How it all begins...

[engineeredout]

Yesterday, Thanksgiving, being thankful for spending the day in the Emergency Department... Actually it wasn't too bad. My wife had to work as well and there was plenty of food around.

19 YO male pops up on the board. CC is "Back Pain/Weakness". Triage note states that patient has worsening LBP over the past two days associated with difficulty walking. Immediately I think "Oh crap" because in the city that I work in, this complaint is pretty much Epidural Abscess until proven otherwise. I've seen more of these than I ever thought I would.

I go in the room and there is this guy laying on the stretcher with his parents sitting in the room. I start asking about what is going on and why he came in, getting most of the answers from the parents. I have to keep redirecting and saying that I'd like the patient himself to answer the questions. He states it is across his lower back, he has been having this back pain for several months but it was worse over the past couple of days. He follows with ortho and had an MRI recently but did not know the results. Denies saddle anesthesia, bowel dysfunction, urinary retention/incontinence. Kicked parents out of the room, questioned about drug use, and he emphatically denied any, except for one time use of anabolic steroids.

Physical exam: has equal symmetric strength b/l LE, 2/4 reflexes, sensation intact. Back exam - tender to palpation mid lower lumbar spine and tender across the paraspinal muscles as well.

Thinking this is most likely muscular strain/inflammation, go back to the computer. Put in my normal back pain cocktail of IM toradol and IM Valium (I believe in the placebo effect of IM vs PO meds) and start looking through his records here. I hit Jackpot.

YESTERDAY, in my system, his MRI from his orthopaedist. Read as L4/L5 and L5/S1 minimal disc protrusion but nothing else. I do a little happy dance. I mean, how often do you get an MRI less than 24 hours old showing that you do not have to worry about cauda equina or SEA? I think to myself wonderful, get him a little more comfortable, likely DC with NSAIDs and muscle relaxants, follow up with ortho and PT.

Father comes over to my workstation (love that everyone can do that). Asks me "Can you give him something for pain? He is in a lot of pain". I tell him "Yes I ordered medicine, I'll have his nurse get it to him right away".

"Well, what pain medicine did you give him?"

I said "A medicine called Toradol for pain and inflammation, and Valium for muscle spasms".

"Oh. Well toradol never worked for me. Only Dilaudid works for me".

...

My heart sank at that moment.

Now I'll say this after the fact, but I will openly admit that when I saw the parents, I thought drug abusers. Yes I'm a bad person, I prejudge people whom I don't know, I had no compelling evidence of it, they're people too, we're all God's children blah blah blah. I still thought what I thought.

I tell the father that toradol works for a lot of patients, and in particular for his son would target the likely cause of the exacerbation of the pain which is inflammation. So I would like to give him the medicines and then see how he does. He grumbles and goes back into the room, for what I would imagine would be him telling his son that he's going to get a medicine that will never work.

Magically the patient's pain improves. He is able to sit up on the bed and says his back feels looser. IT isn't that busy in the ED on Thanksgiving so I have a prolonged discussion with all of them about the MRI results, about back pain, about how the worst thing he can do is sit in bed, that he needs antiinflammatories, movement, and follow up with ortho and PT. Mom tells me that the patient still has pain and she can't bear to see him with pain. I explain to them that we will not be getting him 100% pain free in the Emergency department, but our job is to make sure there is nothing life threatening, to improve his symptoms so they are tolerable, and to have him follow up with the right people. I tell the nurse that we need to get him up and walk him around the ED and if he can walk, he can go.

Back at my station, prepping discharge instructions, the nurse comes to me and says that Mom says that he is in too much pain and cannot walk. My attending sitting next to me, an older gentleman, very laid back, nonconfrontational, who has been practicing > 25 years, said "Just (admit to) OBS him and be done with it".

I was annoyed. I said "OBS him for what? He hasn't even tried to walk yet. He hasn't failed anything. Lets get him up and walking".

Patient ambulates out of the room, not in marathon shape, but able to get around unassisted. Discharge is clicked.

Mom comes up to me. "He can't go home. He can't walk!". I reply with "What do you mean? I just saw him walking. He looks much better than when he came in." "Yeah his pain is fine now but what happens at home tomorrow when he has to go up stairs?". "That is why he will be getting the oral version of the medications he got today, and first thing tomorrow I want you to call the orthopaedic doctors". She leaves.

Nurse comes back again from her discharge attempt. Informs me the mother states once again the patient cannot walk. When the nurse tried to explain to her that narcotic medications are not the answer and an admission wouldn't actually fix any of the problems causing her son's pain, she replies with "I know all about narcotics. I've been clean for two years"

I go in the room. Get the patient out of bed. Walk the patient around the very large ED Pod. He is walking, unassisted, next to me. But, right in the background, is mom yelling "DONT WALK IF YOURE IN PAIN!!"

The patient, and his parents, ended up leaving the ED, with parting words of "Don't worry baby. If you're still in pain, we'll just go somewhere else."

It was like drug seeking by proxy. The kid never asked for narcotics, or anything else beyond what I told him. But here were the parents, setting him up for failure before he even got his first treatment. Telling him the non -narcotics were not going to work and that for his herniated discs he needed to stay in bed and use dilaudid. It's like watching a car crash in slow motion. We all know what direction this kid is headed in because we see it each and every day. A road involving surgeries and pain medications, disability and ER visits. All predetermined for someone who isn't even old enough to legally drink his pain away.

This is how it all begins

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[PatsyStone]

The only person worse than the parents is your attending who said to obs the guy

 

[southerndoc]

Two things:

Luckily I have security available for patients that don't need to be there and who are refusing to leave. I have to make really sure that discharge is what they optimally need and there is no doubt in my mind that they shouldn't be admitted or receive further workup before being shown the door.

Secondly, one of our docs saw a patient with intractable back pain who had an MRI done 24 hours earlier at one of our sister hospitals (the results were available). The patient bent over to pick something up 2 hours before her second presentation and immediately felt increased pain, saddle anesthesia, and weakness. One might think she was just making up those symptoms to score some pain meds. He repeated the MRI -- and had to "discuss" it with radiology to do so -- and the end result was cauda equina syndrome with an emergent trip to the OR. I only knew about the case when I saw her for an unrelated complaint a few months later and was looking through her visit history and saw the 2 MRI's within 24 hours. The first showed a small herniated disc, the second showed a large central herniation with cauda equina syndrome.

Makes me cringe every time I see a young back pain patient.

 

[Tenk]

Next time put your finger up his butt and pinch so he takes this stuff more seriously like we do.

 

[DeadCactus]

There are few things I hate more in the emergency department than walking out of a room feeling certain that the teenager or young child I just saw will never have the chance to grow up into a normal person because of their parents psychopathology. At least your patient made it to 19 without buying in, he has a chance if he can get out of the house...

 

[TrumpetDoc]

In the community, the reality is their "experience" can and will effect your pay (sometimes a substantial percent depending on work situation). Press Ganey scores are like bad things on your credit report...that $/i#| sticks with you. So if they were pissed...and the parents would overwhelmingly likely be filling this PG out and you get say 1s on it...it will continue to haunt you PG average/percentile until it is diluted out.
As a newer attending you don't have a large n of PG scores so bad ones really burn:/ I missed out on many a bonus check because of a few bad apples in a sea bunch of overwhelmingly good PGs.
I worked in two previous shops that bonus heavily with PG and people were brought in (admitted) often in lieu of leaving "unhappy"
Just the world we are forced to practice in.

Working in a shop that does not pay on this crap is a Godsend BTW.

 

[deleted245139]

This is why I never forget that these poor kids in the peds ER with terrible parents grow up to become those adult patients. Not always... But some of these kids never had a chance :\

 

[Apollyon]

I worked in two previous ships bonuses heavily with PG and people were brought in often in lieu of leaving "unhappy"

Can you translate this? It looks like you typed it on your phone. I don't understand it. I think "ships" was meant to be "shops", but I can't follow the rest.

 

[WilcoWorld]

Can you translate this? It looks like you typed it on your phone. I don't understand it. I think "ships" was meant to be "shops", but I can't follow the rest.

I think he means that, in some ED's where patient satisfaction was stressed, the docs would admit an unhappy patient simply so the patient wouldn't get an ED survey from PG.

 

[Apollyon]

I think he means that, in some ED's where patient satisfaction was stressed, the docs would admit an unhappy patient simply so the patient wouldn't get an ED survey from PG.

Ah, now I get it. I thought the "people" to whom he referred were new doctors! It didn't click, because a pt we transferred rom the ED to another hospital got a P-G.

 

[TrumpetDoc]

Yes. "Shops, that bonus us" and brought in meaning admitted or Obs...sorry about that. Edited

 

[Siggy]

Yes. "Shops, that bonus us" and brought in meaning admitted or Obs...sorry about that. Edited

What happens if the inpatient team comes down, evaluates the patient, and refuses the admit (granted, it's rare that this ever happens)?

 

[TrumpetDoc]

^^ They can discharge them. But this is very rare.

 

[Siggy]

^^ They can discharge them. But this is very rare.

I recognize that it's very rare, but when the only reason a patient is being admitted is because the patient is unhappy, then that becomes a whole different issue than the standard social admit. This is especially true when it starts affecting the inpatient teams score... and reimbursement... because the ED admitted a patient who didn't warrant admission so they can duck a pain seeker and instead hang the PG score on the hospitalist when the hospitalist has to do the dirty work of not giving narcotics.

 

[cbrons]

Possible the parents just wanted his pain meds for themselves once prescribed

 

[TrumpetDoc]

I never said it was good medicine or ethical, but it did and likely does happen at heavily PG reimbursed departments. This did happen, and with regularity, as did other practices and cultural things that led to my leaving the group (contract group).
I did not do that myself as I was younger and what not, but I paid for it mind you. I would be left out of the PG bonus pool and counseled by the seasoned docs on how to play the system. It was pretty pitiful.

 

[hundreddaysoff]

I recognize that it's very rare, but when the only reason a patient is being admitted is because the patient is unhappy, then that becomes a whole different issue than the standard social admit. This is especially true when it starts affecting the inpatient teams score... and reimbursement... because the ED admitted a patient who didn't warrant admission so they can duck a pain seeker and instead hang the PG score on the hospitalist when the hospitalist has to do the dirty work of not giving narcotics.

If the hospitalist gets paid per patient, why wouldn't they just give narcotics and discharge once the patient is happy and call it a day? (Thus perpetuating the patient's unhealthy expectations of the medical system.)

 

[Siggy]

If the hospitalist gets paid per patient, why wouldn't they just give narcotics and discharge once the patient is happy and call it a day? (Thus perpetuating the patient's unhealthy expectations of the medical system.)

1. It's unethical and bad medicine.
2. Inpatient physician billing is done via E/M codes just like ED physician billing.
3. Just like ED billing, inpatient billing, is affected by patient satisfaction scores.
4. Why would a hospital drop an ED group and not a hospitalist group when it comes to lower reimbursement based on HCAPS scores?
5. If the ED gets paid per patient, why wouldn't the ED just give narcotics and discharge the patient once the patient is happy and call it a day? (I mean, you're the one asking this question like the ED can't do this too)

 

[hundreddaysoff]

1. It's unethical and bad medicine.
2. Inpatient physician billing is done via E/M codes just like ED physician billing.
3. Just like ED billing, inpatient billing, is affected by patient satisfaction scores.
4. Why would a hospital drop an ED group and not a hospitalist group when it comes to lower reimbursement based on HCAPS scores?
5. If the ED gets paid per patient, why wouldn't the ED just give narcotics and discharge the patient once the patient is happy and call it a day? (I mean, you're the one asking this question like the ED can't do this too)

Re (5), of course often the ED *does* do this. Hospitalists never see those patients because they don't get admitted. That still leaves a ton of patients who, despite our best efforts to dissuade them, won't be happy until they are admitted for pain control. A hospitalist here tells me he makes more money the more patients he sees. The simpler the patient, the more time he has to see others. He often rounds on 30 patients a day. I imagine pain-control patients are fairly simple in the grand scheme of hospitalist affairs. At any rate, he manages them for me with a smile.

Agree that objectively all this is unethical and bad medicine. It's why I try to avoid giving opioids to anyone for any reason. That still leaves a lot of hard cases (like the parents in the stem) where I see as my only choices (1) give opioids, make happy or (2) discharge frustrated and angry +/- with security involvement. I hope as I go through residency I will get better at this.

 

[jl lin]

Yesterday, Thanksgiving, being thankful for spending the day in the Emergency Department... Actually it wasn't too bad. My wife had to work as well and there was plenty of food around.

19 YO male pops up on the board. CC is "Back Pain/Weakness". Triage note states that patient has worsening LBP over the past two days associated with difficulty walking. Immediately I think "Oh crap" because in the city that I work in, this complaint is pretty much Epidural Abscess until proven otherwise. I've seen more of these than I ever thought I would.

I go in the room and there is this guy laying on the stretcher with his parents sitting in the room. I start asking about what is going on and why he came in, getting most of the answers from the parents. I have to keep redirecting and saying that I'd like the patient himself to answer the questions. He states it is across his lower back, he has been having this back pain for several months but it was worse over the past couple of days. He follows with ortho and had an MRI recently but did not know the results. Denies saddle anesthesia, bowel dysfunction, urinary retention/incontinence. Kicked parents out of the room, questioned about drug use, and he emphatically denied any, except for one time use of anabolic steroids.

Physical exam: has equal symmetric strength b/l LE, 2/4 reflexes, sensation intact. Back exam - tender to palpation mid lower lumbar spine and tender across the paraspinal muscles as well.

Thinking this is most likely muscular strain/inflammation, go back to the computer. Put in my normal back pain cocktail of IM toradol and IM Valium (I believe in the placebo effect of IM vs PO meds) and start looking through his records here. I hit Jackpot.

YESTERDAY, in my system, his MRI from his orthopaedist. Read as L4/L5 and L5/S1 minimal disc protrusion but nothing else. I do a little happy dance. I mean, how often do you get an MRI less than 24 hours old showing that you do not have to worry about cauda equina or SEA? I think to myself wonderful, get him a little more comfortable, likely DC with NSAIDs and muscle relaxants, follow up with ortho and PT.

Father comes over to my workstation (love that everyone can do that). Asks me "Can you give him something for pain? He is in a lot of pain". I tell him "Yes I ordered medicine, I'll have his nurse get it to him right away".

"Well, what pain medicine did you give him?"

I said "A medicine called Toradol for pain and inflammation, and Valium for muscle spasms".

"Oh. Well toradol never worked for me. Only Dilaudid works for me".

...

My heart sank at that moment.

Now I'll say this after the fact, but I will openly admit that when I saw the parents, I thought drug abusers. Yes I'm a bad person, I prejudge people whom I don't know, I had no compelling evidence of it, they're people too, we're all God's children blah blah blah. I still thought what I thought.

I tell the father that toradol works for a lot of patients, and in particular for his son would target the likely cause of the exacerbation of the pain which is inflammation. So I would like to give him the medicines and then see how he does. He grumbles and goes back into the room, for what I would imagine would be him telling his son that he's going to get a medicine that will never work.

Magically the patient's pain improves. He is able to sit up on the bed and says his back feels looser. IT isn't that busy in the ED on Thanksgiving so I have a prolonged discussion with all of them about the MRI results, about back pain, about how the worst thing he can do is sit in bed, that he needs antiinflammatories, movement, and follow up with ortho and PT. Mom tells me that the patient still has pain and she can't bear to see him with pain. I explain to them that we will not be getting him 100% pain free in the Emergency department, but our job is to make sure there is nothing life threatening, to improve his symptoms so they are tolerable, and to have him follow up with the right people. I tell the nurse that we need to get him up and walk him around the ED and if he can walk, he can go.

Back at my station, prepping discharge instructions, the nurse comes to me and says that Mom says that he is in too much pain and cannot walk. My attending sitting next to me, an older gentleman, very laid back, nonconfrontational, who has been practicing > 25 years, said "Just (admit to) OBS him and be done with it".

I was annoyed. I said "OBS him for what? He hasn't even tried to walk yet. He hasn't failed anything. Lets get him up and walking".

Patient ambulates out of the room, not in marathon shape, but able to get around unassisted. Discharge is clicked.

Mom comes up to me. "He can't go home. He can't walk!". I reply with "What do you mean? I just saw him walking. He looks much better than when he came in." "Yeah his pain is fine now but what happens at home tomorrow when he has to go up stairs?". "That is why he will be getting the oral version of the medications he got today, and first thing tomorrow I want you to call the orthopaedic doctors". She leaves.

Nurse comes back again from her discharge attempt. Informs me the mother states once again the patient cannot walk. When the nurse tried to explain to her that narcotic medications are not the answer and an admission wouldn't actually fix any of the problems causing her son's pain, she replies with "I know all about narcotics. I've been clean for two years"

I go in the room. Get the patient out of bed. Walk the patient around the very large ED Pod. He is walking, unassisted, next to me. But, right in the background, is mom yelling "DONT WALK IF YOURE IN PAIN!!"

The patient, and his parents, ended up leaving the ED, with parting words of "Don't worry baby. If you're still in pain, we'll just go somewhere else."

It was like drug seeking by proxy. The kid never asked for narcotics, or anything else beyond what I told him. But here were the parents, setting him up for failure before he even got his first treatment. Telling him the non -narcotics were not going to work and that for his herniated discs he needed to stay in bed and use dilaudid. It's like watching a car crash in slow motion. We all know what direction this kid is headed in because we see it each and every day. A road involving surgeries and pain medications, disability and ER visits. All predetermined for someone who isn't even old enough to legally drink his pain away.

This is how it all begins

Excellent write up. Of course, strangely for me in particular, I have no words. Known enough of these kinds of parents.
All I can say is keep going with your memoirs and get them published. You should write!

Also, thank you for going the extra mile with this kid.

 

[tsbqb]

Off topic I realize, but is it easy for you to get an emergent mri?

 

[Daiphon]

Possible the parents just wanted his pain meds for themselves once prescribed

You need to delete "possible."
-d

 

[Interpolfanclub]

Concur with previous poster, you can really write. Good job.

Also, parents were definitely being manipulative. Toradol, discharge, no narcs after a long discussion with parents regarding the patient's young age and how we wouldn't want to get him hooked on something. Already a big problem in the community etc etc.

I also would document extensively in the chart for the inevitable arrival of the complaint letter/call.

 

[WilcoWorld]

I recognize that it's very rare, but when the only reason a patient is being admitted is because the patient is unhappy, then that becomes a whole different issue than the standard social admit. This is especially true when it starts affecting the inpatient teams score... and reimbursement... because the ED admitted a patient who didn't warrant admission so they can duck a pain seeker and instead hang the PG score on the hospitalist when the hospitalist has to do the dirty work of not giving narcotics.

1. It's unethical and bad medicine.
2. Inpatient physician billing is done via E/M codes just like ED physician billing.
3. Just like ED billing, inpatient billing, is affected by patient satisfaction scores.
4. Why would a hospital drop an ED group and not a hospitalist group when it comes to lower reimbursement based on HCAPS scores?
5. If the ED gets paid per patient, why wouldn't the ED just give narcotics and discharge the patient once the patient is happy and call it a day? (I mean, you're the one asking this question like the ED can't do this too)

I don't think that anyone on this forum is advocating this behavior. We're simply saying that it is a predictable response to the PG metric design.

 

[TrumpetDoc]

I don't think that anyone on this forum is advocating this behavior. We're simply saying that it is a predictable response to the PG metric design.

Exactly! Not something I condone either, but this does happen as we all know.
Having moved from a place with such an inane focus on this has been extremely liberating.

 

[GeneralVeers]

I don't care about PG and I certainly wouldn't give narcotics or admit someone just for that. What I do care about are patient complaint letters. Whenever a patient submits a complaint, it takes time for a hospital admin person, and the ED director to assess. That means they are thinking about about me when they are looking at the complaint. The last thing you ever want is hospital admin thinking about you. You don't even want them to know you exist. I'll generally try service recovery if I think a patient is likely to write a complaint letter. I still won't give narcotics or admit, but if I sense a letter might be in the works then I will buff the S**T out of the chart to explain why/why not I didn't do something.

 

[Spinach Dip]

Possible the parents just wanted his pain meds for themselves once prescribed

You need to delete "possible."
-d

My first thought also.

...Or maybe he's selling them and mom & pop are taking a cut of the proceeds...

 

[dotcb]

Although it hardly needs saying, I'll add this article summary from University of Maryland EM Pearls:
---------------------------

If there weren't enough reasons to avoid opioids, here is another: opioids don't work for low back pain (LBP).

Objective

A well-done, double-blind, randomized controlled trial from JAMA set out to compare functional outcomes and pain at 1 week and 3 months after an ED visit for acute LBP among patients randomized to a 10-day course of (1) naproxen + placebo; (2) naproxen + cyclobenzaprine; or (3) naproxen + oxycodone/acetaminophen.

Intervention

• Nontraumatic, nonradicular LBP of 2 weeks’ duration or less
• All patients were given 20 tablets of naproxen, 500 mg, to be taken twice a day.
  • They were randomized to receive either 60 tablets of placebo; cyclobenzaprine, 5 mg; or oxycodone, 5 mg/acetaminophen, 325 mg. Participants were instructed to take 1 or 2 of these tablets every 8 hours, as needed for LBP.
• Patients received a standardized 10-minute LBP educational session prior to discharge.

Outcome

Neither oxycodone/acetaminophen nor cyclobenzaprine improved pain or functional outcomes at 1 week compared to placebo, and more adverse effects were noted.

Application to Clinical Practice

Among patients with acute, nontraumatic, nonradicular LBP presenting to the ED, avoid adding opioids or cyclobenzaprine to the standard NSAID therapy.

References
Friedman BW, et al. Naproxen with Cyclobenzaprine, Oxycodone/Aceaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA 2015;314(15):1572-80.

 

[Xerxes1729]

Off topic I realize, but is it easy for you to get an emergent mri?

It depends. If it's truly indicated, no. I do have to talk to the radiologist and explain why I want to bump an outpatient or call in the tech overnight. "Fever, back pain, IV drug user, elevated ESR" - no push back. "Pregnant, RLQ tenderness, leukocytosis, nondiagnostic ultrasound" - no push back. "Lower back pain x1 week w/o any red flags but the patient really wants it" - not happening.

I rotated at a place as a resident where they could get an MRI immediately for anything. Sudden-onset dizziness in the stroke window? Don't bother with a neuro exam, you can get an MRI of the posterior fossa with a read in thirty minutes. I think that's pretty atypical, though. Maybe unique.

 

[Goro]

This is a fantastic case and I hope you write it up somewhere, even in a lay publication!

Yesterday, Thanksgiving, being thankful for spending the day in the Emergency Department... Actually it wasn't too bad. My wife had to work as well and there was plenty of food around.

19 YO male pops up on the board. CC is "Back Pain/Weakness". Triage note states that patient has worsening LBP over the past two days associated with difficulty walking. Immediately I think "Oh crap" because in the city that I work in, this complaint is pretty much Epidural Abscess until proven otherwise. I've seen more of these than I ever thought I would.

I go in the room and there is this guy laying on the stretcher with his parents sitting in the room. I start asking about what is going on and why he came in, getting most of the answers from the parents. I have to keep redirecting and saying that I'd like the patient himself to answer the questions. He states it is across his lower back, he has been having this back pain for several months but it was worse over the past couple of days. He follows with ortho and had an MRI recently but did not know the results. Denies saddle anesthesia, bowel dysfunction, urinary retention/incontinence. Kicked parents out of the room, questioned about drug use, and he emphatically denied any, except for one time use of anabolic steroids.

Physical exam: has equal symmetric strength b/l LE, 2/4 reflexes, sensation intact. Back exam - tender to palpation mid lower lumbar spine and tender across the paraspinal muscles as well.

Thinking this is most likely muscular strain/inflammation, go back to the computer. Put in my normal back pain cocktail of IM toradol and IM Valium (I believe in the placebo effect of IM vs PO meds) and start looking through his records here. I hit Jackpot.

YESTERDAY, in my system, his MRI from his orthopaedist. Read as L4/L5 and L5/S1 minimal disc protrusion but nothing else. I do a little happy dance. I mean, how often do you get an MRI less than 24 hours old showing that you do not have to worry about cauda equina or SEA? I think to myself wonderful, get him a little more comfortable, likely DC with NSAIDs and muscle relaxants, follow up with ortho and PT.

Father comes over to my workstation (love that everyone can do that). Asks me "Can you give him something for pain? He is in a lot of pain". I tell him "Yes I ordered medicine, I'll have his nurse get it to him right away".

"Well, what pain medicine did you give him?"

I said "A medicine called Toradol for pain and inflammation, and Valium for muscle spasms".

"Oh. Well toradol never worked for me. Only Dilaudid works for me".

...

My heart sank at that moment.

Now I'll say this after the fact, but I will openly admit that when I saw the parents, I thought drug abusers. Yes I'm a bad person, I prejudge people whom I don't know, I had no compelling evidence of it, they're people too, we're all God's children blah blah blah. I still thought what I thought.

I tell the father that toradol works for a lot of patients, and in particular for his son would target the likely cause of the exacerbation of the pain which is inflammation. So I would like to give him the medicines and then see how he does. He grumbles and goes back into the room, for what I would imagine would be him telling his son that he's going to get a medicine that will never work.

Magically the patient's pain improves. He is able to sit up on the bed and says his back feels looser. IT isn't that busy in the ED on Thanksgiving so I have a prolonged discussion with all of them about the MRI results, about back pain, about how the worst thing he can do is sit in bed, that he needs antiinflammatories, movement, and follow up with ortho and PT. Mom tells me that the patient still has pain and she can't bear to see him with pain. I explain to them that we will not be getting him 100% pain free in the Emergency department, but our job is to make sure there is nothing life threatening, to improve his symptoms so they are tolerable, and to have him follow up with the right people. I tell the nurse that we need to get him up and walk him around the ED and if he can walk, he can go.

Back at my station, prepping discharge instructions, the nurse comes to me and says that Mom says that he is in too much pain and cannot walk. My attending sitting next to me, an older gentleman, very laid back, nonconfrontational, who has been practicing > 25 years, said "Just (admit to) OBS him and be done with it".

I was annoyed. I said "OBS him for what? He hasn't even tried to walk yet. He hasn't failed anything. Lets get him up and walking".

Patient ambulates out of the room, not in marathon shape, but able to get around unassisted. Discharge is clicked.

Mom comes up to me. "He can't go home. He can't walk!". I reply with "What do you mean? I just saw him walking. He looks much better than when he came in." "Yeah his pain is fine now but what happens at home tomorrow when he has to go up stairs?". "That is why he will be getting the oral version of the medications he got today, and first thing tomorrow I want you to call the orthopaedic doctors". She leaves.

Nurse comes back again from her discharge attempt. Informs me the mother states once again the patient cannot walk. When the nurse tried to explain to her that narcotic medications are not the answer and an admission wouldn't actually fix any of the problems causing her son's pain, she replies with "I know all about narcotics. I've been clean for two years"

I go in the room. Get the patient out of bed. Walk the patient around the very large ED Pod. He is walking, unassisted, next to me. But, right in the background, is mom yelling "DONT WALK IF YOURE IN PAIN!!"

The patient, and his parents, ended up leaving the ED, with parting words of "Don't worry baby. If you're still in pain, we'll just go somewhere else."

It was like drug seeking by proxy. The kid never asked for narcotics, or anything else beyond what I told him. But here were the parents, setting him up for failure before he even got his first treatment. Telling him the non -narcotics were not going to work and that for his herniated discs he needed to stay in bed and use dilaudid. It's like watching a car crash in slow motion. We all know what direction this kid is headed in because we see it each and every day. A road involving surgeries and pain medications, disability and ER visits. All predetermined for someone who isn't even old enough to legally drink his pain away.

This is how it all begins