Help for a new intern

[medivac]

So I'm new to EM, but not to medicine, as I've done a transitional internship, and then 4 years as a flight surgeon in the Navy. There, I knew my patients, and for the most part was a colleague with most of them.

Drug seekers in the aviation community are almost unheard of.

I'm pretty conservative when it comes to narcotics in these first few months of my civilian residency. Most back/neck/knee etc pain goes out with NSAIDS and perhaps a muscle relaxant.

I treated a patient with a "typical" migraine a few nights ago. We have access to clinic notes and previous ED visits on our computer. She's a frequent flier, and an admitted addict. Her PCM recently cut way back on her narcotics. She had been in to the ED the week previously, during office hours. The MD on then had documented a phone conversation with the PMD who endorsed a course of action. On her visit with me, of course, it was after hours. I repeated the previous ED treatment: 12.5 of phenergan, iv fluids, and 4 mg of dilaudid until good pain control. Previous visit took 8 mg. 12 mg in, she was "almost" under control. She and her mother reported that they were ok going home, as long as they had a script to go, as they were not sure when she would get back to see PMD.

Side note: PMD note one week previously had documented patient was to start on community methadone treatment, and f/u with PMD in day and 5 days. Pt denied knowing this plan.

I gave a script for 2 mg of Dilaudid, #5 dispensed.

The next night, an area pharmacy called the ED looking for me. The patient was trying to fill my Rx and refill her vicodin Rx for 50 pills. I told the pharmacist I was not comfortable with her filling both Rx, as the patient had not told me she was taking Vicodin.

Today, I got a page in the middle of the day. (I'm on nights, so the %*@ beeper woke me up) The hospital operator was holding this patient who wanted to speak to me.

So here's my quandry (sp?--whatever) I didn't take the call.


I did not go into EM to have follow up. I don't want patients calling me at home. I did that for the last 4 years with my pilots calling me at all hours with their complaints. If this patient had a problem, she should go to the ED as instructed on the discharge paperwork, or AS I SUGGESTED get herself to a new PMD who would refer her to the headache or pain clinic to wean her off the drugs.

Was this wrong? It's eating me up a bit. I'm hoping it's just leftover from being someone's "Doc" for such a long time. Should I have taken the call and gotten grief from her for denying her more narcotics? Had to explain again that while I sympathize (again, sp?...get over it) with her withdrawal headache and other somatic symptoms, I refuse to continue her addiction?

Will I grow out of this refusal to be a drug seeker's candyman, as some of my attendings seem to think?

I'm really just looking for reassurance, but I'm thick skinned enough to take hits if I deserve it. Like I said, I'm new to this civilian EM thing, tho its the only thing I've ever wanted to do forever.

*sigh*

To end on a good note, the nurses have stopped breaking me in with their painful initiation rites. Nights are much more enjoyable!

medivac

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[ERMudPhud]

When I go home to go to sleep I turn off my phone, cell phone, and if I still had one my pager. End of story. Someone in the hospital was giving out my home phone thinking it was an office phone. I tracked that down and made it stop. You are not their doctor.

 

[basementbeastie]

you are fine.

 

[waterski232002]

It is inappropriate for patients to page you at home. They should go to the ER if they have an issue, or page their PMD's answering service who will appropriately "turf" the call. It's not your responsibility to follow-up with her. That's what the PMD is for.

 

[BKN]

Today, I got a page in the middle of the day. (I'm on nights, so the %*@ beeper woke me up) The hospital operator was holding this patient who wanted to speak to me.

So here's my quandry (sp?--whatever) I didn't take the call.

So I think your problem is that you gave narcotics to an addict. Of course she's gonna try to get more.

BTW Well demonstrated that narcotics are not effective for migraine. Don't give them for that. Instead phenothiazines or ergots are effective with nsaids as backup. And tell her she won't get narcotics from the ED in future.

 

[southerndoc]

So I think your problem is that you gave narcotics to an addict. Of course she's gonna try to get more.

Yep, feed a stray cat and it's your friend for a lifetime.

You have a new friend, medivac.

 

[beyond all hope]

I am pretty aggresive about sending seekers home. If come to the desk bothering me I will talk them down the first time, and call security to have them escorted out the second.

That being said, it's often hard to distinguish the seeker who's looking for a high and the seeker that's genuinely combatting pain. Giving a seeker narcs hurts no one but that seeker, but withholding narcs from someone who's in real pain is not a good thing. So, if I'm on the fence, I give a short course of narcs with no refills and will admantly refuse any negotations. 'Aw, doc, Vicodin's not enough for me...'

I have been known to give out my cell phone number to patients whom I'm afraid will get lost to followup, but it's not a common occurance, and I would never give out any numbers to a narc seeker.

You will quickly learn your personal threshold for taking calls outside of the ED. Most EM docs will never, ever do it, and I can certainly respect that decision. We are not the primary docs. However, I like getting calls from patients that have AMAed later telling me that they're okay, or even asking me for advice.

 

[bartleby]

If you see someone who has failed all other treatments for migrane but appears to be in pain, give them a narcotic if you must, but only under strict limits. If they come in saying "only dilaudid works" then I politely explain to them that, as they surely know themselves from previous visits to the ED, that reglan/triptans/ergots/depakote/etc are meds which can terminate a headache but that narcotics do not. If they are not willing to try these abortive meds then they're wasting your time as well as theirs, as I can guarantee they're going to leave the ED with a headache anyway.

After going through the treatment algorithm of abortive meds, if they insist on having a narcotic after a good faith effort at treatment, I tell them that the chances of their headache going away is nil regardless of how much dilaudid I given them and that they will get a single dose of a narcotic before their IV is pulled and they're discharged for them to go home and sleep their migrane off. I don't "chase the dragon" with meds for four or five hours testing the upper limits of the opioid tolerance and taking up an ED bed for someone whose disposition is already quite clear.

If you have someone who has a true status migrane and is puking their guts up despite all you've done this is a different story and this person may require admission, obviously.

I do not discharge migraneurs with narcotics, as complicating their treatment with opioids will not make their headache go away and will likely make their life worse. A more fruitful approach is to get them plugged in with a neurologist who will be able to try other preventive modalities (TCAs, bblockers, depakote, etc). If they are unwilling to follow up with a neurologist then you have no chance of helping the person uninterested in helping him or herself.

 

[The White Coat Investor]

I don't answer pages (I don't own a pager actually). All of my patients who need follow up care from me come into the ED and see the person on. Welcome to civilian medicine. I just started active duty with the Air Force and I saw only one person that remotely qualified as a drug seeker in my entire first month.

 

[JustADoc]

There's nothing wrong with being fooled once (or even twice), esp. when you don't know the patient (yourself). Sometimes you have to give them the benefit of the doubt and bite the bullet.

Assuming you're in a residency, your superiors should have protected you. As an attending, I generally do all the suspected seekers myself. Residents who don't know the patients have a tendency to feed them and give the patients positive reinforcement.

Assuming you're in a residency, what ER residency has their residents carry a beeper?!? Turn it off! Don't feel bad about not taking the call, it is completely inappropriate for the patient to try to nail you down for any reason.

One way of stopping seekers is to tell them that you think they're addicted (and if you're lucky, then dump them off to psych / detox). It's also perfectly fine to say "no". No one ever dies of pain, esp. if it's chronic. Just protect yourself and see that it's not something bad (for instance see if this patient had a hCT at some point or other HA work-up). Another way out is to refuse to give them anything in the ED, and offer them admission.

Your patient probably could have taken all 50 vicodins and your dilaudids and still be able to go have a burger and fries. She sounds tolerant.

Hope this helps...

 

[RuralMedicine]

So I think your problem is that you gave narcotics to an addict. Of course she's gonna try to get more.

BTW Well demonstrated that narcotics are not effective for migraine. Don't give them for that. Instead phenothiazines or ergots are effective with nsaids as backup. And tell her she won't get narcotics from the ED in future.

Thank you! (I'd love to forward this to the ED physicians at the hospital where I admit---and can we add many forms of chronic pain to the list?) I tell patients this all the time but since they usually get whatever they want when they go to the ED it gives them little incentive to see their PCP and actually address their issues and other medical problems.

 

[BKN]

and can we add many forms of chronic pain to the list?

Absolutely. Add to that renal colic and biliary colic respond well to NSAIDs. NSAIDs are smooth muscle relaxants and have been shown to lower intervesical and interureteral pressures. The pain is due to stretch of the smooth muscles. An occasional patient will need narcotics as well. If you have an ED info system, you can check on previous visits easily.

Add the fact that one can usually demonstrate either a GB stone or hyrdonephrosis with bedsie US or formal imaging - and the addicts only have the back pain scam left.

If a ED group makes a conscious effort not to become the addicts' filling station, you'll get little further abuse. Life becomes much easier; it is at our place.

 

[Dr.Evil1]

What about sickle cell or tooth pain? Chronic pancreatitis? People will always find a way to get pain meds if they want to abuse. If they are truely addicted to opoids then they can always buy them too. I agree that if people demonstrate a consistent pattern of drug seeking behavior then witholding opoids is appropriate. I think that sometimes we get on a pedestal and withold meds from someone who actually might need it. Make sure you are right when you decide that the patient is just looking for meds because trust me you feel really bad when you are wrong.

 

[BKN]

What about sickle cell or tooth pain? Chronic pancreatitis? People will always find a way to get pain meds if they want to abuse. If they are truely addicted to opoids then they can always buy them too. I agree that if people demonstrate a consistent pattern of drug seeking behavior then witholding opoids is appropriate. I think that sometimes we get on a pedestal and withold meds from someone who actually might need it. Make sure you are right when you decide that the patient is just looking for meds because trust me you feel really bad when you are wrong.

Well, I'm in El Paso. Our sickler died several years ago and we haven't seen any since.

I don't believe that we are in any disagreement. I certainly give out opioids for patients who need them. I was just commenting that:
1. for several diseases that traditionally are faked, opioids are not the only or even the best treatment.
2. Further for those same diseases, objective imaging is available that wasn't years ago.
3. Being generous with opioids to obvious addicts leads to their returning and telling all their friends.

 

[docB]

On a semi related note I just got a note from the NV Board of Pharmacy which has a group of investigators who track seekers/abusers. I usually get one of these notes every month or so. If you’ve been hit by a seeker who has gotten onto their radar they let you know. This particular patient had over 180 prescriptions for narcs, benzos, soma and so on over the last year. In addition to his PMD and his partners he had been seen by me and 7 of my partners. It’s interesting to note that the EPs always write for 5 to 30 pills while his PMD and the covering docs wrote for 60 to 180 pills. I tried to count it up and he had something like 5000 Vicodin HP, 2500 Soma and enough benzos to make mother’s little helper go apnic. Anyway I’ve committed that patient to memory.

 

[Dr.Evil1]

I was remembering a patient from hell that I had reciently who I thought was drug seeking:

She was new to our hospital, having had all her treatment at a suburban hospital that would no longer treat her because she lost her insurance. She had abdominal pain with nausea and vomiting. She had a long history of pancreatitis (not an alcoholic). She entered my module then proceeded to urinate on herself and made a dramatic presenation during my H+P. We couldn't get a line on her so we did an art. stick for blood. IV access was a problem for the next 8 hrs (she neglected to tell me that she had her first cutdown at age 16, aprox 20 years ago). She was given 5 mg of SQ morphine x 2 over the next 8 hrs because I didn't believe her pain was real. Turns out her amylase and lipase were normal (chronic pancreatitis) but her urine amylase was positive. It took general surgery and 4 additional attempts to get a line but finally we were able to adequately treat her with IV hydration and pain medication. I felt like an ass because the first thing that I said to my attending when I met the patient was "this one is full of sh_t". She actually turned out to be an honest patient who was in real pain and my first impression really tainted my therapeutic relationship with her. It all worked out but was a real learning opportunity.