I'll be the first and step up in defense of Floppy regarding the pain issue. My personal beliefs regarding pain are based only on 1) treating lots of people in FM who suffer chronic pain, and 2) being someone that has some degree of chronic pain every day of my life.
I'll explain: Not quite a decade ago I injured my back during a military exercise and literally thought I could never possibly feel pain that bad again in my life. The accident led me to feel like 220 volts of electrons had been injected with a 60cc Toomey syringe right into my lumbar spine. I could not feel my left leg at all on the medial side from the mid thigh distally, and could not even lift it at the hip more than 30%. I had the misfortune of going to an ED where the doc had seen one too many back pain patients and he did the old "lumbar series", plus oral Robaxin 750mg and Vicodin 5/500 one each. That took the pain from a 19 on a scale of 1-10 down to a 12!! Of course the L-spine series was normal because we all know how common any sort of bony abnormality is acutely in that region.
But like all lumbar back pains (98%), within a month I was almost normal again save the sensory loss. My strength was 90% back as well. I had an epidural steroid around that time and only 1-2 times per year since then do I have an issue with my back. But the last couple of years I have had some acute episodes from doing something stupid, where I literally have to be in the fetal position on my side on the couch. My latest MRI shows paracentral herniation at 3 levels with thecal sac compression. I live through this and still manage to get plenty of cardio, swim, everything except running. But on occassion, like I mentioned, I have a terrible time. A few times I contemplated calling an ambulance because I only had my cell phone and couldn't get off the couch to take a whizz. That time I just pissed in my gatoraid bottle and waited for my wife to get home.
But having been through this, and sometimes having a bad week, I can testify that it is one of the most humiliating and uncomfortable situations to be in when you are a knowledgable provider in pain. You always wonder if someone thinks you are "seeking" and its sort of the same feeling you get when you walk out of Target and the "alarm" goes off because some cashier forgot to take the tag off your sales item. You laugh but I carry my MRI result folded up in my wallet because I worry I could be in an accident and the ED doctor NOT understand or believe I have some serious underlying pathology. I'm not about to let some arrogant prick tell me I am not hurting if I am....and well past feeling guilty about having pain!
Since being a patient myself in these situations, I look very differently at patients who come in complaining of severe pain. I really am bothered by young interns and residents who acquire that "people asking for pain meds are always abusers" attitude. Trust me, when you are hurting that bad and you have had the problem before, you know what works and does not work. I personally believe that you are obligated to treat acute pain acutely and aggressively unless you have a real freaking good reason not to. As long as you cover your a$$, and do a very thorough exam, you should be able to determine who is really in pain and treat them appropriately. Don't place yourself on some pedistal and assume that everyone for whom Toradol does not work is drug seeking. I have been known to load a reliable patient with 75mg Demerol and 10mg Valium each IM when they are having such a back spasm they cannot bend, breath easily, or move without intense pain. A smart provider can almost always tell the real thing from the unreal. And you owe it to your patients and yourself to learn how to treat these people appropriately. The provider who says "I don't prescribe or give narcs", and the provider who learns from the get go that the ED is "not the place for pain patients" is in the end a bad ED doc. The ED is the end of the line for some people who suffer pain, and it is our obligation to treat them.
All I am saying is don't develop bad habits before you really take the time to learn who is jerking your chain. Its better to give an actor pain meds if documented appropriately than to deny one single person pain meds because you are a cynic. And for God's sake don't always freak out when you see someone coming into the ED for acute pain on top of their chronic pain for which they already take 3-4 Darvacet per day. Don't assume because it would put most of us on the floor unconscious that its not someone's normal day to take 20mg of Oxy BID.
Pain is way misunderstood from the ED standpoint and I applaud the geriatric doctors and oncologists who have finally got onboard to help keep people from suffering. Most of these good PCP's and specialists can help keep pain patients out of the ED if they just treated it appropriately in their offices. Its truly an urban legend that docs get busted for treating pain anywhere near appropriately. All the guys I know who got burned for narcs were running cough syrup mills or allowing someone to use their signed pad too leniantly...like a midlevel or a nurse refilling over the phone. Examine, document, and treat accordingly. Sure you will overtreat a few patients here and there, but your pain radar will never be fully developed if you are a skeptic already the day you leave residency.
