When Keepin' It Real Goes Wrong

I love the Chappelle Show and was beyond excited to find out that Dave Chappelle actually lives in SW Ohio, actually about 10 minutes away from me. he had a segment called "When Keepin' It Real Goes Wrong". YouTube it if you haven't seen it, but the theme of the segment was someone who misguidedly "kept it real" (i.e. had the wrong attitude in an inappropriate situation) and then suffered for it. I'd like to use this idea to highlight some of my more recent experiences.

My intention for this blog is not to be a place to rant or vent (I usually do enough of that at work), it is meant to be a place of mediation, entertainment and introspection. However, I'd like to consider this an educational post about how to treat your healthcare workers. Almost all of us went into medicine because we genuinely want to help people, as cliche as that sounds. We like to make people feel better, and most surgeons would argue, we like to cure your diseases. This is true for the nurses, the PAs and NPs, the techs, even the environmental crew. As sick as it sounds, we actually like hospitals and the idea that we get to participate in an important, if not critical part of the patient's life. That being said, there are times when we hate our patients, without question, and if it were even remotely ethical, we would either throw them out the door or muzzle them.

Trauma patients are a very special mix of patients. While there are the innocent people who had random badness happen to them, a large majority of our patients (particularly on the weekend or on payday) are made up of people who brought the badness on themselves. While the sober un-helmeted motorcycle crash is stupid, he isn't really hateful, he (hopefully) only hurt himself. The worst patients are the drunk and/or high douchebags (for lack of a better word) who decided to drive some sort of motor vehicle. Not only have they put their life in danger and are now our responsibility to save, but they can and do hurt and kill innocent people. Aside from this, they also usually come in abusive and combative. As doctors we have taken an oath to treat and heal all that are in need, but let me tell you, sometimes this is nearly impossible. Usually a little passive aggression helps you out, maybe pressing a little longer where the patient said it hurt, or letting the guy with the biggest hands in the room do the rectal instead of one of us gals with tiny fingers. It's nothing detrimental to the patient, but it gives you a little sense of reciprocity.

Sometimes passive aggression just doesn't cut it, and that's where a kind of verbal aggression sets in, at least for me. I can have a little bit of a sharp tongue and speak without a filter (I'm kinda working on tempering it, in my spare time), so when one of these patients comes across my path and "keeps it real", I'm a little more inclined to "keep it real" myself and orient them to the reality of the situation, meaning I am in part of the team that is in charge of what happens to them and they have zero control of the situation. I like to think of this as patient education, disabusing them of their delusions. Generally, once reality and/or sobriety sets in, they come around to our way of thinking. Of course, there are some people that are just assholes drunk or sober. But I'd like to illustrate this with two recent, favorite examples.

The first was a young man who was brought in with a stab wound to the groin by his girlfriend. One can only speculate what she was aiming for, but was a little lateral to it and could have possibly gotten his femoral artery, which is a pretty big artery. I had just finished a case in the OR (probably butt puss, the intern's usual case) and was asked to hold pressure on the stab site to try and keep the hematoma from expanding. There's a saying in surgery that there are a few places into which a patient can bleed out: the chest, the abdomen/pelvis, the thigh, and the floor. This patient was possibly at risk of exsanguinating into his thigh and my job was to prevent that while the second on-call attending and more OR staff made their way to the hospital, it was a trauma filled day and our on-call attending was already in the OR with another patient. The amount of pressure and the place in which I had to apply pressure was surely not very comfortable for the patient, it was painful for me as well on many levels. As I'm sure you could imagine, this young man was colorful, to be euphemistic. This was not the first time this girlfriend stabbed him, he had been shot and he had many scars from myriad scuffles with her. He would not stop complaining about how bad my pressure was hurting his leg and complaining about everything and then accusing me of enjoying hurting him. The nurses would try and come to my aid and say how i needed to apply that much pressure to help him, etc, we try and take care of each other. I let this go for about 20 minutes or so (maybe less) before I informed him in no uncertain terms that an injury to the femoral artery could cause a patient to bleed out completely in 6 seconds (his injury was nowhere near the caliber you would need for that, but it was a fact I thought was pertinent to share, I'm all for patient education) and that if my pressure was too much of a bother to him, I would happily remove my hand and let us see what happened, because pressing down on his groin was not exactly my idea of a good time either. Sometimes you just need to establish who is the alpha in the relationship. His eyes widened at this "education" and he quickly changed tune. The nurse chimed in and said something to the effect that he should be thanking me for saving his life and quit being nasty. From that point on, he was much more agreeable. In fact, I learned way too much about him and offered that he should reconsider his current relationship or at the very least have his girlfriend pursue anger management. He was at least entertaining for the duration of our time together after our orientation to reality. He walked out of the hospital fine the next day, I'm sure I'll see him again courtesy of his girlfriend.

The latest and greatest illustration of how not to treat your life-saving team came in the other night. He had a blood alcohol level that would leave most of us intubated or dead, but he went out driving, obviously without his seatbelt. I was at the head of the bed for this trauma. He came in bloodied and combative. While I was doing the primary survey, he decided he didn't like what we were doing: asking questions, listening to breath sounds, finding pulses, drawing labs, you know, generally working towards finding and fixing his injuries. When a patient is on the long-board and in a hard collar so they can't move their neck and head, especially with the bustle of the trauma bay, it can be hard to communicate with them, so often you have to lean over their face and speak loudly and clear. As I was doing this, the patient decided he had enough and decided to spit his bloody sputum at my face. Luckily, I had a face-mask and shield on, so it just hit the mask, but he did have a blood-borne communicable disease (which I found out later, and only incensed me more) and that's just bad form to spit at the people helping you. One of my awesome trauma nurses who was near me put a hand over his mouth and educated him that spitting blood at people was unacceptable. He proceeded to flail around, lifting his head and being uncooperative and all the while complaining that he couldn't breathe. I assured him that if he was speaking this much he could breath. He then decided that the hard-collar was to blame and wanted it off and assured us that it would be okay, he knew he was medically fine. At this point he had not only spit viral blood at my face, flailed around, cursed at all the staff and was generally unbearable, but more importantly, he was so intoxicated that he could have been doing serious, irreversible damage to himself by moving around and being uncooperative. If he had an unstable cervical spine fracture, he could have transected his spinal cord by moving his head all over. It was time for me to "keep it real". When he declared he knew he would be fine, I asked him if he had gone to medical school to which he replied, in colorful language, that he had not. I then informed him that those of us who had would be the ones making all of the decisions about his care and it was in his best interest to be cooperative. He eventually calmed down and had very few injuries. I decided to tag along for his post-op check and see if he was actually a decent human when sober. During our exam I asked if he had been out of bed (one of surgery's favorite activities for our patients), and he said no because he felt so bad. I inquired as to what felt bad and he said he felt awful about what he did. I took this as a perfect time for "patient education". I told him that was appropriate, he was lucky, he could have hurt himself worse and others, but also that he was incredibly uncooperative and abusive to the staff that was trying to save his life that night. He apologized and actually genuinely seemed repentant. I'm not optimistic about my odds of not seeing him again as a trauma, but hopefully he'll be less hateful to the staff next time.

In summation, while we, the medical staff, can sometimes seemingly be a little insensitive to our patients because it's easy to forget that our normal day is the worst day of our patient's life (I'm sure I'll post on that at some point), we actually care about our patients, no matter how abusive. What it essentially boils down to is the "golden rule", treat others as you wish to be treated. No one gets an award for being the most stoic, most abusive or most uncooperative patient, just like no one gets an award for being most aggressive doctor, sassiest nurse or most dismissive. I happen to be biased towards the hospital workers because, honestly, not a single one of us would opt to spend Saturday night dealing with drunk patients instead of being out with our friends having fun, but this is the life we chose and, honestly few of us would give it up. I'm just saying, be cognizant of your attitude in situations and make sure that it's appropriate, in the hospital and out. Don't let "keeping it real go wrong".