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The Art of Medicine

Tough love

Godfrey, Alexandra MS, PA-C

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Journal of the American Academy of PAs: January 2014 - Volume 27 - Issue 1 - p 58
doi: 10.1097/01.JAA.0000438542.11204.77
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The girl with reflex sympathetic dystrophy, depression, and borderline personality disorder wants a pain shot for her abrasions, the tiny cuts crisscrossing the back of her hands. “They're agony,” she says.

“I am sure they hurt,” I say. “What happened?”

“Well, it was nothing really. I opened a window to clean it, and it”

I nod, thinking the scratches look like trails from fingernails. I study her skin. “It's unusual for glass to cut you like that. Was the window old? Did it break into shards?”

The girl shrugs. “I dunno,” she says. “The glass was thin. It just kinda broke.”

I clean her wounds, checking carefully for glass. Her injuries do not match her story, and her narrative lacks detail. I talk to her about her mental health. I hear nothing to suggest danger to self. She has some other agenda. I hope by listening to her and caring for her injuries, I will understand her. She wails when I rinse her hands, pulling them away. I try to soothe her. “You won't feel this for long. Cuts sting. You'll feel better soon.”

The girl appears calmed by my words, but when I touch her hands to dry them she flinches as if struck in the face. “Are you okay?” I ask. Silence. I gently apply ointment to her wounds. I ask if she would like some ibuprofen or Tylenol. This tips her over the edge.

“My hands hurt. I need a pain shot. Dilaudid or morphine. I can take Tylenol and Motrin at home. Give me a pain shot.”

I pause. I don't want to give her a pain shot. How can these minor abrasions create such agony? How can she expect this! I suppress my irritation and my desire to tell her the ED is for emergencies, not for kids wanting a high. I consider the wasted resources, patients waiting, escalating costs, people in crisis, bodies broken, real emergencies. I care but, despite my training, I feel frustrated. Taking a deep breath, I explain, “I don't give pain shots for abrasions like yours. I know you hurt, but I really think OTC meds are a better option.”

My words infuriate her. I try talking to her about the risks and benefits of opioid use. She rolls her eyes. She leaves the ED angry. She thinks I do not understand, but I know opioids will never cure the pain beneath those cuts on her skin.

My next patient, a 40-year-old physician with the perfect narrative, presents for a stat upper endoscopy. She uses medical terminology: “I have postprandial mid-epigastric pain with radiation to my chest, constant nausea, and fatigue. I have early satiety and weight loss. I stopped my PPIs a year ago. I have a history of PUD and anemia.”

I ask her questions. She denies hematemesis, dizziness, and melena. She tells me the labs she wants. She refuses a plain radiograph film, an ECG, and cardiac workup. Her rectal exam is normal and her stool guaiac negative. She has epigastric and right upper quadrant (RUQ) tenderness but declines an ultrasound of her RUQ: “I know it's not my gallbladder.”

An hour later, her labs come back normal. Her vitals are stable. I suggest she go back on her PPIs and schedule an appointment with GI. She looks panicked. She is accustomed to getting her own way. I hear her breathing; slow respirations laden with frustration.

“I don't have time for this. I need that scope today. I am busy. I need this now. I have a job.”

I stop for a moment on the edge of something incommunicable. How can this educated clinician expect me to provide her with a nonemergent EGD stat? I feel frustrated. I watch as she interlocks then unlocks her fingers expectantly. The ED isn't a one-stop-shop! Can't she see the trauma around us? I realize I cannot always meet patients' expectations. I care, but I need to use our medical resources wisely. The ED isn't for kids with dysphoria wanting a high. It isn't for stable patients, even physicians, wanting a routine test stat.

I say, “The endoscopy suite needs to be open for patients with emergent problems. I can schedule you an earlier outpatient appointment.”

Like the patient before, she leaves upset and disappointed. Perhaps my tough love approach didn't work.

But sometimes, it is the best and only care I can give.

© 2014 American Academy of Physician Assistants.