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Dear Drug Seeker, I Hate You.

Discussion in 'Emergency Medicine' started by Old_Mil, Jul 10, 2011.

  1. Old_Mil

    Old_Mil Senior Member
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    I hate you because you think you can march in to any ER in the country and demand narcotics your way like it is Burger King. I hate you because your fake symptoms force me to throw away millions of dollars of our national treasure on tests that don't need to be done. I hate you because there is an army of oily lawyers and patient advocates who don't know the first thing about medicine ready to take up your cause. I hate you because in wasting the time of our ER staff, a harmless grandmother in the room next door must be tied to her bed because there is no sitter.

    Did I mention that I hate you and that I hope you all perish in some fiery Percocet induced (single car!) crash and burn in hell for all eternity?

    I did? Ok, well thanks for letting me repeat myself.

    Have a nice day.
     
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  2. GeneralVeers

    GeneralVeers Globus Hystericus
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    Your attitude is disgraceful! These are valued "clients" of the hospital, and it's your duty to please them at whatever cost. If that means throwing away millions of dollars in extraneous testing, and giving them Dilaudid rapid IV push until they stop breathing so be it! As long as the hospital CEO gets their patient satisfaction bonus, nothing else matters, especially not the "appropriate" practice of medicine.
     
  3. meowdoc

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    I just started my EM rotation, but I've found myself pretty amused with these people so far. Like the one young patient that fell off a roof a week prior but had no physical or radiographic evidence of injury and then offered up their allergies to norco, darvoset, and tramadol. Good times!! Everyone deserves an evaluation according to my medical school and I guess chronic pain/narcotic addiction is a real disease state depending on how you look at it.

    Edit: a real disease state obviously not appropriate to the emergency setting but you cant be sure until youve done the evaluation I guess.. oh well
     
  4. Pinner Doc

    Pinner Doc drop knees, not bombs
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    ;)
     
  5. meowdoc

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    haha ok.. point taken
     
  6. OP
    OP
    Old_Mil

    Old_Mil Senior Member
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    Soon, meowdoc, you too shall turn to the dark side.
     
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  7. Arcan57

    Arcan57 Junior Member
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    I'd like to give a special shout-out for the seekers who have chosen chest pain as their symptom of choice. With your uncontrolled HTN and DM (and probably HLD if you ever went to a PCP to get diagnosed) and you're hx of PE (probably from an indeterminant V/Q years back done because your venous system no longer supports a 20g IV), you're forcing me to at least get an EKG and markers on you which will tie up a room for at least 2-3 hrs. Your insistence that you've never had this type of pain, despite it being described exactly the same in the documentation of the previous 4 visits, will generate a sense of unease even though rationally I'm as likely to have an MI as you.

    Your inexplicable ability to arrive in the ED regardless of time of day or day of week is matched only by your inability to get transportation back to your house, apartment, or bridge abutment. So what should never have been an ED visit suddenly turns into a 4-5 hr stay once you factor in the begging/bartering for a bus/taxi voucher or private helicopter. And kudos on picking a chief complaint that some of my colleagues will prescribe narcotics for or even give you the golden ticket: being admitted. Random reinforcement works as well in the ED as it does in Vegas. You know if you just come back often enough, you're going to get what you want one of these times.

    Congratulations on getting the CEO on your side. If I leave you in the waiting room as I deal with people that have actual emergencies, my door-to-MD time becomes unacceptably long. The only thing you missed out on is lobbying Press-Ganey so that they remove that stupid restriction about not sending surveys to people that have been in the ED within the last 60 days. Just remember, our phone lines open at the end of the show and will be open for at least the next 2 years.
     
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  8. AmoryBlaine

    AmoryBlaine the last tycoon
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    Small change in topic:

    I actually find myself far more annoyed with the trivially injured patients who scream in pain whenever anything is even gently palpated.

    Sane world management: "Listen sweetheart, you slipped and fell down. I know that you say you cannot move anything and that your back pain is 12/10, but really you simply cannot possibly have a fracture. Let's save both of ourselves time and money, take you off this backboard, give you a motrin, and send you on your merry way. No I'm sorry, I don't think you're going to be able to sue Tim's House of Groceries for your own clumsiness. You are a grown up and your level of drama from this is actually embarrassing for you and me. You should not be sobbing right now, considering I've seen people your same age with open fractures cracking jokes at me and 85 year old women with destroyed hips smiling while they thank me. And by the way your morbid obesity is going to make your recovery from this trivial incident 10x more complicated. The amount of force delivered to any part of your body was about 5% of what the average small town high school running back takes on every single offensive play. He gets right back up and continues playing."

    Real world management: CT brain, CT c-spine, XR TLS, various extremity films. Because if you do miss a transverse process chip you are going to get murdered.

    The amount of concern displayed by family members of these patients never ceases to amaze me. "Doctor, will they be alright?"
     
  9. GeneralVeers

    GeneralVeers Globus Hystericus
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    Had a narc-seeker arrested this week using a fake ID. He had been seen under his previous name almost weekly in the ED for nearly a year. His complaints were typical of Sociopathic Malingering Syndrome (SMS) and ranged from chest pain, abdominal pain, back pain to unwitnessed seizures. Finallly in June of this year enough of us cut him off of pain meds that he had to buy/steal an ID of a person who looks nothing like him. He had five visits under the fake name until I saw him and looked at his ID. I called PD and they took him to jail.

    Today PD was back in the department asking about "damages" to the hospital since he was comitting fraud. His bill for one visit in June was $12,000 so with 5 visitis I gave the estimate of $65,000.
     
  10. Interpolfanclub

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    The hysterical slip and fall, pain everywhere, brought in by ambulance patient is probably the least gratifying patient I see. These patients also typically have multiple previous visits for "ovarian cyst pain," "out of meds," and "anxiety." I generally explain to the patient and their multiple overly concerned family members that if I touch something and you say it hurts we will have to xray and/or CT it. I do this in a deferential and polite way but a little part of me dies inside each time one of these patients eats up a room for 2+ hours while being coddled...

    Whew, I feel better. On the upside, I did get to reduce a BB FA FX in an 8yo, a finger dislocation and a shoulder dislocation in about an hour last night. That I guess, is why I do this.
     
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  11. Arcan57

    Arcan57 Junior Member
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    You know those patients as soon as you walk into the room. If you can get to them prior to family, you have a decent chance of sending them out without a work-up. The problem is that they are usually on their cell phone talking to family while being wheeled to the room, making outrunning them almost impossible.

    On a related note, I also hate the family/friends that you think are going to be helpful but make everything much worse. Whether it's a psych patient that's BFF keeps egging them on, or a sister that is convinced their niece's sniffles are meningitis... STFU! On a related note, if anyone has successful tactics for getting inappropriate family members out of the room without generating patient complaints then let me know.
     
  12. EM2BE

    EM2BE Elf
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    I found the general "We usually allow only 1-2 visitors at a time" to be very helpful. Also helps if you have staff that will initiate and follow up on this to make sure only 2 will stay and the rest will go out to the waiting room.
     
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  13. The White Coat Investor

    The White Coat Investor Practicing Doc and Blogger
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    That's awesome. I'm going to start calling PD about our fraud cases.
     
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  14. Apollyon

    Apollyon Screw the GST
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    At my last job, I found a guy using fake ID. Even though we had police in the ED, and I had the remarkable luck of encountering this guy again, with the exactly same story (out of about 60 docs), the police weren't more than cursorily interested. I mean, I dug up his old name, compared the birth dates and SSNs, and gave the police the info. He got a ticket.

    Considering how smooth he was, and how easily he could perpetrate this scam, and how difficult it would be to track from our side (he didn't even recognize me, despite being in the same part of the same ED; I could understand if I was wearing something different, like no white coat or scrubs, or was at another ED), I realized how big this thing might be.
     
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  15. GeneralVeers

    GeneralVeers Globus Hystericus
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    Fortunately my hospital is in a quiet suburb of LV, and our police are relatively bored here. They are happy to arrest some of these losers, provided we have reasonable evidence.
     
  16. southerndoc

    southerndoc life is good
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    I'm hoping my health system's attorneys eventually allow us to adopt a policy to not treat patients with chronic pain.

    After having my life threatened, I decided to give it and just write for narcs and give all the Dilaudid patients wanted. I felt like I sold my soul to the devil. I know my patient satisfaction scores will drop because I rarely give out narcs anymore, but I feel more comfortable with myself by not being a candy man. I've made it through entire shifts seeing 36 patients in 12 hours and not writing a single narcotic prescription.

    Allergic to morphine? Let's try some fentanyl. Allergic to Toradol and every NSAID known to man? "I'm sorry, I don't have anything to treat your pain."

    ED physicians beware: states are investigating ED physicians who prescribe narcotics for trivial things (sore throat, repetitive chronic pain patients, etc.).
     
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  17. WilcoWorld

    WilcoWorld Senior Member
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    Another vote for being more bothered by the pan-spinal tenderness status-post low speed rear-end MVC patients who "can't!!!" move their legs and predictably walk out of the ED after a complete spinal series that's negative for any injury.

    I have taken to documenting "no objective findings of iunjury" on these charts. It makes me feel a little better.
     
  18. NEATOMD

    NEATOMD Senior Member
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    Had one of these on my last shift. As usual, she "hadn't" had any narcotics prescribed to her in the past. I love going into the room with my state prescription drug monitoring website printout showing the 30 prescriptions for narcotics in the last month. Usually, I act hysterical claiming someone must have stolen their identity and get really afraid for their safety. Then, I hand them a phone along with their discharge paper to help them dial the police to report their stolen identity. I doubt I get very good PG scores for this sort of thing at this point in my career but I'm working on it. Interestingly, the guy who I actually got the whole idea from has the best patient satisfaction scores in town.
     
  19. EctopicFetus

    EctopicFetus Keeping it funky enough
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    I sent a dude to jail too. So stupid. His ID said he was only 33 but told the nurse he was from out of state dropping his kid off for college (in May). When she said boy you had her young he said he was 21. Needless to say a quick call to PD and off he went.

    I feel for you guys and your seekers.

    When I was a resident Peter Rosen shared with me.

    "some patients are trolls, you have to engage the trolls and there are 3 outcomes. Either you win (you get your way and dont get pissed off), they win (they get their win and you get upset) or you tie (You get your way and get upset)."

    I have shared this nugget with some of our nurses and we play this game. Luckily we have a pain management protocol and complaints regarding pain management are not up for review by the hospital (but they are by our group). I document that the drunk with a BAL of 300 cant get ativan cause I worry about them, same for the drunk with TBD (total body dolor).

    In the end much like I try with my kids I dont reward bad behavior. You misbehave you get treated like a misbehaving kid.
     
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  20. Pinner Doc

    Pinner Doc drop knees, not bombs
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    Where I trained, we could get a good report of controlled substance prescription history on patients if we chose to look into it. However, it only tracked up UNTIL the last month or so - so there was really no way of knowing if they had had any relevant scripts over the past 4 weeks. I found this especially frustrating.
     
  21. OP
    OP
    Old_Mil

    Old_Mil Senior Member
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    One?

    23% of the charts I picked up last shift fell into this category.

    11% of the charts I picked up the previous shift fell into this category.

    I know you're going to ask where I work: the answer is in hell.
     
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  22. xaelia

    xaelia neenlet
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    As far as I can tell, there is no online database access for Texas - which makes me sad. North Carolina had a very functional website. I would love to be corrected.
     
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  23. Apollyon

    Apollyon Screw the GST
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    According to our state narc control, the only two states without a narc database are Hawai'i (as ours is being revamped) and Missouri, and MO has no plans to institute one. Maine just came onboard.

    I said to the guy that Missouri will become to the drug seekers what Virginia is to people that want to buy guns.
     
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  24. EctopicFetus

    EctopicFetus Keeping it funky enough
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    Arizona has a great one. Goes back 1 year.

    Drug seekers beware. I love walking into the room with the printout and telling them.. nope cant help you. You have a serious problem. Dont come back for pain meds cause you wont be getting them here.
     
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  25. DrMom

    DrMom Official Mom of SDN
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    DEA info

    Ours is nearly real-time. I love taking in a printout showing the Rx they filled within the last 24 hours after they told me they had "run out" or whatever the story du-jour is.
     
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  26. dchristismi

    dchristismi Gin and Tonic
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    Please don't tease me like that.
    It's not nice.

    Florida is, um, a little behind the times.

    But a new law says that you can't distribute pills from your office.
    Yes, we had to have a law that says you can't hand out schedule II narcs.
    We'll see if it helps.

    Our database is stuck in committee. Or perhaps, the govenor just derailed it on purpose. Oh wait...
     
  27. xaelia

    xaelia neenlet
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    There is a database in Texas, but so far I have only found a form to print out and mail.
     
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  28. GeneralVeers

    GeneralVeers Globus Hystericus
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    Our new Nevada database just came online this year. They outsourced the web programming and site maintenance to a private company, so needless to say it's a whole lot quicker and more efficient than the old government-run database.

    It's usually accurate back to within 7-10 days. If you had a prescription for 90 percocets 10 days ago and you're now "out of them" either you're selling, or you should be in fulminant liver failure.
     
  29. docB

    docB Chronically painful
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    I haven't had good luck with the new system. It seems like every time I put in just the name and DOB which is the minimum I get a "there are multiple patients with that name" message. When I start adding more info I get the "no one matches that information" message. I've never once been able to get any info out of the new system.
     
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  30. Flopotomist

    Flopotomist I love the Chicago USPS
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    Despite MO not having a database, we do have the luxury (curse?) of having one certain drugstore chain have a relative monopoly on pharmacies. One call to them (and they are all linked via computer) and you can get a nice run down of what scripts have been filled. Not sure the legality of this strategy, but it works. ;)
     
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  31. Groove

    Groove Member
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    My worst other night....wait for it....fibromyalgia ATV accident. I would have taken bamboo shoots under my nails to get her out of the ER at one point. If I had my way, I'd wrap those people in bubble wrap and poke dixie straws through for breathing before letting them loose outside.
     
  32. tkim

    tkim 10 cc's cordrazine
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    Mass just came online with one that is only current to the last month. However, I call the last pharmacy listed and ask for any more recent rxs than what was listed. Works pretty good.
     
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  33. Katydid

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    Wait, there's a database that tells you when the pt. last got a scrip for narcotics in this state? (I'm in KY)

    I know we have an in-house database at the pharmacy (small local pharm) where I work (I'm just the delivery chick, don't go thinking I'm a PharmD or anything), that tells us when someone had X scrip filled/refilled, and when they can get a refill. I didn't know there was a database state-wide (or there is meant to be a database state-wide) that tells the doctor when the pt. last got a scrip for narcotics.

    Of course, considering we have people who are clearly doctor-shopping, it makes me wonder how well this works. Or is this database meant for emergent settings only?

    Forgive me if these are stupid questions, it's 2AM CST, and the heat index is still a brain-melting 97F outside. Indeed, combined with the nasty sinus infection (let's not talk about it - I still haven't got my sense of smell totally back yet, and I'm still sounding like I'm hacking up hairballs), my brain has left the building. Hopefully, it has gone somewhere cooler.
     
  34. southerndoc

    southerndoc life is good
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    I got a good laugh a few months ago when a patient told me they had stage III fibromyalgia. I asked her if stage IV was terminal and she said yea. :laugh:
     
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  35. Pinner Doc

    Pinner Doc drop knees, not bombs
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    It's tricky. They tell you to look for multiple variations in the same name (Sarah vs Sara, etc), alternate spellings, different addresses for the same person... you get the idea. I've seen this more than once. People will change small details in their personal info, or use different bdays or addresses, just to cover their trail.
     
  36. Zanegray

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    Damned if we do... Damned if we don't.
    I guess we'll have to just do the right thing.
     
  37. Zanegray

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    One word. Three syllables. Awesome.
     
  38. NEATOMD

    NEATOMD Senior Member
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    No, I was referring to a hysterical slip and fell patient that hurt everywhere. I don't have as high of a drug seeker percentage as where you work, but it's probably 2 or 3 a shift or 5-10%.
     
  39. Apollyon

    Apollyon Screw the GST
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    Well, don't be cryptic. What is "the right thing" to you?
     
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  40. adismo

    adismo covered in moon dust
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    one of my dreams in live is to see DSB become a criminal offense...


    one where I can get the ball rolling and call PD and have Johnny 'the back pain' Sakovsheet and his demands for Benadryl and Phenergan along with "my Dilaudid" removed in handcuffs and booked and in front of a judge the next morning. I don't care what happens next, just get him out of my sight and out of the way of the crashing patients and the leaking AAA in the waiting room.

    oh and while I'm at it, how about a 10 year moratorium on lawsuits against Dr's - but that might save way too much money in healthcare - we won't know what to do with all that cash.


    ... but then I woke up
     
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  41. dchristismi

    dchristismi Gin and Tonic
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    I thought "awesome" was only two syllables, unless you're stoned. Then it can be variable to the degree of awe-some-ness-sss-sss-ss.

    Random late night thoughts...
    Unless it was some other three syllable word that I cannot figure out from your post.
    (I swear, it's just post-shift wine, that's all!)
     
  42. TrumpetDoc

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    Yeah, as if jumping off the exam table (literally) when I so much as contact the skin of your likely sprained ankle or soft tissue contusion will push me to narc you up
    OMFG how at that point I am just blowing up inside! I think my core temp actually rises in those cases.

    And I am not typically one to doubt patients pain but give me a freaking break!
     
  43. WilcoWorld

    WilcoWorld Senior Member
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    Yep - this behavior is so infuriating because it makes me completely unable to actually, y'know, diagnose the problem.
     
  44. TysonCook

    TysonCook Senior Member
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    ...the more ridiculous it is the less time I spend in the room...

    Inversely proportional time.....

    "....Ma'am, you fell 3 feet and landed on your bottom, I can see absolutely NO logical reason for your pain and reviewing your chart it seems you have chronic pain.... BY DEFINITION, CHRONIC is not an emergency.....blah blah blah...."

    ...as I say the above I give them their paperwork for discharge...

    If they "can't walk" they get one of the following:
    1) a wheelchair to the waiting room, they usually find the strength to leave.
    2) a 18g needle test to check their nerves
    3) security to escort them out

    (obviously the above apply only to those that are 100% FOS - e.g. you watched them walk in)

    I had one several years ago that after looking at the database had something like >4,000 Percocet tablets prescribed in the last month....

    "sir, you've had over 4,000 Percocet tablets prescribed to you in the last 30 days. This equals 1300 grams of Acetaminophen over 30 days which is above the toxic level. You are clearly not in liver failure" .....
    "....so, I'm going to step out and make two phone calls, the first is to Toxicology, if they are not completely amazed, the second phone call will be to the police department for drug diversion...."

    As he walked out he got reminder that the police will be called on every visit he makes to the Emergency Department.
     
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  45. JMHO

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    You Disgust me both as a Doctor and as a Person. It is Doctors like you who treated me like I was a Pill Seeker, a Idiot and a Liar for 2 years! I was told my pain was Ovarian in nature too. I even had a Hysterectomy to try and beat the pain.

    I went to the Emergency Room, I went to my OBGYN, I went to my PCP, I went to a new OBGYN, Then I went to a new Emergency Room. I explained my weird pain in the lower belly and inner thighs over and over again. But you know what I was always told?
    " Narcotic's are not the answer!" " You do realize this is a Emergency Room , right?"

    I said fine then don't give me Narcotics just find out what is wrong with me!

    Out of 12 Doctors who examined me, only one did a Ct scan and it was of the Pelvic area , not where the Injury was from. Can any of you guess what was wrong with me?

    My symptoms got worse at the end of 2010 and I switched Doctors at the new year. The first person I saw was a Nurse Practitioner. She ordered a Ct scan of the spine. T12 , L1 Right Sided Herniation and severe Central Spinal Stenosis. It took a month just to find a Neuro who would touch me. By the time I found a Decent Neuro , I had lost control of my bladder and could barely walk.

    My New Neuro had me in Surgery 24 hours after I called his office. Primary Diagnosis? Have you figured it out yet?

    Cauda Equina Syndrome, Secondary to Conus Medularis Syndrome. Thats right T12 L1 Is the tail end of The CM Branch of the nerves and the top of the Cauda Equina. So I had two Conditions requiring emergency surgery that 6 ER Doctors missed.

    The Neuro gets into my Spine and Ends up spending 7 hours of a 10 hour surgery chasing Down Disk Fragments. 9 of them total. Then a Disectomy, Laminectomy, and some other crazy sound procedure. So from what I understand each of those pieces of disk would have been a Emergency in itself!

    Now Im lucky most days if I dont need to self cath , and I cant leave my house with out a cane. Up until a month ago I was still in Chronic Pain. Nucynta changed that for me and most days I can walk and move around my house at least.

    All this crap, and Im not even 30 years old yet. I will use a cane and cath for the rest of my life. All because a Doctor like you guys failed to slow down and connect the dots of my symptoms. Not all of us are Seekers. I sure as in the hell wasn't.
     
  46. Rendar5

    15+ Year Member

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    ...so you went to the ER because you tripped on the sidewalk and everything hurt and you were convinced that every bone in your body was splintered and refused to leave until you had 12 different CT's and were upset when we woudln't give you a percocet Rx simply because you had already filled a Rx for 120 percocets 3 days ago for your previous slip and fall as confirmed by your narcotics database?

    because that doesn't sound like what happened to you, so all your righteous fury seems a bit misplaced on this thread that you sought out just so you could yell at a doctor you've never even met before.
     
  47. hothause

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    I also think it's important to maybe step back a second and realize that perhaps the doctors who treated you weren't callous pricks. Maybe at the start of your health problems your presentation wasn't consistent with cauda equina. I don't think they were trying to screw you by just saying "oh, let's ignore her in particular." Sometimes the diagnosis comes after exclusion of other badness. I'm sorry you had such a bad go, but this thread is an attempt to vent for all of the patients who DO come in shopping for narcotics, some right after being seen and being given a prescription an hour ago from the ED 2 miles away in the same hospital system. Not everyone who comes in and needs narcotics is a drug seeker. We get that. But people who abuse the system are annoying and a distraction from people with real medical emergencies like yourself.
     
  48. WilcoWorld

    WilcoWorld Senior Member
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    I am sorry that you have suffered from a debilitating disease, but I strongly disagree with your assesment of your providers and with your capitalization. I am glad that you have begun to find some relief and I sincerely hope that your future medical encounters are less frustrating.

    I encourage you to try and see this from our side. Cases like yours are precisely the reason why drug seeking behavior angers us so. When we each see 3 or more patients a day who lie and fake symptamatology it makes diagnosing cases like yours like finding a needle in a haystack. If there were no drug seekers, then when an atypical presentation such as yours came in we would be much more able to recognize that something is seriously wrong and that a cause must be found.
     
    #48 WilcoWorld, Jul 19, 2011
    Last edited: Jul 19, 2011
  49. MeowMeowCAT

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    Have any of you guys had any experience with post-accident "injuries". You know the kind where the actual accident does not equal to the actual pain the person claims to be in, basically insurance exploiters. Simple fender-bender and the person claims to have a list of injuries as a result.

    Do you just go ahead and treat said person. Basically what do you do in a case where they are not after the narcotics but there just to rank up in medical bills to profit from insurance.

    Sorry if it is a bit off topic, but seems kind of related to suspicious ER visiting.
     
  50. WilcoWorld

    WilcoWorld Senior Member
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    I start by assuming that the patient is being honest. I try to explain things in a non-judgemental way such as saying "You can have whiplash without having tenderness on your bones. I know that you have neck pain, what I am about to check for is broken bones, so I am trying to see if you have tenderness specifically where I'm pressing when I'm pressing there" before I try to clear the c-spine clinically. Then I do the work-up that is indicated by their exam. If it's a really obvious case of lawyer-baiting, then I'll make a special note on the chart saying "no objective evidence of injury found" and give a diagnosis of "neck pain" rather than "cervical strain".
     

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