15 October 2010

Friday Flashback - Small Victories Part Two

I work from time to time at a rural hospital up in the mountains. It's a pleasant change of pace from the high-intensity trauma center where I do the majority of my shifts. The acuity, volume, and patient population vary dramatically, as you might expect. The Big Hospital sees over 100,000 ED patients annually, whereas the rural shop sees less than 20,000.

One interesting consequence is that the nurses in the little hospital seem to know all the patients, either socially or from previous ED visits or both. Depending on the circumstances, it can be very helpful or very awkward (or both). One recent night, a woman came staggering into triage clutching at her lower back. The charge nurse groaned upon seeing her, and took me aside: "We know her from before. She's a big-time drug seeker, and has been caught on more than one occasion altering and forging prescriptions from this ER." She pulled out a binder where we keep "care plans" for patients with chronic pain and narcotic issues. The patient's history was laid out there in its sordid detail, and supported the Medical Director's recommendation that this individual not be prescribed narcotics. "Just kick her out of here, will you," the nurse suggested.

As helpful as this kind of advance knowledge is, I kind of hate it. I still have to go in and see the patient, and it's very hard not to be prejudiced about the encounter and give the patient a fair evaluation. Especially when the vast majority of time the prejudice would have been accurate. So I try to push the "drug-seeker" conclusion out of my mind until after spending some time with the patient. But it's not easy.

This encounter, however, did not seem likely to diverge from my preconceived expectations. She informed me that this was her standard back pain for which she was on a staggering dose of narcotics (OxyContin, 80 mg TID plus oral Dilaudid!) but the pain had just become intolerable. It was with a sense of despair that I went through the formulaic questions necessary to differentiate chronic back pain from an acute emergency, and her answers were bland and unrevealing. I noticed, though, that she was sort of writhing on the bed, and when I asked her directly, she said that, yes, in fact, the pain was coming in waves. Hmmmm. Might there be something more than myofascial back pain?

So I got a simple test: a urinalysis. It showed a microscopic amount of blood in her urine. The nurses rolled their eyes at me when I ordered a CT scan of her abdomen, but to my mild surprise and infinite satisfaction, the scan showed a large obstructing kidney stone!

It just goes to reinforce the old adage that even drug-seekers get sick, too. But then I found myself with a conundrum: how on earth was I going to control her pain. When you are on high doses of pain medicines, they lose their potency, and I estimated that I could use all the morphine in the hospital without making a dent in her pain. Worse, she had deteriorated somewhat in the time it took to get the scan, and when I saw her again, she was pale and covered in a sheen of sweat.

Predictably, she was "allergic" to Toradol, as many drug-seekers claim to be (it doesn't provide the euphoria that narcotics do) but when I questioned her carefully she said it just "upset her stomach" and "doesn't work for me." So I explained that I thought narcotics would not help her pain, but I thought Toradol might, and she agreed to give it a try.

Forty minutes later I checked on her again and she was resting comfortably. With gratitude, she said, "I can't believe how well that stuff worked! I never would have thought it." A little while later, she went home, feeling "100% better," and I faxed some prescriptions over to the pharmacy for her. By god, it is satisfying when things works like they are supposed to, and in this case, it perfectly split the Gordian knot of pain management in the opiate-addicted patient.

Originally Posted 28 November 2007


5 comments:

Pro said...

Good it worked out well, without morfin.

Where I live, it’s often us a combination between:
i.m./i.v. Voltaren/Diclofenac and Buscopan/Butylskopolaminbromid.

Mal Content said...

Just really amazed that you can get a CT on the same day that you want it...Oh Lordy Lordy...I can only imagine what its must be like working in the First World!
PS...we use a Voltarol suppository and IV Buscopan combo.

WongML said...

Awesome work doc.

-MS4 and EM bound

Anonymous said...

Kidney stones. As someone who has had them, and numerous procedures because of them, for over 20 years, the thing that irks me the most is the problems that drug seeking patients cause for folks like me.

If have to go to an ED other than the one I work in or the one in my home town I always, always, always, get the look and the bajillion hour wait for them to prove it is a kidney stone and then some pain relief.

This is one time when I wish electronic records were available so they could look and see that 9 times out of ten I refuse any medications to take home with me and every time I have reported to an ED for "flank pain" it has been kidney stones.

For me I think Toradol is so/so. Sometimes it has helped and sometimes it has not.

jacopo said...

I had a 6mm obstructing stone during my intern year. My presentation was a bit strange and the attending ended up giving me 2 mg total of Dilaudid prior to diagnosis (I only weighed maybe 140 at the time; I remember saying, "My pain is still about an eight, but I don't care anymore." After the CT, 30 mg of Toradol and the pain vanished. Phenomenal.