Because of our jobs in the emergency room, we tend to see the extremes of human behavior. We may be cursed at, spit at, or physically assaulted just five minutes before being incessantly hugged and complimented by the same patient, an elderly woman with dementia. We may be talked down to or screamed at by the frequent narcotic abuser. We may be treated with the kindness, respect, and compassion, the way our parents taught us to treat others, by yet other patients, despite their not feeling well. The combinations of personalities and behaviors are endless. And interesting.
As a result, most of us have learned to be on-guard with our observations and our emotions. Because of so many interactions with patients and their families and friends, we have become experts, to use the term loosely, in quickly recognizing the differing personalities that may dominate a treatment room during a visit. Demanding? Check. Abusive? Check. Genuine kindness? Check. Attention-seeking? Check. Fun-loving? Check. Shy? Check.
Once we recognize a patient's personality, we can tweak our approach, our interview, our exam, and our treatment to fit that individual patient. It becomes easier to climb over the hill and treat the medical emergency that brought the patient to us.
Walking into Room 22, I was surprised to find a woman in her mid-thirties lying on her treatment cot, appearing quite comfortable as she watched TV. However, as her eyes darted in my direction while I walked through the door, she immediately began rocking and writhing in her bed, loudly moaning her misery.
I stood and watched her for a few seconds. Her behavior was interesting. It appeared that this patient was trying to tightly blink her eyes, to produce some tears, while she kept glancing out of their corners to gauge my reaction. I continued to stand quietly by the foot of her bed.
Finally, she calmed down enough for me to introduce myself. "Maam," I said, acknowledging her pain, "I'm sorry you're in pain. As soon as we talk and I do an exam, I'll be able to share with you what I think and what work-up and treatment you may need."
It turns out that this woman, diagnosed with irritable bowel syndrome, chronic abdominal pain of unknown etiology, and fibromyalgia, drove two hours with her boyfriend and two children to spend a long vacation weekend in our town. Within an hour of arriving, she developed her abdominal pain and decided to seek out an emergency room for treatment. "Honey," she had said, repeating the story for me, "you take the girls and have fun while I go get something for this pain." The ambulance picked her up at her hotel and brought her in while the family went to the beach.
Out-of-town visitors presenting to our ER with chronic pain issues always make me a bit more cautious of suspecting narcotic abuse, and this woman certainly seemed to fit the part. Sure, etiologies do exist for abdominal pain that can come on suddenly and wax-and-wane, but this woman, with a little distraction of conversation, seemed to be able to turn her pain outbursts "on" and "off" with the flick of a switch. As I palpated her abdomen, she would scream out even before I touched her. And during one scream, when I asked the patient her daughters' ages, she stopped the screaming immediately and answered my question as if we were at a restaurant having a dinner conversation. Hhhmmm.
"Maam," I said, after finishing her physical exam, "your findings are very atypical. You have good vital signs, no fever, and your abdominal exam, outside of your bursts of pain, is not revealing anything specifically wrong." As if on cue, she began to moan and rock within her cot again. It was over in just a few seconds. I continued. "We'll get some blood and urine samples to test, perform a pelvic exam, and give you something to make you more comfortable."
She nodded before asking the question I presumed would come. "Umm, doctor," she asked, "what are you going to give me for pain?"
"Toradol," I answered, watching her face closely for a response. Yep, there it was--her grimace. Toradol, as many patients know, is a non-narcotic IV and oral pain relief medication. It works great for several emergency illnesses, including kidney stones and migraines, and is a good alternative medication to offer someone in pain that might be suspected of having narcotic abuse issues. Of course, half the patients will say it doesn't work or they are allergic to it.
"But it doesn't work for me," the patient said, again on cue.
"I'm sorry, maam," I said, "but that is what I can offer you as we do your work-up. She decided to refuse the toradol dose.
As we waited for her results to come back, I had asked the nurse to leave this patient's curtain open a little bit and observe her. Sure enough, when this patient didn't think she was being observed, she calmly watched TV and even, at one point, climbed out of the bed and used the telephone while opening a top cabinet drawer. She was probably disappointed to find the q-tips, the strep-collecting tubes, and the tongue blades that greeted her. The other drawers, of course, were locked.
And every time the nurse or I entered the treatment room, the patient would begin rocking and moaning almost immediately. And stopped again as we walked out. Walk-in--scream and moan. Walk-out--TV-watching time.
Coincidence? Or not?
Her test results, as we suspected, returned negative. Every single one. Surprisingly, this patient gave me information to call her family doctor, which I did, and found out that she had significant pain control issues despite having a thorough, negative work-up and multiple visits to varying emergency rooms. "Please, do not give her any narcotics," her doctor had explicitly asked, although I had already arrived at this decision on my own. "I suspect," he continued, "that she may be abusing pain medication."
I went back into the room and explained everything to the patient, including my conversation with her family doctor. "I can give you something for the pain, maam," I said, "but it will be a non-narcotic, similar to toradol."
"Forget it," she said, easily jumping out of her cot to begin changing from her gown. "I think the pain has passed." I wished her the best before stepping out of her room. Before leaving, I was told, the patient got upset that we would not call an ambulance to transport her back to her hotel. "How about the beach, then?" she asked.
At the end of the day, most of us in medicine want to be wrong when our hackles go up and we suspect someone of narcotic abuse. Unfortunately, though, this sub population of patients does exist. And in certain geographical regions, it can be quite large. Unless I am extremely suspicious, as I was in this case, I will typically treat pain complaints and then try to figure out if the source of pain is real or made-up for abuse reasons.
Would it be wrong of me to say that we are happy when the pain turns out to be real?
I finally figured out who this patient was on the phone with, though, when she was in her treatment room. It was Sandra Bullock. Calling this patient to tell her that she wanted her Best-Actress Oscar back.
As always, big thanks for reading. I would sincerely like to thank all of you for your awesome comments in wishing my daughter the best and safest of trips. To the commenting Australians, thank you for your reassuring words...she arrived yesterday and has already fallen in love with Sydney! Well done. Have a great weekend and see you next week...Jim.