposely hurt me, and even then I'd probably just walk away.

    I'm sure it will all be fine, but it's so stressful right now!

    We are working with our homeowners insurance guy and also have a lawyer on the backburner just in case. Thanks everyone for all your help/support.

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  53. You bet--anytime. And I've never sued anyone in my personal capacity either, except for divorce, and that was so low key that I was the acting attorney for both of us (he thought it was boring).

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  54. "shit likes this gets under my skin and i can't let it rest. here's a suggestion. go to a porn store and get the inserts out of all manner of gay porn mags. sign him up. done. no fingerprints! and now that i mention it i did not recommend this and i mean it merely as a joke. do not commit mail fraud! something along these lines though... oh, it would be delicious"

    911: tricky.
    You can't give out medical advice on this blog, so you stick to porn advice. good thinking. I'm so proud of yopu!
    (devorahh? spellchecer advice?)

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  55. anon that rhymes with fadgirl

    Reading your story makes me angry that this is what we have come to. Ward Cleaver would have forced Wally to go and apologize for getting blood on the neighbors driveway had he broken his finger there. At the very least, let your kids know that this guy is the devil and his kids are spawn of the devil, and to stay as far away as possible.

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  56. sc: good advice. Fadgirl: sc is a smart cookie. That's what Richter thinks, not that Richter is much of an authority on law, blood, neighbors driveways, or anything, really, (poor misunderstood) Richter.

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  57. TRICK OR TREAT ME
    Hmmmmm. So somewhere in the far off reaches of Canada, north of the border, this poor old man was
    kinda being underserved by his hot shot medical team, despite all reasonable attempts at care & intervention. Seniors are known to be non-compliant, yes.... What to do? When nothing else works, call Adult Protective Services! Not only can they get into everyone's medical records (forget about HIPPA, guys & gals), but I would have LOVED to see the expression on Doctor Zhivago's beautiful, arrogant face. How many people do you know who can level the playing field, six-feet under, during a PCP's business hours? At least one, and her name would be......Can't say that, can I. Actually, we were just trying to save you ER docs from that myxedemic geezer coding in your fine ER. I thought you would appreciate the attempts, as does the old geezer. One life saved, one primary......ohhhh, don't go there. I am so in trouble if Dr. Zhivago reads this. I sure hope you docs have a sense of humor. Blessings, Nefertiti
    (post TAHBSO)
    (& fighting for her young)

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  58. Very good,have you seen all the mentally ill that post on Ratemds.com? It's sad.

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