Catch-22?

[gotname]

I hope you all don't mind if I jump in here for a minute. If you do, can we pretend otherwise?

I am curious about a conversation I recently had with an ED physician and just wondering if most of you concur.

Wait, don't slay me yet...keep reading.

At a new ED, I had a bit of a rough start with the doc (things eventually turned around and all went well). Prior to discharge, he explained our initial contact by saying that many times, red flags are a catch-22 and unfortunately, we would probably have had the same encounter if I had "been the opposite". He said that many times...

If a patient (new) comes in with a complicated/chronic medical history and knows "too much" then it is suspicious. But the same applies if they act as if they don't know anything, especially when it comes to strong meds.

Disposition vs. described discomfort level makes a difference. A seemingly comfortable (not grimacing, crying etc.) patient stating significant discomfort is suspicious. But so is one who is crying, groaning, complaining and basically being way too expressive about their state.

He also gave me an example of how a patient (used my visit) can have a medical condition and how that condition is typically expected to present vs. how the patient presents/acts and how that can be a red flag (if they are below what is expected or way over).

Anyway so I thought I would ask what you all think. Do you agree/disagree?

Thanks

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[Birdstrike]

This site is not for patient advice and certainly not a one for patients to come, to find doctors to criticize other doctors' care.

 

[Doctor Bob]

Do you agree/disagree?

Yes

 

[gotname]

This site is not for patient advice and certainly not a one for patients to come, to find doctors to criticize other doctors' care.

Absolutely no advice needed and the doc turned out to be extremely helpful. He was also friendly and apologetic hence the chat. So I was just really curious if what he said is a popular outlook for ED physicians or not. That's all. If I still can't ask that, please let me know or lock thread. Thanks

 

[gotname]

Yes

Thanks for responding.

 

[GeneralVeers]

Drug seeker!

 

[gotname]

Drug seeker!

LOL. Guilty! I just can't get enough of that...epi and anti-nausea meds.

 

[Doctor Bob]

This site is not ... for patients to come, to find doctors to criticize other doctors' care.

Yea... there's a textbook for that.

If a patient (new) comes in with a complicated/chronic medical history and knows "too much" then it is suspicious. But the same applies if they act as if they don't know anything, especially when it comes to strong meds.

It's the dilaudid game.
"Only one med works for my pain... it's something that starts with a d... da... di... dila... something... I can't remember the name"
It occurs so often that it's an ED trope.

Disposition vs. described discomfort level makes a difference. A seemingly comfortable (not grimacing, crying etc.) patient stating significant discomfort is suspicious. But so is one who is crying, groaning, complaining and basically being way too expressive about their state.

Patients are terrible at rating their pain. If you tell me your pain is 10/10, but are calmly sitting in bed, or texting on your phone, of course I'm going to call bulls*** on you. 10/10 means you couldn't possibly experience any more pain. Part of me wants to kick those people in the shins when they say that because by their admission they couldn't experience any more pain. I have had people with 90+% deep partial thickness body surface area burns who only rate it as an 8-9/10.
Or when you're rolling around in bed, screaming, moaning, weeping, and generally carrying on in a histrionic fashion, with stone cold normal vital signs, and no objective physical exam findings... that's also suspicious. Especially when the degree of expressive wailing increases whenever a staff member walks by or into your room.

 

[gotname]

It's the dilaudid game.
"Only one med works for my pain... it's something that starts with a d... da... di... dila... something... I can't remember the name"
It occurs so often that it's an ED trope.

 

[Old_Mil]

I hope you all don't mind if I jump in here for a minute. If you do, can we pretend otherwise?

I am curious about a conversation I recently had with an ED physician and just wondering if most of you concur.

Wait, don't slay me yet...keep reading.

At a new ED, I had a bit of a rough start with the doc (things eventually turned around and all went well). Prior to discharge, he explained our initial contact by saying that many times, red flags are a catch-22 and unfortunately, we would probably have had the same encounter if I had "been the opposite". He said that many times...

If a patient (new) comes in with a complicated/chronic medical history and knows "too much" then it is suspicious. But the same applies if they act as if they don't know anything, especially when it comes to strong meds.

Disposition vs. described discomfort level makes a difference. A seemingly comfortable (not grimacing, crying etc.) patient stating significant discomfort is suspicious. But so is one who is crying, groaning, complaining and basically being way too expressive about their state.

He also gave me an example of how a patient (used my visit) can have a medical condition and how that condition is typically expected to present vs. how the patient presents/acts and how that can be a red flag (if they are below what is expected or way over).

Anyway so I thought I would ask what you all think. Do you agree/disagree?

Thanks

It depends.

 

[gotname]

It's the dilaudid game.
"Only one med works for my pain... it's something that starts with a d... da... di... dila... something... I can't remember the name"
It occurs so often that it's an ED trope.

Wow what is it with dilaudid? I just discovered this phenomena with that ED visit - I have spent my life at 2 EDs with familiar faces so turns out I am really naive! I was offered morphine off the bat and declined and when asked what I typically get for pain I said dilaudid and just moved on to what I would kill for (phenergan) not realizing that I should explain myself...they didn't know me
Cue Monty Python scene "run away! run away!" as my credibility went out the door.

 

[gotname]

It depends.

I am listening...

 

[Groove]

I don't get it. Are you wanting to know how to best convince the ED doc of your "genuine pain" and affect maximum persuasion coefficient into obtaining some VITAMIN D? (ivpushplease!)

 

[gotname]

Patients are terrible at rating their pain. If you tell me your pain is 10/10, but are calmly sitting in bed, or texting on your phone, of course I'm going to call bulls*** on you. 10/10 means you couldn't possibly experience any more pain. Part of me wants to kick those people in the shins when they say that because by their admission they couldn't experience any more pain. I have had people with 90+% deep partial thickness body surface area burns who only rate it as an 8-9/10.
Or when you're rolling around in bed, screaming, moaning, weeping, and generally carrying on in a histrionic fashion, with stone cold normal vital signs, and no objective physical exam findings... that's also suspicious. Especially when the degree of expressive wailing increases whenever a staff member walks by or into your room

Too much drama. I see what you mean. And yes, we suck at rating pain or at least I do. A few years back, one of the ED docs I see told me to use my worst pain in relation to the #, an 8 in my case (and definitely keep 10 for getting beat up by a gang of gorillas then set on fire) then always rate using that as a guide. If I hit a new 8 or go to a 9, then go by that new experience. I found that extremely useful.


Anyway, thanks Doctor Bob! ED docs need to lock some people in a basement somewhere and demand the invention of the GotYourPain Meter. But first, you all must find a unanimous 1 to 10.

Btw, sorry! I cannot figure out how to do all the quotes on one post...I'm not cool

 

[gotname]

I don't get it. Are you wanting to know how to best convince the ED doc of your "genuine pain" and affect maximum persuasion coefficient into obtaining some VITAMIN D? (ivpushplease!)

I have seen ED docs only at two hospitals all my life and I happened to get sick while out of town and it was just such a different experience. The ED doc explained to me at the end why he initially thought what he did and so with that, I guess I am just really...interested? Curious? About what he said and if that POV is the norm. That is all - my medical issues are well taken care of.

I sense sarcasm...I assume vitamin d is not vitamin d?

 

[Groove]

I have seen ED docs only at two hospitals all my life and I happened to get sick while out of town and it was just such a different experience. The ED doc explained to me at the end why he initially thought what he did and so with that, I guess I am just really...interested? Curious? About what he said and if that POV is the norm. That is all - my medical issues are well taken care of.

I sense sarcasm...I assume vitamin d is not vitamin d?

So, let me get this straight... You have 2 ED experiences in your entire life and after the second one become overwhelmed with curiosity over the nature of ED physician/patient encounters within the primary context of "suspiciousness"? I mean, you get home and start googling "emergency medicine forums" and spend an inordinate amount of time to get our perspective on which patient encounters are the least suspicious???? Really?

Yes, color me sarcastic....AND suspicious.

 

[gotname]

So, let me get this straight... You have 2 ED experiences in your entire life and after the second one become overwhelmed with curiosity over the nature of ED physician/patient encounters within the primary context of "suspiciousness"? I mean, you get home and start googling "emergency medicine forums" and spend an inordinate amount of time to get our perspective on which patient encounters are the least suspicious???? Really?

Yes, color me sarcastic....AND suspicious.

Well, I really like to color but I like being reasonable a lot more. If you did read the posts...I have been/go to only 2 EDs (hence the earlier mention of being treated by familiar faces etc.) - my many, many, many visits in my lifetime have been and are limited to those 2 EDs until this experience because I was out of town.

I used this forum because I already knew it was here...was not furiously googling like it's going out of style.

I am confused as to how I have stepped on your toes besides telling you that the info you are incorrectly assuming is clearly written up there somewhere...or just ask.

 

[Doctor Bob]

Anyway, thanks Doctor Bob! ED docs need to lock some people in a basement somewhere and demand the invention of the GotYourPain Meter. But first, you all must find a unanimous 1 to 10.

Well...

Perhaps it's a subtle nuance, but some (many? all? none?) EM docs don't care about your pain.
They care about what is causing your pain, and how it is distressing you as a secondary effect.

Pain is not an emergency.
The thing causing you pain is (possibly) an emergency.

So, for me, a rated pain scale is meaningless. I really don't care if you call it a 1/10, 5/10, or 10/10. I'm not going to give you meds any differently.
Vague undifferentiated abdominal pain? Ok, I'll give opioids until I have objective data saying there's nothing acute or there's a condition that is worsened by opioids, at which time I'll stop. And I'll give you tylenol. Doesn't matter if you continue to rate it at a 10/10 or not. My exam and workup have not found anything that rises to the level of medical necessity for opioids. So, sorry, you don't get them. At least not from me. Someone else may have a different philosophy and that is their choice.
"But you're not addressing my pain". I am, I'm just not addressing it in the way that you want.

/tangent

 

[gro2001]

Well...

Perhaps it's a subtle nuance, but some (many? all? none?) EM docs don't care about your pain.
They care about what is causing your pain, and how it is distressing you as a secondary effect.

Pain is not an emergency.
The thing causing you pain is (possibly) an emergency.

So, for me, a rated pain scale is meaningless. I really don't care if you call it a 1/10, 5/10, or 10/10. I'm not going to give you meds any differently.
Vague undifferentiated abdominal pain? Ok, I'll give opioids until I have objective data saying there's nothing acute or there's a condition that is worsened by opioids, at which time I'll stop. And I'll give you tylenol. Doesn't matter if you continue to rate it at a 10/10 or not. My exam and workup have not found anything that rises to the level of medical necessity for opioids. So, sorry, you don't get them. At least not from me. Someone else may have a different philosophy and that is their choice.
"But you're not addressing my pain". I am, I'm just not addressing it in the way that you want.

/tangent

I disagree. While I am as frustrated by all the drug seekers as the next guy, there are few things I care more about in the ER than treating GENUINE pain. Here is why... Let's look at our other potential goals as physicians in the ER...

Diagnosis? I care. But I may or may not be able to figure out what's wrong with a patient. A lot of patients get discharged or admitted either without a diagnosis or a catch all that's not really a diagnosis (I'm looking at you, musculoskeletal pain!), and that's fine, as our job is to rule out the life threats and not necessarily figure out the details.

Life saving treatment? Yes, of course I care. But how often do we actually save a life? Every once in a while, but not nearly as often as we like to think. Most of the time, people who are going to die are probably going to die regardless of what we do and all we do is change the location from the ER to the MICU.

However, I should ALWAYS be able to treat pain. Hypotension, concerns for sedations, refractory nature of the pain, etc are usually just excuses for ineffective pain management and deficiencies of skills.

 

[BJJVP]

"However, I should ALWAYS be able to treat pain. Hypotension, concerns for sedations, refractory nature of the pain, etc are usually just excuses for ineffective pain management and deficiencies of skills."

I am not arguing...I am actually looking for better pain mgmt strategies. How do you treat pain in hypotension? To be honest, I can only think of fentanyl...& if I recall correctly, the idea that there is less histamine release and therefore less hypotension is only theoretical. What about a sleepy pt with a subarachnoid/small subdural with a nasty orthopedic injury? Thanks.

 

[gotname]

Perhaps it's a subtle nuance, but some (many? all? none?) EM docs don't care about your pain.
They care about what is causing your pain, and how it is distressing you as a secondary effect.

Pain is not an emergency.
The thing causing you pain is (possibly) an emergency.

So, for me, a rated pain scale is meaningless.

I think it is ultimately meaningless as far as measuring pain or level of distress (they don't seem to always be synonymous) because there is what the scale "objectively" expects pain to be, what the person experiencing the pain believes it is and what the person treating it thinks it is. I think its utilization is often lost in translation and not for lack of caring but simply because of different expectations about said pain.

However, it can track pain trends which I assume is the end game in treatment besides finding out the cause. But what I fail to understand as a patient is why numbers are the way to go when one can just as easily say "mild" "moderate" "severe" or "I think I'm dying"...and in an ED visit setting, it seems as if the last two should be the obvious reason to be there.

The quip about GotYourPain Meter - although it is impossible to do so, would it not (in the land of unicorns and such) make the process easier if you really could measure pain as simply as you do BP or temperature and all you have left to do is hopefully find the emergent/non-emergent cause? Less nerve-wracking for the patient and less migraine-inducing for the doc.

 

[gotname]

I disagree. While I am as frustrated by all the drug seekers as the next guy, there are few things I care more about in the ER than treating GENUINE pain. Here is why... Let's look at our other potential goals as physicians in the ER...

Does this (treating genuine pain) not go hand in hand with caring about diagnosis as essentially treating said pain is part of handling what's causing it? Or do you mean trying to find the underlying cause is the priority?

 

[shookwell]

Well...

Perhaps it's a subtle nuance, but some (many? all? none?) EM docs don't care about your pain.
They care about what is causing your pain, and how it is distressing you as a secondary effect.

Pain is not an emergency.
The thing causing you pain is (possibly) an emergency.

I disagree strongly. I think pain control is secondary only to stabilization of unstable patients. I think pain control is more important than diagnosing disease or admitting/discharging patients. I'm willing to give 100 drug seekers dilaudid rather than deny pain medicine to even one person in genuine pain.

 

[WilcoWorld]

How do you treat pain in hypotension?

Fentanyl is one good option. Ketamine is another. IV acetaminophen is a third (I'm serious).

 

[Makati2008]

I think it is ultimately meaningless as far as measuring pain or level of distress (they don't seem to always be synonymous) because there is what the scale "objectively" expects pain to be, what the person experiencing the pain believes it is and what the person treating it thinks it is. I think its utilization is often lost in translation and not for lack of caring but simply because of different expectations about said pain.

However, it can track pain trends which I assume is the end game in treatment besides finding out the cause. But what I fail to understand as a patient is why numbers are the way to go when one can just as easily say "mild" "moderate" "severe" or "I think I'm dying"...and in an ED visit setting, it seems as if the last two should be the obvious reason to be there.

The quip about GotYourPain Meter - although it is impossible to do so, would it not (in the land of unicorns and such) make the process easier if you really could measure pain as simply as you do BP or temperature and all you have left to do is hopefully find the emergent/non-emergent cause? Less nerve-wracking for the patient and less migraine-inducing for the doc.

You have fibromyalgia or lupus?

 

[BJJVP]

[QUOTE="I'm willing to give 100 drug seekers dilaudid rather than deny pain medicine to even one person in genuine pain.[/QUOTE]

I used to think like Shookwell but I think that view is too simplistic. I have seen several small ERs become so distracted with waiting rooms full of entitled addicts and seekers that the staff cannot adequately take care of critical pts (the nurses are too burnt out, staff morale is low, they think nobody is actually ill, which leads to poor pt care and high RN/MD turnover and it all leads to an endless feedback cycle).

I have to admit that pain control philosophy is something I have struggled with for a long time. Part of the problem is that pain perception involves more than pathophysiology...cultural and psychological factors affect treatment and outcome expectations and pain perception significantly. I had one doctor tell me that he doesn't hesitate to rx percocets for dental pain because "toothaches really hurt." That may seem reasonable at first, but what do you do when the percocets don't work? Go to IV dilaudid? We can all agree that there should be a cutoff point. The problem is the general public/press ganey pushers/administrators tend to disagree significantly with doctors on what the reasonable cutoff point should be. One side sees only heartless doctors and untreated pain while the other side sees addiction, abuse, and overcrowded EDs. We give kids with fractures Tylenol, ibuprofen, T3's, but we also get many adults with minor fxs who say that the Vicodin ES "isn't touching the pain." There is a disconnect here that really makes the job frustrating. It is even more frustrating when we are painted out to be unsympathetic doctors who don't care about the suffering of patients.

 

[gotname]

You have fibromyalgia or lupus?

No. Systemic mastocytosis and vasculitis (HS).

The rest (anemia, orthostatic hypotension, pancreatitis etc.) have been recurrent enough to be their own problems and are treated as such - but are considered to have started as complications or part of the "disease package" of one or both (the mastocytosis/vasculitis).

What led you to fibromyalgia/lupus?

 

[gro2001]

"However, I should ALWAYS be able to treat pain. Hypotension, concerns for sedations, refractory nature of the pain, etc are usually just excuses for ineffective pain management and deficiencies of skills."

I am not arguing...I am actually looking for better pain mgmt strategies. How do you treat pain in hypotension? To be honest, I can only think of fentanyl...& if I recall correctly, the idea that there is less histamine release and therefore less hypotension is only theoretical. What about a sleepy pt with a subarachnoid/small subdural with a nasty orthopedic injury? Thanks.

I don't think fentanyl is significantly more cardiovascularly stable than morphine or hydromorphone, though it might be a little. But if I have someone who is hypotensive and in significant pain (say, trauma), I give them pain meds while simultaneously addressing their hypotension (leg raise, fluids, pressors, procedures). A patient who is getting sleepy from their unprotected subarachnoid hemorrhage or expanding subdural is probably heading towards intubation and OR/ICU anyway. While a touch of opioids may put them over the edge, so may the extra bleeding that's going to happen from their pain induced, sky high, MAP.

 

[KarlPilkington]

gro2001, I agree 100%.
I have a no screaming rule with my sick patients. If you have something truly wrong with you, I will give you meds until you stop screaming, often these meds are fentanyl and ketamine, but at times they include succinhycholine. On the other hand if you have nothing emergently wrong with you, I am hesitant to give multiple rounds of IV opioids. Acute pain is very real and very treatable, chronic pain is likely real, but in the ED we have few tools and even worse data to guide our treatments. Life is painful, opioids help a certain proportion of our patients but stand to hurt what seems to be an equal number of them.

 

[Tenk]

Just refer all your patients to my avatar and you'll have great success.

 

[DrDrummer]

Just refer all your patients to my avatar and you'll have great success.

Or your avatar's very pharmacologically close relative: http://www.accessdata.fda.gov/drugsatfda_docs/label/2007/018445s058lbl.pdf -- patients can even get some to go!