difficult ETOH pt

It's hard, I know.

Talk with your coworkers - responsibility for care of him should absolutely be rotated, or if your ED is that small - tag team, so that no one person bears the brunt of his drama alone.

Recognize that as a chronic substance abuser, he is, right now in his life, a master manipulator. His drama is his - don't let it be yours.

Talk with your supervisors/management and your ED docs - see if you can prompt some discussion of this patient to get consensus on what his treatment plan will be. We see a large number of chronic substance abusers in my (larger) ED. Though they must always be evaluated by an MD to rule out trauma or other acute medical condition ... those who are ambulatory and pain-free are given a list of drug & alcohol resources and discharged pretty quickly.

Does your ED have a social worker or case manager who has called the patient's family when he presents to the ED? This patient is young enough that someone may yet be able to create the right conditions for the right family intervention to evoke some change. It can be nearly impossible to do that with a long-term alcoholic who burned all his/her family bridges 30 years ago -- but this patient is still young enough that I would consider that approach.

Do the best you can to maintain your professional boundaries. Let us know how this is going.

We have a lot of these types. We have many indigents who come to the ER after someone sees them sleeping in an alley, drunk as a skunk, smelling of urine or vomit, or both. We just let them sleep it off, give 'em a sandwich and a road test, try to get them a bed in detox. Sometimes they'll get a line and some fluids.

There's really not much else for the ER nurse to do, it's just a part of the job that there are dysfunctional people who abuse the system. It's best to stay detached. You must accept the things you cannot change with serenity. We can not save every baby bird.

Is the patient in AA? In my area there are numerous groups/meetings throughout the week.

Is the patient in AA? In my area there are numerous groups/meetings throughout the week.

AA or NA only helps if the pt is ready for change. If he keeps using cocaine and coming to the hospital intoxicated multiple times a week he does not sound ready for change to me

AA or NA only helps if the pt is ready for change. If he keeps using cocaine and coming to the hospital intoxicated multiple times a week he does not sound ready for change to me

I have family members who belong to AA. So I speak from their experience. People who start attending AA are not always ready for change of course; it often takes time for them to embrace the teachings of AA and to be willing/able to put them into practice. AA is the place to start. And yes, of course, some people are never willing/able to change.

I would talk to your Medical Director and come up with an ED care plan, you do not need a PCP for that. On some of ours over the years we would have a plan in place to only treat objective findings (i.e. withdrawal s/s). We would have a plan to NOT feed them, to NOT give them a treatment room. If they were SI the plan would be to put them in a hold room with nothing but a mattress. Some of this may seem extreme but the only way to decrease the abuse is to take away what the reason they are coming to your department.

As far as for you, please be careful to not let your frustration show in your care, and do everything you can to not bring it home. I feel sorry for someone like the person you describe and feel that it must be sad to be killing yourself just to escape whatever he/she is trying to escape. Many cases came to mind in my own experience that are nearly identical to what you describe, the last I can remember died in an ally after passing out drunk in the winter. She was 26 and in our department at least twice a week, never wanting help just angry that someone called the cops to land her in our department.

Just keep swimming and really appreciate those cases where you can make a difference. Drug and alcohol addiction is an illness in my opinion and your patient is afflicted. If you think about it in that sense it might be a little easier to handle.

L

He doesn't want to change. Cant help that sadly.

You've already received excellent advice. I can't really add much to it, other than to think of your interactions with him as a dance. As long as he is being appropriate, non-manipulative and open, go ahead and engage with him, be empathetic and all that stuff. The moment you start feeling that little "tug" that you're being hooked in, just withdraw emotionally. Provide the care you're supposed to provide, but don't let yourself get drawn in emotionally. Be detached.

This is therapeutic for both him and yourself. By engaging with him as long as he is being appropriate, he gets the empathy he deserves, and you get to be a good nurse providing appropriate empathy to someone who really does need it. By pulling back when he starts in with the manipulative behavior, you avoid feeding into it and thereby reinforcing it- and by pulling back instead of letting yourself get frustrated or angry, you protect yourself.

I think of it as "throwing the switch". We all have that radar to recognize a potentially manipulative person the moment we set eyes on them, either as we're triaging them or when we room them, or when they roll in on the ambulance gurney. It's a sixth sense you develop working in the ED. You recognize them, and you know how things are going to go. They're going to be all pleasant as peaches and pie until something starts to go in a direction they don't want it to. It's like the train starts to take a side track, so they "throw the switch" to keep the train on the track they want. They will do this very cleverly, but you know you can recognize it when it happens.

The dance involves being able to recognize the moment they throw that switch and being prepared enough for it that you can just pull back emotionally instead of reacting negatively to whatever behavior they employ to throw the switch.

The ability to do this dance requires a LOT of practice! But once you let yourself get angry or emotional about the person and their manipulative, nickel and diming of your time and energy, you have lost. You might as well hand them your wallet and the keys to your car, so to speak. You can be supportive of the positive things you see in them, concerned for their well being, empathetic and engaged, but without letting yourself get triggered- the key is learning to recognize that moment where you need to pull back.

quote>>>" His drama is his - don't let it be yours"

And give thanks he is not your husband, brother or son. And remember,people like that are your job security.

So many sad and hopeless people in this country.