Deceptive Offender for Chest Pains

Nurseik · Apr 7, 2012

Good Job! It must really be hard not to rely on the patient's hx.

Very Interesting and funny to read. I was laughing all thru while reading.

Keep Up the Good Work!!!!

ddunnrn · Apr 8, 2012

I am a little curious as to where you worked, and what kind of facility it was-county jail or state or federal prison? I have never been exposed to the use of the term "offender" in reference to a patient, and to me it seems a bit unethical or contrary to nursing standards. Maybe it's because the jail I worked at for ten years had many detainees who were not yet convicted, and therefore we never knew who was an "offender" or not. On the other hand, I quite agree with the need to be objective in all assessments of patients' complaints. In the city jail I worked at (population approx. 9000), our inmates would claim they were diabetic so they could get out of their cells 2x/day to get blood sugar checks, and also get a diabetic snack; some would claim to have a seizure disorder to make sure they got a bottom bunk; and my personal favorites were the ones who claimed they had Tourette's so they could curse out and disrespect the staff and not be subject to discipline.

Vespertinas · Apr 8, 2012

Much respect! Well written, great assessesment skills, wise interventions, mature handling. It was a pleasure reasding your story.

libran1984, ASN, RN · Apr 8, 2012

It was a state prison. When you by DoC standards it was preferred that when you address an offender you address them as "Offender Smith" or "Offender Doe". Most of the time nursing staff just called them "Mr. Smith" or "Mr. Doe". However, when you look at everyone's EMR they are rarely referred to as "the pt". Its always Offn or Offender.

As far as nursing ethics went, most of them go out the door and caused a lot of grief for me being it was my first job, almost two years ago. The only real disinfectant you had was soap and water. There was no hand sanitizer, cavi-wipes, or alcohol to clean counters, gurneys, or exam tables with. Bleach was reserved only for the cleaning crew and due to DoC being under such a tight budget, would only afford one 1 gallon bottle of bleach per unit each month. It was the offenders who took sanitation jobs that controlled the bleach and bless their hearts they made that bleach last as long as they could but it was no good. The Community acquired MRSA was rampant unlike anything I'd ever have imagined. Most of the time nursing staff was encouraged to bring their own soap and water into work b/c we'd have gone through DoC's soap supply for that month.

Continuing on with ethics, we did not wipe the offenders before sticking them with insulin syringes. Alcohol wipes were always being stolen and considered a very valuable commodity.

In addition the health services unit became so obsessed with making budget management never focused on how to address offender issues or concerns. It became a viscous cycle in many cases - the offender would write a health care request form with a complaint. The offender would be seen by the nurse and if warranted be referred to the Doctor. The Doctor would then see the offender within 48 hours after Nurse Sick Call - supposedly. Instead no one ever scheduled the offender to see the doctor after being referred by the nurse. It caused a lot of grief and offenders would write back over and over again.

Even more sad you could never believe nor trust the offender and his History. Most everything you ever heard was a lie and it took several hard lessons for me to understand that. And then in the few instances that someone isn't lying, they royally get screwed over. Examples of this included.....

One offender would fake seizures and scared one of our senior nurses b/c she thought he was having the mother of all seizures. When the doc strapped the offender down and began cleaning his throat with betadine and opened a trach set he spoke aloud to the nurses that we'd have tube him with a trach. The seizure immediately stopped and the offender started yelling and apologizing calling the doctor several obscene things.

A different offender had a terrible case of staff. A very young guy in his early 20's. He talked indepth about how he had an infection control doctor and how ever since he was 14 the staph infections he'd get could only ever be treated by IV abx like vanc. Well, the doctors didnt believe and this particular offender had developed staph on his scrotum- very very painful. It was lanced twice and every abx from Bactrim DS to Clarithromycin / clindomycin and Rocephin .... everything. Then finally after over a month of battling this horrid infection he was admitted to the infirmary for 1 month to receive IV Vanc.

Prison was a very harsh setting and I dont miss any of that drama. I do miss the Signal 3000's which were our Emergency runs. There was a lot of great woundcare, trauma, and mental ailments that I miss treating.

deftonez188 · Apr 8, 2012

This was an excellent read, and your narration provides significant insight. Thank you for sharing.

Enthused RN, BSN, RN · Apr 8, 2012

Fantastic read, thanks for sharing! I'm only in my first semester in my nursing program but somehow I was able to follow along with your assessments and rationales ... goes to show that basics really ARE important (VS, head to toe) and you don't always need fancy equipment because it can't replace your brain!

Esme12, ASN, BSN, RN · Apr 8, 2012

Well said......nicely done!

Phoenixbyrd · Apr 8, 2012

This is the first article I've commented on. Just excellent - it has given me an idea of what correctional nursing can entail.

Multicollinearity, BSN, RN · Apr 9, 2012

Regarding emergencies (like chest pain) I have found the most challenging inmates to be the ones from special lock-down units. I'm talking about the ones who are in segregation due to high-level gang memberships and criminal operations/conspiracies while in prison. They fake serious illness all the time so they can get out of their isolation cell and try to communicate and issue orders to inmates in the yard. It can be as subtle as another inmate getting a one-second glimpse of them and then the lock-down inmate flashing a barely observable signal.

I give inmates the benefit of the doubt the first time and even the second time. I am very cautious and am careful to stay within my scope of practice. I think of the 1/10,000 case, like what if this healthy appearing 20ish male really is having a cardiac problem? I have seen cases like the annoying 20ish healthy I/M who had an MI with atypical presentation, etc. Glad I didn't dismiss him!

I have a particular strategy for the malingerers who have demonstrated a pattern of repeated claims of emergency medical crises. I'm talking about the lock-down inmates who claim severe emergencies several times per day or per week, and workups have found no pathology.

When this type of I/M claims an emergency I see them. I bring them to the medical unit. I do an assessment that is standard practice. And then I tell them the assessment has found no objective signs that are usually seen with their complaint (if this is the case). And then I say nothing. I've sat there in silence for 5-10 minutes before. It's excruciating with your phone ringing off the hook, and you're thinking of all the charts piled on your desk.

Finally the I/M will speak or get tired of waiting in silence (usually). They usually switch to a new complaint, claiming it was a misunderstanding. For example, I/M had claimed an asthma attack. There are no objective findings at all. (And I can tell the difference between fake throat-wheezing v. real wheezing, etc.) Then the I/M will often shift to something claiming miscommunication and say no, it's not asthma symptoms, it's light-headedness. The BP and VS will be elevated from their work of faking the asthma attack. So I'll take the BP again, and it's normal or high. I'll say something to the effect of "your BP is within the normal range (or high if that's the case) which means objective findings or evidence for feeling light-headed and about to faint don't quite seem right." By this point the I/M is often deciding to try intimidation through subtle verbal menacing. The nurse cannot flinch or "make nice." Then the I/M may switch to a new complaint like it's the headache, not really light-headedness. Or he may start unloading f-bombs and demand to go back to his "house."

What I do is assess for each claim and when they are clearly malingering, and with a pattern of blatant malingering, I then address each claim by simply saying there are no objective findings like we typically find for that complaint. If the inmate says something like "you are saying I'm faking...I'm going to grievance..." then I say something to the effect of "I'm concerned because if you say you have xyz symptom, and I find no physical findings that go with that symptom, then I'm concerned you could have something else wrong. Would you want us to treat you for the wrong condition? That would not be in your best interest, medically speaking." I'll bring up some unrelated example like "If you said you thought you had asthma and we treated you for it without any physical findings and you really had lung cancer, wouldn't that be bad?" And then sometimes, depending upon the case, I bring up psychological distress, and how this can manifest as physical symptoms. I then tell them our psych doc may come see them. They hate that and get exasperated, oftentimes.

Eventually, this often leads to the I/M getting mad because he's not getting what he wants, and he says he now has no symptoms, feels better, and wants to leave the medical unit. I love it when it ends that way, and it often does! I then call the on-call HCP and describe each complaint and corresponding assessment. I get a telephone order to send the I/M back to housing or, if we must, depending upon the situation, another order. I often discuss it with the psych doc who goes to see them the next day at their housing.

If this is carefully, tactfully, and matter-of-factly done, the inmate gives up and ends up saying he no longer has any symptoms and wants to go back to his "house." And the beauty of it is I have assessed each and every complaint and gotten an HCP order, appropriately. This method has worked for me with the worst malingerers. What's interesting is these malingerers then start showing up in medical on other nurses' shifts, not mine. They know our schedules, and they hear us on the radios.

libran1984, ASN, RN · Apr 9, 2012

I love your approach, Multicollinearity!! The waiting game is often a difficult one to do.

PlaidPaisley · Jun 29, 2015

Great advice! Thank you.