During your emergency care career, you will not be able to avoid seeing the so-called VIP (very important…) patients from time to time. Whether it’s a VIP according to someone else higher up, general society or even your own perceptions actually does not matter – the end game is one and the same.
The best time to ponder and prepare regarding your future approach to VIP patients is now – before you are in the midst of the actual situation.
Now, if you are an idealist, things may seem blatantly easy. You shall and you of course will evaluate each one of your patients the same, regardless of anything about them! It may in fact feel insulting if someone were to insinuate that this case deserves or requires that “special” or “above and beyond” care. Doesn’t that imply that all of your other patients so far have been getting just average or so-so treatment?
A VIP patient is like a parcel box that arrives with a “handle with care” stamp. And the question is – are we not caring that way already?
Unfortunately, that is now how things may appear to others – exactly why patients and family members put on institutional badges or start mentioning names as you walk in the room. In a short while, random suits whom you have never met or knew existed descend from upstairs to “check on things”, as they seek you out to shake hands and make eye contact. And the general atmosphere affecting not only yourself, but also your nurses and everyone around slowly starts to resemble the buzz felt near a transformer booth.
The ethics and the philosophy of VIP-EM (I’m patenting the podcast name if you’re not) would take up a heavy volume. For our purposes, we will make it simple:
VIP-EM situations will potentially push you toward one of two things: either withholding what you normally would have done, or doing what you otherwise wouldn’t have done.
Let’s take an example of either situation to illustrate.
- A secretary of a hospital network CEO arrives with her 3-week old having a fever at home. Someone had called the charge nurse ahead of time, and they are given a priority room, ahead of others. The baby looks fine and is, oh, so cute! You, unfortunately, know what needs to happen, and so does the useless WBC count. But…lumbar punctures hurt, and the mother is seeking out in your eyes the permission to defer it. So you send the happy baby home to its life-saving next day pediatrician follow up appointment and its Listeria meningitis demise…or do you?
- A local TV station news anchor, and a friend of the Chief of the surgery department, pulls a shoulder while attempting a muscle up as part of the new IM-50X weight loss program. Physical exam findings are minimal, the XRay is normal and there is no concern for any neurological or vascular injury. You are requested to order a STAT MRI and to perform a shoulder steroid injection. Instead of the orthopedist on call, a special sports specialist catering to the town football team will be arriving in 3 hours to evaluate the patient, who will continue to hold up the ED bed. You will of course be prescribing narcotics for home…or will you?
Thinking about such hypothetical scenarios now to understand who you are and how you would behave will serve you well when the time comes. Regrettably, such education is often omitted from official medical school “handling difficult patients” curricula and cultural sensitivity training.
While I’m not an ethics professor, I do think there are three special circumstances within the entire VIP conundrum to consider.
The first is about returning someone injured in the line of public service to active duty. Whether it’s a colleague with a needle stick, a fireman needing clearance from minor inhalation or a police officer inadvertently embedded with a taser dart by one of his own – if you can return them to work rapidly and ahead of others, you should probably do it. First heal the healer goes a long way not only in major disasters, but in everyday life as well. It’s the basic utilitarian argument.
The second has to do with taking extra steps to ensure someone’s privacy. If the patient is the kind of a persona who has paparazzi following them day and night, going the extra mile to create conditions of confidentiality that are no more than usual is probably okay.
Third, I do want to mention that while the sense of entitlement to extra or special care among the VIPs may be prevalent, the latter trend does not encompass everyone. Just like you will never plant the seed of suicidality by asking a patient if he or she is suicidal, you are unlikely to offend a potential VIP by asking directly if it is okay for you to treat them as everyone else. You will be amazed, but quite a few people who have to carry out their lives in full view of the public or are subjected to immense professional responsibilities never want to be treated differently in the first place. Getting what I call a brief “fame holiday” may in fact be therapeutic and exactly what they need.
There are very few things in EM that are both deadlier and more unfair than VIP-medicine. Anticipating and mitigating potential fallout before it happens is a tough skill to learn. Knowing that such situations are unavoidable is the first step.
Last, while dignitary emergency medicine (DEM?) is not (yet) a legitimate EM fellowship, you can certainly read more about what’s being thought on this topic within the general medical field:
Al Mulhim MA, Darling RG, Kamal H, Voskanyan A, Ciottone G. Dignitary Medicine: A Novel Area of Medical Training. Cureus. 2019 Oct 22;11(10):e5962. doi: 10.7759/cureus.5962. PMID: 31799098; PMCID: PMC6863586.