NinerNiner999 said:
For what its worth, when I was in medical school I worked at two different ED's - one of which had Demerol (my home ED), and one which discontinued it halfway through my fourth year (across town). Around the same time that it was discontinued, there was a documented increase in the number of patients with "intractable pain" who began coming to our ED, staying for hours on end taking morphine and dilauded "without effect" (I remember one abdominal patient I had who could barely maintain coherent speech, let alone see me through his pinpoint pupils) but demanded Demerol for relief. It was so bad at the time that staff from the other ED were invited to our ED to identify their frequent fliers and bring old charts for our records. One random day when visiting staff came by, there were 7 "chronic pain" patients who were known to the visiting attendings. SEVEN in one day!! An internal study of our department later revealed a surge of nearly 11% over a four month window, with electronic chart review of the words Demerol and pain showing a concordant increase over months past. We eventually discontinued Demerol in our ED and from what I hear, visits are on the decline. Take from this what you will.
I know that the topic of pain control and chronic pain management can be a powder keg for some people, but in general and in our field - it can also be a huge medicolegal landmine that brings up other questions - should EDs be responsible for chronic pain management? To what extent do educated addicts warrant their workups (what do we do with the Demerol seeker with the "worst headache of his life" who "hit his head" ). I can see Katee's point and I can also see MudPhud's point, but truthfully, I don't think anything I read will ever influence my decision to dispense pain medications, aside from clear FDA and evidence-based medicine suggesting the contrary (or a cruise and a steak dinner from Glaxo
, j/k).
I'm not educated enough to truly tell anyone that they don't have pain - and I don't think I will ever be (unless we put polygraph machines in the rooms), but I'm learning to refine decision-making regarding ordering CT's and performing LP's. I'm also aware that the patient who ties up my bed for hours with "intractable pain" needs admission to the hospital, discharge home, a properly documented set of AMA papers, or an eventual administrative discharge from my facilty for numerous bogus complaints. These unfortunately are not blanket decisions for a subgroup of patients, but are in the differential of disposition for everyone who names a drug in their allergy list or by request. Pain is one thing, but once I've ruled out the bad things that can actually kill a patient (and pain is actually quite far from my list), its time for the next sick patient to have their turn.
I don't know ...I agree chronic pain is not the responsibility of the ED. Acute pain is. I witnessed something tonight that really got me angry so I'll share.
35 yo woman presenting with acute lower abd pain in RLQ. Pressure 158/103, HR 112, R 21, temp 36.9., vomiting writhing in agony. I knew her as one of my old babysitters. Totally cool, proffesional woman with 2 kids and an awesome hubby.
She was crying, and I was sitting a little bit away from her waiting for my instrutor to show up so I heard the whole conversation.
doc: So you're having some pain huh?
girl: Yes..too much..its excrutiating.
Doctor went on to do his assessment, palp, blablabla
girl: Can I please have something for pain?
Doc: Well you look like you're allergic to quite a few things but I'm willing to bet they're just sensitivities right?
(ends up she was allergic to morphine and hydromorphone and some food allergies and penecillin)
Doc: what helped with your pain in the past since you were here 5 years ago for the same thing.(suspected ovarian cyst)
Girk: I got Demerol and it worked very well
Doc: Well unfortunately for you I don't give Demerol so I 'll have to give you toradol.
girl: It wasn't enough the last time! (a litle frantic now)
Doc: Well theres a lot of things that are wrong with that drug so I don't give it anymore. Tough luck for you though.I'm sorry.
Girl: starts crying.
She eventually got toradol, gravol and a shot of fentanyl but ..you guessed it....it didn't last 45 minutes.
Now according to me that was a totally cruel thing to do. Our hospital still uses demarol ...alot. For him to withhold it from this poor lady was just plain mean and totally uncalled for. She has no renal impairment, no hx of seizures, shes only been to the hospital 2x for this before and is an avid runner. She hates drugs but she asked for relief by the one person with the power to do it and he refused. It was really busy tonight.....everybody has to run around like their heads were cut off, including the doctor and he has to reasess her every 40 minutes, order more med and waste time when he could have bought time and gave her the damn drug and it would have been all good for at least 2or 3 hours. Demerol was made as an option for pain for petes sake. Its there...freaking use it!!!!!
I found it a little bizarre to witness since we've been discussing it here.
And to top it all off I overheard him telling a nurse to give another pt a script for 10 percocet. freaking 10. The poor guy cant go to a dentist until monday becasue he gets paid and can't afford to go sooner! 10! What an insult! The guy was again a good upstanding citizen with no chart. Hes never been there before. He goes to school too. My school
The doctor didnt even ask how many he will need to take and base the script on that. 10.
This doctor was definatly not treating the person and barely treating the pain A real opiophobic if you ask me.
I understand your points that its just too much hassle to treat all the druggies but please folks...keep an open mind. If the pt seems to NOT be one of "those"........and they ask for something they know will work better than something else. Dont freak out because they can pronounce it and automatically think drugseeker, secondary gain.
Thanks for letting me vent.
I welcome consructtive feedback. I'm trying hard to understand his actions but I'm really struggling. What will I do when I'm doing an ER rotation ? I'm gonna freak out if I see that again!!!!!
Didn't her vitals reflect pain?
Ended up having an appendectomy
PS: I'm learning alot by asking questions so I'm not exactly argueing with you. THank you for reading.
Katee