So are there other special groups that hit the emergency department on holiday weekends like this?
One of the groups of patients that have a hard time in the regimented world of the ED are the ones with personality disorders. People with things called borderline personality disorder, histrionic personality disorder and avoidant personality disorder don’t mesh well with a place where someone else tells you what to wear, where to sit and stay and when to go to the bathroom.
According to the new DSM-5, a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Let’s break down this DSM-speak for you, dear readers.
Personality disorders show us an enduring pattern of inner experience. It doesn’t matter what the circumstance, what the stress, or what the setting, folks with PDs are going to have a hard time.
Prime example: you know very well that if you go the ED for your health care that you are likely to wait. And wait. And wait. And wait some more. A man with Narcisisstic PD will most likely respond to this “normal” stress by loudly proclaiming to the triage nurse that his illness is much more important than anyone else’s, that his time is more valuable, and that his as-yet-undiagnosed condition will probably be worthy of publication in several juried medical journals. This is his inner world. He is more important than you. He is more interesting than you. He should be bumped ahead of you in line. Even though he might be indigent, he should be given the very best care there is. Just beacuse he’s, well, HIM.
The fact that these PDs start in teenage years or early adulthood is a problem, in that the patient with PD will learn very earily on how to get the system to respond. A woman with Borderline PD comes to the ED with moderate symptoms of depression and anxiety. All of her lab work and studies are normal, her physical exam is unchanged from the last one documented and she is bascially ready for discharge to outpatient followup. Her doctor, who she has already put on a very high pedestal, comes in to tell her that she is being released. In purely medical terms, she flips out. The doctor immediately falls off his pedestal, hard, and becomes the worst practitioner in the entire world, stupid and ignorant and incapable of seeing what kind of care she needs. She fusses. She fumes. She might show inappropriate, intense anger at being discharged (remember, she has just been told that she is basically okay, something most of us would be happy to hear in the ED as we are being sent home).
PDs are stable over time. From one ED visit to the next, the woman with Histrionic PD will show the same pattern of excessive emotionality, attention seeking, and dramatic acting out that will most likely lead many ED staff to shun her (not always consciously, mind you). This is the patient who opens her gown just a little too wide at the top, exposing her ample bosom to the male nurses or doctors when not necessary for examination. She is the one who will always have every hair in place, perfect makeup, and freshened bright red lipstick even though she has just reported abdominal pain that is “10 out of 10” and excruciating. She sexualizes the encounter, manipulates the staff, and if her perceived needs are not met she may have a dramatic fainting spell, pseudoseizure, or bizarre migraine out of the blue just as her discharge paperwork is being completed.
It is difficult enough to sort through the myriad symptoms, lab values, scans, x-rays, histories and old records to come up with a solid working diagnosis in the ED and get a patient triaged, diagnosed, treated and out the door. Add to that the pressure of working in the context of personality disorders, which are not uncommon in patients who present to the ED for treatment, and the ED staff may find themselves in a hell of a mess.
The trick here?
Remember your training.
Use your head.
Don’t rise to the bait.
These folks are sick just like anyone else. It’s just that the way they respond to medical stress is the same way they respond to changes in their love life, a broken water pump in their car, or a clogged toilet in their bathroom.
See past that, to what the real issue of the moment is, and you’re halfway home.