Lack of Compassion, Or What the Patient Needed?

[medic09]

The other night I got a 'withdrawal' patient in the ER. Quotation marks, because much of his presentation wasn't typical illness from withdrawal. It often he appeared he was just being difficult. He was supposed to go to the sobering center, but was up and vomitting so much that we couldn't send him. Since I had an empty treatment room, his nurse transferred him to my care for the rest of the night.

This fellow was lucid, and his responses were appropriate. At times he behavior was a little 'off', but seemed forced or contrived. Same with his vomitting. I was giving him pretty hefty amounts of Ativan per protocol, but he was just soaking it up with little effect. I was often in the room answering his calls, and he was giving me orders as to what meds he expected.

Up to this point in the narrative, I'm okay. Some are just demanding. But this guy kept getting up out of bed, taking off the monitor leads, pulse-ox, etc. Every ten to fifteen minutes I had to remind him that for his own safety, he had to stay in bed. He could call, and we could get whatever he needs. He kept getting out of bed; 2-3 times/hour. At one point he got up, and started off down the hall to get himself some ice. Of course, he tore out his IV. No simple matter, given that he had lousy drug addict veins.

So now, I gave him a piece of my mind. I told him he was acting like a spoiled brat (he's 29 yo), and he needs to cooperate with us so that we can give him good care. At one point I also pointed out this is an ER, and we have genuinely sick and injured people who also need our attention. I was using a pretty angry tone of voice after a while. I pointed out we didn't want to use physical restraints. We gave him Haldol eventually, and that didn't do much either.

I wasn't genuinely angry, though I was getting annoyed by his confounding his own care.

I'd like to think that I acted in line with the Rambam in Hilchot Talmud Torah, that a teacher musn't every be actually angry with a student, but they may act that way to get a point across and discipline them. Even so, the tech commented this was one of the few times he'd ever seen or heard me sound angry with a patient. (I did it once when a patient accused us of "Nazi treatment", and once when a patient endangered one of our female techs, a little cowgirl who could've kicked him to hell and back, and I threatened to deck him.)

So, is this appropriate for a Jewish nurse's behavior? Is this consistent with how the Torah teaches us to treat others, especially our patients? Have any of you similar concerns?

[achot]

Sorry for the delay- wrote a lengthy answer on Friday and the computer crashed or ate it or something
We are not judged by the once in a lifetime (Chad pa'ami) responses to out of the ordinary (charig) circumstances, but we are judged by our average- so I dont think you need to worry, I am sure you had the pts best interests at heart and sometimes it aint pretty, havent you ever had to do something to your children and felt terrible about it...CHosaych SHivto, Sonay B'no....(withhold the rod....)
We once got a schizophrenic, manic depressive youngish single woman to our Alzheimers unit...( an admission from the Psych hospital- Kfar Shaul)...the woman was so upset she refused to eat- and was combative etc. at first we left her alone but she pulled out all IV's, manipulated NG-tubes out of her mouth, refused her pills, made injections very difficult and would have died of dehydration. The CNA's held her down and force fed her, it took 3 or 4 of em, it wasn't pretty, I objected, but was told, better that than to let her die. Well after 2 weeks of this torture (beleive me I felt it as much as her, and tried to be gentle with her and make it up to her with pleasant treats which she threw back at us) she did a 180 degree turn, and is now so pleasant- her meds kicked it, she is now cooperative, eats well,. participates in activities including those outside her locked unit and is genuinely happy with a a high quality of life, her friends visit daily and are delighted with her etc. I am not saying that the end justified the means and I would hate to be judged on the basis of force feeding her, but what can you do...Like I said it was Chad Paami and Charig.
May Hashem bless all your work and make your etgarim easy

[lazer]

To answer your question "Is it appropriate" I believe we need to do what is effective... the ends justify the means if a person is interfering with necessary care. After all, nurses may legally restrain pts which is assault and battery in another context.

In your particular situation, this person lacks impulse control. He has certainly been talked to and yelled at much in his life and I don't think the maximum harsh tone of voice would effect him. The comment there being genuinely sick people and his acting like a spoiled brat puts you at loggerheads with him, why would he listen after already earning your disapproval?

People who observe you were surprised because your typically calm demeanor was ruffled. At that point, that fellow "won".

You were justifiably frustrated by his impacting your ability to care for him and your other pts. It may have been time to marshal your resources and get your charge RN and/or security involved. Dealing with uncooperative people in the past I try to stay clear of accusations. I try to be dispassionate, but tell them that I will not allow anything to stand in the way of my responsibility to care for my pt. It is not necessary to say that we don't really want to restrain you, but if you do this and this we might be forced to restrain you.

In any case, it sounds like a tough situation that needs the patience of a malach!

[chanab]

Oy! Are you sure he isn't one of ours visiting out your way???

I unfortunately get stuck on the phone or in rooms with ridiculously obnoxious pts way too frequently (No!! I NEED the purple coated morphine. Really? Cuz pharm says there is NO pharmacological difference!) It is really really really hard not to tell them to shut up and that I have other pts waiting who's needs are more acute, or more important, than whatever inanities they have come up with today. I agree with lazer that it is imp to never mention the other pts as much as they may be on your mind. It is also imp, no matter how much you want to say it, to not call them all the names going through your head (like spoiled brat, jerk, and other words I won't post here). Not saying those things is probably more r/t professsional conduct as opposed to Torah observance. But I am all for threatening and using forceful language when called for. And I don't think that puts you at odds with being a good Torah observant Jew. Telling him that he'll end up in restraints is great, becuase ultimately pulling out his own IV repeatedly could be dangerous and it is your responsibility as the nurse to monitor his safety. Why it would be downright un-nursely of you not to say it! (OK maybe stretching it a little with your description of the above pt, but still valid).
And in terms of pts (or co workers) making you lose it, I recently started doing something that I have found very helpful when I'm ready to blow a gasket. In that past I have counted to 10 and repeat as necessary. Recently I started counting in Hebrew, with an emphasis on echad. Echad makes me think of Hashem and that He is going to help me manage whatever stressor I am currently dealing with. It's not a complete solution, but it's been helping.

[medic09]

You guys are great, thanks for the responses!

Chanab, that last little bit about the effect of Echad is a true gem. Really a gem. Thanks. I don't usually forget Who I work for; but sometimes a reminder is good.

[Rivka P]

just browsed, but I think it's fine to mention that although you are there to care for your patient the best you can, there are other patients in the hospital that need your attention as well. For example, I called respiratory to come give an anxious patient a treatment. They tell me they are responding to a MET team call. (Medical Emergency Team, I think)
So I told my patient that the respiratory therapist is with a medical emergency, saving their life and will be here as soon as possible. Just because society is selfish, doesn't mean you cannot teach your patients a little patience and understanding.