Television has the Emmys, film has the Academy Awards. If emergency medicine had an award, it would be for Stupid Patient of the Year. Why SPY? You can blame it on the Emergency Medical Treatment and Active Labor Act (EMTALA), which guarantees that anyone who comes to an emergency department of a hospital, for whatever reason, is entitled to see a doctor -- whether or not the person is actually sick.
The top award, for best picture, goes to the patient who expended the greatest effort to get to the E.R. in the face of the least degree of illness or injury. People certainly deserve some recognition for their inspiring creativity and determination to attain emergency care when they have no discernible pathology. As in any good awards show, I'm saving the big prizewinner for last.
Yet the subcategories are spicy and bountiful: most horrifying self-inflicted injury, nonlethal; most horrifying self-inflicted injury, lethal (oops, stepping on the Darwin award turf -- apologies); most disproportionate fear of poisoning; most overblown symptom; most worried by a worrisome health report; and most creative excuse to cadge a prescription for antibiotics.
The aggravatingly common, loathsome practice of scamming for narcotics is not without its own distinct pathology and might also qualify as a category (the Jim Carrey: These patients come in all the time with nothing wrong -- other than their craving -- and leave empty-handed).
It must be stipulated that psychotic patients are not eligible. We're only interested in those who, seemingly, understand and abide by the boundaries of normal behavior.
The floodgates are jammed open. The EMTALA requires emergency room doctors to provide a "medical screening exam" and to stabilize all patients, but does not specify who should do the examination or how extensive that exam must be. Mercifully, litigation has given substance to these wispy vagaries. A doctor must treat every person who opens our doors. This has been a boon to worried patients everywhere, an invitation to healthy people to clog up an already overburdened system.
Want a doctor to see your child? Come on in -- and immediately become eligible for a SPY! Don't worry, we recognize the sacrifices made by parents: A humble bow to those mommies and daddies to whom no sacrifice is too great for their children. Current nominees are those who recorded the following chief complaints for their completely healthy babies:
I must admit, the intentions for the EMTALA were good. Hospitals were turning patients away because they had no money -- which isn't ethical -- and the EMTALA was supposed to change that. So the federal government, in effect, legislated a right to health care -- but not the correspondent legislation that would require insurance companies to pay for it. Both houses of Congress adopted "prudent layperson" language last year stating that when people go to the E.R., they know they're sick enough to need emergency care, so their health insurance should cover it. But the language was ultimately killed.
So the government can define what constitutes a medical emergency in order to require me to see a patient but not when it comes to making the insurance companies cough up for my enforced service.
Although I'm confused by all this, at least prudent laypersons throughout the land are not. They know that enjoying completely good health is no obstacle to being checked by a doctor. That can be the only explanation for the episode of the Farouk family (whose names have been changed), a nominee for the group achievement award.
The Farouks were at some sort of ethnic carnival, delightedly partaking of native costume displays, exotic dance, music and magic. When it came time for lunch, the entire clan -- five or six children, a couple of uncles and aunts, and grandparents -- drank juice from boxes. Within an hour or so, six of them started hurling, and hurling repeatedly. So they did what comes naturally in this rich country: They called 911.
The ambulance folks quickly made an important discovery. The juice boxes had expired, by about five months or so. No need to worry, much less go to the hospital, they said, prior to departing. By then, many of the Farouks had stopped vomiting, but this reassurance did not deter them. All feared poisoning from the sour juice, despite the fact that they felt better after disgorging themselves. All were, at the point I saw them, fine.
In truth, I don't expect patients to know when something is wrong. That's my job. But I'd like to care for just the ones who are pretty sure something is wrong, as opposed to those who feel OK but just want my confirmation. I'm pretty sure the Farouks would never have come in for that final degree of reassurance if they had thought they'd have to pay up.
This is our dirty little secret, the biggest gripe of emergency doctors and nurses everywhere: The only patients we truly despise are the ones who would never come in if they had to exchange money for their peace of mind.
Here's how this ludicrous, egregiously excessive episode looks from inside the pit: We had to evaluate six patients who had already recovered from a minor gastric irritant, tying up the ambulance people, triage and treating nurses and keeping the doc (me, goddamn it!) from taking care of someone else who might actually have been sick or injured.
Candidates for the SPY, like contenders for the Museum of Bad Art, are not as plentiful as it might seem at first glance. The shortlist is colorful and instructive all at once.
To wit: In the midst of an ice storm, I once treated a store clerk who had sprained his ankle four or five days earlier; it looked mildly swollen but otherwise unharmed, and signs of resolution were clearly evident. And while I had not actually watched the guy walk in on his own two feet, he crossed a sheet of ice to get to me, which indicated he could get from place to place.
Hemming us in on all sides were literally dozens of other people with freshly fractured bones. I put on my "honest guy" face and told the clerk squarely that he was clinically clear, that I was relying on my judgment, and my judgment alone, to penetrate through the layers of skin to see that his ankle bones were intact. He looked right back at me, in his "honest guy" face, and told me that he would feel much better if the final say came from an X-ray.
I traded my "honest guy" face for my "customer is always right" face, but just for a second. Then I tried to be a hero. "Honest guy" face came back and said that the backup in X-ray was hours, and that it would take even more time to look at his film and then have the radiologist confirm my reading. I really wanted to save him the wait.
But he put on his "what do you take me for, some kind of a chump?" face and told me he wanted the X-ray. So I put back on my "customer is always right" face and promised I'd be back in a jiffy. And sure enough, hours later, he found out that nothing was wrong.
Now while you may find his story intriguing, just wait until you hear about the progenitor -- and the inspiration for the SPY award. Her story comes from the category with a fathomless pool of aspirants: stupid genital tricks.
The amateurs vying for this award have run through a numbingly familiar ensemble of tricks: the lock around the testicle, the exotic-lotion burns on moist mucous membranes, the items inserted into various openings. Yadda yadda. But the most sublimely ridiculous encounter of my entire medical career, one that has nestled itself quite fondly in my heart, occurred when I was a resident. Janey (not her real name) showed up one day in the pelvic room after her boyfriend found something in her vagina that, try as they might, they couldn't get out.
"Did you put anything in there?" I asked.
"Not really," she said. She knew I was going to ask this; she had already been asked by the triage nurse. The registration clerk had duly noted her chief complaint as "FB vag," or foreign body in the vagina.
"What do you mean, 'Not really'?"
She and her boyfriend had been playing "rough" a week earlier, and he may have put something up there in order to just take it out again -- like a game. "I don't remember leaving anything in there, but, you know, something might have gotten lost. You know?"
No, I don't know about these things, but I do know fishing, and this was a fishing expedition. A female (nurse or tech) always escorts male physicians who perform pelvic exams, and the nurse helping me that day relayed (out of earshot) the string of things that had at one time or another been recovered from vaginas in the E.R.: a condom, a dildo, a french fry, an egg (in the shell), a marble, a Tylenol bottle, a light bulb (small, dicor-style), a roll of film, a set of keys, one of those poofy-hair voodoo dolls.
After several attempts outside the door to quell our hysterics, we returned to the room to position Janey in the stirrups and trawl for treasure. I opened the speculum and looked.
"Ummm ... " I started. (How does one go on in such a situation? What would Miss Manners do?) "There's nothing in here. Are you sure it didn't come out?"
"No, I felt it in there just before we got here."
Alrighty, then. I looked at the nurse and she shrugged, biting her cheeks. "You look," I told her. She didn't see anything, either.
I stood up to do a manual exam. Maybe it was really small and somehow hidden behind a fold or recess. I pushed on Janey's cervix to see if there was any tenderness.
"That's it. You got it."
"This?" I said, wiggling it.
"That's it. It feels round."
"What did you find?" the nurse asked.
"When did you lose this in there?"
"I don't remember. Maybe a couple of months ago."
Months? I thought. "This is your cervix, it belongs there. You're supposed to have one of these." I jiggled it again. The nurse lost it, bending over in a fit of choking laughter.
"That's what my boyfriend was grabbing on to."
I hope he didn't try too hard to get it out.
When, as sometimes happens, I burst into spontaneous laughter, it's because I find myself thinking of Janey's acceptance speech for her lifetime achievement award.