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Coming Up Short

Meghan G. Liroff ~

"Why so short?" says the four-year-old girl who's here with an upper-respiratory infection.

Standing safely between her dad's knees, she wears a bright pink jumpsuit. Her cheeks are dimpled; her hair is piled in a frizzy bun. She looks me up and down, as if trying to make sense of me.

I can't help laughing.

It's true, I think. At five feet even, I'm not blessed with height--but I make up for it in chutzpah. I squat down to bring my eyes level with hers.

"I'm not laughing at you," I reassure her. "I'm just laughing because you picked up on a major thread in my life."

Gently, I change the subject to her and her stuffy nose. After examining her and finding that everything is normal, I step out to see the next patient.

I'm an emergency physician working in an urban emergency department, and I've just graduated from residency. While continuing to hone my professional skills, I'm also striving to absorb and reflect on my countless human encounters in hopes of growing into a wise and self-actualized person.

It's a tall order.

This shift is busy but exciting. The next patient is in septic shock--a potentially fatal infection. My team and I hurry to place a breathing tube and central and arterial lines and start him on the right medications. When we're done, he looks stable, and I feel a rush of accomplishment: My first septic patient as a staff physician has received textbook care.

Stepping into the hallway, my surgical mask dangling from my neck like a medal, I feel exhilarated--ready for anything.

A nurse heads my way.

"Your patient Mr. Theodore is being rude to the staff," she says urgently.

I'm taken aback. When I first examined him, a couple of hours ago, we seemed to have a good rapport.

A middle-aged Caucasian man, he'd described chest pain starting some weeks back, after he'd helped a friend to move a sofa. I'd joked with him that his kindness was to blame for his pain.

He had the birth-death years of fallen friends tattooed across his chest, along with the words "remember" and "God," hearts and crosses. His exam and vital signs were normal, but I'd ordered blood work and a chest X-ray to rule out anything sinister. Having seen his EKG and blood-work results (all normal), I've only been awaiting his X-ray results.

"He's yelling profanities and acting belligerent," the nurse murmurs. "Would you please go talk to him?"

Of course. The buck stops here. Still feeling pumped about my feat of lifesaving, I head to Mr. Theodore's room.

He's pacing the room and tearing the monitor leads off his chest.

"Fuck this, man!" he shouts. "I haven't seen a doctor yet. I don't give a fuck about whoever else is sick! I only care about me. What the fuck is going on?!"

I notice that he's now wearing sunglasses--indoors. That's an etiquette taboo anywhere, and in an emergency department, it also signals "irrational." To my relief, two security guards, ex-Detroit Police Department officers whom I've known since residency, have followed me into the room and are standing directly behind me.


"I'm sorry you've had to wait," I say calmly. "I'm the doctor you saw two hours ago. Remember, we discussed your chest pain, and I listened to your lungs and ordered a chest X-ray?"

Mr. Theodore stops and gapes at me.

Suddenly I feel vulnerable: Do my youth and my femaleness delegitimize me in his eyes? Surreptitiously, I check that my badge is flipped to the side that says: "DOCTOR."

You're the doctor here, I remind myself. You set the temperature. Don't react. Respond.

"May I continue?" I ask. Asking permission can help to deescalate a potential conflict.

"Okay," he says. I feel the tension cooling.

He sits on the bed, and I stand before him, hands on hips--a power pose.

"I've seen your lab results," I say. "Everything is normal--"

"I've been waiting for hours to see a doctor!" he interrupts. "And I don't care about anyone here except me!"

I start over, and the same thing happens--several times in a row.

His stubborn repetition of these selfish sentiments--and of not having seen a "real" doctor--starts to wear on me. But I keep on doggedly.

"Your labs and EKG are normal--"

"Can I ask a question?" he interjects.

"No! I'm not finished yet!" I snap, stepping closer to him--an almost instinctual power move that, honestly, isn't me. I've been riding the adrenaline high of having done good...Now what am I doing?

"What are the cops doing here? I'm not gonna do nothing," he says petulantly.

"They're not here for you; they're here for me," I say, with a little upward thrust of my jaw for emphasis.

Am I making a veiled threat? I wonder, surprised. I've never physically harmed anyone...I was raised by bookish hippies. I was a liberal-arts major--when I slide-tackled people in soccer, I helped them up afterwards!

Yet here I am, standing only two feet from Mr. Theodore, drawn up to my full five-foot-nothing. I look down at him; he tilts his head up to look at me. It's a ridiculous scene.

"I want to get out of here," he mutters. I can't blame him; I've turned into a bully.

"This isn't a prison," I fire back with fake calm. "You're an adult; you make your own medical decisions. Your X-ray isn't back yet, so I can't rule out something serious like a collapsed lung--"

"I want to get out of here," he repeats.

"Okay," I say. I turn away in surrender and head for the door. My patient's not listening--and, I guess, neither am I.

"Excuse me," I tell the security guards as they slide out of my warpath.

Outside the door, regret overwhelms me, and my shoulders slump.

Back in the physicians' office, I sit down at my computer and feel a mix of anger and humiliation and heat spread from my face down to my chest.

I start to document the encounter: "Patient is removing his leads, pacing, yelling profanities. He requests lab results; he requests reasons for the delay, he is speaking full and complete sentences; while pacing the room, patient does not complain of chest pain...."

I give myself partial credit for my attempt at objectivity. Still, I can't formally sign this note yet; I need to wait until my heart rate improves.

Still typing, I reflect on how I should have handled this situation.

I was immature, I chide myself. Things could easily have become violent. I was once choked by a patient in an isolated emergency room. This time I was lucky; I had backup.

But there's no denying the truth: I feel embarrassed because I lost my cool, because I behaved so poorly and took things personally, because I judged this patient harshly.

Full-fledged doctor though I am, sometimes it's still amateur hour. If the right triggers are there, my youth and righteousness and fatigue and inexperience can silence my maturity. Because that happened here, I failed to give Mr. Theodore the care he deserved.

For one of the few times in my life, I feel small.

I've got a lot to learn, I think, and sigh. How about the next time I'm facing a hostile patient, I get humble and respond to that person's fear and vulnerability before reacting with anger? If I judge my patients, I can't give them good care.

The shift ends.

As sorry as I feel for how I handled things with Mr. Theodore, I take comfort in one thought: Tomorrow, I'll get more practice.


About the author:

Meghan Gaffney Liroff is currently an emergency physician at Henry Ford Medical Center and a volunteer professor at Wayne State University School of Medicine, in Detroit. "After completing residency, I returned to writing because it was my first love. I write in order to learn the humanity of medicine." Her favorite book is The Velveteen Rabbit. Her writings can be found in FemInEm and Emergency Medicine News and are forthcoming in Annals of Emergency Medicine and Journal of Emergency Medicine. On Twitter: @gaffmeg.

Story editor:

Diane Guernsey

Comments   

# Ellen Kolton, MPH 2017-08-26 11:49
Dear Meghan, I loved your piece: it was humble, honest and kind of amusing/sad. I could easily picture the scene and applaud you for your frankness. I think it will make other clinicians working in the often-surreal setting of an ER hesitate before letting an irrational patient get the better of him/her. It happens- you learned! And so did we.. Thanks
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# Martina Nicholson MD 2017-08-25 22:48
Dear Meghan, Thanks for this story, which I love because it is not smoothed over. There is that edge of growing pains and concern in it, and the feeling that maybe we just can't get it right sometimes. I like how well you told it!.
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# Pris Campbell 2017-08-25 18:14
I also thank you for your honesty. I once had a long term gyn rag at me hostily no matter how many ways I told him I didn't know the answer to his question about a very old attemot by my regular doctor to change me to synthroid. I finally called a few days later, ready to get my records and change doctors. His nurse told me he'd been up all night and was seeing his doctor later where he was diagnosed with diverticulosis. I think if any doctor is beginning to feel out of control with anger he or she has to find a way not to take it out on the patient. Practice and self awareness are indeed two very good routes.
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# Susan Turner 2017-08-25 18:01
Thank you for your honesty!
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# Ronna L. Edelstein 2017-08-25 17:42
Meghan, doctors are humans, not gods. As a result, doctors are entitled to have the strengths and the weaknesses that define all humans. You lost your patience with a patient, just as I sometimes lost my composure with a student. It happens, we learn, and and we move forward. That is the long and short of it!
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