It was quiet for the most part. Mostly little kids with high fevers. All of them looked well. Flu, rotavirus, viral upper respiratory tract infections; blah blah blah. Only a couple of cases stick out in my mind.
The first was a 73 year old guy with opiate dependence. He has chronic low back pain and apparently was placed on fentanyl (synthetic morphine) patches over 10 years ago. Typically the patches contain 25 micrograms of the drug, but his contain 75 micrograms, and he wears two at a time. The fentanyl slowly absorbs through his skin for 3 days and is then gone, at which time he removes them and places two more.
I liked him because he was straight forward. No long drawn out stories about vague symptoms prompting me to obtain expensive medical workups. Instead a simple chief complaint: “I’m out of my medicine.” Granted, how he ran out was unclear: you what? Took them off in your sleep? Accidently threw two of them away? Fine, whatever, he probably doubled at some point.
He receives one month’s worth of patches through the VA, and his next refill was 6 days from presentation. We had a total of five 25 microgram patches available to me in the ER. So I put 3 on him, gave him the other 2 to put on three days from now, and sent him home.
I felt like some of the nurses were miffed with me. How could he “give in” to this drug seeker? He’s weak, he’s a “candy man.” He’s gonna cause all the seekers in a 200 mile radius to descend on our little ER.
I care about what they think about me, but more importantly I have to do what I feel is right for my patients. This man is 73 years old and will be hopelessly dependent on opiates until the day he dies. What will a stern lecture and clonidine/phenergan do for this guy? It’ll promptly put him into withdrawl, which is non-life threatening but will make him feel absolutely miserable for the next week. Aren’t I supposed to relieve suffering? Was I not taught to do no harm?
All patients are unique. If you’re returning over and over you’ll get a referral to your primary doc or the pain clinic. If I think you’re selling it I’ll boot you out the door. If you’re relatively young and still have a chance to lead a productive life, I start the detox myself.
And then there are the cases above.
March 12, 2007 at 2:24 pm
Although I’m not a doctor, my wife is a nurse, and I hear the stories about “seekers”…I think you did the right thing. To make the assumption that since you gave meds to one person in one situation, does not imply that you will make the same decision for all patients. This is an imperical leap that too many people make.
The point is really that – yes you were taught to do no harm – but you were also trained (and trained and trained I imagine) to evaluate the situation, which you did!
The dozens of seekers that cause the fear on behalf of the nurses, won’t become a reality – at least not for long – when you reach and act upon a different situation.
May 11, 2007 at 12:39 am
I am neither a doctor nor a nurse, but my grandfather suffered chronic pain for more than a decade before I was born until he finally passed on when I was 13.
He was on 120 mg of codiene every 4-6 hours, along with sleeping medications, Valium to relax his muscles (of course, you know what kind of dependence that can cause, as well as the seriously dangerous side effects of abrupt benzodiazepine withdrawal), etc, etc.
Before I was born, he was hospitalized for a cardiac issue and the admitting doctor did not request a medication history, nor consult with his internist regarding his medications. Within 48 hours he went into full-blown psychosis. After another 24 hours they got a psychiatrist in for a consult, and he asked my grandmother what medication he had been taking. She didn’t know thier names, but apparently brought every medication he’d had stored in the house — a suitcase full — hoping that one of them could explain his rapid decline in mental function.
They started him back on the Valium and the codiene, and he regained lucidity in 8 hours.
I personally think the problem was the abrupt Valium withdrawal, but opiate withdrawal along with the return of his severe pain could have contributed to his condition.
I think you did the right thing as well. BTW: I also liked your comments regarding the way you differentiate between drug users when they are asked.
You might have forgotten the “Paranoid, looking around for anyone who might be listening, extremely bad teeth, bad skin, and very jumpy” — but that one is likely obvious.
January 10, 2008 at 3:25 am
Long comment ahead. I realize this is an old post, but I just found you and I’m reading through the older stuff.
First of all, I’ve never done street drugs, and my crappy/missing teeth are due to malnutrition combined with lack of $13K to fix them. Malnutrition from my gastric bypass, which left me otherwise completely healthy and almost 200 lbs. lighter.
Second, I’m almost 30, and the dose that this patient was on is the dose I’m on with the fentanyl, for 4+ years of unexplained, chronic back pain, which is getting progressively worse and spreading to my abdomen. I hate the feeling of being treated like a drug seeker, when I walk in, barely upright from pain, when my pain has flared beyond what I can tolerate. I am finally about to start seeing a pain clinic for it, but that doesn’t mean that the pain has been less real or more tolerable to this point.
Please continue to be the doctor who medicates pain, even when it’s in someone who is chronically in pain. My patches keep me at a daily 4-5. When I’m up to 7 or higher, I can no longer do anything but whine and pray for divine intervention.
Also, please don’t assume that me coming to the ER is because I don’t understand that chronic pain isn’t an emergency. I’ll sit in the waiting room for as long as it takes, as uncomfortable as it is, for people who are sicker than me. However, maybe a little bit of treatment for the pain issue, when I come into the ER suicidal from my 9 pain level, is warranted, as opposed to the “You have a chronic condition, so we’re not going to medicate you at all. You can take a couple of Tylenol.” Because when percocet is like eating M&Ms, Tylenol’s going to do anything for me? When I have never before been driven to suicidal thoughts from pain or anything else?
I have a lot of respect for most ER staff. The nurse who told me that, if he had his MD, he’d have given me something and completely disagreed with the doctor’s decision, and who helped calm me down by talking to me about our children who are the same age…he was amazing. The LPN who looked at my mouth and said, “Wow, your teeth are AWFUL!”? Not so much. The ER doc who ran two CTs on me for abdominal pain to make sure it wasn’t a hot appy (they couldn’t find my appendix in the first scan)? Lots of respect. Also to those who understand that I can be in pain and still be trying to joke, because it’s the only coping mechanism I have.
Just don’t EVER forget that I know my body better than you do, and me knowing names of medications and reporting a pain spike doesn’t make me worthless street trash, or anything more or less than a human being who is suffering. The history of pain medications means I’m resistant to them after so long, not that I’m looking to score. I hope this patient at least finds some peace in the end of his life.