28 November 2007

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.


  1. A great post. I also work part time in rural ED and part time in urban trauma center (though not as busy as yours). I have been impressed with how well the care plan system works in the little ED--but as you said, you have to treat everyone the same because you will be surprised.

  2. As a chronic back pain patient who is prone to kidney stones, I am glad to see that you did a work up on her. I am also glad to see that you followed the instructions by her physicians. I have heard more than once, "Your doctor doesn't work in this ER and I am going to treat you as I see fit..." In my case this has either snowed me (4 mg of Dilaudid IV plus valium and nausea meds... NAPTIME) or caused a bad case of hives or been told you are already on meds "Take 2 Tylenol"...

    Thank you for being a good doc!

  3. I would strongly encourage you to look into Osteopathic Manipulative Medicine. As a first year osteopathic medical student I've been blown away by what they can do for people with these treatments

  4. Yeah, because any sort of manipulation is going to get rid of that kidney stone.

  5. Yeah, go back to med school, be an MD and a DO. Dr. Dr. Shadowfax!

  6. I have decided I really enjoy your style. You are intelligent and worldly. You strive not to judge a book by its cover. Instead, you think critically and manage to make your way through speed bumps in your way.
    I can appreciate a physician with those qualities. You are rare. Never lose your spunk! Your patients are lucky to have you.


    I am not a drug seeker. I work for a hospital in the pacific NW.

  7. good thing u didnt kick her out, she could have sued ur ass off lol. also im an opiate addict, im clean now thanks to buprenorphrine(subutex/suboxone). i was a drug-seeker before tho its funny to read about it now after 2 years of clean time . ers were my drug dealers.

  8. What constitutes a drug seeker? I am a RN that has worked in the ER and now in ICU. Every time I talk to a different person they have their very own definition. Sometimes all it takes is being on workers comp, other times it's a diagnosis of chronic back pain, chronic migraines anyone? fibromyalgia, kidney stones...I always thought a drug seeker was someone who regularly (at least once every two weeks) came to the ER and asked for narcotics irregardless of the severity of their diagnosis.
    See that sneaky assumption that every doctor and nurse would always do a complete and thorough investigation of the presenting complaint every time and get a diagnosis?

    I think this because where I have worked they made it compulsory not to leap to any moral judgments about people. We provide health care , we aren't experts on polite behaviour and being a good citizen so we realize we aren't qualified to make moral judgments about people.
    This was made compulsory because a very dumb and mean doc and nurse judged that a gentlemen who came in complaining of agonizing back pain was a "drug seeker". They gave some Toradol and quickly gave him the boot.
    He died shortly afterwards at home......
    yes, dissection and finally rupture of an aortic aneurysm.
    Neither one of these supervisors of morality even lifted the guys shirt.

    I am always saddened by these posts. The sudden surprise, the shock and awe of discovering that all people will go for medical help when in enough pain. Sometimes that pain comes from medical problems caused by non prescribed medications. Our job is then to diagnose and treat, it could be nausea and anxiety from withdrawal or it could be something that will cause their immediate death.
    I really, really wish people would keep their personal beliefs at home where they can lecture their spouse, kids, brothers, sisters and gramma about the right way to behave and just treat the medical problems with medical solutions at work.
    Thanks for making sure this person got treatment and thanks for thinking of a plan to help her get through something so very painful.

    Putting judgments aside and just doing what must be done and then doing it well all have become rare and vanishing acts as of late.

  9. This comment has been removed by a blog administrator.

  10. A kidney stone is a hard mass developed from crystals that separate from the urine within the urinary tract. Normally, urine contains chemicals that prevent or inhibit the crystals from forming. These inhibitors do not seem to work for everyone,

    kidney stones


Note: Only a member of this blog may post a comment.