He looked pretty comfortable on the stretcher - unconcerned, even.
32 years old, already with bilateral toe amputations from massively uncontrolled diabetes. He had already had bone infections, a condition known as osteomyelitis, and he had been through a few months worth of IV antibiotics through a PICC line. Somehow he still managed to be completely noncompliant with every and all medical therapy suggested for him.
"Evening, sir, my name is Dr. Zac. What brought you in tonight?"
"I think I got the bone infection again, and I want my Dilaudid," he said, casually, "I'm allergic to morphine and Vicodin, all I take is Percocet and Dilaudid now. Also, I would like Phenergan and Benadryl with it."
I paused. There are few things that bother me more than a patient requesting Dilaudid, Benadryl, and Phenergan in the very first sentence. That particular cocktail of drugs is well known among ER physicians for being an incredibly potent high, and the immediate request for that triumvirate somehow belies a concern of illness from the patient. Most patients come in worried about what is causing the pain, and want an answer - the pain control comes second.
In this particular case, though, he was really quite sick. He had a fever, his heart was racing at about 120 beats per minute, and his foot looked infected - and the infection was spreading up his leg.
Turns out he hadn't been bothering to check his blood sugars - routine for him, upon reviewing his chart - and his blood sugar was also around 350, which is great for hungry, thriving bacteria.
I started an IV on him, drew cultures of his blood, started potent IV antibiotics, and immediately called the admitting physician. I begrudgingly gave him a small dose of Dilaudid - he had put our other pain medications on his "allergy" list, a common gambit among patients who want their physicians locked in to giving them the stronger medications only.
The nurse came to get me 30 minutes later. "Room 5 says he's leaving. He's got stuff to do at home."
I was floored, so I went and had a long talk with him. I'm a firm believer that fear-based talks don't do anything for people and that positive reinforcement is more useful.
Still, I tried both.
"I can't force you to stay, and I know you don't like checking your sugars. Listen, I'm not the diabetic, I never have been. I have no idea how difficult it is to check sugars and dose insulin all day, every day. What I do know is that from what I'm seeing here, you're probably about to lose your leg, just like you lost both toes. I don't know, maybe the infection will even spread throughout your body this time and kill you."
"I can help you if you stay. I can get your sugars down, I can get antibiotics in you, we can try to figure out a way to make your diabetes control work for you before you become crippled."
"Tonight is one of those turning points in your life. Stay, and we have a fighting shot at stopping this. Go, and you'll always regret not staying, right here, right now, when you lose your leg."
Nothing I said stopped him from going. He said he'd come back in the morning, but he never showed. It's not often I feel like I've failed someone, but I feel like I failed him. Then again, if I couldn't convince him to stay despite my best efforts? Well.
I guess some people just like to play with fire.