Maybe Red Riding knew something we didn't...
Stereotypes. Hot button, much maligned, difficult to dispel. It all ties back to our human ability — and sometimes compulsive need — to find patterns and assign groups. Helps the poor lump of fat riding in our cranium track and understand the complexity of the world we inhabit.
And, when you think about it, assuming everything striped was a hungry tiger until proven otherwise was probably a good thing. At least, the humans who thought this way survived and passed down their paranoia to successive generations.
That being said, assuming anything about a person because of the way they are dressed, act, or speak can land you in trouble. In the medical world, it can lead to misdiagnosis, damaged trust in healthcare, and bad outcomes. That is why it is crucial to obtain a good history from your patients and not assume anything based on their demographics or lifestyle.
Some people will get really offended when you ask them if they use legal or illegal drugs or alcohol. Like, super pissed. Sometimes, it’s because they're in denial. Some, just self-righteous. But you always ask.
Story time.
I was a newer nurse, maybe a year of experience. Feeling confident in my basic skills, starting to know my specialty pretty well. Able to rattle off my patient education and medications. I get report one fine morning and it seems business as usual. A pneumonia case, extubated but still needing oxygen. A scheduled carotid endarterectomy, discharge this AM if vitals look good. And an older female hemorrhagic stroke, minimal deficits, but we’re on watch because she’s taking anticoagulants for atrial fibrillation. Reversed in the ER, but high risk.
Pretty straightforward PCU load. I review my charts, check results. Ask so-and-so about her baby. Usual morning stuff.
Pneumonia guy is doing alright. Feels like garbage, but no longer trying to die. Get him some water and move on. Endarterectomy lady is in her chair, ready and raring to leave. Let her know the surgeon will round later in the morning, then we’ll boot her out.
Stroke lady. Quintessential grandma. (Not my grandma, who chain smoked slims because they were ‘healthier.’) This one though… Fluffy white hair. Twinkling eyes. Glasses on a sparkly chain. She was even crocheting. “For my grandbaby, due next month. Number 12!”
I give her a thorough exam. Alert and Oriented x4. (“My grandnephew is in nursing school!”) Monitor shows rate-controlled a-fib, S1, S2 to auscultation, slight systolic murmur. Lungs clear, diminished bases. Bowel tones positive, moves all extremities, very slight weakness to L side, but she’s handling that crochet hook like a pro. Extra-ocular movements intact, teeny tiny droop to L mouth, but no dysarthria or aphasia. In fact, she’s chattering away. No complaints otherwise, “just this darn arthritis.”
Easy peasy. I go to get her meds, but get a phone call from her doctor before I’ve pulled more than metoprolol.
“Uh, Anna?”
“Yeah?”
“Ms. Grandma’s labs just resulted. Could you double check them for me?”
Weird, but okay. I pull up her chart and click into the results tab. “I see them. Her sodium’s a bit low, but at her age—”
“Are we sure the drug screen is accurate?”
Beats me. It was done in the ER (no shade, just facts), but most likely. I scroll down. UA is clean, but the tox-screen has a flag.
Amphetamines.
Okay, more weird. “Maybe she’s taking stimulants for something?” I double check her history for ADD or the like.
Doctor already sounds defeated and it’s 0830 in the morning. “I went through her history and didn’t find anything. Could you ask her?”
“Sure. I’ll call you back.”
So, I stroll into Ms. Grandma’s room and ask, “Excuse me, ma’am. Just a quick question. Do you take anything medications for Attention Deficit Disorder or any other mental health issues?”
She blinks at me. “No, just my heart pill, and the blood thinner, and my water pill. Why?”
“Well, your urine sample came back. You don’t have an infection, which is great, but the drug screen had something odd in it.”
Her eyes go wide. “Drug screen?”
Uh-oh. Soothing education time. “When someone comes in with altered mental status, even if we’re pretty sure it’s a stroke, we always do a drug screen just in case there’s a toxin or something.”
She beams at me, the perfectly white and even teeth of her dentures gleaming. “That is so thoughtful of you!”
Not what I was expecting, but alright. “Uh, er, thanks. Well, yours came back positive for amphetamines. Sometimes, certain medications can cause a false positive or—”
She interrupts me with a chuckle. “Oh, that’s sounds right. I ate some yesterday.”
I am sure my face does this:
“‘Ate some?’” I repeat blankly.
“Yep!” Stich, stich, stich. A miniscule sleeve is forming under her nimble fingers.
“You ‘ate’ some amphetamines.” I try to make it a neutral question, but I fear my incredulity creeps through.
“Yep.”
“On purpose.”
“Well, I was feeling a bit sluggish.” She nudges her glasses into place, round and so thick her eyes look twice their normal size. “So, I ate a few of the candies my husband brings home.”
“Your husband brings methamphetamine home?” I start to smell smoke and I fear it is my own brain, struggling as I try to absorb this. “Uh… is this the first time?”
“Oh no!”
At this point I am speechless.
She needs no assistance, merrily chattering away.
“A few years ago, he brought home some of that meth stuff the kids were doing. Just to try it! I had so much energy! I cleaned the whole house in two hours!”
I have so many questions and they jumble together, clogging up my synapses so none can come out.
She’s in her 70s. Where is her also 70s husband getting methamphetamines?!?
Is he casing alleys? Asking around his shuffleboard group for their preferred dealer? Do his kids/grandkids get it for him? ‘Here, gramps, picked you up a few bumps at a party this weekend.”
She claims to have never smoked, hardly drinks (“not anymore, dear, bad for your liver!”), and goes walking with her ‘girlfriends’ three times a week. “Oh, I did some of the marijuana when I was young, we all did!” but no other drug use.
Then ¾ through her life she just… starts doing meth?
Stich, stich, stich. She’s still talking, now about her eldest daughter, married to a navy man, and I have to interrupt.
“How often do you… ‘eat meth?’”
“Oh, once a week or so. More during the holidays, when everything is so busy!”
My friends, I had to hold onto my Nurse Face™ so hard. I smile gently and say, “Well, ma’am. I don’t think that’s a very good idea.” (Thinking: WTF lady?!? Meth?!?)
“Oh?”
“Amphetamines are really bad for your heart. Since they are stimulants, they can cause fast heart rate and high blood pressure. You have a few risk factors for stroke, but those candies might be why you had one yesterday.” (Like when your blood pressure was 230/120 on admit!!!! No wonder you popped a bleed!!!)
“Really?” A little dismay, but mostly interest. “Oh no! Well, I’m glad you told me, dear.”
“So, you should probably not take it anymore. And neither should your husband. I wouldn’t want him to have something bad happen, too.” (Like having his heart explode!!!!)
“Oh, of course.”
“Okay. Well, I’ll go get your morning meds.”
“Thank you, dear!”
I call the doctor and I swear I heard his head hit the desk. A few times. His voice is weak and I wonder if he’s going to quit and become a plumber. “Okay, thanks. I be around to see her in a bit.”
I, also, put my head on the desk. Before long, Ms. Grandma ambles by with the physical therapist, a fluffy cat cardigan over her hospital gown and her slip socks pulled nearly up to her knees.
“Gets bad when it rains, you know, dear. I always sleep with my hot water bottle, helps with the sciatica.”
People don’t do that, right? Am I just unknowingly innocent? Because people don’t just ‘eat some meth,’ or any other substance on a whim. “Hey, I’m feeling a bit tired today. Should I have some coffee or… I know! Cocaine!” Right?
Seriously.
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Enjoy!
Anna, RN, BSN, CCRN
Necessary disclaimer: I am discussing medications and medical conditions in this article based on my personal experiences as a nurse. Your facility may have different requirements and resources. Use your own nursing judgement to assess and treat your patients according to your governing body and facility guidelines. All information within this article is correct to the best of my knowledge, but should be confirmed through verified evidence-based sources. I am not responsible for any clinical decisions made based on this article.