Question...how would you treat

DocWagner · Jun 6, 2004

This is not an academic question, really a poll more than anything...then I will tell you what happened to ME.

50 yowf presents with husband to local ED complaining of rash and "skin burning". Seen at urgent care 2 days prior told she had "a pinched nerve", then she developed a vessicular rash. She has no significant medical history, no meds (out of vicodin from urgent care). No significant social history. Benign exam except for ZOSTER like areas in the T9 dermatome on the right.

She is tearful as it "burns". Husband states, "she didn't sleep at all last night...she is pretty tough, but this is really killing her" (yeah, this looks like garden variety MILD shingles)

That is it.

Tell me HOW YOU WOULD TREAT THIS. (this is easy, but the result is quite frustrating)

Sessamoid · Jun 7, 2004

Sounds pretty routine to me, which I realize is how it's meant to be. I doubt a poll would yield anything unusual. Pretty much everybody I know would give famciclovir or valacyclovir with adequate pain medication. So what happened?

docB · Jun 7, 2004

Sessamoid said:
Sounds pretty routine to me, which I realize is how it's meant to be. I doubt a poll would yield anything unusual. Pretty much everybody I know would give famciclovir or valacyclovir with adequate pain medication. So what happened?

Ditto

(and fluff to make > 10 characters)

spyderdoc · Jun 7, 2004

I concur doctors. I think Famcyclovir has been more proven to prevent post-herpetic neuralgia....
Also may add topical anesthetic...
Mark

Sessamoid · Jun 7, 2004

spyderdoc said:
I concur doctors. I think Famcyclovir has been more proven to prevent post-herpetic neuralgia....
Also may add topical anesthetic...
Mark

Ditto. I like viscous lidocaine. Neosporin is also now available OTC with lidocaine. I had one patient who came in after a laser dermabrasion which had the laser turned up a bit too high. One little layer of viscous lido, and she thought I was god.

Seaglass · Jun 7, 2004

TCA's can be useful for neuralgia due to shingles.

C

DocWagner · Jun 7, 2004

My treatment (quite generous I believe), IM MSO4, vicodin, valtrex, cool compresses and encouragement...
Pt.'s husband FLIPPED OUT, we have a "Pain control" pamphlet in the waiting room (worst idea in the world) "here at ____, we want to adequately treat your pain..." this guy throws it in my face tells me she needs Percocet because she is in so much pain and he knows percocet is stronger than vicodin (automatically sounds fishy)...I offer to reasses after we let the shot take effect and then we can decide what pain meds are best as I could try percocet, just not both vicodin and percocet, he refuses and literally goes to the front desk, sees the nursing supervisor (??) and states he is going to the administration (I fully expect a letter).
Nursing has my back and were also caught off guard.
He looked absolutely like a reasonable man initially, 40's, well groomed, well spoken.

By the way...I was moonlighting, and for those of you that think this is a "typical" patient...everything is amplified when you moonlight.

so that prompts the question "what is adequate pain control"

NinerNiner999 · Jun 7, 2004

I suppose from a patient perspective, the customer is always right 😀. Seriously, I would think adequate pain control is anything the patient feels relieves their pain (and not their husband's in this case)...

Febrifuge · Jun 7, 2004

I can't say for sure, but my guess is that if the individual said certain key words or behaved with the right sort of indignance, security might have been called, at least at Big Crazy County Med Center where I work.

It seems to me that was a generous and highly patient-centered course, too.

spyderdoc · Jun 7, 2004

DocWagner said:
guy throws it in my face tells me she needs Percocet because she is in so much pain and he knows percocet is stronger than vicodin (automatically sounds fishy)..."

Nice thing about working in Cali is that one needs a triplicate to write for percs. I just tell them sorry, I don't carry triplicates, and offer them either of the big three that I can write without it...Vicodin, Darvocet, or T3's....
Unfortunately, the triplicates are going away in Cali at the end of the year, so we will be free to write for anything on a script blank....I guess the new script blanks are tamper "resistant" to prevent forgeries....We'll see.

Also when I was in residency in CT, everyone got percs...I never even wrote for vicodins until I moved out to Cali...Go figure.

This really is a typical case, and I really do empathize with you. I was scared ****less when I first started moonlighting as well...All the little things you don't care about as a resident sure seem a lot more important when you are the final signature at the bottom of the chart! As you go on, you will develop into a well oiled machine, able to weed out the 90% of non-emergent stuff so as to shine like a star when you actually have to treat an emergent patient! I read your posts and you seem like you have a good head on your shoulders...You will do well young Jeti!
Peace out
Mark

A little elf · Jun 7, 2004

vicodin, acyclovir (or your vir of choice), and amitriptyline; No percs, because I'm feeling mean

DocWagner · Jun 7, 2004

My real intention is to honestly see what other national trends are with dealing with this situation.
It is quite interesting as we have the "Press-Gainey" scores in our hospitals...and when you work in a private hospital, things are different and quite "patient satisfaction" centered. I really feel this is an odd and disturbing trend.
This is "bread and butter" pathology, but certainly not a typical response by a patient...a patient who feels he should dictate care.
It absolutely begs the question "what is YOUR idea of pain control" ??
(I am attempting to use a difficult situation to prompt thought)

If we as physicians have the ability to use multiple methods to deal with pain...what prompts you to choose your method?? What is "pain control"...should patients have to feel pain, or only dull pain?

I think these are good questions.

Bandit · Jun 7, 2004

gabapentin 300 tid works great for post herpatic neuraligia.

ERMudPhud · Jun 7, 2004

I typically write for Tylox(like perc 5/500) for everything but that is partly a protest against all the permutations of vicodin and percocet. I don't think I would have even given the parenteral morphine for shingles. For everyone talking about post herpetic neuralgia don't forget what we are talking about here is the acute pain of shingles not the chronic post-shingles pain.

Our hospital has a patients bill of rights and last night I had someone present with abdominal pain who refused every test and treatment unless I could tell her what it would cost. I tried to tell her I didn't know for sure what each medication, test, and intervention would cost. She carefully read the patient's bill of rights and found the part about an estimate of cost will be provided if requested before anything is done. I pointed out to her that it was 1:00 AM on Sunday and the billing office was closed and the charge nurse pointed out that this particular "right" applied only to non-emergency care. In the end I spent 4-5 hours intermittantly arguing with/counseling her and all she consented to was a dip UA and an IM shot of phenergan. She went home asymptomatic but with no idea what was wrong.

docB · Jun 7, 2004

DocWagner said:
My real intention is to honestly see what other national trends are with dealing with this situation.
It is quite interesting as we have the "Press-Gainey" scores in our hospitals...and when you work in a private hospital, things are different and quite "patient satisfaction" centered. I really feel this is an odd and disturbing trend.
This is "bread and butter" pathology, but certainly not a typical response by a patient...a patient who feels he should dictate care.
It absolutely begs the question "what is YOUR idea of pain control" ??
(I am attempting to use a difficult situation to prompt thought)

If we as physicians have the ability to use multiple methods to deal with pain...what prompts you to choose your method?? What is "pain control"...should patients have to feel pain, or only dull pain?

I think these are good questions.

I trained in cali and had to deal with the triplicate bit so I never wrote for percs. When I came to Vegas I found that the other docs write for percs all the time. I still give vicodin or lortab primarily and I only give percs if there's some special reason. When a patient or a family member is being a jerk I don't like to feel bullied so I don't know what I would have done in your situation. I've found that family members who are overbearing control freaks often relieve their lack of control over a medical condition by pulling this kind of crap. I think that it allows them to recast the event in thier minds from something that happened that they asked for help with to a situation where they grabbed the bull by the horns and made the right thing happen for their loved one. In thier little minds it's better that way.
As for "What is adaquate pain relief?" who knows. I'd say parenteral pain med followed by oral narcotics is clearly standard of care and only if the pt failed that should the holy grail of seeking, the "admit for pain control" be considered. I also don't think that the difference between vicodin and percocet is that great although the percocet is more euphoric.

Febrifuge · Jun 7, 2004

DocWagner said:
...It absolutely begs the question "what is YOUR idea of pain control" ??
(I am attempting to use a difficult situation to prompt thought)

If we as physicians have the ability to use multiple methods to deal with pain...what prompts you to choose your method?? What is "pain control"...should patients have to feel pain, or only dull pain?

I think these are good questions.

I absolutely agree these are important questions. Hopefully, I have something to contribute; although I am around EP's all the time in my role as a tech, I don't have to/ get to make these sorts of decisions. However, I've lived with chronic pain. My nasty psoriatic/ rheumatoid arthritis is under wicked good control thanks to Enbrel, but there was a stretch in 2000/2001 when I literally could not walk without a cane.

So, many of my attitudes about health care and how it "should" be practiced come from my time as a patient. Likewise, some of my attitudes about how one is "supposed to" go about being a patient are informed by my experiences on both sides of the conversation, plus my own goals and experiences re: medicine.

Anyway, I am confident when I say this: for a patient to expect a health care practitioner to remove all pain is unrealistic, unwise, and a little silly. Pain is a part of life. Likewise, for practitioners to expect to take away all pain is unrealistic, and on both sides there is a risk of starting a cycle of expectation that is impossible to sustain.

I have no idea how to effect a change away from this "customer"-focused idea that all pain is bad, and any pain is unacceptable. I agree that people like the spouse in that example are exerting control (attempting an appropriate thing in an inappropriate way). The situation demands sympathy, but also resolve. If treating the patient as a whole, and not just the symptoms, is the right way to go (and I believe it is), then there will be times when what is best for the person may not be the single very most advantageous or convenient course.

After all, the ultimate goal is a healthy person free of pathology, right? I would take the tack that modern pain "control" can at times be more like camouflage, and masking symptoms is an inferior result to resolving them.

Katee80 · Jun 7, 2004

What the h*** is so great about percocet? 😕
-------------------------------------------------------------------
I've asked this before but why is it strange when a pt asks for something by name? If through valid experience, they feel one med works better than another, shouldn't they have the choice? Unless they've been there a million times asking for it of course...don't.
--------------------------------------------------------------------
Just for future reference guys. 😀 I don't want to become a pushover to these pts either.

Sessamoid · Jun 7, 2004

Katee80 said:
What the h*** is so great about percocet? 😕

Approximately twice as potent at analgesia as hydrocodone with higher oral bioavailability. Back when I was in Florida, I prescribed all but the most benign fractures percocet, because that **** HURTS! In Cali, that's still triplicate, so I just don't bother. I'll probably go back to that when Cali makes it prescribable with an ordinary script.

I'm not particularly fond of pain meds personally -- immediately following knee surgery (twice) I refused all IV meds and grudgingly took oral meds when the nurses nearly forced it on me. But I do respect that people often don't have a high pain tolerance.

Katee80 · Jun 7, 2004

Sessamoid said:
Ditto. I like viscous lidocaine. Neosporin is also now available OTC with lidocaine. I had one patient who came in after a laser dermabrasion which had the laser turned up a bit too high. One little layer of viscous lido, and she thought I was god.

Thought you were god? You mean you're not? 😛

ps: how do you highlight only a portion of a quote?

Apollyon · Jun 7, 2004

Katee80 said:
Thought you were god? You mean you're not? 😛

ps: how do you highlight only a portion of a quote?

Katee80 said:
Like this, you ask?

You have to put the and [/b (left off the last ] so you could see it) around the text you want to highlight.

Sheerstress · Jun 7, 2004

Husband states, "she didn't sleep at all last night...she is pretty tough, but this is really killing her"

If the patient states that the pain is 10/10, and as truly bad as they can possibly imagine, one thing you might want to offer, if you're comfortable doing so, is an intercostal block with bupivicaine.

Nerve blocks are also excellent for people with severe toothaches as well. It sometimes helps me assess the situation - the people who are truly in pain are so grateful in the end, whereas the drug seekers often dial down their initial agony presentation, and start ranting about how terrified they are of needles 🙄

Katee80 · Jun 8, 2004

Apollyon said:
You have to put the and [/b (left off the last ] so you could see it) around the text you want to highlight.

Just practicing hehe...

And I didn't get it.

I'll try again or wait til my roomy gets back from rounds before I make MORE of an a** of myself.

Grrrrrr.... 😳 Oh yeeeeeah. Medical school here I come.

DrQuinn · Jun 8, 2004

A little late to the conversation (spent 3 days at the Vinoy Renaissance, a stone's throw away from Sessamoid's old digs)... but...

When I sniff some fishiness about pain control in the hospital (not just the ED as I'm doing a lot of off service months here...) is that I will tell them:

"I will never be able to get rid of your pain. I can take the edge off and reduce it, but I will never be able to bring your pain even close to a zero. The only way I can do that is to intubate you and sedate you with drugs so you do not feel anything. You have a broken (insert bone here), it is natural for you to have pain."

I had to do a day at the Neurosurgery outpatient clinic (READ: Most painful day of my internship)... and the NS attending had this little spiel which I may have to take (spoken to patient):

"The only people who deserve opioid pain medicines are those with cancer. If you are on an opioid for over a month, it will alter your brain chemistry and you will be in pain the rest of your life. Your pain now will be nothing compared to what it will be like if you use these pills long-term."

Q, DO

DocWagner · Jun 8, 2004

So it sound to me that everyone has a different idea of pain relief...

it is an interesting question...no? It sounds like each and every resident would have been in the same position as myself, as anything short of admission would have been substandard in their eyes.
It is always interesting when you have a "reasonable" "normal looking" gentleman threaten the "administration" in a yelling form...especially in front of other staff and patients, and especially regarding pain control (something I think I take good consideration of).

As we each go through similar situations sometime in our careers (not in residency, as the mentality is different when you moonlight in a private hospital or when you are attending...as in my case), it is conceivable some of us may become "the candyman".

Katee80 · Jun 8, 2004

QuinnNSU said:
A little late to the conversation (spent 3 days at the Vinoy Renaissance, a stone's throw away from Sessamoid's old digs)... but...

When I sniff some fishiness about pain control in the hospital (not just the ED as I'm doing a lot of off service months here...) is that I will tell them:

"I will never be able to get rid of your pain. I can take the edge off and reduce it, but I will never be able to bring your pain even close to a zero. The only way I can do that is to intubate you and sedate you with drugs so you do not feel anything. You have a broken (insert bone here), it is natural for you to have pain."

I had to do a day at the Neurosurgery outpatient clinic (READ: Most painful day of my internship)... and the NS attending had this little spiel which I may have to take (spoken to patient

"The only people who deserve opioid pain medicines are those with cancer. If you are on an opioid for over a month, it will alter your brain chemistry and you will be in pain the rest of your life. Your pain now will be nothing compared to what it will be like if you use these pills long-term."

Q, DO

The only ones who deserve opioids (pain relief) are cancer pts? Thats ridiculous. :idea:

I wouldn't believe in treating benign pain long term with opioids, but for him to say what he did..... goes against a certain oath doesn't it? Maybe I'm being too sensitive but I would want my pain dealt with...cancer or no cancer.

There...I've said my piece...bring on the tar and feathers. 😉

DrQuinn · Jun 8, 2004

Katee80 said:
The only ones who deserve opioids (pain relief) are cancer pts? Thats ridiculous. I wouldn't believe in treating benign pain long term with opioids, but for him to say what he did..... goes against a certain oath doesn't it? Maybe I'm being too sensitive but I would want my pain dealt with...cancer or no cancer.

There...I've said my piece...bring on the tar and feathers. 😉

Ah, perhaps I should have said more than one months' worth. Of course anyone in acute pain (i.e. fractures, sprains, sickle cell crisis, etc)... but I'm talking outpatient medicine here.

Q, DO

Katee80 · Jun 8, 2004

QuinnNSU said:
Ah, perhaps I should have said more than one months' worth. Of course anyone in acute pain (i.e. fractures, sprains, sickle cell crisis, etc)... but I'm talking outpatient medicine here.

Q, DO

Phew! I was hoping, I was hoping. 😀

docB · Jun 9, 2004

Coincidentally I just had a patient that found a doctor who prescribed her IM demarol for her migraines. She actually had a bottle of injectable demerol and syringes at home for her migraines. She came to me cause she took 3 hits of 300 mg each and, believe it or not, then had decreased LOC and a seizure. She woke up and was so offended at my suggestion that she has a problem that she said she will be writing the state med board. She will only find real relief of her pain when she goes down and no one is there to call 911.

LaurieB · Jun 9, 2004

QuinnNSU said:
I had to do a day at the Neurosurgery outpatient clinic (READ: Most painful day of my internship)... and the NS attending had this little spiel which I may have to take (spoken to patient):

"The only people who deserve opioid pain medicines are those with cancer. If you are on an opioid for over a month, it will alter your brain chemistry and you will be in pain the rest of your life. Your pain now will be nothing compared to what it will be like if you use these pills long-term."

Q, DO

I'm showing my ignorance here, but I was wondering if this is always true for opiods. Ths past year I encountered a chronic pain patient who took 4 grams of morphine sulfate a day on a long-term basis and still felt pain. It was always a mystery to me because that seemed like such an astounding amount of painkillers. This could explain her situation.

DocWagner · Jun 9, 2004

DocB that is a FANTASTIC example!
Damned if you do...damned if you don't.

DrQuinn · Jun 9, 2004

LaurieB said:
I'm showing my ignorance here, but I was wondering if this is always true for opiods. Ths past year I encountered a chronic pain patient who took 4 grams of morphine sulfate a day on a long-term basis and still felt pain. It was always a mystery to me because that seemed like such an astounding amount of painkillers. This could explain her situation.

Patients begin to develop a tolerance to opioid medications... Just look at any heroin addict who has been through detox but after the 4 week program tries to inject the dose they were abusing before the tolerance. BOOM they code... because they lose their tolerance to the opioids.

I'm not a pain specialist... but I am in complete concordance with the other posters in this thread... giving out opioids to the majority of patients (who don't have cancer or acute injury) is often a bad idea.

Q, DO

Katee80 · Jun 9, 2004

DocWagner said:
DocB that is a FANTASTIC example!
Damned if you do...damned if you don't.

I'm pretty sure that everyone who takes narcs at home as a last resort are not ALL obtuse 😉

Sucks to see such a dolt (not my first choice of names), give chronic pain pts such a bad rap.

Katee80 · Jun 9, 2004

docB said:
Coincidentally I just had a patient that found a doctor who prescribed her IM demarol for her migraines. She actually had a bottle of injectable demerol and syringes at home for her migraines. She came to me cause she took 3 hits of 300 mg each and, believe it or not, then had decreased LOC and a seizure. She woke up and was so offended at my suggestion that she has a problem that she said she will be writing the state med board. She will only find real relief of her pain when she goes down and no one is there to call 911.

😕

lloydchristmas · Jun 11, 2004

DocWagner said:
My treatment (quite generous I believe), IM MSO4, vicodin, valtrex, cool compresses and encouragement...
Pt.'s husband FLIPPED OUT, we have a "Pain control" pamphlet in the waiting room (worst idea in the world) "here at ____, we want to adequately treat your pain..." this guy throws it in my face tells me she needs Percocet because she is in so much pain and he knows percocet is stronger than vicodin (automatically sounds fishy)...I offer to reasses after we let the shot take effect and then we can decide what pain meds are best as I could try percocet, just not both vicodin and percocet, he refuses and literally goes to the front desk, sees the nursing supervisor (??) and states he is going to the administration (I fully expect a letter).
Nursing has my back and were also caught off guard.
He looked absolutely like a reasonable man initially, 40's, well groomed, well spoken.

By the way...I was moonlighting, and for those of you that think this is a "typical" patient...everything is amplified when you moonlight.

so that prompts the question "what is adequate pain control"

I'd say, "you know, now that you revived my memory, I read that Neurontin was better than vicodin or percocet so I'm tearing this vicodin up". Then the husband would force me to call the cops and have his ass hawled off.

Screw the drug seekers. Make the bastard wait in the waiting room. Yeah, he'll try to sue... but they never do if you actually beat them to the idea. "see you in court..." If you jump in front of the sue wagon, they'll think twice about f*cking with someone that displays such a loose-cannon attitude.

Katee80 · Jun 12, 2004

lloydchristmas said:
I'd say, "you know, now that you revived my memory, I read that Neurontin was better than vicodin or percocet so I'm tearing this vicodin up". Then the husband would force me to call the cops and have his ass hawled off.

Screw the drug seekers. Make the bastard wait in the waiting room. Yeah, he'll try to sue... but they never do if you actually beat them to the idea. "see you in court..." If you jump in front of the sue wagon, they'll think twice about f*cking with someone that displays such a loose-cannon attitude.

Actually, if he was smart he'd jump right on the bandwagon with you since the person sueing ends up paying all the costs of both parties. (in certain situations)

I'd be like: "Bring it"

SaltySqueegee · Jun 12, 2004

Katee80 said:
Actually, if he was smart he'd jump right on the bandwagon with you since the person sueing ends up paying all the costs of both parties. (in certain situations)

I'd be like: "Bring it"

Bring it... :laugh:

I can imagine these words with a double chest slapping motion

... and let the games begin! :laugh:

👍 or 👎 depending on how you look at it.

But seriously. Why aren't doctors going on the offensive and attempting to sue their patients? My thoughts are that the patients might behave themselves a little more... :laugh:

yeah right... like that would ever happen... there I go showing my naivity...

lloydchristmas · Jun 13, 2004

SaltySqueegee said:
Bring it...

I can imagine these words with a double chest slapping motion

... and let the games begin! 👍 or 👎 depending on how you look at it.

But seriously. Why aren't doctors going on the offensive and attempting to sue their patients? My thoughts are that the patients might behave themselves a little more... yeah right... like that would ever happen... there I go showing my naivity...

I love when I get to act like that. I have to wait until they display a threatening move; but when it does... I love being an ex-linebacker.

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