#1 Dinosaur has an excellent post on his blog about the differences between drug seeking behavior in Emergency Departments versus physician offices. He writes:
Most of the (blog) “literature” on drug seeking comes from the ER and pre-hospital bloggers. To them, seekers are all stupid, lazy, unwilling to confront their demons/addictions, often belligerent and overall pains in the ass.
I read his blog because he invariably posts a well-reasoned discourse on the things that simply induce a vitriolic rant from the rest of us. He makes me think, and his post on the subject illustrates the lengths to which a conscientious physician will go to identify, and treat, what he believes is a legitimate pain complaint. Knowing when it’s the Real Deal boils down to one word – relationships.
The more you know about that patient, the more likely you are to treat any of their ailments appropriately. Pain is just one example, and Dino Doc pegs it – the patients who are unwilling to do their part to develop that trust between physician and patient, are most likely there just for a fix.
Unfortunately, we don’t have much opportunity to develop patient relationships like that in EMS or Emergency Departments. What relationships we do develop are weighted toward the type of people who won’t make the effort to gain the trust of their primary care physician. When we see people repeatedly, it is almost always for one thing – drugs.
It bothers me a bit, however, that I’d be characterized as he does in his post. I don’t pigeonhole patients that neatly, although I can see how you’d get that impression from some of my posts. The particularly cutting remark came from Cathy in the comments section:
I also agree that after reading some of the ER blogs, I NEVER want to ask for pain control while in their ERs.
Now there is a shaming comment if ever I heard one. Cathy, you should never be ashamed to ask for treatment for a legitimate complaint. If you’re hurting, a competent clinician can usually tell.
If you read this blog, you already know the types of patients who earn my scorn. What you may not know is that, everywhere I have worked, I have been the Candy Man.
When I worked for Huge Soulless Corporate Conglomerate EMS, I routinely administered more narcotics than any other medic, save one. That particular fellow jumped at the chance to give any medication, often on the flimsiest of pretenses, and quite often he’d exaggerate clinical findings in his reports to get the orders he wanted. His nickname in the local ERs was “Overkill.”
I’m aggressive with the use of some medications and reticent with others, but I believe that benzodiazepine sedatives and narcotic analgesics are some of the safest drugs we carry.
Yeah, I said the mind-altering, potentially addictive drugs are the safe ones. In EMS and the Emergency Department, in the doses and intervals we typically use, these drugs are very safe, and not likely to result in addiction. The potentially harmful side effects are short-lived and relatively easy to manage.
Prescription narcotics and sedatives however, well that’s an entirely different kettle of fish. There is a much finer line to tread there.
Oxycontin? There’s a reason they call it Hillbilly Heroin.
Prescription Xanax? A scourge. Hate that stuff.
It doesn’t take an open femur fracture or organs falling out to get pain medication or empathy at Podunk General Hospital, Nail Salon, Tire Repair and Crawfish Hut. We get our drug seekers like everyone else, but if the story is even remotely plausible, they’ll get medicated – even if we think they might be seeking. What they usually won’t get is a prescription to take home.
A sample of a few of the patients I’ve advocated for in the past weeks:
For the eight-year-old with a dislocated shoulder and a major fear of needles:
AD: “Hey Doc, how about intranasal Versed and Fentanyl for the kid before you do the reduction? It’ll kick in faster than the IM morphine, and we’ll save him a needle stick.”
Doc: “Doesn’t the conscious sedation protocol require an IV?”
AD: “Yeah, but it doesn’t say you have to have an IV first. I’ll stick him when he’s nice and relaxed.”
For the sixty-year-old woman with chronic knee pain who insists on using us as her primary care clinic.
Doc: “She ain’t getting squat. She’s in here every month. Give her a 10 mg Toradol tablet and send her home.”
AD: “Just go look at her, Doc. She’s really hurting.”
Doc: “She has a phone. She could have called her own doctor for a refill.”
AD: “So she’s stupid. Doesn’t change the fact that she’s hurting, and besides, stupid people keep us in business.”
Doc (sighing): “Okay, fine. Give her 60 mg of Toradol IM, and an extra-strength Vicodin. But no scrip!”
AD: “You are truly dripping with the milk of human compassion, Doc. If calculus hadn’t kicked my ass, I’d have wanted to be a doc just like you.”
For the 26 year old Iraq war vet, discharged last year and literally trembling from head-to-toe with the DTs:
AD: “Hey Doc, aside from the banana bag and the thiamine, how about some sedation for this guy?”
Doc: “Not until we get his drug screen back.”
AD: “It’s been back for twenty minutes.”
Doc: “Okay, I’ll go see him in a minute.”
AD: “You know I love you Doc, but you’re not the one in there retching his guts out and shaking like a crack baby. The guy quit drinking cold-turkey and came to us for help. Let’s try to make him comfortable.”
Doc (sighing again): “Fine, 2 mg of Ativan IV push. Any other orders, Doctor AD?”
AD (blowing kisses): “Well, now that you mention it, some IV Zofran for his nausea would be just swell.”
For the girl with polycystic ovary disease, a UTI and way too many abdominal problems to mention:
Doc: “Are her abdominal CTs back yet?”
AD: “Nope. Probably take another thirty minutes. She says she’s still in severe pain.”
Doc: “She’s already had 10 mg of IV Morphine.”
AD: “And she’s still hurting, as evidenced by the piteous moans, writhing around and the BP of 160/94, heart rate of 126, and respirations of 28. Something tells me we ain’t making a dent, and that hypotension and respiratory depression are a long way off.”
Doc (rolling his eyes and writing the order): “Okay, 5 mg more of Morphine, and repeat it in ten minutes if she hasn’t gotten relief. And you are really starting to chap my ass.”
AD (winking): “Damn, that sounds painful. Would you like me to ask the doctor to order something to take the edge off?”
