Friday, July 9, 2010

Traveling Pain

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.


Kate said...

I want to laugh, but it makes me sad. Sigh.

Tanya said...

I feel badly for you as well as your co-workers, that you have to deal with this problem so often.

Katie said...

It stinks that such people exist and that you have to encounter them on a regular basis.

Glad to hear Emma made it safely!
<>< Katie

Have Myelin? said...

Alcohol and drug abuse truly sadden me....We need to do more for them.

I don't know what the answer is.

Amy said...

Ugh, it's so awful that people like this waste your time and waste medical dollars attempting to feed their addictions. (Great post though.)

Anonymous said...


Webster said...

My neurologist recently tried Ritalin for my MS fatigue. It does help better than anything else I've tried for the lethargy and sleepiness type of fatigue I sometimes have. However, I must go to his office to get a refill Rx because apparently Ritalin is a controlled substance with a street market value, and is often abused. Who knew?

So, you made a good call. Congrats! I wonder if Sandra ever gets her Oscar back? I'm thinking it may have been sold.

Anonymous said...

Terrible that this woman abused the system and tied up an ER bed that might have been needed to save a life.

IrishPoet said...

Working in a pain clinic for over 10 years I knew where this was headed before the end of the 1st paragraph...unfortunately we see folks like this all the time, and they use up valuable time and resources that could be given to treat patients who are REALLY suffering from pain, which are many...not to mention the very substantial $$$ costs these people waste with their ER visits, which impacts everyone negatively...our docs are also very good at recognizing these folks right away but they still waste valuable clinical and human resources at an increasing rate...

911RN said...

Sadly, I see it too many times per day. Drug seekers are the bane of our existence in the ER. We have a sixth sense for 'em and can usually spot 'em from reading the chart (they are usually allergic to all the non narcotic pain relievers).Or we sniff it out upon entering room with first mention of what is going to be given for pain- if it's non- narcotic- it will never work for them!

Poor use of our resources but happens everyday(often mutiple times per day) in every ER in the country. BIG Sigh!

Empress Bee (of the High Sea) said...

sadly i will admit that my son has done the same thing. thank goodness he is no longer on drugs but it was a very long road in which he ruined his career completely. no matter, he is clean now well over a year and living in a halfway house and working in a treatment center. yay him!

keep checking up on 'em doc! that's what they need. drs. that give in are helping them kill themselves. you (still) rock doc!

smiles, bee

Karen said...

I guess these patients think that they are the only one to do this. Sandra Bullock on the phone - Ha!

Anonymous said...

From what you have written, it sounds like BPD, possibly due to C-PTSD from childhood sexual abuse. Did you consider this?

Anonymous said...

I recently had surgery and told the enesthesiologist that I was allergic to toradol. Post op the CRNA gave me toradol and I ripped her a new one; she said: "nobody is really allergic to toradol, you obviously "want" a narcotic". What an absolute bunch of crap. I left, just in time to end up in the ER with a bad GI bleed and hives. Stop assuming that everyone "wants" a narcotic; I want a provider who listenes and who gives a damn.

Leslie said...

While these patients drive me as crazy as everyone else, I do think it's important to remember that anyone who would interrupt a vacation with their family to go hang out in an ER is really suffering. She is just not suffering something that will get better with opiates.

DrAnge said...


Even if she does have a mental illness caused by who knows what - an ER docs' job isn't and can't be to deal with that. Even if they were to spend the time to try to diagnose that they shouldn't be opening up conversations about past PTSD experiences in a setting without privacy or any follow up. She has a family doctor who should deal with the long term issues and the ER should only be used for acute emergency problems!

Heather said...

Glad your baby arrived safely to Australia's open arms...

It's sad, you know, that so often we know the "cardinal signs" of narcotic abuse. It's so stinking common..and sad.

SeaSpray said...

I figured where this would go ..after the first fake observed.

It's too bad time is wasted because of these patients. And it hurts the ones truly in pain sometimes because staff becomes jaded.

How odd is it that if wife and mom is hurting enough to go to the ER ..that family still goes to the beach while she is alone in the ER? I think I'd be miserable ..worried about her.

Awww nice for your daughter getting to travel like that. So how is DAD now that she is there?

Anonymous said...

Dr. Ange,

Well-put and agreed.