Wednesday, June 20, 2007

"Little Pipsqueak"

There are two schools of thought about drug-seekers in my ER. Half of us think that we should give them nothing so that they'll go away. The other half think that we should give them whatever they want so that they'll go away.

Both want pretty much the same thing. For the drug-seekers to go away.

There is an inherent problem with both schools. It's called the "yo-yo effect". If you give them their drugs, they come back for more. If you don't give them their drugs, they come back and try again with a different story. Either way, they come back.

It's a classic "damned if you do, damned if you don't" scenario.

One of our docs that belongs to the "damned if you do" school was on the other night. He started out one of our regular "mysterious 10/10 abd pain that gets much worse when you're in the room" patients with a Morphine/Phenergan cocktail. Now, everybody knows that you can't go straight to the morphine. You have to start off small and build up, because whatever you give them at first will not work. No matter what it is.

Consequently, when I asked her how the medicine was helping her pain, (in my "caring" voice), the dose that would have knocked me on my ass for a week was "barely touching it".

She said, "I wish the doctors would just listen to me. I know what will work. The only doctor around here that will listen is Dr. Jones (another "damned if you do" school member). Why can't Dr. Smith just pull my chart and see what Dr. Jones did last time? It's all there. I just need some Dilaudid. That's the only thing that works."

As an aside: Every time someone tells me that Dilaudid is the only thing that works, I have a moment that I want to say, "Then what the Hell are you going to do if you ever have any real pain that you need us to take away?"

Anyhoo, I went back up to the nurses' station and told Dr. Smith that he isn't as good as Dr. Jones, because Dr. Jones is the only doctor working here that is smart enough to figure out that Dilaudid is all that works on poor Mrs. Need-a-Fix's pain.

His response?

"Give me her chart. There's no way I'm going to let that Little Pipsqueak out-dilaude me!"

Mrs. Need-a-Fix now thinks that Dr. Smith is the best doctor in our ER.

Ah. Office politics with narcotics. Gotta love it.


Xavier Emmanuelle said...

"Ah. Office politics with narcotics. Gotta love it."

Oh. My. God.

That is simultaneously the funniest thing I've heard today, and really sad.

Babs RN said...

We had one in particular like that, part of a mother-daughter duo. Mom likes her Demerol, daughter had graduated to Dilaudid. The last words I ever spoke to the daughter were those gently advising her that after two injections of 2mg each (that "weren't touching it") that she was maxed out on the Dilaudid and there wasn't anything stronger available to give her. She'd reached the end of the line.

Two weeks later she was back in the ER again in full arrest. Dead at 32. What all these drug-seekers don't comprehend is the fact that they're killing themselves with this stuff. Or maybe they really don't care. But we have to find that fine line between managing pain and doing no harm. In today's environment I can't say where that line exists or what can be done to define it.

Meanwhile, Mom still likes her Demerol.

Mark said...

Why focus on the quick deaths?
People can poisen themselves to death with alcohol and nicoteen it just takes longer. I think all drugs/medication should be available to adults without prescription. Then E.D. workers would only have to work to revive people, if people take an overdose. Crime should go down if the price in the pharmacy on drugs is cheaper and better quality than on the street. But we all know this won't happen due to the voters who subscribe to the view my son/daughter/husband/wife/brother/sister
had a disease of drug addiction, it was beyond their control. The drug made them kill themselves, so we have to make drugs illegal.

Loving Annie said...

Xavier and Babs said it really well.
Drunks and druggies keep our E.R. full... Shame, when there are people out there with REAL emergencies...

John McElveen said...

I say we get the pull down hoses (Like at a Jiffy Lube) Line them up in beds on a slow moving floor and let them pick out thier favorite cocktails along the route outside to where their ride awaits.

They can only pick -2-sounds like a Loterry doesn't it) of any combination Narcotic/Anti-emetic- EX: Nubain/Phenergan, Demerol/Vistari-OK, so I'm giving way my age. We even came up with a new Name for a common mix- "Zubain"- Nubain ammount q.s. to experience level and Zofran.

Of course if a non-experienced one picks Nubain then we get to watch full withdrawal senes played out in front of us!

I am truly concerned about the massive quantities of drugs sought by our society- but we have created our own Monster with our Instant gratification and we should never ever have to bear One seconds worth of pain. Coupled with a crappy reality at home- it's no wonder they want to alter their perception of it because a lot of them are so empty inside- my OWN observation and no facts to back it up..

I really waffle and have spent times in Both Damed if you Do/Don't camps. And I also have no solution to this chronic problem.

Great post as usual..have a great week


Joeymom said...

I have a personal vendetta against drug-seekers.

When I had a gall stone while still in the hospital with my firstborn, the shot of Demerol did NOT touch the pain. It took HOURS for me to get anything else (and to tell you how rare it is for me to get pain meds, I have no idea what they put me on. It was in an IV with a button that my mom told me to keep pushing, to the point I had to tell her to shut up), in part because what do you think when someone you thinnk has a case of post c-section gas is telling you Demerol didn't touch it?

Thank God for the NICU nurse who figured it out.

Anonymous said...


I do know what it's like when nothing touches the pain -- acute appendicitis plus an impaction. I know what it's like to beg those around you to end the pain whilst simultaneously begging God to end your life. (Or bargaining with him. "God, if you make it stop, I'll become a nun and pray to you every day of my life.") I was curled in the fetal position, with a heart-rate of 150 and a bp of 50/palp. And puking on myself. From the pain.

That's why the couple of 10/10, sitting quietly, and specifically asking that their doctor NOT be my dad because he doesn't "understand the problem" -- lolz. Instead, it's "Is Dr. Whatever on? He was great."

And the stupid thing is that I really care about some patients. Sometimes, we do get someone in with fairly tolerable pain who ends up crying quietly in the corner after 3-4 hours of waiting for a room. Of the half-dozen or so that I asked the nurse to re-triage because of a substantial pain increase, they all got taken straight back because of drastically altered vital signs.

Of course, the only ones that the administration hears about are the ones who complain, right? And those are the ones with the entitlement complexes whom I mostly ignore because they don't actually have an emergency.

Can you tell that I'm getting bitter? It feels like for every person who thanks me/hugs me/shakes my hand -- there are ten people who will bitch about *me* (like I'm the charge nurse or something) because their emergent hangnail was not seen in a timely fashion.

It makes me wonder why I should go out of my way for anyone.

Ambulance Driver said...

You know, I can be a pretty convincing bullshitter. Maybe I should start giving people some of that new Normolsalin or maybe some .9% Nackle and say, "I sure hope this works. The last guy stopped breathing on me cuz it was so powerful..."

911DOC said...

lortab/prozac/xanax salt-lick in triage with a work-note dispenser. $10 cash. seeya.

RealisticRN said...

Yeah, but I don't think Medicaid would cover saltlick, do you? Of course, they would forgo the work-note, so that wouldn't be a problem...Yikes, that was ugly...true, but ugly...sorry...
Agree with mark...all drugs (except antibiotics) should be available to anyone and everyone. Have at it! And I'm even willing to treat your OD's with respect and dignity in the ED! Alright, maybe not kids under 11...

RealisticRN said...

BTW monkey, I bet Dr. Smith was better looking than Dr. Jones, right?

beajerry said...

I love it when they tell me they're allergic to Toradol.

I can't help but smirk like Bush at a press conference.

RealisticRN said...

I can't help but smirk like Bill when wagging his finger!
I think we should do a national research project...anyone who says they are allergic to toradol, we should give it just to see if we are correct in our assumption that they are FOS!--of course, we will have the RSI kit/intubation equipment at the bedside (JUST IN CASE they were telling the truth!) Of course, critical care time would not be charged to them (or to Medicaid/Medicare--or if they so happened to be actually really insured!!!!!Like that would happen...)

shrimplate said...

Maybe they could sell the work-notes to buy another hit.

Anonymous said...

As a chronic pelvic pain patient (don't cringe - we know we are nightmares to treat), it was undiagnosed adenomyosis that started it all. No boggy uterus to give us a hint. Just chronic ovarian cysts and chronic pain. No one ever thought to do an MRI -not 5 ob-gyn's, not 4 ER docs, nor any of the nurses and certainly not the primary care physician - no one ever suggested an MRI (second only to a hysterectomy in finding adenomyosis). Started a four-year path to hell. By the time of hysterectomy, I had become an expert at "the look" --you know that look that medical people give you when they think you are full of it. My faith in medicine had tanked. Two months after hysterectomy and not all of pain gone, ob-gyn basically threw up hands. Hysterectomy was months too late. Entire pelvic floor in "worst pelvic muscle spasms I have ever seen" state. New ob-gyn, simple Q-tip test and new diagnosis of pelvic floor myalgia. Sure would have been neat to have found that adenomyosis a couple of years earlier, like before those nasty involuntary pelvic floor muscles started working overtime. Imagine a charley horse in your pelvis and a bed post in your anus and you'll know what everyday was like. A hundred trigger point injections, 34 botox shots, biofeedback, psych and stress counseling and now ultrasound. Plain and simple ultrasound with botox and yes, relief begins at last. We aren't all drug-seekers but many of us are pseudo drug seekers because we know "the look" and "the attitude" and we are afraid to tell you how much pain we are really in.....because we don't want to be labeled drug seeking. I'll take toradol any day of the week for a migraine, works like a charm in about 30 minutes. But for pelvic pain....forget it. It's like using a fly swatter on a pit bull.

Two tips (maybe not on everyone but certainly on many CPP women) -weight loss and blood pressure. My weight loss was almost 60 lbs. My normal BP - 90/60, BP in pain 130/80ish. Check the pt's chart for weight loss and normal blood pressure or try asking. Filling up stomach equaled pressure on pelvis equaled more pain so we stop eating.

For all the CPP patients that walk into your ER, please don't assume drug seeking and give us that look and that attitude. We don't want to be there any more than you want us there. But mostly we really are tired, scared and isolated women whose lives are on hold until someone, anyone can find a way to get the pain stopped for good. And of course we know which drugs work and which ones don't, we've been doing this for months and months. Really from our perspective it isn't drug seeking. It is get us out of pain and please cure us seeking.

Thankfully, with the dedication and empathy of my current ob/gyn (who even called for help from physicians at local and out of state universities) and the capable hands of my physical therapist, my horizon is once again filled with hope of getting my life back. You can have the drugs, I'll take a rum and coke on a sandy beach any day. Thanks for listening.

Anonymous said...

I go to the hospital maybe once or twice a year for migraines so bad that, no joke, the pain is a 10 out of 10. At that point, I am seriously contemplating hitting my head against a brick wall to "distract" me from the migraine pain. I'm also throwing up near-continually. Sometimes I'm so nauseous that even AFTER the Phenergan I'm STILL throwing up.

I only come in once or twice a year because the rest of the time, the Imitrex (or the aspirin, Tylenol, and ibuprofen combination--ALL of which I try ANYTIME before I contemplate going to a clinic or ER) works.

I have had these migraines since my teens. I have a neurologist I've seen for years. I've been tried on all the drugs that sometimes help people with migraines (e.g. Topamax). They help a little, but nothing seems to keep me from a once-or-twice-a-year ER visit. It's generally an ER visit because my migraines almost ALWAYS come on in the middle of the night or early morning hours. Don't ask me why--they just do.

I am ALWAYS polite to the staff. If I am going to have to wait a long time, just please turn out the lights, give me a blanket and a bucket, and I'll wait.

Having had these for, now, decades, though, I'm telling you--I DO KNOW WHAT WORKS AND WHAT DOESN'T. I have had to come in and face the judgmental bullshit I've seen on some of these blogs, and gotten treated with Reglan (!) for near-continual vomiting and Toradol only for bang-your-head-against-the-wall pain. Guess what happens? I end up back in your ER as soon as I can get another ride. 'cause guess what else? I don't know diddly about fibromyalgia, but migraines are, for sure, 100% real.

Given that I come in only once or twice a year and don't have or use ANY "pain pill" prescriptions, how does this make me a "drug seeker"?

So why should I get lumped in with the other drug seekers and have this assumption made that that's what I am? Why should I be treated any differently from anyone else with a "legitimate" complaint? I assure you, the headaches are no picnic. (BTW, my mother and sister both get 'em too.)