05 November 2010

Friday Flashback - A New Threat

I wish I could say that every patient encounter worked out well, that all my patients went home happy and satisfied.   It would be nice, but unfortunately that is not true at all.   There are many patients who present with unrealistic expectations or an agenda which is non-therapeutic and I am relatively straightforward and unapologetic about correcting patient's misconceptions about the care that is or is not appropriate in the ED.  Unsurprisingly, this often, though not always, involves narcotic medications.

Which is not to say that I am a jerk.   I try to be compassionate, and I try to find alternative solutions, and I have been told that I can turn away a drug-seeker more nicely than any other doctor in the department.   But when it is time to say "no," I say "no," firmly and without evasions or excuses.

People don't like to hear that.  All the more so in this "the consumer is king" environment of customer-service culture we foster in the medical industry these days.   So, when I do say no, as nice as I try to be, some people get upset.  Sometimes they escalate.  They hurl insults, spit, throw themselves on the floor and throw a fit, or feign unconsciousness.  I have been threatened with complaints to administration, with lawsuits, with actions against my license, and even with physical harm.  I pride myself in being determinedly polite and non-responsive to behaviors like these, since, if I engage, it only further escalates the situation, and the threats are usually empty (though I am rather security-conscious both in and out of the hospital).

I thought I had heard it all, but I got a new threat recently.  The context was one in which I felt a little bad about having to say no.  The patient was a grandmotherly sort of lady in her middle years.  She presented a sad and pathetic figure as she told me her tale of ongoing diffuse body pain which was poorly controlled even on high doses of methadone.   Alas, she was out of her meds and wanted a refill (actually, her initial request was to be admitted to the hospital).   She was unable to explain how she had come to be out of her pain medications.  A quick record biopsy showed that she had many, many previous ER visits for pain medicine refills, and had been on a pain contract with her doctor, who had terminated it because of her repeated violations of their agreement.

In light of this, I felt it would not have been appropriate to provide further narcotic medicines through the ER.  She had been out of her meds long enough that she was not in symptomatic withdrawal.  She had already been referred to a pain management clinic for future care, so there was not much more for me to do.

She escalated; I explained my thought process.  She yelled, she wept, and she begged.  I held firm, and she was discharged.  On her way out she stopped by the charting station and said, with a vicious spite in her voice, "I hate you.   You are a terrible, terrible person, and I hope you suffer, and I hope your children suffer.  In fact, I am going to make sure of it.   I am going to go home and make a voodoo doll of you and all of your children and I am going to stick pins in all of them!"

What does one say to that?  Suddenly I didn't feel so bad about saying no any more.  Bemused, I encouraged her to "have a nice day" as she stormed off.

This job is never dull.

Originally Posted 6 November 2007


  1. If there's one thing guaranteed to not make *anyone* feel bad about saying no, it's threatening or abusing their family. That kind of stuff is never on, even when 'you're just saying it' and nothing will come of it - still leaves a bad taste in one's mouth.

    Props, sir, for your continued politeness.

  2. That poor woman. What must she have been suffering to make her vent such bile? If only she could have realized where she would end up when she started down that road.

  3. Man, drug addicts are a sorry sight to see.

    Hats off to you for not smiling or laughing when she made such a ridiculous threat.

  4. wow, what an angry little troll. do you ever make a note of such comments made in your note?

    we recently started a statewide prescription medication monitoring database for schedule drugs in the state where i work. it really levels the playing field with narcotic seekers when you can log on to the internet and see all of the various oxycontin scripts they've filled in the past couple weeks, etc...

  5. Voodoo doll...now there's one I haven't heard before.

  6. I guess that reinforced to you that your decision to say no was the correct one....

  7. Just wear your black belt around your white lab coat. It'll confused the drug addicts and make them think you're a ninja and not a doctor. No one Fs with a ninja.

  8. Voodoo = CAM don't worry

  9. No good punishment goes unturned.

  10. I'm usually pretty compassionate towards addicts, as it's a disease in its own right, but any compassion I would have felt for her would have evaporated the moment she expanded the threat beyond just me. On the upside, it's an implausible threat, ulike a threat to find your address in the phone book and shoot your family in the night. I no longer have a listing in the phone book...

  11. Not to defend this horrible woman's behavior in anyway, but how did she become a narcotic addict in the first place?

    Because doctors doled out narcotics like candy because it was the easiest way to get her out of their hair.

    The medical profession as a whole deserves some responsibility for a large majority of these people, the 7 to 15 percent of the general population of the pacific northwest who are addicted to prescription narcotics.

    Until someone clamps down on the Dr Feelgoods who dole out the narcs because its the easiest thing to do, good for their Press-Gaineys, they're afraid of patient complaints, whatever, we're going to keep seeing this type of shit.

    When I started nursing 30 years ago we were giving people 30 milligrams of codeine for migraine headaches. Now they need IV dilaudid. Morphine isn't even strong enough anymore. Where did these people learn this behavior?

    Also, you may have put your foot down this time, but she'll come in your ER next week and see another doc and even though its documented that she threatened your family on this visit, next time she'll walk out with her narcs.

    Its not the patients behavior that we need to change. Don't kid yourself. Its the prescribers.

  12. dancestoblue11/15/2010 8:56 PM

    Two things.

    A friend called me up, telling me he was deadly ill, and needed support, and I went to his home. He said he needed to go to the hospital; okay, I took him to the ER here in town. We sat in that ER through all of a beautiful, beautiful spring day, he's moaning the whole time, finally we see a doc (btw, I am NOT complaining about how long it took to see a doc, clearly it was correct in this situation) we see a doctor and now it comes out -- he wants benzodiazepenes. And he was not physiologically addicted, he wasn't kicking or anything, and he absolutely was not in the pain he'd told me about all day, which of course had become fairly apparent anyway; he just wanted the edges of his day rounded off. I do have compassion for drug addicts and I give what I can to support anyone in need, but I will never, ever again pick up his phone call.

    A man I know, sixty years old, his hip blown out and needing replaced, he's in agonizing pain ALL THE TIME and so he takes more than he should of his limited scrip, almost every month he's kicking again, and in horror-show pain, to boot. He's a good man, he's just in real pain and not able to hold out against it, a weakness on his part that I cannot judge him for, and will not. He is on disability, the VA has refused for years to give him the hip replacement, and this while chiding him for abusing the drugs; sweet. Finally, later this month he will get a new hip put in, and this nightmare can end. Though he's got bad bone genetics, bad history from both his mother and father, so who knows what might be next.

    His doctors have taken the same line you've taken with this woman, and it's the correct thing to do I'm sure. It's just a real rough scene, no matter how you look at it, and this second man has never tried to rope me into any of his problems like the first man did, thus I help him when I'm able, in whatever ways I'm able.


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