I want peaches!

There’s nothing like taking care of a patient who uses their medical acuity as a bargaining chip to manipulate doctors and nurses. I had a patient come to the ED recently complaining of generalized weakness and fatigue. This patient had kidney disease, and he was intermittently on hemodialysis. He was a very thin malnourished man who looked like personal hygiene was a foreign concept and any attempt at self-care was unfathomable. I was concerned about his health status and wanted to do some blood work to check his electrolytes for potentially dangerous abnormalities. His initial ECG was normal so I was less concerned for immediately life-threatening abnormalities, but I was still concerned for evolving conditions. Unfortunately this patient was one of those “difficult to get access” patients meaning getting an IV in this guy was a lot of work. After several of my best nurses failed to gain access I was called to the bedside to place an IV. This was not an uncommon situation, but the fun thing with this particular patient was that he was refusing any more attempts until “I get some dinner”. Now I understand this patient was probably hungry – he certainly looked like he hadn’t been eating well- but the ED isn’t really well-equipped to cater to nutritional needs of patients. We operate an emergency room. I can’t think of one situation where providing a meal-tray could avert a life-threatening problem. We do try to be accommodating as much as possible, and when a patient is medically cleared we try to provide them with whatever food we have available. However, trying to determine if a patient has a life-threatening condition while they refuse to cooperate isn’t the most fun thing to deal with in a busy ED. My nurse was able to get him a meal tray in an attempt to bribe him to let me place an IV line and obtain blood for analysis, but he took one look at it and asked “where are my f$#king peaches – I want me some f$#king peaches”. Great. I don’t keep peaches around the ED. Why do people come to the ED asking for help and then make impossible demands which impairs the delivery of care? I felt like telling him “look buddy- you came to me”. I finally coaxed him into letting me put an IV in his external jugular vein and that’s when things got even more interesting. Try sticking a needle in someone’s neck while they are maintaining a running litany of profanity and threatening you with physical violence if you don’t succeed “because they already stuck me enough!”. Of course the IV blew. Blast. The patient didn’t carry out his threats, but he stepped up his swearing and continued to demand peaches. Another meal tray later and I was able to coax the patient into one more IV attempt even though I still hadn’t been able to procure any peaches. “I still want me some G-D peaches!” thank god that attempt was finally successful – blood was obtained, fluids were given, and the patient’s medical status was stabilized and laboratory abnormalities were addressed when the results returned. All accomplished despite the patient’s multiple attempts to block delivery of care. The patient was admitted to the hospital for extreme failure to thrive and malnutrition, and a special request was submitted for peaches on the patient’s dinner tray.