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At Your Defense: Getting Punk'd A New Liability in EM

Reyes, Carlo, MD, JD

doi: 10.1097/01.EEM.0000532164.33510.d7
At Your Defense

Dr. Reyes is the vice chief of staff and the assistant medical director of emergency medicine at Los Robles Hospital in Thousand Oaks, CA. He is also a clinical professor in emergency medicine and pediatrics at Olive View/UCLA Medical Center, a health law attorney with Boyce Schaeffer Mainieri, LLP, in Oxnard, CA, and the founder and CEO of Health-e-MedRecord, a patient-centered and emergency physician-designed EHR solution. (www.health-e-medrecord.com.) Follow him on Twitter @carloreyesmdjd, and read his past articles at http://bit.ly/EMN-Defense.

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There's a disturbing trend for front-line providers in medicine. It apparently isn't enough to worry about nailing the diagnosis and landing top satisfaction scores. Now we also have to look out for something unexpected: patients pushing us to the brink of rage and recording it on their phones.

Most patients innocently record things in the ED out of sheer fascination. I often have patients whipping out their phones to attempt to record me as I repair their (not so) gruesome laceration. I remind them that hospital policy prohibits this, and cite HIPAA because it seems like the right reference. But those were the good ol' days.

Patients now have harnessed the power of social media for nefarious purposes—to make EPs look baaaaad. Recently, an addiction medicine physician was recorded at an outpatient clinic yelling at a patient and kicking her out. (http://bit.ly/2ChdJcQ.) At first blush, it looks like the physician lost it. Completely.

The police report painted an entirely different picture, however. Apparently, the patient and her daughter had been verbally abusive to the staff, upset that they had been waiting 45 minutes for a pain prescription. The video showed the last few minutes of the long ordeal involving verbal threats and abuse by the patient against the clinic staff and physician.

Every experienced EP has witnessed some form of patient manipulation. Unfortunately, this physician experienced an extreme situation that placed him under national scrutiny, thanks to social media. EPs need to recognize these manufactured patient situations designed to induce them to abandon their better judgment and sometimes their professionalism.

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Framers and Seekers

Some patients set up EPs by filming a video that shows an EP's refusal to treat a patient's pain adequately or provide a medical screening exam like in the example above. This, in turn, can be the fuel to drive an EMTALA investigation or a complaint to a hospital administrator.

What are some things that EPs can do to prevent or at least mitigate the effects of such a patient, often called a framer? Recognize when a patient is setting you up. Patients and their family members who verbally assault you without any basis are attempting to manipulate you. Best case, they are bullying you to get you to do something contrary to your best clinical judgment. Worse, they are hoping that you will lose your cool, making you vulnerable.

Don't let anger get the best of you. Admittedly, I have gotten angry on numerous occasions, and none of them was worth it. You should always attempt de-escalation techniques, but step back and get help if you sense your anger rising. Sometimes that help may be hospital security or the police.

Seekers are patients who fake symptoms for secondary gain, which is almost always narcotics. This is an everyday occurrence in emergency departments. We should give nearly all our patients complaining of pain the benefit of the doubt, and note the red flags that suggest drug-seeking behavior, such as asking for pain medications by name or feigning vague memory of the name of the medication that has worked before. (“It starts with a ‘D.’ What's that medicine again?”) Or asking for an IV because “that's the only way it works.” Sometimes they claim that someone stole their pain medications, which sounds eerily similar to a third-grader's claim that her dog ate her homework.

One important pitfall here is anchoring, which can lead to misdiagnosis. Mrs. K. was a 32-year-old woman, a frequent flyer who came in for abdominal pain and vomiting, usually at night. And here she was again. Scanning through the prior records, I saw negative CT scans and diagnoses ranging from vomiting to gastroparesis to colitis. The only constant was her recurrent complaint of abdominal pain.

Working the overnight shift, I recognized her name and thought to myself, “The last time all it took was one dose of hydromorphone and she could go home.” After she insisted that her multiple allergies precluded her from getting anything else but hydromorphone, I reluctantly ordered it. After repeated doses and liters of saline later, she was still vomiting. Six hours in (and one hour from the morning shift starting), I was left with getting yet another CT scan.

As I was about to sign out the CT results to the next shift EP, I got the reading—sigmoid volvulus. It immediately dawned on me: She may have been suffering from intermittent volvulus all this time. This time, it almost killed her. Anchoring almost made me miss it.

EPs are best served by treating each patient with the utmost respect. Remaining the ever-vigilant diagnostician allows you to serve your patients with the best care. Identifying a patient's nefarious intent allows you the opportunity to steer clear of harm.

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