Night Shift: The Problem of Pain

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I hate pain.  Not just my pain, though I hate that, too.  But I hate everybody’s pain.  I’ll take fever, vomiting, diarrhea any day over pain.  I want to find out what’s causing the pain so I can fix it so there won’t be any more pain.  But the patient just wants me to stop the pain.  Even before I have the first clue as to what’s causing the pain.  But if I do that, there’s a good chance I’ll never find out what’s causing the pain.  So the patient gets mad at me.  Now I have pain.

Take for instance a patient that I had many years ago, but I remember like it was yesterday.  Coming into the room I had to awaken the patient.  At first he tried to talk to me from beneath the sheet that he had drawn over his head.  I couldn’t understand a word he said.  It was all garbled with a think African accent.  When I finally coaxed him out of his hiding, he told me he was in terrific pain from his sickle cell disease.  He also complained of pain in both calves and moderate shortness of breath.


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Conundrum number one: Sickle cell pain crisis is real and it is really painful.  My sense of sympathy and desire to relieve his pain was heightened. But he didn’t look like he is in any real distress.  After all, I had to awaken him from sleep.  He said his pain was mostly in his shoulder, yet he complained of pain all over as well.  His calves were tender though not swollen.  He was tachycardic.  But he demonstrated no other signs of DVT or PE.  Then he began a rambling story of being tortured in his home country showing me scars on his hands and arms.  He was in this country seeking asylum.  My sense of sympathy got even higher.  But the scars were old and well healed.

When I asked about his sickle cell pain and who normally treated him, he gave me the name of a known hematologist in the area that practiced at another hospital.  “You know we are always here for any and everyone,” I started to explain.  “But why, if you don’t mind me asking, why did you come here tonight instead of the hospital where your doctor practices?”

“It’s close to where I work,” he said.


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“Did you just get off work?” I responded.  Did he work a whole shift with sickle cell pain crisis, I wondered.  Again, my thoughts waffled back and forth between admiration for a man who could work a whole shift with sickle cell pain and suspicion of someone who possibly just wanted drugs.

“I’ll need to contact your doctor,” I explained after tiring of teasing the history out of his sporadic memory.

“He usually gives me a prescription for, uh, ‘oxy’ something,” the patient said in his clearest language yet.  Now my mental scales began to tip in favor of drug seeking.

“I’ll be glad to give you something tonight if your doctor approves,” I said. “But I won’t be sending you home with any prescriptions for oxycontin.”


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“Let me go give him a call,” I said beginning to leave the room.

“He’ll need a line and bloods,” I said to the nurse as I left.  “Be sure to order a retic count.  I want to see if he is really in any crisis at all.”

“And what are you going to do for his pain now?” he asked.  I stopped.  There was a battle of sympathy and science going on in my head.

“Give him Tylenol and ibuprofen for now,” I said with clinical detachment.  “I’ll contact his hematologist and go from there.”

I put in the order set for sickle cell disease and ruled out DVT/PE.  Of course, his hematologist was unavailable after several calls to the answering service.  I was able to determine that he had been seen at our facility before complaining of the same shoulder pain.    His labs never demonstrated stress on his bone marrow.  But x-rays did demonstrate aseptic necrosis of the humeral head.  That would be enough to cause chronic shoulder pain.  I was beginning to feel ashamed of questioning his story of pain.  Was it just cultural incompetence on my part, I berated myself, that I would doubt his story because of his stoic nature.

“The guy is refusing his Tylenol/Ibuprofen,” the nurse said with some exasperation as he approached my cubicle in a huff.  “And now he is refusing to have his studies until he gets his morphine.”

Just give him some damned morphine, my brain screamed.

“Oh, and now he is complaining of nausea and tremors,” the nurse added.

Oh crap, I thought after a moment’s reflection.  How could I have missed it?  The guy is in withdrawal.  I hurriedly walked back to his room.

“How many oxycontins do you take each day?” I asked the patient almost bursting into the room.  “And when was your last dose?”

He looked at me suspiciously.  “I don’t take oxy…con…tone,” he said slowly.  Now he was examining me.

“Do you use heroin?” I asked bluntly.  He only returned a blank stare.  Was it defiance or fear behind that look, I thought?

You moron, I finally thought to myself.  He’s here trying to get asylum.  Do you think he’s going to tell you his is a drug addict buying heroin off the street?

“Has your doctor ever talked to you about being dependent on the pain medication he gives to you?” I finally asked trying to recover the clinical balance of the conversation.  He just looked at me shaking his head as if he didn’t understand my question.  We were in a stalemate.

He had good reason for needing pain medication.  But he didn’t look subjectively like he was in any pain whatsoever.  He looked like he was in opiate withdrawal.  But he was denying it, possibly for cultural or legal reasons.  Was I treating his spinal cord’s need for pain relief from sickling blood cells that were clogging the capillaries of his bone marrow?  Or was I treating his frontal lobe’s need for opiates to stop the flood of norepinephrine coming from his drug withdrawal?

Now I really needed to talk to his doctor or get to all of his medical records.

“What should I do?” the nurse asked impatiently.

“Just give me a few more minutes.”

As the ER backed up due to me chasing his medical records and primary doctor my brain just screamed at me.  Will you please just give him the damned morphine?  That’s what everyone else has done.  He’ll get his morphine and be on his way.  Yes, he’s in withdrawal.  But he’s not admitting it.  So just give him what he wants and let his withdrawal be someone else’s problem.  You have other patients who need your attention.

            Finally I gave up on getting to the bottom of the real cause for the patients visit and went back to the room to either talk him into a buprenorphine induction to treat his withdrawal or surrender to his desire for opiates.  But when I got to the room, it was empty.

“He left,” the nurse said coming into the empty room shortly after me.

“Did he say where he was going?” I asked.

“Nope.”

“Maybe he’ll go back to the other hospital,” I said with naive hope.

At the end of the day I failed this patient. I neither addressed his pain nor the withdrawal, whichever was the cause of his distress.  And this is painful to me.

ABOUT THE AUTHOR

FOUNDER / EXECUTIVE EDITOR Dr. Plaster has been an emergency physician for more than thirty years, working exclusively night shifts for the past twenty years in emergency departments across the country. During that period he joined the U.S. Navy and served two tours in Iraq. Dr. Plaster is the founder and executive editor of Emergency Physicians Monthly and the founder of Plaster Publishing.

2 Comments

  1. Lassiter Rich on

    I feel your pain.
    The collective ‘We’ have created this complex problem. (The patients, Big Pharma, the nurses, and the docs)
    But I don’t feel bad when a patient up and leaves. It lets me know he/she really didn’t have an emergency. So whether this was a refill of their opiates they ran out of, lost, overtook, whatever, or withdrawal from those opiates, I don’t feel too bad. I didn’t ask them to leave, but they solved my pain by eloping. No one dies of those things. (Well, except for the OD, but they’re not the ones complaining to me of pain.)
    You did the right thing to pursue his PCP or Heme/Onc. More of us should do that.

  2. Hi Dr. PLASTER:
    Since the patient did NOT go to his H/O’s hospital ED, I would not waste my time trying to research this ostensibly manufactured crisis of a (questionably genuine) SS crisis. Without BOTH of his contextual cooperation & compliance, after explaining his need for IVF, I would at most have given him Norco (5/325) @ 0.5 tab po & sent him on serial lying way: OTD-AMF-YOYO…

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