CPAL

I had one of those nights in the ER when you just want to tug on the big pull chain in the sky and flush the entire place. My patients average tonnage was something just over 400 pounds per person. Maximum height reached all the way up to 5’ 4”. Is there some reason bipolar passive-aggressive corpulent women find the need to gravitate to the ER on Sunday nights? Are they so lonely they would rather come to the ER and get stabbed with sharp objects rather than stay home alone and run up their electric bill with their “back massager?”

Hi, my name is Azygos, what can I help you with tonight?

I had a DVT two weeks ago (review of chart revealed it was December 3, 2003) and I still have pain in my leg. I tripped and fell down yesterday and both my knees hurt and I have chest pressure that is a 7/10 and radiates through to my back. I have chest pain that radiates to my left armpit and it hurts to raise my arm. I need to have a Doppler done right now to make sure the DVT isn’t getting bigger.

That’s almost exactly what she said. My first thought was that she was trying to get herself admitted to the hospital. I’m sorry we just don’t have the ability to get a Doppler study done at this time of night. We don’t have any technicians on call to do the studies. (This was at 0100, chart review showed she had the previous Doppler at 1346).

This argument went on for quite some time and she was never satisfied that I couldn’t get the study done at one in the morning.

It says in the nurses notes that you stopped taking your coumadin two weeks ago, I attempted to clarify.

I ran out two weeks ago and can’t afford to get any more, she said. (she is on welfare and Medicaid)

I took this to mean she had not taken coumadin for the past two weeks. Later I will discuss this further. I did a complete physical exam and determined she had a muscle strain in her left axilla, probably as a result of her fall, although the tsunami warning center had not issued an earthquake alert for central Arizona as would be expected if this rotund monstrosity had actually fallen. During the examination the patient insisted that her right foot and ankle were swollen. I looked at it from every angle and compared it to her left ankle and foot. They were exactly the same size and had 2+DP pulses.

I ordered bilateral knee x-rays, a chest x-ray, and later the doctor added a right ankle x-ray. I did a complete cardiac work-up and a d-dimer, minus a PT. I didn’t order the PT because I thought she was completely FOS anyway and would have kicked her ass out if it were not for the fact that the ER doc’s work-up everybody. I offered pain medication several times and the patient refused, she then went into long tirades about her pain and that was the reason she had come to the ER. Each time I offered pain medication she refused.

After the ten negative x-rays were examined and all the negative lab work was returned I went to tell the patient.

All the x-rays are normal, I said, nothing is fractured and the chest x-ray looks good too. I got back all the lab work and it is all normal, no heart problems, and no blood clots.

What about the PT, the patient asked.

I didn’t do one, there was not any reason to do one, you stopped taking coumadin two weeks ago right? I said.

I didn’t stop taking coumadin two weeks ago, I ran out and I couldn’t afford it, she said.

So you stopped taking it two weeks ago, I asked?

No, she sniped back at me. I ran out and couldn’t afford it.

Ok,  I asked, DID YOU TAKE COUMADIN TODAY!

No, was the reply, the last time I took coumadin was two weeks ago. I don’t think you know what you’re doing and I want talk to the doctor, she said.

It was just before this statement that I really wanted to pull my reflex hammer with the sharp point on the handle out of my back pocket and pith this bitch.

Look, you stopped taking your coumadin two weeks ago so I had no reason to do an INR on you, it would be pointless. But, if you want to talk to the doctor, I will go and ask him to speak with you.

The doctor went in and offered to order an INR, which the patient refused. He then told her she needed to get out of our ER and go home because we were not going to admit her to the hospital.

Discharge diagnosis- CPAL, corpulent, passive-aggressive loser.

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