How To Make a Doctor or Nurse Cry: The Tragic Trinities.

The Happy Hospitalist asked Facebook fans to describe three diseases or patient and family characteristics  that lead to tragedy for healthcare providers when seen in combination with each other and the results were remarkable.   If you are not yet a fan of The Happy Hospitalist Blog Facebook Page, make sure to join now and never miss another status update again.   Every doctor or nurse has their own  tragic trinity combination that brings tears to the very psyche of their soul.

For example, some doctors have pseudoseizures when they see  the tragic trinity of pelvic fracture + observation status + angry daughter watched the 60 Minutes episode on demanding physician write inpatient order.  Some hospital floor nurses cry uncontrollably when they see naked crazy guy in ER +  5 minutes to end of shift + phone ringing with ER ready to call report.  Exposure to these deadly combinations will help doctors, nurses and other healthcare providers survive should they ever find themselves in these dangerous situations.

Dionysus

Is this humor dark and tasteless?  Yes.  So is burned tofu, but you never hear anyone complaining about that.  If you are not in healthcare, you won't understand the crude humor presented here.  If you have a weak stomach, I suggest you stop reading immediately and get some Pepcid.  However, if you are a healthcare provider and you want to learn about potentially deadly combinations you may encounter in your career, I suggest you keep reading.  Study these tragic trinities.  Memorize them and prepare yourself for the day when they show up in your clinic, ER, nursing home or hospital floor.

Without further delay, here is the definitive list of The Tragic Trinities of Healthcare.  If you happen to think of any that may have inadvertently been left off the list, make sure to add them to the comments so all doctors, nurses and other healthcare professionals can  prepare themselves.

• 93 years old + family no longer allowing ativan to be given + patient thinking they're in combat.
• Frequent flyer overdose (found down naked in her yard again) + schizophrenia + doctor who thinks its funny/appropriate to order 0.5MG haldol!
•  I might as well spritz it in the air and ask her to inhale! Jeesh! It's 5mg per dose or don't bother ordering it!
• Pancreatitis + npo + walking off to eat in cafeteria, always back in room when pain meds due with pain and vomiting.
• Yells at staff to push Dilaudid 4mg and phenergan 50 mg faster (and you were 3 minutes late with the meds). 
• Moving in with lamp, bath rug, own cordless phone, and pumpkin to carve (along with knife) + on Medicaid + has lawyer, and mother on speed dial and brags about getting disability due to his back issues.
• Explosive diarrhea + non ambulatory + family left so they 'wouldn't be in the way'.
• Dementia + UTI + daughter who has spent a little too much time on Web MD.
• Sleeping meds + bowel meds + unable to transfer without ceiling lift.
• 91 year old LTAC patient with chronic peg and trach + failure to wean or thrive + full code.
• Missed period + wants pregnancy test + brought all 5 kids under the age of 4 because couldn't afford a babysitter.
• 95 years old + fall resulting in hip fracture, SAH and fractured ribs + momma will be fine!
• Bath salts OD + severe agitation on ketamine drip on a vent + the mom that claims "my baby would have never done those he if knew they were drugs!
• Viagra + nitro + wife and girlfriend at the bedside.
• Child with fever for 3 days, no meds + used EMS to come in + no ride home + needs a work note for a shift that starts in 30 minutes.
• Missed last 2 dialysis treatments + increased SOB + going to leave AMA once emergent dialysis treatment is over.
• Psych patient on the medical  floor with 1:1 sitter + poops in his hands and rubs it in his leg wounds so he can " die from infection" + decides to walk the unit and has blood dripping from leg wounds + is farting and pooping as he is walking through unit with gown dragging and butt hanging out. 
• Severe COPD + chronic trach + kicked out if LTAC for smoking through the trach.
• Confusion + C. diff + family who won't wear the isolation gowns and stand over your shoulder telling you how to take care of the patient.
• Chronic pain + Substance abuse history + "allergic" to NSAIDS. 
• But that Dilaudid stuff worked pretty good.
• Hillbilly trifecta: Hillbilly + ATV + Alcohol/Narcotics.
• ESRD + severe sepsis + has  son who is a doctor in another state that wants everything done for his mother who is 96 years old.
• ETOH + GIB + family in denial.
• "What did you do to make dad crazy.   He doesn't drink!"
• End stage disease + pain/anxiety + spouse refuses all benzos and  narcs because he'll get better if he's not sedated.
• Child with mild rash + stay at home mom with multiple rings and Coach purse + cancelled Zumba class.
• Ivy League grad student + too drunk to go to jail +  JCrew sweater/shorts = douchebag trifecta.
• Gangbanger with a GSW +  3 baby mommas all showed up at the same time and are not happy with each other + a couple of suspicious looking characters stalking the hallways trying to find this idiot so they can finish the job.
• Fibromyalgia + ETOH + expert at knowing how to abuse the system.
• Metastatic disease + comfort care + crazy daughter wants IVF antibiotics, solumedrol and accuchecks.
• Fainted at home + didn't call doctor + on five blood pressure meds + anemic from chemo + lives alone.
• Missed probation appointment + dirty urine + "If I'm not admitted, I'll kill myself".
• Patient npo sneaking water from the faucet + profusely vomiting + legitimately sick with pancreatic issues and a high BAC.
• Chronic pain + 7 medication and 4 food allergies + 3 Service animals for "stress disorder".
• Status post five rounds salvage chemotherapy + Hypotensive and tachycardic in oncology clinic + Direct admitted for goals of care discussion and hospice placement.
• Fibromyalgia + neuropathy + bipolar
• Middle age divorce + Bipolar + quack diagnosis of adult onset ADHD + dexamphetamine prescription + internet testosterone injections.
• A non-compliant diabetic, frequent flyer + who does drugs and comes in only to vomit every where because of the DKA + when feeling better demands all sorts of things than signs out AMA!
• Intubated/near extubation pneumonia + psych patient in which doctor discontinued all psych meds + sedation "holiday".
• Patient with TIA symptoms that left AMA and came back after you filled out AMA paperwork + wanted TPA when he returned and physician ordered it and you had to administer it + leaving AMA again 3 hours later.
• Hasn't taken any insulin or done a finger in a month ( cuz they didn't feel like it) + ate whatever they felt like + blood glucose over 1000 + an enabling significant other....
• I think we could actually keep this one going.
• Large, former military man + new neuro checks ordered from a fall + extreme Sundowner's with paranoia. 
• Pre syncope + 35 medications + 93 years old, with very very concerned children if patient will survive the night.
• On a balloon pump + stands up to poop + what a wonderful day, 
• Called the cardiologist and they say "Huh, bet you never saw that before!"
• Multiple fractures + DT s+ Laculose.
• Trach + pseudomonas + head injury.
• Numbness/tingling + 15 "allergies" (ranging from vanilla flavor to morphine) +  history of anxiety or headache.
• Patient with spouse of 8+ years at bedside for hyperglycemia with stated signs and symptoms of high blood sugar being a swollen vagina with blisters + husband also reporting same symptoms when his blood sugar is elevated + RN notes herpes outbreak during straight cath.
• Patient observed throwing themselves out of their wheelchair + they really didn't need it +  then screaming for help while you are trying to triage a walk in MI
• Inpatient with severe asthma + walked out on own after less than 24 hours with IV in arm "to brush teeth" +  readmitted to ER via ambulance less than half-hour later.
• Goody powder + pradaxa + anything.
• Chronic dizziness + drug "allergies" + borderline personality disorder.
• Severe DTs + "allergies" to Haldol, Ativan, and Librium + enabling daughter at bedside that says that shes going to take daddy for a smoke and a drive just as soon as he gets released. 
• And of course, he "don't drink but 6 days a week!"
• Dementia + chronic fatigue + only daughter is a lawyer in New York.
• Fibromyalgia + 8 drug allergies + TID Xanax = 3 vials of propofol for anesthesia induction and a rough emergence.
• Sepsis + DTs/withdrawal + combative and wanting to spit at everyone + RN making it to the back of his head to put a mask on his face while others are restraining his wrists = him spitting on himself.
• Allergic reaction to lisinopril + steroid allergy + no mental capacity to appreciate the irony.
• Uncontrolled pain + daily office visits + incomplete documentation, coding and compliance queries provider for documentation. (The coder's perspective)
• Dialysis + patient is a tree stump (mostly amputated bilateral legs and arms) + unstable arrhythmias.
• 92 year old family matriarch + full code + 37 family members with sudden onset of acute tachylordia with multiple JC's--except the two that "done fell out".
• Gastroparesis + narcotic dependence + morbid obesity or anxiety.
• Acute respiratory failure + acute on CRF + worse CHF = circling the drain.
• Nausea and vomiting + no IV access+ new resident.
• Smoker + COPD on home O2 + family keeps leaving room to go on smoke breaks.
• 600 pounder + refuses the bariatric room + is max assist.
• OD + opiate addiction + EMS administered Narcan.
• Gastroparesis + no veins + no brains.
• Weakness/dressing change/uses a walker + certified by psych for inpatient mental health + unfunded status needs to go to state hospital = 5 month hospitalization.
• Non-English speaking + terminal illness +family 'wants everything done'.
• 8 medication allergies + fibromyalgia + on Seroquel.
• Morbid obesity + chronic joint pain + poor surgical candidate.
• CHF + advanced COPD + on a ventilator.

"How to make a nurse cry:  chronic pain + 14 food allergies + 3 service animals for stress disorder."

Tweet