I recently had a patient in the ED who did have a lot of pain from her 1mm kidney stone. Understandable. However, the drama and borderline traits exhibited by her and her husband were highly disruptive to the staff and surrounding patients in the ED especially as we had a crashing patient who went into septic shock with a BP in the 50s before our eyes. The patient and husband were highly disruptive because of the perception that we were ignoring the patient and not taking care of her needs. I called security and the police who escorted the husband and another visitor out of the ED. I did not approach the husband as he was making a scene. We were all afraid he would come back with a gun. I did go back to the patient to give her more pain medication. This didn't stop the high drama from the patient. Besides for yelling about the pain, the patient was yelling that we didn't check her labs or urine (we did). She was also upset that we did not offer her a tampon or pad after we did her pelvic exam because she was bleeding. We never offer pads and I have never heard such an angry outburst over a pad.
Is there a one liner that you have in your back pocket that will help the patient and or visitors recognize their childish behavior and that we will not help them if they continue with this behavior.
Would something like this work? (Of course have security officer with you)
To the husband: Mr So and So, I can see that you are very upset. However, nobody deserves to be spoken to the way you are speaking. The other patients are disturbed by your outburst. If you want to be helped, you need to calm down and stop yelling. Yelling will not get you help faster. The doctor is with a critical patient at this time. I cannot give your wife a third dose of pain medication until there is an order from the doctor. I will have the doctor come check on your wife as soon as she is available. Is there anything else I can help you with?
To the patient: I can see you are very upset and would like more pain medication. As soon as the doctor puts in an order for more medicine I will bring it to you. The doctor is with a very sick patient at this time. Would you like and ice pack or some warm blankets to help manage your pain until we get an order? I will ask the doctor for some more medicine as soon as she is available. Is there anything else I can help you with?
Unless there are large volumes of blood which there wasnt we usually dont offer a pad. Patients have their own. Of course if someone asks we will get them what they need. This patient didnt even ask.
I have no idea how the patient is. I work in the ED. After the fentanyl and toradol and a dose of ativan her pain went down to a 4 and she was discharged. The spouse was much more calm after being kicked out of the ED and when he called to ask his wife something I apologized for the impression that we were not meeting his wifes needs. We let him back in. FYI, this was not an elderly couple. They were in their 20s and acting in the stereotype of my generation (me me me). Contrast this to my other patient in severe pain with her husband also of my generation and there is a world of a difference and we were still busy with crashing patient.
Friend, don't put the quiet ones on a pedestal and curse those who are more demonstrative. I know we take a liking to some patients more than to others. I understand where you're coming from.
The doctor is mainly at fault. He needs to be educated.
Did the stone pass?
You can do some follow-up sometimes (not with pt at home) even if you work ER.
For the pt who is terrified and in excruciating pain, nothing matters except finding relief. Expecting her to think about the needs of yourself and other pts is not realistic and not right. You will learn this if you ever personally experience severe, severe pain. I hope the doctor does, too.
Blood - just give a pad. The pt has pads at home, not necessarily with her in the ER. Would you like to lie in a bloody bed? It's cold, wet, embarrassing. How hard is it to slap a pad on her or hand it to her?
I'm not offended. I'm advocating for my mental health patients who suffer worse outcomes when they're admitted to the hospital, in part because of associations like the one you drew between your annoying patient and borderline personality disorder. I think the practice of using mental illness labels as a way to describe difficult patients is unprofessional for that reason. I don't need to be there to know that it isn't okay. Even if I were this patients PMHNP, and had just finished describing them in a note as having borderline traits, I would still find it unprofessional to describe them that way on AN or in casual conversation. Just describe the behavior, and leave the diagnostic labels in the chart.
I was in the similar situation quite recently, and made a conclusion that you are indeed right. When patients (and family, for that matter) are labeled as "borderline" or "depressive", they are treated like such and do not receive interventions they really need to succeed, including a good ol' dose of reality. Instead of being educated and guided, they can be easily signed off because they are perceived as mentally deficient and therefore "people who cannot be reasoned with".
The family I took care of had to learn a lot and quickly in order to take their ailing mother home. They were behaving with every single "borderline" trait you can think of and soon became conventionally known as such. The unit came to the point where the staff was mandatory rotated. When it was my turn, I spent a good deal of time with the family in the room just observing and quietly going about my tasks and suddenly it dawned on me: they were simply just as rude, abusive, guilt-tripping, splitting, etc., etc., toward each other as they were toward us. They were not "borderline" or anything else from the mental health realm, they were just part of the "ME!!!" generation who grew up in inner city slums and never saw or heard anything better.
I'd got couple of more people in room and the next teaching session started with direct and witnessed explanation of 1) how things are run here and what the plans and timelines are, and 2) that the blaming and falses-searching party is over, and we're gonna to get it done, or the Mother is bound to a LTC somewhere. "De-escalation" and "recovery" were not instant, but very lasting.
Friend, don't put the quiet ones on a pedestal and curse those who are more demonstrative. I know we take a liking to some patients more than to others. I understand where you're coming from.
The doctor is mainly at fault. He needs to be educated.
Did the stone pass?
You can do some follow-up sometimes (not with pt at home) even if you work ER.
For the pt who is terrified and in excruciating pain, nothing matters except finding relief. Expecting her to think about the needs of yourself and other pts is not realistic and not right. You will learn this if you ever personally experience severe, severe pain. I hope the doctor does, too.
Blood - just give a pad. The pt has pads at home, not necessarily with her in the ER. Would you like to lie in a bloody bed? It's cold, wet, embarrassing. How hard is it to slap a pad on her or hand it to her?
Presumably the stone passed because I saw the same patient last night screaming about something else and not writhing in pain like the first time.
The patient was spotting, if that. She did not wear a pad/tampon to the hospital.
I totally disagree. Particularly in an ED setting; if this isn't a preexisting diagnosis, personality disorders are not something that is likely going to be diagnosed in the short time that they are in the ER.
As far as the "trait"...more likely their outbursts are just rude and poor behavior, NOT an actual mental health issue. To jump to the conclusion prematurely is like assuming that a demanding and overbearing pt. mother in pediatrics has munchausens by proxy. Sure, you might be right on the rare occasion, but more often you end up doing more harm than good by putting that label on them. It is incorrect to identify all outbursts and inappropriate behavior as being a trait of a mental health issue.
Not to mention adding to the stigma that mental health already has, like Dogen said. If nothing else, its not PC.
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If you read what I wrote carefully you wouldnt have written this. I did not say she was Borderline. I was identifying some of the ways she was acting as borderline traits which does not mean she has borderline personality disorder. As I said before, lots of people exhibit borderline traits from time to time which does not mean they have a disorder. To get to the level of disorder means that your life is disrupted. I have a friend with a personality disorder and have read about personality disorders to learn more about them.
I read what you wrote. Carefully, and in fact, more than once. I disagree. And I stand by what I wrote.
Ten years ago people like this - just the extreme cases - would be charged and fined for disorderly conduct. When the fines accumulated the judge would sentence them to thirty days in the county jail along with a stern lecture about abusing EMS and ER services.
They stopped frequenting our ER.
That would be great. Only one problem is that ten years ago, if I remember it right, someone who was arguing with abundant profanities in coffee shop because the coffee was not as "perfect" as expected would not be drawing mass of positive opinions from others there, who seemed to fully appreciate the fact that the wrong $3 coffee might "kill" someone's day, life and the whole Universe as well.
And I do not remember being ever treated as a "customer" when in hospital 12 years ago.
1st post: "Besides for yelling about the pain, the patient was yelling that we didn't check her labs or urine (we did). She was also upset that we did not offer her a tampon or pad after we did her pelvic exam because she was bleeding. We never offer pads and I have never heard such an angry outburst over a pad. "
Lev was never asked to provide a pad. She has said you had to be there and I
believe her about that and the status dramaticus *******ry.
I have been a psychiatric nurse for almost 40 years. One of the things I learned from one of my supervisors early on was "you can't argue with a crazy person."
I would keep my responses to this situation very simple. Something like, "I want to help but I need you to please lower your voice so I can explain what I'm going to do."
The patient being irrational is one thing; the family being irrational is another. That is definitely uncalled for. And sometimes they can be worse than the patient, making one wonder who really should be the patient But I guess that goes to some people are jerks no matter what. I agree with having the family leave the situation and trying to be compassionate as difficult as it might be, which probably will help quell the situation with family/friends out of site.
perhaps explaining why the pain..its a kidney stone which is shaped like a ....barb wire fence on steriods.
An informed patient is a calmer patient. No need to call in the SWAT team for kidney stone.
The more water she drinks, but its still going to hurt like hell. She could have a low pain tolerance, but she needs to drink a lot of water. It could happen again.
Part of working in the ED is learning how to manage difficult people. Your mandate as a nurse is to care for the patient. Not feelings-wise, but action-wise.
I get not wanting to deal with jerks. I don't like doing it either.
But it is OUR JOB. I like calm and collected patients better than the screaming me-me's. But that's not what you get all of the time.
Just because your patient is a jerk doesn't mean they should be treated like a psych patient.
Honest communication, boundary setting, and consistency are the way to go. Not one-liners. They tend to escalate the problem.
Your ED should have some conflict resolution training. I suggest you make use of it, unless you LIKE beating your head against a wall. 'Cause expecting irrational people to act rationally is just going to give you a headache.
Excuse me this is the ED. You my dear, are not an emergency. We have attended to you. There are people in here that are emergencies. If you think being annoying is going to get you more attention, you are correct. I am calling security right now and you will get that attention. Probably not what you are really wanting but you are bringing this to yourself. So put a sock in it and sit back and relax.
Specializes in Med/Surg, OR, Peds, Patient Education.
We have a couple doctors who will order morphine 4mg IV q15 PRN. And then we have doctors who are super safe to the extreme that they want to be in control of every dose. This is the same doctor who we had to ask at every move if we could titrate up the norepi (on the crashing patient).
It is obvious that patients are not the only "jerks." Physicians can fall into that category a, disturbing, fact with which we are all familiar.
But I guess that goes to some people are jerks no matter what. I agree with having the family leave the situation and trying to be compassionate as difficult as it might be, which probably will help quell the situation with family/friends out of site.
Kooky Korky, BSN, RN
5,216 Posts
Friend, don't put the quiet ones on a pedestal and curse those who are more demonstrative. I know we take a liking to some patients more than to others. I understand where you're coming from.
The doctor is mainly at fault. He needs to be educated.
Did the stone pass?
You can do some follow-up sometimes (not with pt at home) even if you work ER.
For the pt who is terrified and in excruciating pain, nothing matters except finding relief. Expecting her to think about the needs of yourself and other pts is not realistic and not right. You will learn this if you ever personally experience severe, severe pain. I hope the doctor does, too.
Blood - just give a pad. The pt has pads at home, not necessarily with her in the ER. Would you like to lie in a bloody bed? It's cold, wet, embarrassing. How hard is it to slap a pad on her or hand it to her?