Attendings, how strict are you with pain meds and antibiotics?

[Angry Birds]

Kindly discuss.

I myself am very strict with the former but find myself succumbing to the latter.

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[The White Coat Investor]

Don't kill yourself over either, but part of being a good doc means using both judiciously.

 

[Xerxes1729]

I should be more consistent, but I'm not. If it's early in the shift and I have time, I'll sit and explain why you don't need antibiotics for your cold. If I'm trying to get out or am getting slammed, sometimes I'll just cave for the sake of getting you out the door quickly with minimal fuss.

I also write a lot of scripts for two to four tabs of Percocet. Is that passive-aggressive? It probably doesn't help my patient satisfaction surveys.

 

[msgsk]

We've had a recent big push on pain management as admin thinks it's the biggest correlator to patient satisfaction.

I usually don't mind writing for 5-10 tabs of narcotics even in the most questionable cases and our patients don't usually mind as long as they receive something.

 

[The White Coat Investor]

2-10 pills? Why bother. At 2 every 4 hours you're only providing 4-20 hours of pain relief, no? Seems kind of silly sometimes. But I confess I pretty much only write for more than 15 if there is a broken bone.

My favorite is when I look up somebody's controlled substance database report and see a script for one pill. I find it hilarious that a doctor wrote it, and even funnier than somebody actually filled it. If that isn't a sign of a drug-seeker, I don't know what is.

 

[cyclohexanol]

I should be more consistent, but I'm not. If it's early in the shift and I have time, I'll sit and explain why you don't need antibiotics for your cold. If I'm trying to get out or am getting slammed, sometimes I'll just cave for the sake of getting you out the door quickly with minimal fuss.

I also write a lot of scripts for two to four tabs of Percocet. Is that passive-aggressive? It probably doesn't help my patient satisfaction surveys.

Passive aggressive is a script for percocet 5/325mg 0.5 tab PO BID disp #1 no refills.

I reserve it for people who fight me over analgesics and "refuse to leave" until they get their percocet. Sure I could just have security escort them out, but I like the passive aggressive rx better.

 

[Birdstrike]

2-10 pills? Why bother. At 2 every 4 hours you're only providing 4-20 hours of pain relief, no? Seems kind of silly sometimes. But I confess I pretty much only write for more than 15 if there is a broken bone.

My favorite is when I look up somebody's controlled substance database report and see a script for one pill. I find it hilarious that a doctor wrote it, and even funnier than somebody actually filled it. If that isn't a sign of a drug-seeker, I don't know what is.

Most of the 1 or 2 pill prescriptions are a benzo for sedation/claustrophobia for an MRI or a couple pain pills for an outpatient procedure. So it's not funny, hilarious or silly. In fact, it's super smart and more judicious and ethical than the easier route which would be to do the 30 day crowd-pleaser mother-load of a controlled substance.

 

[Apollyon]

Most of the 1 or 2 pill prescriptions are a benzo for sedation/claustrophobia for an MRI or a couple pain pills for an outpatient procedure. So it's not funny, hilarious or silly. In fact, it's super smart and more judicious and ethical than the easier route which would be to do the 30 day crowd-pleaser mother-load of a controlled substance.

Back in my first job, I gave a sketchy patient 1 Percocet on an Rx to go. He said "You have the worst bedside manner I've ever seen!" (<-- true story)

 

[Angry Birds]

I write for Dolobid (an NSAID), which sounds a lot like "Dilaudid." Usually works.

 

[Birdstrike]

I make them all crack the Code of Hammurabi, first. If they can, they get whatever they want. If not, "Suck. It. UP. and go to In And Out Burger ER down the road, buddy!"

 

[WilcoWorld]

I make them all crack the Code of Hammurabi, first. If they can, they get whatever they want. If not, "Suck. It. UP. and go to In And Out Burger ER down the road, buddy!"

Did you know that Richard Feynman (Nobel Prize winning physicist and conga drummer) deciphered the Mayan language just for fun? IMO he ranks as one of the world's most awesome people ever.

 

[Cerberus]

I work at a County shop without PG surveys to worry about.

If I think you don't need antibiotics I don't write them. I try to explain in terms they can understand why they don't need them and usually they don't cause me a headache.

Drug seekers are more difficult. I generally tell them it is not our policy to write narcotic pain meds for chronic conditions. It often ends up with histrionics, insults, threats but I don't really care. If I have to have security escort them out.

 

[xaelia]

I can't be talked into antibiotics if I don't think they need any. Usually just a lot of quiet sadness at their perceived time wasted after I finish my little bit about the harms of antibiotics in the context of no possible benefit.

I used to be a county-type shop where narcotic requests were met with a GTFO. Now, I'm in an integrated system and the general culture is the ED is sort of an extension of our primary care team – so I end up writing for more bridging narcotics etc. when the PCP isn't available.

 

[Apollyon]

Usually just a lot of quiet sadness at their perceived time wasted after I finish my little bit about the harms of antibiotics in the context of no possible benefit.

Yeah, that 30 seconds is a killer: "the worst thing would be to get a rash and an allergy and diarrhea, when the antibiotics wouldn't even treat the problem".

 

[Promethean]

2-10 pills? Why bother. At 2 every 4 hours you're only providing 4-20 hours of pain relief, no? Seems kind of silly sometimes. But I confess I pretty much only write for more than 15 if there is a broken bone.

A <10 pill script is appropriate for short term management of acute pain.

Yes, that is only 8-40 hours of relief (why take 2 at a time?) if it is being taken round the clock, q 4. But someone who is really in pain, not just seeking a thrill, may not really need round the clock dosing for days on end in order to effectively manage pain. It may be that their pain is manageable with distraction, NSAIDs, etc. most of the time, but that they could benefit from taking a single percocet for extraordinary exacerbations or to help them be comfortable enough to get some rest. 1-2 doses of opiates a day can be enough to make some kinds of acute pain tolerable. Pain-free is a dangerous expectation. Judiciously used, an emergency prescription of 6 or so pills should absolutely get someone through the worst parts of a sprain or other minor crisis, especially if they can then follow up with a PCP. Injudiciously abused, at least it isn't enough to do them a great deal of harm.

 

[Birdstrike]

Yeah, that 30 seconds is a killer: "the worst thing would be to get a rash and an allergy and diarrhea, when the antibiotics wouldn't even treat the problem".

"...or if you're lucky, you'll develop a superbug that would maim you, not kill you, by rotting your limbs off with resistant nec/fash that would be untreatable by any known antibiotic But if you really insist, you can have them."

"Okay, that'd be good. You're awesome, thanks."

 

[deleted109597]

Did you know that Richard Feynman (Nobel Prize winning physicist and conga drummer) deciphered the Mayan language just for fun? IMO he ranks as one of the world's most awesome people ever.

He also taught himself how to pick locks while at Los Alamos. Agree that he's pretty awesome.

 

[ccfccp]

Did you know that Richard Feynman (Nobel Prize winning physicist and conga drummer) deciphered the Mayan language just for fun? IMO he ranks as one of the world's most awesome people ever.

They have a Nobel Prize for conga drumming? Sign me up!

 

[Apollyon]

Did you know that Richard Feynman (Nobel Prize winning physicist and conga drummer) deciphered the Mayan language just for fun? IMO he ranks as one of the world's most awesome people ever.

I just want to learn to play the ukulele and to speak German before I die!

 

[Promethean]

I just want to learn to play the ukulele and to speak German before I die!

Your wishes are granted:




You are welcome.

 

[The White Coat Investor]

Most of the 1 or 2 pill prescriptions are a benzo for sedation/claustrophobia for an MRI or a couple pain pills for an outpatient procedure. So it's not funny, hilarious or silly. In fact, it's super smart and more judicious and ethical than the easier route which would be to do the 30 day crowd-pleaser mother-load of a controlled substance.

Well sure, if that's their only script in the last year, or if there are only 1 or 2 others. But when that one pill is one of 2000 for the year.....

 

[WilcoWorld]

Interesting (by which I mean infuriating) ruling here.

More and more, I think that the decline of American Medicine is a result of a pervasive paradox: we value personal freedom, but do not recognize personal responsibility. You just can't have one without the other.

 

[DrDrummer]

He also taught himself how to pick locks while at Los Alamos. Agree that he's pretty awesome.

The majority of my interview with the chair at Harbor-UCLA was talking about Richard Feynman (their chair has a PhD in physics) and his bongo playing, lock picking ways. Never thought that random knowledge would come in handy.

 

[Birdstrike]

Interesting (by which I mean infuriating) ruling here.

More and more, I think that the decline of American Medicine is a result of a pervasive paradox: we value personal freedom, but do not recognize personal responsibility. You just can't have one without the other.

You're right. You can't have one without the other. But in this country we want have our cake and eat it, too. We elect lawmakers and judges that not only allow this nonsense, but encourage it. Let's have people sue Wine Spectator magazine, because they recommended the wine that "caused" the alcoholism, also.

As far as that ruling, its absurd, but it's not anything new. Many patients have sued their doctors for supposed "iatrogenic addiction." How many of those are actually successful, I don't know. It's no more than an extension of the, "Anyone can sue anyone for any reason, no matter how ridiculous" precedent we have in this country. We need more judges that do a better job about dismissing these nonsensical cases out of hand, but they don't. They side with the plaintiffs attorneys (because most of them are attorneys first) and allow abuse of the, "Everyone deserves their day in court" concept. Part 2 of the problem is that juries then render verdicts that go along with it. The result is that we have cases like this:

"Drunk Man falls on subway tracks sues and wins $2.3 Million"

http://gothamist.com/2009/02/18/drunk_man_wins_23_million_for_falli.php

Hopefully, most of these cases either get dropped or result in dependent verdicts when it's shown the doctors prescribed for legitimate medical use (hopefully) and followed DEA guidelines (hopefully).

 

[AmoryBlaine]

Quite strict w/ abx. It's generated several formal complaints but my shop doesn't get too worked up when a viral syndrome is pissed they didn't get zpak.

Usually max #15 narcs for anything less than large bone fx or cancer.

Absolutely no parenteral narcotics ever for chronic pain patients, toradol or PO norco. They usually leave as soon as they find out nothing is coming IV.

No IV benadryl either, ever, to chase pain meds. If someone says they break out with dilaudid unless they get benadryl then I tell them I'm not giving them either b/c I'm not comfortable giving them a med they are allergic to.

Often end up writing: "pt stormed out of ED, refused to participate in evaluation."