10 January 2008

Couldn't Happen to a Nicer Guy

I read on KevinMD about the angry tirade CNN's resident demagogue, racist, homophobe and all-around scumbag Glenn Beck posted on YouTube, in which he detailed what sounded like a truly horrible post-op experience. He wrote about horrible uncontrolled pain, an unanticipated trip to the ER (complete with obligatory false expectations of "Your doctor called in and your room is waiting"), and an admission for pain control.

Let's be frank. I have a keen Bullshit Detector. It comes with working for a decade in the ER. Beck's behavior sounded, to me, like the classic behavior of a drug-seeking patient. Complete with dramatic description of the pain, hysterical behavior, unrealistic expectations, and requirement for massive doses of opioid medications. But I read Beck's narrative with a grain of salt. I didn't know what surgery he had had, and I imagined that it might have been a lumbar laminectomy or fusion or something like that, and those can indeed result in very severe post-op pain. His behavior, while a little over the top, would not be inconsistent with a dramatic personality and severe pain. So I cut him some slack and moved on.

But then I found out what he had had done: hemorrhoid surgery.

I shit you not.

It's hard to imagine something more trivial. Uncomfortable? Surely. Desirable? No. But ohmygod did this guy make a mountain out of a proverbial molehill (no pun intended).

Let's go through this in detail:

"The anesthesiologist told me later [...] I've never had anybody wake up on the table before. He said, as soon as I turned you off, as soon as I turned all the juice off because we were done, he said, you woke up and turned around and said, I'm in pain. He said, so I turned everything back on. It took three hours to stabilize me on pain. [...] When I was in the recovery room, the nurse who was watching me, I would hear alarm bells and she would say, "Mr. Beck, breathe, Mr. Beck, just take a deep breath." I was not breathing. "

So this would imply to me that he was not under general, but maybe MAC (moderate sedation), in which the goal was to make the patient sleepy but not "fully out." Many hemorrhoid cases are done under local only. It's ridiculously uncommon to wake up from general anesthesia via an inhaled anesthetic or propofol. Apparently he had a very high medication tolerance (consistent with his prior history of substance abuse) and complained of persistent pain even when he had received so much medication that he was experiencing respiratory depression.

The exact timeline after that gets fuzzy, understandably. He was seen in the ER for urinary retention (not uncommon after getting high doses of narcotics). He was apparently admitted and recounts being on a PCA, "Morphine, fentanyl, Toradol, percocet every two hours and a morphine pump," and discharged on a fentanyl patch! Inpatient for five days! Wowie. For a hemorrhoid.

I can understand and sympathize with Mr. Beck if there was indeed a delay in getting the catheter in. In our ER those cases usually get brought more or less right back, because retention is so uncomfortable and it's such a quick fix. He was annoyed with the staff's apparent lack of empathy. I wonder if his histrionic behavior at triage contributed to the lack of urgency the nursing staff felt in addressing his complaints (in general, the more dramatic the behavior, the less acute the problem). It's hard to say whether the staff was truly indifferent and callous, or whether Beck's self-absorbed perspective just made them seem so. Either is perfectly possible, but Beck's credibility isn't running real high in this self-aggrandizing narrative.

Some of KevinMD's commenters thought that it was dumping on the ER that he was sent there for admission. In fact, I disagree. I go nuts with frustration when people show up saying "my husband's doctor called, they're expecting him, he needs to have a catheter put in and he needs pain medication right away; he needs to be admitted." But given that he had urinary retention, the ER was in fact an appropriate place to go, and the evidence would suggest that his doctor did the right thing and admitted him himself. So, not truly a dump.

I'm still amazed that the surgeon admitted him for hemorrhoid pain. I wonder, had he not been a TV personality and VIP, would he have been? In my experience, these cases wind up with the surgeon (or his on-call partner who doesn't know the patient) not seeing the patient and telling the ER doc over the phone "just send him home." In most cases, this puts me in the position of being the "bad guy," but on the other hand, I'm used to being the bad guy, and there is little justifiable indication to admit people for pain which in any reasonable person would be managed with NSAIDS and mild to moderately potent opioids.

Patients like Beck are a terrible challenge. With prior histories of drug abuse, they often have poor response to standard treatments for pain, and concomitantly, a very heightened perception of pain. Throw in poor coping skills, a sense of entitlement, maybe narcissistic personality disorder, and it's a management nightmare. No amount of medicine is ever enough. You can, as demonstrated, put them into a drug-induced coma and they still complain of unbearable pain, and the pain does not resolve even as the physiologic insult heals. So as a doctor, you either wind up over-medicating them to little effect (and feeling like you are contributing to the problem), or sending them out, still complaining of pain, and feeling like a heartless bastard.

One might hope that this experience might teach Beck some empathy and compassion, traits notably absent from his media personality. The tone of his blog post makes me expect that he will instead mount a crusade against the evil and indifferent medical community and their inability to treat hemorrhoid pain. Great; just what we need. Just as well nobody is watching.

14 comments:

  1. Mr. Beck, I mean you ABSOLUTELY no offense with this, but i feel like I need to say to you: Sir, prove to me that you aren't a self-absorbed, megalomanical, narcotic pill gobbling piece of sh*t.

    ReplyDelete
  2. House Whisperer1/11/2008 9:31 AM

    Hope they were able to avoid his head during the procedure.

    ReplyDelete
  3. Annoyed ED Pharmacist1/11/2008 11:43 AM

    Beck's entire opioid-induced story aside... How many times does the FDA need to tell people to quit using fentanyl patches for PRN analgesia, yet it still happens?

    http://www.fda.gov/cder/drug/advisory/fentanyl_2007.htm

    Maybe they just considered him opioid-tolerant and let him have it. Given his prior history, what's to say he doesn't go home and point the hair dryer at it to get a better buzz?

    ReplyDelete
  4. Dude was on Fentanyl patches along with Perkies for post-op HEMORRHOID pain? Hell, I'd make the doctor come in and put those on himself. That just doesn't make any sense.

    ReplyDelete
  5. Beck's rant, sense of entitlement, and insatiable appetite for narcotics reminds me of the same petulant cry from the left demanding government entitlements.

    ReplyDelete
  6. You write "I read Beck's narrative with a grain of salt..." and "...I cut him some slack...."

    This after you begin your post by calling him a "demagogue, racist, homophobe and all-around scumbag."

    I appreciate your giving him the benefit of the doubt, but with an established bias like yours, why even try to be fair?

    ReplyDelete
  7. I hope to heaven that in real life you are a kind, loving person with a lot of redeeming qualities. I hope you are a dedicated family man who is always ready to support a friend. I hope your patients all believe that you are a compassionate and caring doctor. Because reading invective like this just makes me sick. Not sick because I am afraid of disagreement, not sick because I am swayed by your arguments, not sick because I am intolerant of dissent, not sick because I am a member of the conservative elite. I find your thoughts and feelings as conveyed in your writing not just misguided and wrong, but actually disgusting and disturbing on a visceral level. I would argue with you but I just don’t think we even have enough common ground to have a conversation. So, I apologize for lowering this to an ad hominem comment. Feel free to delete it. I did, however, want to express my feelings before signing off.

    Good bye.

    ReplyDelete
  8. You were saving that, I see. Well played.

    ReplyDelete
  9. I had no idea who Glenn Beck was until this came up on the Internet and I saw that man complaining. Maybe he has some life threatening illness... Even, though,this looked more like whining than anything else.

    I find your post well written, logical and very informative. It answered some questions I had.

    Thanks to you, we now have the other side of the story.

    ReplyDelete
  10. Naw, I'm just messing with you. I think Glenn Beck is a pussy too.

    ReplyDelete
  11. well played indeed panda bear.
    lol

    ReplyDelete
  12. Heh. I started to watch his video, and I didn't even get to him accounting any of his medical nightmare before I shut it off. No way do I believe one word coming out of that man's mouth, and he was just talking about a lot of nothing at that point.

    ReplyDelete
  13. Problems with Health care found.2/04/2008 4:10 PM

    CNN's resident demagogue, racist, homophobe and all-around scumbag Glenn Beck

    Good Grief! You are the type of ER doctor Glen Beck talks about. You sound like a uncaring, mon compassionate doctor who should get as far away from any hospital as you possibly can. What the hell does any of what you feel about him have to do with what he went through? Do you always decide what kind of care a person received based onm their personality? If that is the case then maybe you wil get that in return one day. You are scary.

    ReplyDelete
  14. People's pain experience is different for every individual, and having a low threshold is expected in a certain segment of the population. I have not seen Mr. Beck's video, but I am shocked to see a medical doctor determine how much pain a person is in by how "trivial" they consider the problem. I have peripheral neuropathy and my pain is severe even though the physical "insult" that originally caused the pain is long healed. There is actually a good deal of evidence that my chronic neuropathic pain may have resulted from undertreatment of the original acute pain. Indeed, pain occurs even in places that aren't there, as in the very common instance of pain in phantom limbs following amputation. This pain is not more valid simply because a limb amputation is a more serious operation than a hemerrhoidectomy. The only person who knows how much pain a patient has is the patient. There is absolutely no evidence that supports withholding narcotic pain relief in an effort to prevent addiction. Lack of pain medication causes far more unnecessary suffering than pain medicine addiction.

    ReplyDelete