This morning as I was leaving my shift, one of the local cops mentioned that they are having a real problem with Vicodin sales and use … in the high school. Kids strung out during classes. Must be a great learning experience.
Where do you think these teenagers are getting their stash?
Then there’s this article about a doctor who was sued for giving pain medications to a patient and not sufficiently warning the patient about its possible effects upon driving. (Hat Tip to Kevin, MD) Oral arguments and the opinion of the court are at this link.
Keep the above in mind as you read the following which happened a few days ago.
A lady with a previous history of chronic neck and back pain now comes in with frontal headaches for the past month. Of course, her pain is a 10 on a 1-10 scale. She gets dizzy at times when she stands. Sometimes she gets nauseous. She says that she has vomited twice in the past 3 days. She used to take Vicodin for her back and neck pain, but she’s out of them now. I look through her old charts. She seems to like Dilaudid and Vicodin.
It’s a busy shift, so she had to wait for a couple of hours. When I walk in the room, she’s laying on the bed with her arms folded. She seems upset with the wait, but she’s playing the “nice” card, I can just tell. She’s sizing me up from in between those fingers over her eyes. Very polite. Says “thank you.” Compliments me on being so nice even though we’re so busy. I engage in some small talk with her and she actually is a nice lady. The little voice in back of my head is literally kicking me in the mastoid right now. “Hey! WhiteCoat! Don’t be a sucker. She may be nice, but remember her history! Being overly “nice” is page 2 of the drug seeker’s handbook!”
Since her headaches are a “new” complaint, I examine her from head to toe. No fever. No sinus pressure. No temporal arteritis. Fundi normal. No photophobia. No meningeal signs. No abdominal problems. No focal neurologic deficits. Oh, by the way, she still has that chronic pain in her back. Can’t find anything abnormal on her exam other than her “10 out of 10” pain.
I don’t care how nice she is, she isn’t getting Dilaudid. We give her some Phenergan for her nausea and some Imitrex for her headache. Her headache improves to a 5 out of 10.
“By the way, doctor, my head still hurts. Could you please give me something else for pain?”
“Absolutely,” I tell her. “But it isn’t going to start with the letter ‘D,'” I think to myself.
We give her some Toradol. Her pain is down to a 2 of 10. “See, lady?” I think to myself, “you don’t need narcotics to get rid of your pain.”
When we tell her that we’re going to discharge her, she is actually grateful. She thanks everyone for being so nice. “Kill ’em with kindness.” That’s page 3 in the drug seeker’s handbook. Well it worked. I sent her home with some Imitrex, Phenergan, and a couple of days worth of narcotics. The little voice in my head pulled the otoscope off of the holder and whacked me in the back of the neck with it. What a sucker I am.
That’s not the end of the story, though.
Two days later she’s back. Of course there’s another doc working that day. Divide and conquer — I think that’s page 6 in the drug-seeker’s handbook. Now it’s the sob story. The pain medications aren’t helping. Her head hurts. She’s vomiting more. Her doctor doesn’t have an open appointment. Oh, and now she fell and hit her head before her last ER visit, but forgot to tell the ER doc. Her neck hurts from the fall, now. Just to add to the drama, she’s acting like she’s confused. It isn’t January 2008, it’s really January 2007, “isn’t it?”
“Oh well, what the heck,” the ED physician thinks, “why not irradiate her body a little more?” So he orders a CT scan of her head.
Brain cancer. Multiple metastases. Poor prognosis. As in she’s going to die soon.
This was one of those “Hey, you remember that patient …” moments for me when I came to work for my next shift. People were knocking each other over when I walked in just to tell me.
At first, I felt horrible about considering that she could be a drug seeker. But I got her out of pain when she came to see me. At least that’s how I rationalized it to myself.
Then I felt bad for not doing the CT scan when she came to see me three days prior. Was there really an indication for ordering it? Maybe, maybe not. Just like the Super Bowl, everyone can always sit back and second guess what might have happened if ….
All these warnings from our malpractice insurers about saying “sorry” as an admission of guilt have me too afraid to just walk upstairs to the floor, sit on the side of her bed, and ask her how she’s doing. I genuinely feel bad for what she’s going through. The little voice in back of my head started to mumble something. I grabbed him and whipped him against the wall. Maybe he’ll just shut the hell up for a while.
Maybe my human side will win over my chicken shit doctor side and I’ll hit the 4th floor button on the elevator after my next shift. Then again, maybe I’ll procrastinate long enough and she’ll be discharged.
When people complain that doctors don’t want to treat their pain in the ED, this is a perfect example of what emergency physicians and nurses go through every day. Where do we draw the line? How likely is someone to abuse the prescriptions we give them? Do I risk putting more drugs out on the street? Or do I risk not helping someone truly in pain? All we have to go by is someone’s history … just in case you were wondering, drug seekers lie.
It scares the hell out of me that a prescription I write could some day be sold to my own kids and start them on the road to drug addiction. Yet it scares me just as much that I could let another person suffer in pain because I was too afraid to write her a prescription for narcotics.
And the public wonders why we think drug seekers suck.