Have you seen this new disease?

[Arcan57]

So lately our hospital has been seeing an epidemic form of a uncomfortable but benign condition that has mutated into something much more difficult to treat. Even more scary, it doesn't seem to be respecting traditional risk factors and vulnerable populations. It gets worse in that one of our front-line drugs for this condition is no longer available due to manufacturing issues. Please let me know if you've seen this disease entity and if you've found an effective treatment.

I don't know if it's already been described in the specialist literature, but I call this disease - Multi-Drug Resistant Abdominal Pain (MDRAP). While it's been previously seen in populations with diabetic gastroparesis, cyclic vomiting, fibromyalgia, and narcotic dependence lately we've had a run (3-4/shift) of previously healthy patients who have benign histories, typically LUQ ttp, and completely negative work-ups (including CT w/IV&PO contrast on those who required admission). Neither protonix, GI cocktails, hyocyosamine, or multiple high doses of IV narcotics (typical dose range 12-24mg morphine equivalent) provides pain relief and these patients are typically admitted for symptom control with a negative in-patient GI work-up.

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[Rendar5]

We call it *****-itis, or medicaid syndrome. There is no cure, other than multiple ED visits.

 

[Arcan57]

We call it *****-itis, or medicaid syndrome. There is no cure, other than multiple ED visits.

That's the thing, this has been middle aged people with jobs and private insurance. It's weird because they don't come across as trolls but they also don't get better. And also, I love the sound of multi-drug resistant abdominal pain.

 

[RustedFox]

That's the thing, this has been middle aged people with jobs and private insurance. It's weird because they don't come across as trolls but they also don't get better. And also, I love the sound of multi-drug resistant abdominal pain.

This.

Narcotic Bowel Syndrome. There's such a narc-problem here in FL it makes MY abdomen hurt every shift.

 

[gman33]

Admit them all so you don't get dinged on the press ganey

 

[neusu]

As an evident "'back pain specialist" as a neurosurgery resident..

I often wonder what goes through these people's heads'..

Hey, it's Tuesday night and I feel like getting high, why don't I show up at the local ED and complain of severe back pain, maybe radiating, or if I really want to hang around, incontinence?

Certainly, you have to treat pain. People have different pain thresholds. No one I have ever had as an inpatient after maximally invasive spine surgery needs 4 mg of dilauded every hour..

 

[bougiecric]

What a great term. I'm totally stealing it to use repeatedly during my next shift.

I do believe there is one anti-AP-ic that MDRAP is often still sensitive to: droperidol. Unfortunately this has been unavailable in our ER for months.

 

[WilcoWorld]

Excellent thread Arcan…before I even got to bougiecric's post I could guess that this was going to turn into another of our love letters for droperidol. It was definitely my first line therapy for MDRAP. Since it's become unavailable I've had a little success with low-dose haloperidol+diphenhydramine, but nuthin' works like the dro.

 

[EM Junkie]

Love it.

Also a fan of Droperidol or Haldol.

We also have a "No Dilaudid/Demerol" policy, so that helps.

I'll often tell them if their labs are normal they're getting discharged. I couldn't give a rat's a$$ what their BP is (always >200). As long as their potassium is >2.8, it's off to the house they go.

 

[deleted547339]

This.

Narcotic Bowel Syndrome. There's such a narc-problem here in FL it makes MY abdomen hurt every shift.

Amen. Add on meth if you're in the central florida area, lol.

 

[zinjanthropus]

Haldol

 

[Spinach Dip]

ADD:

Acute
Dilaudid
Deficiency

 

[southerndoc]

ADD:

Acute
Dilaudid
Deficiency

AKA Dilaudipenia

 

[deleted547339]

Love it.

Also a fan of Droperidol or Haldol.

We also have a "No Dilaudid/Demerol" policy, so that helps.

I'll often tell them if their labs are normal they're getting discharged. I couldn't give a rat's a$$ what their BP is (always >200). As long as their potassium is >2.8, it's off to the house they go.

I get the no Demerol, but no vitamin D? I get that the addicts love it, but its a good drug for people in severe pain. When I think someone is seeking, I'll make up a policy, "no narcs for X. Y, Z" or "only for people that have cancer or going to surgery" or some nonsense like that.

 

[KarlPilkington]

I hate dilaudid.

My new years resolution was to not use dilaudid unless someone had cancer, or in the case of a sickle cell patient who was compliant with outpatient meds/appointments. 11 months in I've yet to have one case where I was unable to get someone comfortable using morphine/fentanyl. If you're having pain 0.1mg/kg morphine with 0.05mg/kg after ~20 minutes is a great medicine. Morphine has less mu receptor affinity, so you get great pain relief without the overwhelming euphoria that comes from Diluadid, which really hits that mu receptor. Dilaudid has become just as problematic as demerol in our shop due to folks who really want that rush you get from dilaudid.
Outside of cancer/ss I tell patients "I just don't use dilaudid for this kind of pain." I've had a dozen patients storm out but have had no patient complaints.
I'm a huge advocate for treating pain/anxiety. I'll give a dose of versed for foley placement, I'll use EMLA for IV placement in adults, I just don't give Dilaudid.

 

[Arcan57]

Fentanyl actually seems to work really well for sickle cell pain. I don't know of any study showing that fentanyl has decreased euphoric effects compared to dilaudid, so I'm not sure how evidence based is KP's stand against dilaudid

 

[EvoDevo]

One trick that I've been using is the 1 mg Dilaudid in 50 mL NS run over 20 minutes. Pts get pain relief and it (anectdotally) seems to avoid giving the euphoria. I've actually had my narc seekers get up and rip out IVs when they see that.

 

[VA Hopeful Dr]

One trick that I've been using is the 1 mg Dilaudid in 50 mL NS run over 20 minutes. Pts get pain relief and it (anectdotally) seems to avoid giving the euphoria. I've actually had my narc seekers get up and rip out IVs when they see that.

I started doing that last year for some of my more questionable inpatients (after reading a post here, very possibly yours)... my LOS in frequent flyer patients improved remarkably.

 

[deleted547339]

Do y'all not have a fentanyl shortage?

 

[Arcan57]

Do y'all not have a fentanyl shortage?

Great googly moogly... are you serious?

 

[deleted547339]

Great googly moogly... are you serious?

Yes? I thought there was a national fentanyl shortage.....we only use it when we have a pt in severe pain and hypotensive.

Are y'all not restricted in your use of it?

 

[deleted547339]

I mean to say I can't just order fentanyl because I don't want to use dilaudid. I have to have a reason other than not liking dilaudid.

 

[deleted77919]

No fentanyl shortage/restrictions here. Would have to seriously change my practice habits.

 

[EM2BE]

One trick that I've been using is the 1 mg Dilaudid in 50 mL NS run over 20 minutes. Pts get pain relief and it (anectdotally) seems to avoid giving the euphoria. I've actually had my narc seekers get up and rip out IVs when they see that.

Works well. Except when the nurse hooks it up and realizes there is no pump. Leaves it clamped and walks out of the room. Returns to find the patient opened the clamp and it was running wide open. Let's just say that patient got discharged as soon as labs showed no sickle cell crisis. No prescriptions. No more pain meds. The patient was done. And the chart got flagged even though it was the first visit.

Do any of you have a system to flag charts of patients with issues? I love it. It gives me an idea of what I'm walking into. The downside is it can make you have a judgement before seeing the patient. I try my hardest to keep an open mind so I don't miss that bad thing one of them are bound to have at some point.

 

[Arcan57]

Works well. Except when the nurse hooks it up and realizes there is no pump. Leaves it clamped and walks out of the room. Returns to find the patient opened the clamp and it was running wide open. Let's just say that patient got discharged as soon as labs showed no sickle cell crisis. No prescriptions. No more pain meds. The patient was done. And the chart got flagged even though it was the first visit.

A minor point but you're doing things very wrong if you're expecting labs to show a vaso-occlusive crisis.

 

[alpinism]

Dilaumed is the answer.

http://www.gomerblog.com/2013/11/look-alike-sound-alike-medication-praised-er-physicians-everywhere/

 

[deleted547339]

No fentanyl shortage/restrictions here. Would have to seriously change my practice habits.

Im jealous.

 

[EM2BE]

A minor point but you're doing things very wrong if you're expecting labs to show a vaso-occlusive crisis.

It wasn't labs alone. It was patient behavior. The patient looked way too comfortable coming in the door. I was suspicious when the patient said they were from out of town (I'm talking 5 states away) and here visiting their spouse who lives here. And the spouse wasn't with them. It was a friend with them. And they didn't have a job in their normal location, so no reason to live so far away. And.... (Let's just say, the more the patient said / did, the more I didn't believe them.)

 

[I am THAT patient]

I've read many posts on this website and if this group represents the physicians who will be treating me, my children and grandchildren, I fear greatly for their health. I am THAT PATIENT. I have chronic pancreatitis. Ever heard of a pancreas, other than not to touch it? An AP attack will obviously show elevated lipase/amalyse and often LFT's. BUT, a person with chronic pancreatitis often has flare ups for which their meds at home do not help, hence their trip to the ER for help. But, a lazy, unmotivated ER resident probably does not know that with chronic CP, the pancreas is burnt out and lipase/amalyse doe not elevate. What then? Most CP patients have pain meds at home as well as nausea meds. We Hate coming to the ER to be treated as drug seekers. We have prescriptions to help the day to day every day pain, but we come to you when nothing is working. Have a little compassion, young doctors. Just because a bone is not sticking out through our skin does not mean that we are drug seeking. We are seeking help - from you. Please explore chronic pain and especially chronic pancreatitis. If you want to be of benefit to your patients, you will.

 

[jdh71]

I've read many posts on this website and if this group represents the physicians who will be treating me, my children and grandchildren, I fear greatly for their health. I am THAT PATIENT. I have chronic pancreatitis. Ever heard of a pancreas, other than not to touch it? An AP attack will obviously show elevated lipase/amalyse and often LFT's. BUT, a person with chronic pancreatitis often has flare ups for which their meds at home do not help, hence their trip to the ER for help. But, a lazy, unmotivated ER resident probably does not know that with chronic CP, the pancreas is burnt out and lipase/amalyse doe not elevate. What then? Most CP patients have pain meds at home as well as nausea meds. We Hate coming to the ER to be treated as drug seekers. We have prescriptions to help the day to day every day pain, but we come to you when nothing is working. Have a little compassion, young doctors. Just because a bone is not sticking out through our skin does not mean that we are drug seeking. We are seeking help - from you. Please explore chronic pain and especially chronic pancreatitis. If you want to be of benefit to your patients, you will.

I promise physicians are very familiar with chronic pancreatitis. This thread isn't about you. Though to be fair far too many chronic pancreatitis patients ARE drug seeking a-holes - don't act like every chronic panc patient is just pure as the driven snow. Since you know so much about it care to tell the group WHY so many chronic panc patients get chronic panc?? Oh yeah. That's right!!! Because they drank themselves into it. Drunks and drug seekers are the same kind of people. Get a little bit of perspective. To come in here and suggest that all of these physicians are "zomg!!!!'1!! Bad physician who lack compasssssdssion!!'nn!!" Clearly misses the point of thread where physicians getting to blow off steam. I suggest you ALSO walk a mile. Maybe when you've been through med school and training you can actually have the appropriate perspective to try and condescend.

 

[I am THAT patient]

I promise physicians are very familiar with chronic pancreatitis. This thread isn't about you. Though to be fair far too many chronic pancreatitis patients ARE drug seeking a-holes - don't act like every chronic panc patient is just pure as the driven snow. Since you know so much about it care to tell the group WHY so many chronic panc patients get chronic panc?? Oh yeah. That's right!!! Because they drank themselves into it. Drunks and drug seekers are the same kind of people. Get a little bit of perspective. To come in here and suggest that all of these physicians are "zomg!!!!'1!! Bad physician who lack compasssssdssion!!'nn!!" Clearly misses the point of thread where physicians getting to blow off steam. I suggest you ALSO walk a mile. Maybe when you've been through med school and training you can actually have the appropriate perspective to try and condescend.

I did not claim to be pure as driven snow. I am 58 years old and am not nor have I ever qualified to be even a social drinker or drug seeker. I worked in the legal field for 30+ years. Even without a medical degree I know that alcohol is not the main cause of CP. If you would review current research, you would know that while many alcoholics get CP, not many CP'ers are alcoholics. You are using out of date texts and/or references. I take great offense at your judgmental righteousness. I'd love to walk a mile in your shoes for a day - provided you walk a mile in mine. Please, in the name of humanity if not the Hippocratic Oath, do not label and judge people, that is not your job. I have attached a link to Dr. David Whitcomb, one of the premier pancreas experts at University of Pittsburgh Medical Center. It would be well worth your time to listen. But then again, why not just treat us all like the drug seeking a$$holes and alcoholics you have just us to be.

 

[jdh71]

I did not claim to be pure as driven snow. I am 58 years old and am not nor have I ever qualified to be even a social drinker or drug seeker. I worked in the legal field for 30+ years. Even without a medical degree I know that alcohol is not the main cause of CP. If you would review current research, you would know that while many alcoholics get CP, not many CP'ers are alcoholics. You are using out of date texts and/or references. I take great offense at your judgmental righteousness. I'd love to walk a mile in your shoes for a day - provided you walk a mile in mine. Please, in the name of humanity if not the Hippocratic Oath, do not label and judge people, that is not your job. I have attached a link to Dr. David Whitcomb, one of the premier pancreas experts at University of Pittsburgh Medical Center. It would be well worth your time to listen. But then again, why not just treat us all like the drug seeking a$$holes and alcoholics you have just us to be.

It is my job to assess patients and give appropriate treatments. Alcohol is THE most common cause of chronic pancreatitis in the western world. If you have some "new numbers" provide them. Money talks, and bull**** walks. I'll be waiting.

Again. The thread wasn't about *you*. But you seem to be too dense to understand that docs blow off steam too. Try. If you can. Not to be so self-centered that you can see not everyone is talking or thinking about you.

I promise the is not a single doc in this thread who won't give you pain meds if you carry a diagnosis of chronic pancreatitis and present with a flare and it all looks legit.

 

[TooMuchResearch]

It is my job to assess patients and give appropriate treatments. Alcohol is THE most common cause of chronic pancreatitis in the western world. If you have some "new numbers" provide them. Money talks, and bull**** walks. I'll be waiting.

Again. The thread wasn't about *you*. But you seem to be too dense to understand that docs blow off steam too. Try. If you can. Not to be so self-centered that you can see not everyone is talking or thinking about you.

I promise the is not a single doc in this thread who won't give you pain meds if you carry a diagnosis of chronic pancreatitis and present with a flare and it all looks legit.

UpToDate still lists alcohol as the etiology in at least 45% of cases, and the list of possibilities includes tropical pancreatitis, which we don't have in the USA, and a bunch of genetic stuff, which presents at a young age and should be easily differentiated from you middle-aged guy who ruined the organ with lifestyle choices.

 

[I am THAT patient]

It is my job to assess patients and give appropriate treatments. Alcohol is THE most common cause of chronic pancreatitis in the western world. If you have some "new numbers" provide them. Money talks, and bull**** walks. I'll be waiting.

Again. The thread wasn't about *you*. But you seem to be too dense to understand that docs blow off steam too. Try. If you can. Not to be so self-centered that you can see not everyone is talking or thinking about you.

I promise the is not a single doc in this thread who won't give you pain meds if you carry a diagnosis of chronic pancreatitis and present with a flare and it all looks legit.

I am not so dense as it may seem to you. I do not assume you are talking about me -- but you ARE and you are talking about the thousands of others across the globe who have the same condition to lesser and greater degrees. Docs have the right and should blow off steam. They should not, however, pass moral or social judgment on the human beings who come to them for help, whatever type help that may be. In two years, I have spent about 80 days in the hospital and it's not because I am an alcoholic or want drugs, but because I was severely dehydrated, in pain, throwing up anything (even a Percocet) that I tried to swallow. I have only had one bad ER experience due misguided nurse practitioner in ER who could/would not understand a thing I told her. I have been blessed to have mostly kind and understanding ER docs. I've only not been admitted from the ER twice, all others, I was in for 5 -10 days. Yeah, we seek that. Tons of fun.

I will find the treatise with the causation statistics and post it for you. A question though, while I have an "official diagnosis," and present with a flare that looks legit - I guess I am not smart enough to understand the definition of "looks legit."

 

[I am THAT patient]

UpToDate still lists alcohol as the etiology in at least 45% of cases, and the list of possibilities includes tropical pancreatitis, which we don't have in the USA, and a bunch of genetic stuff, which presents at a young age and should be easily differentiated from you middle-aged guy who ruined the organ with lifestyle choices.

Wow. What about children, autoimmune, genetic (more cases than you think)? Ruined the organ with lifestyle choices? Please? Do you not treat people injured in motorcycle accidents because they ruined their cranium?



Etiologic Risk Factors
Toxic Metabolic
Alcoholic
Tobacco smoking
Hypercalcemia
Hyperlipidemia
Chronic renal failure
Idiopathic
Tropical
Cause unknown; likely genetic
Genetic
Autosomal dominant
Cationic trypsinogen
Autosomal-recessive/modifier genes
CFTR mutations
SPINK1 mutations
Alpha-1-antitrypsin deficiency
Autoimmune
Isolated autoimmune chronic pancreatitis
Associated with the following:

1. 
   Primary sclerosing cholangitis

1. 
   Sjögren's syndrome

1. 
   Primary biliary disorder

1. 
   Type 1 diabetes mellitus

Recurrent and severe acute pancreatitis
Postnecrotic (severe acute pancreatitis)
Vascular diseases/ischemia
Postradiation exposure
Obstructive
Pancreas divisum (controversial)
Sphincter of Oddi dysfunction (controversial)
Duct obstruction (tumors, post-traumatic)

 

[VA Hopeful Dr]

Wow. What about children, autoimmune, genetic (more cases than you think)? Ruined the organ with lifestyle choices? Please? Do you not treat people injured in motorcycle accidents because they ruined their cranium?



Etiologic Risk Factors
Toxic Metabolic
Alcoholic
Tobacco smoking
Hypercalcemia
Hyperlipidemia
Chronic renal failure
Idiopathic
Tropical
Cause unknown; likely genetic
Genetic
Autosomal dominant
Cationic trypsinogen
Autosomal-recessive/modifier genes
CFTR mutations
SPINK1 mutations
Alpha-1-antitrypsin deficiency
Autoimmune
Isolated autoimmune chronic pancreatitis
Associated with the following:

1. 
   Primary sclerosing cholangitis

1. 
   Sjögren's syndrome

1. 
   Primary biliary disorder

1. 
   Type 1 diabetes mellitus

Recurrent and severe acute pancreatitis
Postnecrotic (severe acute pancreatitis)
Vascular diseases/ischemia
Postradiation exposure
Obstructive
Pancreas divisum (controversial)
Sphincter of Oddi dysfunction (controversial)
Duct obstruction (tumors, post-traumatic)

You're not getting it. We are all well aware that there are other causes of chronic pancreatitis, heck I had an 11 year old patient who got admitted 3-4x/year in residency for this problem. We never assumed it was because she drank. However, alcohol is the MOST COMMON cause of chronic pancreatitis - period. We're not saying that you're a drunk, but at least 45% of chronic pancreatitis patients are/were and they caused their disease through that lifestyle.

 

[TooMuchResearch]

I am not so dense as it may seem to you. I do not assume you are talking about me -- but you ARE and you are talking about the thousands of others across the globe who have the same condition to lesser and greater degrees. Docs have the right and should blow off steam. They should not, however, pass moral or social judgment on the human beings who come to them for help, whatever type help that may be. In two years, I have spent about 80 days in the hospital and it's not because I am an alcoholic or want drugs, but because I was severely dehydrated, in pain, throwing up anything (even a Percocet) that I tried to swallow. I have only had one bad ER experience due misguided nurse practitioner in ER who could/would not understand a thing I told her. I have been blessed to have mostly kind and understanding ER docs. I've only not been admitted from the ER twice, all others, I was in for 5 -10 days. Yeah, we seek that. Tons of fun.

I will find the treatise with the causation statistics and post it for you. A question though, while I have an "official diagnosis," and present with a flare that looks legit - I guess I am not smart enough to understand the definition of "looks legit."

You would understand "looks legit" if you saw chronic pain patients, drug seekers, and chronic pain patients who are also drug seekers every day at work.

 

[TooMuchResearch]

Wow. What about children, autoimmune, genetic (more cases than you think)? Ruined the organ with lifestyle choices? Please? Do you not treat people injured in motorcycle accidents because they ruined their cranium?



Etiologic Risk Factors
Toxic Metabolic
Alcoholic
Tobacco smoking
Hypercalcemia
Hyperlipidemia
Chronic renal failure
Idiopathic
Tropical
Cause unknown; likely genetic
Genetic
Autosomal dominant
Cationic trypsinogen
Autosomal-recessive/modifier genes
CFTR mutations
SPINK1 mutations
Alpha-1-antitrypsin deficiency
Autoimmune
Isolated autoimmune chronic pancreatitis
Associated with the following:

1. 
   Primary sclerosing cholangitis

1. 
   Sjögren's syndrome

1. 
   Primary biliary disorder

1. 
   Type 1 diabetes mellitus

Recurrent and severe acute pancreatitis
Postnecrotic (severe acute pancreatitis)
Vascular diseases/ischemia
Postradiation exposure
Obstructive
Pancreas divisum (controversial)
Sphincter of Oddi dysfunction (controversial)
Duct obstruction (tumors, post-traumatic)

I know the list of etiologies.

You said alcohol isn't a major cause. I said it is. Lifestyle choice.

 

[Birdstrike]

Fact 1-There are a tremendous amount of people with terrible pain from medical conditions that need opiate pain medications that don't abuse them.

Fact 2-There are also a tremendous amount of people with terrible, sometimes life-threatening addictions that will lie, manipulate and even break laws to obtain medications inappropriately who do not realize or want to acknowledge they're in dire need of substance abuse treatment, all of which are characteristics of the disease of addiction itself. These people are overdosing, by accident, in endemic numbers.

CDC: 41,000 drug overdose deaths in 2011, 30,000 of which were accidental (80%) and not intended by the people who were taking them, with 20,000 being from legal, prescription drugs.

http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html

The problem is that patients don't walk into an ED with one of those labels stamped on their forehead. And patient #2 will direct every single ounce of their will and energy to be perceived as if they are patient #1. This makes it incredibly difficult for doctors, nurses and patients alike (particularly patient #1). Making it even more exceedingly complex and difficult, there are many patients with both features, who have terrible pain from a disease, yet may have a terrible underlying addiction also, that they are doing everything they can to hide from their doctors, family members and from themselves.

So while it's easy to say "doctors are bad" because they may get frustrated with having to deal with this impossible dilemma constantly, the reality is that most are trying their best to do the right thing. They want to help those in need, whether that means giving pain medicine to those that need it, or not giving it to those who may be harmed by the medicine by feeding an addiction, who need substance abuse treatment, which many will refuse. We are all, doctors and patients alike, caught between a rock and a hard place with tens of thousand of people dying every year from their addictions. The best doctors do care, and caring does not mean indiscriminately giving out opiates while pretending there is no problem, addiction is a myth and that no one is hurt by opiates. Making matters worse, is that doctors are now being held liable for overprescribing, including criminal and homicide charges, in increasing numbers.

http://mobile.reuters.com/article/idUSTRE78D3P620110914?irpc=932

Bottom line: Addiction is a horrible and widespread disease/societal-problem and it makes things very difficult for doctors, and patients alike.

 

[Petypet]

Bottom line: Addiction is a horrible and widespread disease/societal-problem and it makes things very difficult for doctors, and patients alike.

As someone interested in in EM and Psych, how do we fix this? During my psych rotation we were told don't challenge people, especially with psychosis and addiction (at least acutely). Especially in a press ganey world we don't want to piss these people off, but if we don't help them certainly the vicodin addicts will turn to heroin and probably kill themselves.

Certainly this is not the interest of every emergency physician, but I think some people recognize these downers as a drag, whereas some recognize the underlying pathology and the simple fact that these people need help. Catch-22

 

[Birdstrike]

As someone interested in in EM and Psych, how do we fix this? During my psych rotation we were told don't challenge people, especially with psychosis and addiction (at least acutely). Especially in a press ganey world we don't want to piss these people off, but if we don't help them certainly the vicodin addicts will turn to heroin and probably kill themselves.

Certainly this is not the interest of every emergency physician, but I think some people recognize these downers as a drag, whereas some recognize the underlying pathology and the simple fact that these people need help. Catch-22

There's a tremendous amount I could write on this. Will try to after taking recert boards Sat. Need to get back to studying. Too much time on SDN, already today...

 

[TooMuchResearch]

As someone interested in in EM and Psych, how do we fix this? During my psych rotation we were told don't challenge people, especially with psychosis and addiction (at least acutely). Especially in a press ganey world we don't want to piss these people off, but if we don't help them certainly the vicodin addicts will turn to heroin and probably kill themselves.

Certainly this is not the interest of every emergency physician, but I think some people recognize these downers as a drag, whereas some recognize the underlying pathology and the simple fact that these people need help. Catch-22

On psych, you were told not to tell your schizophrenics not to do meth? That conversation was at least 25% of my rotation.

 

[Petypet]

On psych, you were told not to tell your schizophrenics not to do meth? That conversation was at least 25% of my rotation.

I was in a crisis unit so no challenging was acceptable. It was much like an ED-setting where everything was acute. I didn't get a true outpatient or long term care type experience, hence the naivety.

 

[jdh71]

I am not so dense as it may seem to you. I do not assume you are talking about me -- but you ARE and you are talking about the thousands of others across the globe who have the same condition to lesser and greater degrees. Docs have the right and should blow off steam. They should not, however, pass moral or social judgment on the human beings who come to them for help, whatever type help that may be. In two years, I have spent about 80 days in the hospital and it's not because I am an alcoholic or want drugs, but because I was severely dehydrated, in pain, throwing up anything (even a Percocet) that I tried to swallow. I have only had one bad ER experience due misguided nurse practitioner in ER who could/would not understand a thing I told her. I have been blessed to have mostly kind and understanding ER docs. I've only not been admitted from the ER twice, all others, I was in for 5 -10 days. Yeah, we seek that. Tons of fun.

I will find the treatise with the causation statistics and post it for you. A question though, while I have an "official diagnosis," and present with a flare that looks legit - I guess I am not smart enough to understand the definition of "looks legit."

No. People are NOT talking about a legitimate pain patient. I'm trying to give you the benefit of the doubt that you are simply emotional and not stupid but I'm beginning to have my doubts. We all care about doing the best for our patients. The accusation otherwise clearly shows you don't know what is going on in this thread.

 

[I am THAT patient]

No. People are NOT talking about a legitimate pain patient. I'm trying to give you the benefit of the doubt that you are simply emotional and not stupid but I'm beginning to have my doubts. We all care about doing the best for our patients. The accusation otherwise clearly shows you don't know what is going on in this thread.

S

The reason for my initial post was the horrible disregard for human life being bandied about by a bunch of over-educationed, over-achieving, extremely stressed and overworked Physicians. You are the one who missed the point. The point, in clear terms, is that while it may be a difficult judgment call on your part as to whether or not a CP patient is "legit," that rather than using critical thinking to prepare a plan to care for the patient, many of your peers are judging a patient's pain as "addiction," and therefore should be lied to and sent on their merry way. I concede that there are many addicts out there who do drug seek in the ER. Many if not most CP patients are opiate dependent, quite different from being an addict. CP causes horrible debilitating and totally excruciating pain. It is a life changing disease and it will never get better. Most CP patients, on a regular basis, must weigh whether or not to continue to suffer at home, fearing treatment by an elitist doctor such as yourself. Most of us just stay home and suffer to avoid doctors like you. Then, as a result of not seeking care at the ER, something catastrophic may or may not happen. Just think, we are willing to be nearly dead before presenting ourselves to the treatment meted out by physicians such as you. I am sorry you seem to hate your profession so much that you feel a need to argue with someone and call them names for merely stating their opinion. Your statement that I am "simply emotional and not stupid" is objective proof that you do indeed judge your patients' pain according to the unfortunate stereotypes I mentioned above.

 

[link2swim06]

S

The reason for my initial post was the horrible disregard for human life being bandied about by a bunch of over-educationed, over-achieving, extremely stressed and overworked Physicians. You are the one who missed the point. The point, in clear terms, is that while it may be a difficult judgment call on your part as to whether or not a CP patient is "legit," that rather than using critical thinking to prepare a plan to care for the patient, many of your peers are judging a patient's pain as "addiction," and therefore should be lied to and sent on their merry way. I concede that there are many addicts out there who do drug seek in the ER. Many if not most CP patients are opiate dependent, quite different from being an addict. CP causes horrible debilitating and totally excruciating pain. It is a life changing disease and it will never get better. Most CP patients, on a regular basis, must weigh whether or not to continue to suffer at home, fearing treatment by an elitist doctor such as yourself. Most of us just stay home and suffer to avoid doctors like you. Then, as a result of not seeking care at the ER, something catastrophic may or may not happen. Just think, we are willing to be nearly dead before presenting ourselves to the treatment meted out by physicians such as you. I am sorry you seem to hate your profession so much that you feel a need to argue with someone and call them names for merely stating their opinion. Your statement that I am "simply emotional and not stupid" is objective proof that you do indeed judge your patients' pain according to the unfortunate stereotypes I mentioned above.

The problem is you don't actually work in an ER. You are taking your experience and applying it across the board to all people with chronic pancreatitis.

Yes a proportion unfortunately got the disease without doing anything wrong themselves. They follow medical advice and are using medical resources appropriately. We are not talking about them.

Then there is another SIGNIFICANT population that got pancreatitis by being drunks. Guess what? They still don't give a crap about their health. We make follow-up appointments with their primary care doctor (to get a long-term pain management plan established)...they skip them. This happens 5,10, 20 times in a row. They are give every resource in the world to get appropriate follow-up and care. Eventually it is clear they come to the ER when they have pain and expect a script for heavy narcotics. Prescribing potentially dangerous medication comes with a lot of responsibility on the physician's part. Why would the physician think these people are going to take these medications in a safe manner if they ignored all the previous advice? What if they overdose and die? Ultimately, this isn't the purpose of the ER nor is it the ideal care setting for these issues to be addressed.

 

[Birdstrike]

Lock thread. Pointless.

 

[jdh71]

S

The reason for my initial post was the horrible disregard for human life being bandied about by a bunch of over-educationed, over-achieving, extremely stressed and overworked Physicians. You are the one who missed the point. The point, in clear terms, is that while it may be a difficult judgment call on your part as to whether or not a CP patient is "legit," that rather than using critical thinking to prepare a plan to care for the patient, many of your peers are judging a patient's pain as "addiction," and therefore should be lied to and sent on their merry way. I concede that there are many addicts out there who do drug seek in the ER. Many if not most CP patients are opiate dependent, quite different from being an addict. CP causes horrible debilitating and totally excruciating pain. It is a life changing disease and it will never get better. Most CP patients, on a regular basis, must weigh whether or not to continue to suffer at home, fearing treatment by an elitist doctor such as yourself. Most of us just stay home and suffer to avoid doctors like you. Then, as a result of not seeking care at the ER, something catastrophic may or may not happen. Just think, we are willing to be nearly dead before presenting ourselves to the treatment meted out by physicians such as you. I am sorry you seem to hate your profession so much that you feel a need to argue with someone and call them names for merely stating their opinion. Your statement that I am "simply emotional and not stupid" is objective proof that you do indeed judge your patients' pain according to the unfortunate stereotypes I mentioned above.

You don't know me. And you have ZERO clue in the first or the least how I would treat your pain. I'm far from being an "elitist" doctor. You're making a lot of assumptions and attacking too many straw men to actually waste time pointing out. If I thought you had the capability to have an intellectually honest discussion I might try. But you are unable or unwilling to see past your own personal issue.

 

[I am THAT patient]

The problem is you don't actually work in an ER. You are taking your experience and applying it across the board to all people with chronic pancreatitis.

Yes a proportion unfortunately got the disease without doing anything wrong themselves. They follow medical advice and are using medical resources appropriately. We are not talking about them.

Then there is another SIGNIFICANT population that got pancreatitis by being drunks. Guess what? They still don't give a crap about their health. We make follow-up appointments with their primary care doctor (to get a long-term pain management plan established)...they skip them. This happens 5,10, 20 times in a row. They are give every resource in the world to get appropriate follow-up and care. Eventually it is clear they come to the ER when they have pain and expect a script for heavy narcotics. Prescribing potentially dangerous medication comes with a lot of responsibility on the physician's part. Why would the physician think these people are going to take these medications in a safe manner if they ignored all the previous advice? What if they overdose and die? Ultimately, this isn't the purpose of the ER nor is it the ideal care setting for these issues to be addressed.

You are correct, I only have my own experience. And as unfortunate as it is, I know there are way too many patients just as you described above. I do not have an solution to that problem, but agree that one must be found, soon. I am merely attempting to get you to agree that it may be a good idea to look at a person in the eye, listen to their story and show some empathy. All in 39 seconds - I know you are overworked and your time is very valuable. I have great admiration for the profession as a whole.

But please, give patients the benefit of the doubt regarding their pain and presentation to the ER. Look at their record - 10 admissions for CP, it's probably CP and not drug seeking and shouldn't be treated as such. I can understand that the loud, obnoxious patient wanting a shot for a stubbed toe can drive you to frustration quickly. But please don't paint all your patients with a dirty brush before you see them as they really are.

 

[fahimaz7]

I just use ketamine iv instead of dilaudid, that way when they get a little crazy on us, I can turf them over to the psych unit for evaluation.