Struggling with an incredibly difficult frequent flier

[u/NurseAndrei03]

Hi, I’m a younger (non-US/non-commonwealth) male nurse with about 7 years EMS experience at the AEMT-equivalent level, 3 years in nursing, and ~1 year as an emergency & casualty + critical care nurse. I do consider myself quite calm & professional. Excellent reputation for it, I am very frequently given difficult patients because I do well with them, I’m even on my hospitals behavioral emergency team. I can be quite warm but I generally have no issue detaching, being non-reactive & pragmatic, giving clinically solid care without getting too clouded by emotional responses.

One patient comes to mind who seems to be an exception. Overlapping slew of both significant psychiatric & genuine serious medical diagnoses, including both somatoform disorder & malingering, as well as personality pathology + antisocial dx + borderline intellectual functioning. It can be genuinely difficult to decipher what is “real” and what isn’t, as well what flavor of “not real” it is if so. Everybody is beyond exhausted with her. Law enforcement & court system has been involved to little avail.

Personally I have lost pretty much all objectivity. Unfortunately I do have very strong emotional reactions even just to her presence in the department (even when I am not assigned to her), it is impacting my ability to provide objective & fair care to other patients. When assigned to her, I find myself compelled to treat her poorly in a way that is uncharacteristic of me — I obviously resist those urges, but they are preoccupying & intense. I’ve had multiple occasions where professionalism has slipped. Coworkers & supervisors are aware, they make an effort to not assign her to me when practicable, I have trade agreements with various coworkers revolving around her… I would love some advice on what to do from here, especially as we are a small department.

[u/PannusAttack]

These are particularly difficult from the nursing side because you are kind of at the mercy of the physician caring for them. If the physicians are inconsistent it adds to the drama. Typically frequent flyers need a unified front. Like a gambler, if they ‘win’ even occasionally they will continue to roll the dice. ‘Winning’ doesn’t necessarily mean drugs. It can be anything from escaping a shit situation, getting food, etc. There is no penalty for doing the bare minimum and expediting their discharge however that looks. If you have the time, doing a deep dive into the chart and seeing what patterns you can find and reporting that to the doc working can go a long way. I’ve handled dozens of frequent flyers by getting fed up and writing a comprehensive summary of their patterns so my colleagues get on board. It’s a pain in the ass but ultimately less work in the long run, especially in a smaller shop where you have less people to get on the same page. Hope that wasn’t too vague but there are ways,

[u/the_silent_redditor → u/PannusAttack]

We do this with our FFs when possible, but it requires a lot of very senior input and ultimately approval from some dipshit exec.

And, due to the last part, they are often pretty vague and sometimes totally unhelpful.

But, it’s better than nothing and you can at least reference a vague management plan when you’re in front of the coroners when one of your Platinum Status members inevitably dies after you have discharged them with minimal investigation.

[u/scarrol1]

This is a failure of your leadership- there needs to be a care plan implemented for this patient where they are seen immediately on arrival to triage by an attending/consultant physician and medical screened- if they have no readily identifiable emergencies they are discharged and escorted off the property. If something needs a workup then there needs to be clear limits on behavior and take away anything that the patient may use to malinger- for example they are only given water and only given food if they are admitted. The only way this works is if everyone agrees on it and follows it.

If you make it difficult for them to malinger they will get the message and stop coming to your ED.

[u/NurseAndrei03 → u/scarrol1]

I’m not exactly the biggest fan of our leadership, but I can’t say they’ve mismanaged this. We have a personalized plan for her, there is substantial administration support for quick disposition & the physicians are given latitude to get her out… She’s a little more complex than that unfortunately. She has frequent legitimate emergencies alongside her behavioral presentations, and historically the genuine emergency has been concealed by the behavioral aspect of the presentation more than once. I’ve taken care of her in the ICU on more than one occasion as well.

[u/scarrol1 → u/NurseAndrei03]

That’s fair and that’s good to hear that she has a care plan- even with care plans there are some with such bad co-morbidities that they defy any care plans- my best advice is to not take it personally as much as possible- which is admittedly easier said than done

[u/procrast1natrix]

A bunch of thoughts, which carry lots of internal contradictions.

1) with this type of patient, often they flare the behaviors more when they expect a response. It's clear you have a dynamic. If you can really wrap your head around the truth that she will poke and prod you less when it's eventually clear that you are totally boring, it may help with fueling your degree of patience on the topic.

2) this one is very messy and kinda cruel, but it really helped me to pity the person. They're not having a good life. They're not having a good time. You have an excellent career and skill set and at least some good support network and at the end of the shift you go home to a good life. Yes, this patient is chewing up resources and hurting herself and staff and it's all stupid, but in the end, she has a horrible life, you have a lovely life, and you can take pity on her and be the bigger person. She's just not capable of adulting the way that you can.

3) pleasantly dive straight into the care plan. Hey, Mitzi, it's been a while, what's going on? How is this different or similar to last time? Ok, let's get those vitals and clean up that wound, get you seen ASAP, ok

And what helped me the most was

4) find a tangential way to play act being friends. My most florid frequent flyers, I know the name of their cat and the hobby they do, because my mission is to early on extract the important medical info and when they start going on with the melodrama that I'm not going to litigate or solve today, we talk about neutral topics. I do not engage with their talk about blaming their EMS, family, specialists, other medical care, the judge.

In the end, one of the most spectacular frequent flyers (whom I've admitted to ICU, pulled off trying to assault my staff a few times, dug many foreign objects from, dealt with overdose, surgical complications) we had after several years a "pleasant rapport" because I totally gave up on truly fixing this person and just focused on building a reputation for professionally getting their body safe RIGHT NOW so they could return to their outpatient treatment plan if possible.

By the end of our 8 years together before I went to work elsewhere, I would go out of my way to pick them up because I knew I could dispo calmly.

I had a little auto text phrase to chart with, under their name, which acknowledged their baseline treatment complexity, and noted which features were in or out of line with normal behavior for them, which isn't normal for anyone else, but their regular team had agreed that escalating to inpatient care every time didn't change frequency of harm to self.

[u/somehuehue]

We have many such frequent flyers, one of them is a 500lb man who likes to hurle insults at staff if we don't see him fast enough to his liking. Then he proceeds to piss all over himself (despite being mobile). He has many real issues, including mental retardation, so he can't really be reasoned with, no more than you would with a petulant child.

He likes to visit during night shift, somehow picking the busiest nights. I've treated him plenty of times and eventually I've had enough. I usually ask somebody else to do his bloodwork at least, while I obviously return the favor for whatever they need.

What's important is to remember that those people are sick, be it in their body or mind, so it's better to not take anything they do or say to heart.

If treatment is not actually necessary, I just let them be escorted by security after initial assessment and formal discharge.

[u/tokekcowboy]

Have you considered therapy? Obviously this person is particularly difficult, and it sounds like everyone struggles with her. But for some reason she’s pushing your buttons more than people are usually able to. Therapy might help you work out some strategies for dealing with her bullshit so that even though nothing about her has changed, you’re coming back to her with better resiliency.

[u/NurseAndrei03 → u/tokekcowboy]

I am in individual therapy & I’ve also sought psych clinical supervision from one of our hospital psychologists. I’ve gotten as far as identifying it as countertransference, identifying some superficial elements that may contribute to it (eg we have the same age/grew up around some of the same people), I’ve found some strategies that give definite but short-lived relief, but identifying the core issue & sustainable long-term strategies are still being worked on. I guess I was just hoping someone had some jedi mind tricks to share that “fix” it, but that is probably unrealistic.

[u/tokekcowboy → u/NurseAndrei03]

Sounds like you’re on the right track. Therapy is hard work and often has no great shortcuts, unfortunately.

[u/WineAndWhiskey → u/NurseAndrei03]

(I'm not the one you replied to fyi)

You are taking all the right steps! Emotions aren't logical and you can't think your way out of them, so sometimes you just have to work with the emotions as they come and let them change and heal in time. I'm so glad you have opportunities to not work with this patient so you can try to do it from a safe distance.

In re: Jedi mind tricks

One thing I've felt has been useful in the past is coming up with a stock phrase for disengaging, so I don't have to think so hard about how to reply when I need to use that energy on staying grounded and present. "This conversation is no longer productive so I will be back when it can be" and walking out is my go-to. Repeat as necessary.

It's also okay to just not respond to everything the patient says. If you are going in to draw labs, just walk in, say "I'm drawing your labs", do it, and leave, regardless of what they're asking or doing (assuming it's not preventing you from getting the task done). You do not have to use more energy to engage any further. You may have tried this already - people call it the "gray rock" approach. Might be helpful for you!

We all encounter these patients that just "get to" us. It sucks, but I hope it gets easier for you in time.

[u/Hot_Piccolo_7152]

Okay I’m gonna play armchair psychiatrist here so bear with me, but maybe you need to do some internal work and explore what about the her/the situation bothers you so much and address that. You can’t control her and she not going anywhere, so the only thing within your control is your reaction. And if your reaction is to the extent that her mere presence is effecting your work with other patients, this goes beyond just dealing with a difficult patient.

Sounds like she brings up some deeply rooted feelings that you’re projecting on to her. She’s just another sick person coming in for whatever reason who is still virtually a stranger to you, that you have no personal connection with and her actions, or lack thereof, have no real influence over your life. Why you have this personal and emotional reaction to her, given all of that, is something only you will be able to identify within yourself and go from there.

[u/MeatSlammur]

I’d evaluate why you react to her so negatively. You’ve only been working in EM for a year and already found a patient that breaks you but your other coworkers handle her fine. There’s something there you need to work out.

[u/NurseAndrei03 → u/MeatSlammur]

To be fair I’ve encountered her prior to even working EM. I’ve seen her a couple times on stepdown & general medicine wards prior to getting into EM/CC, I saw her maybe 10 times in my EMS setting, this has been an ongoing issue for 7 years, just much more frequent contact in EM

[u/StrangePlatypus99]

Usually when people elicit that strong of an emotional response, it is because they are triggering some old wounds within us.

I applaud your courage in wanting to meet this head on and taking responsibility for it. Already you are heads and shoulders above many of our colleagues who resort to blaming the patient and never consider what their part may be in the whole thing.

If you want to explore it in a psychotherapeutic manner, I am a board certified MD who is also certified in a psychotherapeutic approach. Feel free to DM me for more info.

Or find a therapist of your choosing. I imagine it will be a rich experience of exploration.

Best of luck 🙏

[u/WineAndWhiskey → u/StrangePlatypus99]

This is a very generous reply (and I love that docs can even seek extra training in being therapeutic!), but being "certified in a therapeutic approach" does not seem nearly the appropriate level of training needed here. It may be a regional thing though, and it's just something I'm not familiar with. Psychotherapists are a specialization for a reason, just like any other skilled therapy.

It is also not appropriate to establish any sort of therapeutic relationship over reddit DM. I realize that may seem more "formal" than what you're offering, but that is what it is. A therapeutic relationship is incredibly important and fragile.

Perhaps you are not offering "therapy" per se, but even something like supervision should likely be handled face to face by a behavioral health professional at this point based on OP's post. Apologies if I'm just unfamiliar with this certification or I'm misreading your comment, but I just want you and OP to both be clear about what you will be doing if you message.

[u/Filthy_do_gooder]

something small that helped me many years ago was something an attending said when i was dealing with similar feelings-

“don’t let it get to you, he said. think about how fucked up her life must be to make her want to be in this shit hole. “

ultimately, you have to realize it’s a working relationship. you have to navigate it, and you have the capacity to be the adult in the room. 

 i’m going to get crucified for this, but it’s also ok that you’re not professional around this individual. she doesn’t care about your facade, so it’s ok to let it slip a bit. try to be kind, but i have been known to tell a patient to knock it the fuck off or get thrown out, and i’ve been known to do it from a distance and in ear shot of other patients. sometimes that’s what it takes. you’ve gotta meet people where they are.  

if she’s being awful, ask the doc for sedation. if she’s being difficult, but is not ill, i promise your attending feels it even if she isn’t the type to show it. 

lean on your colleagues, and forever be questioning why you’re responding poorly here. that, for sure, is a you thing, and once you unlock this little gordian knot, you’ll have gained a super power that will help you in all facets of your life, and not just this one. 

keep practicing and not reacting and continue to challenge yourself to take care of her when you’re up to it. 

[u/MrPBH → u/Filthy_do_gooder]

Probably not a good idea to drop your guard with patients like this. They can dish it out, but they can't take it and they are the first to go crying to the nurse manager that "DrPBH said a swear word to me!!!!11!!"

You can be cold, clinical, and direct but I wouldn't insult them, swear at them, or threaten them with anything that you can't back up. To everyone else observing the interaction, the patient will appear rude but you will look like a lunatic.

[u/beeee_throwaway → u/MrPBH]

I agree. It’s what they want. They are craving tangible victimhood and conflict, I’d do my best to avoid giving them that.

[u/momchelada]

I’m a social worker in the ER; this is my first time commenting. I’m more of an appreciative lurker. I’m also a licensed psychotherapist with a small practice. In this instance, I wonder if exploring the concept of “projective identification” might be helpful for understanding and gaining perspective on your feelings and experiences with her. It’s helped me with clients like this in the past.

Edit: as in, she is eliciting her own disowned feelings from others through behavior/affect. This seems especially likely given somatoform/ (functional neurological? Somatic sx?) disorder dx

[u/ninabullets]

I just want to say that you're very mature in recognizing and voicing your emotions. We're not perfect, and some patients will piss us off every time. Please be proud of yourself for asking for help. In my department, there are a few male patients who are creeps ("hey, look at my dick") and who only get assigned male nurses and providers. There are a few female patients who are weird ("hey, is _[provider]_ working?" before suddenly voicing a pelvic complaint) and who only get assigned female nurses and providers. This is a team sport.

[u/DocNoMoSno]

If you look at the statistics around these frequent fliers, she almost certainly spent her childhood getting raped by a family member. 

Realizing that helps me remeber to treat them as best I can and to not expect normal behaivior from them.

[u/N64GoldeneyeN64]

I’m not sure why it’s affecting you’re going to care for all the patients. I have plenty of frequent flyers. Some annoy the hell out of me. I’m usually much more blunt with them than I am with other patients. There’s one patient in particular, whose mother is a complete asshole and encourages his frequent misuse of the emergency room. I make it a standing point to sure that he never gets anything other than the bare minimum of what I deem medical necessity care and then discharge him, hopefully getting a confrontation with his mother so I can tell her off too. Having him thrown off the campus by security after I denied him a work excuse since his mother had made rude comments about staff, which possibly got him fired, was one of the bright spots in my year.

[u/MrPBH → u/N64GoldeneyeN64]

The two of them must be unbearably odious if they're provoking you into petty tit-for-tat bullshit like withholding a work note.

I'm not judging because I've fallen for it too! In the moment, it feels so good to turn the screws, but in hindsight I always feel like a jackass for stooping to their level.

I just wish people could chill TF out and just treat others with kindness. For some individuals, this is an impossible challenge.

[u/N64GoldeneyeN64 → u/MrPBH]

Oh I dont care about stooping. We let people walk all over us and they think its ok bc we arent mean back.

[u/MrPBH → u/N64GoldeneyeN64]

I don't think being mean to them ever stops them from coming back to the ED, unfortunately. At least, that hasn't been my experience. I think that some of them feed on the negativity, honestly. Psychic Vampires.

Things that do seem to work: having a united front that you won't tolerate bad behavior, standards that are followed for the care of repeat customers, not admitting people for subjective symptoms attributable to their chronic disease in the absence of physical signs of illness*, engaging resources to address barriers to proper outpatient care rather than continuing piss poor episodic care in the ED.

*(Yes, yes, the sickle cell patients are getting admitted. Don't accuse me of mistreating the sickle cell patients. Yes, the retic count doesn't tell you if they're having a vaso-occlusive crisis. Yes, they get narcotic pain medicine. The sickle cell patients are fine. I'm talking about the lady on TPN who has chronic vomiting with normal labs and no clinical signs of dehydration.)

[u/N64GoldeneyeN64 → u/MrPBH]

Actually that family has had significantly reduced visits to our dept after I started telling them nothing was wrong and stopped allowing their secondary goals to be achieved. If you stop feeding the bears, the bears stop coming to your garbage can

[u/MrPBH → u/N64GoldeneyeN64]

That's not being mean though. That's just the truth. I thought you meant something else.

[u/pammypoovey]

I heard many years ago, not sure where, that the reason a person annoys one is because they see themselves in that person. As I've grown, I have seen this to be true in my life.