“I Usually Get Dilaudid and Phenergan”
These are the words that start to change my diagnosis from “kidney stone” to “drug-seeking.”
Two weeks ago, I pull back the curtain, introduce myself, and see a woman writhing around in (supposed) pain, tears in her eyes. She tells me she’s had 4 kidney stones previously. They’re all uric acid stones, which are generally undetectable on X-ray. That she went to a urologist, was on allopurinol, but stopped it two months ago. This all happened in Texas. She tells me where her pain is, and that it radiates to her back and down to her groin. “Kidney stone! It’s a kidney stone!” I tell myself. I am brilliant. I examine her, find some tenderness on her right flank. Her urine has already been sent to the lab. I tell her I’m going to go talk to the doctors to discuss what we can use for pain control. She warns me that she is allergic to aspirin and Tordol–a strong pain reliever but not a narcotic. (Think super-Advil.) Her mouth swells up when she takes either of these. “What terrible luck, a woman with chronic, painful kidney stones and allergies to common pain relievers!” I think. She then finishes her pain medication story: “Whenever this happens, I usually get dilaudid and phenergan, and sometimes ativan because I have anxiety attacks.” And it all goes downhill from there.
I pause, skepticism and cynicism running through my mind, but I give her the benefit of the doubt. Assume nothing, I remind myself. Moments later, the patient’s nurse chases after me in the hallway. “She’s a frequent flyer here, you know. She was just here 2 weeks asking for the same thing. And I guarantee you next she’ll ask for Fentanyl.” Add more skepticism to the pot.
So we check her name–first time she’s been at the hospital. Maybe she’s using an assumed name? We check her urine, and it’s strongly positive for both blood (going along with the stone story) and white cells, indicating an infection. We’re stuck–her story and labs say maybe she’s telling the truth, but everything else is leaning toward malingering. So we start antibiotics for her infection, give her yes, some dilaudid and phenergan for pain control, and I tell her she’s going to need a CT scan. We get the scan setup, and she continues to ask for more pain medication–”It helps for like 2 seconds and then goes away!” Just when she’s ready to go to the scan, she starts asking for some ativan (similar to valium) for anxiety, because she gets claustrophobic in the scanner. We point out her head won’t be in the scanner, just her abdomen and pelvis. She continues. We tell her she’s already had a good deal of pain medication, and we don’t want to continue giving medications that could suppress her respiratory rate. She starts crying, and starts loudly asking, “Why can’t you just help me?? I’m in pain here, I’ve never been treated like this before.”
My resident pops into the room and helps with the authority bit, and later tells me she recognizes the woman too.
She misses her chance in the CT scanner, so we wait. She, as the nurse predicts, starts asking for Fentanyl, a very strong narcotic. She then starts cycling–”I’m in pain,” then “I’m nauseous!” then “I have a headache,” then “I have a sore throat,” then “I’m anxious,” each time asking for a different medication for her symptoms. She finally just goes to the CT scanner, but leaves the scanner with an anxiety attack.
If the woman does have a stone plus an infection, the infection could start climbing up toward her kidney. She could get an infected kidney, could get septic, could die. I discuss this at length with her. I tell her we believe she needs this scan to make sure she doesn’t have such an infection. She gets upset again and says she wants to leave. (I’m leaving out plenty of copious details, as this dragged on for hours.) We talk about why this is a terrible idea, but she wants to leave anyway. I go get the paperwork for her to sign to leave Against Medical Advice. I come back and note 2 things: her hand is down near her genitalia, under the blanket. (This was the case the last time she was here.) She’s either masterbating or giving herself an infection. I try my best to ignore this, which is totally disgusting, and hand her the paperwork to sign. She can barely grab the pen, she’s so sleepy and out of it from the narcotics. She’s still complaining of pain. She signs and initials here and there, and finally leaves. (I throw away the pen.)
Meanwhile, we have 10 other patients that have been waiting to be seen by a doctor; she’s wasted a bed for at least 4 hours. I’m angry, frustrated, and annoyed–and the rest of the nurses and doctors are, too. I sigh, quickly eat a granola bar for dinner, and pick up my next chart: a woman that’s been waiting 6 hours in the lobby to be seen for a simple clogged NG tube.
Update: I forgot to mention the final kicker–the woman asked for “Vicoprofen,” which is like Vicodin, but has ibuprofen in it instead of Tylenol, which is in vicodin. (She says the Vicodin makes her throw up.) My attending was smart, and realized the real reason she asked for the vicoprofen: it has a larger amount of narcotic in it per pill than the vicodin. Another trick of the trade, apparently.
I think I was in the Que after this woman! hehehe, Seriously though I had to wait over an hour recently for my MRI, which I arrived early for, because the woman ahead of me kept going on about her anxiety and making the technicians stop her scan. What made me so angry was that other patients (including myself who was actually in pain) had to wait while this woman played out her histrionics. I understand that some people do suffer claustrophobia but you can tell when people are just faking.
One of my more memorable malingerers was a young man with a case of proctitis that defied and deflected all our attempts and diagnosis and treatment. He was finally admitted for a blue-plate special of testing and consultations (long enough ago that that approach was still possible). He came close to have a diverting colostomy as a end of our ropes sort of thing. Until he was found in a broom closet. Making use of the broom handle.
As to the other case: even fakers get sick. That’s the nub of it!
But wait there’s more! I forgot the most egregious. The patient was a doctor. In for complications of a vagotomy/pyloroplasty, done after innumberable episodes of hematemesis over many months, refractory to diagnosis and treatment. Developed dumping. Had a reverse ileal interpostion. Developed obstruction. I was chief resident on the admitting service for another of many admissions; my first encounter. Her gastroenterologist took me aside to inform me that the original hematemesis had been self-induced: she drew her own blood and inserted it via an NG tube….
I, for one, find people like this simply unbelievable. Who would want to make themselves hurt? Who the heck would fake clausterphobia?
Nobody likes whiners and people who are consatnatly sick are only thought of as whiners - I know, because I’m really sick all the time. I have many stupid, unfair complications of my life, and I’m telling you it sucks.
Stupid people ! If your life is free of medical complications stay free! it is beetter breathing un medicated air.
Wow. Stories like this make me understand (a little) why my doctor jumped to conclusions the way he did . . . I wasn’t a drug seeker, but I can see how it may have seemed that way at the time.
BTW, was there a social worker there? Is anyone following this woman to learn why she is doing this to herself? Or will she just fall through the cracks? Sad.
There wasn’t a social worker or psych, difficult pt–and she probably will fall through the cracks, and show up at our ED again–or one down the road. That was my question for my attending–how do we help these people long-term? Unfortunately we had 5 traumas come in within 15 minutes of each other, so we didn’t have time to talk about it, but I definitely want to figure out what to do in the future.
Man you and I are on the same wavelength. I’m an ED nurse and just wrote a story about frquent flyers seeking drugs. It ell my girlfriend all the time how ABD pain and flank pain are the two most common complaints among drug seekers, and you pointed out all their red flags. Nice story.
It sure would be easier on everybody if addicts could just buy what they wanted, and stay the hell out of the hospital.
I happen to be allergic to multiple long-acting Nsaids.
It’s gotten me some funny looks, and that makes me mad.
ImHO, your job is not to err on the side of refusing meds just in case some addict might get away with feeling good for a few hours. It’s always morally better to err on the side of giving pain relief…
If you want the frequent flyers to go away, then we shuould have a system where purity and efficacy are still monitored, but gatekeeping by physicians is “repealed’. An addict can go down to the CVS and tank up. Fine by me.
Yep, you discovered the bane of emergency medicine. What makes it even more unbelievable is to realize that people like this woman are putting on the same charade perhaps 3-4 times a week — they are just rotating ED’s within a 60 mile radius.
Wow, stories like this are not only a bit disturbing but also bring some light to my experiences in the ER. I suffer from migraines. Sometimes they are so bad that they’ll stick around for over a week. They are debilitating but I am really, really cautious about going in for treatment. I have only done so twice in the 10 years I’ve had them for this very reason. People like this have made doctors so leary that when a person that does need help they are a bit skeptical to give it. The times I went in it took fentynal and phenergen to get me to a comfortable level and I went only under the advice of my doctor (Toridol didnt’ work in office). Would I ever tell an ER doctor that if I ever have to visit again…NEVER. For the simple fact that I don’t like the brow beating and the delay of treatment. Too bad this lady will probably move on to another hospital and fall through the same cracks and cause even more skepticism which just leads to other people getting the short end of the stick.
Could you not have opted for a renal ultrasound instead of the CT?
Renal u/s is not readily available in most hospitals. CT is the study of choice for nephrolithiasis. Although, for Graham, there is one stone that is not detected by CT and occurs in a specific patient population… hmmm.
Anyway, as a doc, I tend to err on the side of giving pain meds. You can’t measure pain, and she does have a physiologic basis given her UA. Furthermore, even in pt’s leave AMA, you can give her a script for Cipro. If you felt that she’s a danger to herself, a 5150 can be slapped. (Backseat driving/hindsight is easy :)
Seriously though, these cases infuriate me to no end. Patients like this ruin it for the rest of them.
These are really tough cases..Being a psychologist who has worked extensively with patients in crisis over the years, there are generally programs out there to help this lady but the real question is: Is she willing to accept help and seek the path of healing for her disease? Many people struggle to get out of this cycle of substance abuse and as professionals we cannot force people to seek the help they need. We do all that we can (tap dance, suggest, recommend, etc.) They may “fall thru the cracks” but sometimes it’s part of the disease process.
Like Shell, above, I am a migraineur. Luckily I am finally with a neurologist who treats my pain with the respect it deserves (meaning, I am not out at all hours of the night a few times a year hoping to find a sympathetic doctor in an ER).
There are so many migraineurs who have been treated so poorly because the medical community has been duped by drug seekers. I found that if anyone is in migraine pain enough to need the services of a doctor at an ER, he/she will not be loud and boisterous. He/she will not be moving around, pacing or otherwise hyperactive. He/she will be quiet and as still as possible.
Migraineurs learn very early on about medications. Once you have had this disease for years and years, you feel like a walking PDR. I have been exposed to literally thousands of medications (intellectually speaking, not by prescription). I read all I can about meds just in case I stumble upon one that just might be helpful for me. Then I must also keep track of the combinations I have tried. I guess that would be pharmaceutical geometry? LOL
Please, please don’t ever dismiss a patient who claims to have a migraine attack. Migraine is not just a headache but the headache part of it is usually the most painful part of being a migraineur.
I am quite thrilled to have been made aware of this site. It is not often I, as a patient, get to listen in on you, as a doctor. After all, we are all human….some are just very lucky to be given the gift of doctoring. Thank you from all the folks who may not have gotten a chance to thank you themselves. I have cut my ER visits way down. I think I have only been twice in the past 3 years. I do like not to be occupying space that would be better off used on someone who is in dire need of it. I also am glad to have a well stocked medicine cabinet. It’s not worth much on the open market but it is a treasure to me. As are all the doctors who have tried their best to fix what ails me.
Thank you.
This is one of the reasons why I’ve avoided going to the ER when having a severe headache (I have Chronic Daily Headache and migraines).
I have to say, though, I’ve had lower body scans and they *do* make me very anxious, I regret not getting some anxiety medication when I had to have my last (for a knee injury). I also tend to have anxiety attacks with my severe headaches.
I’m sorry that health professionals have to deal with addicts, but if you can, give those with chronic pain the benefit of the doubt (as it seems you did). We don’t want to be in pain, and we don’t want to take meds (I don’t get “high” from my vicodin).
I’m sorry this patient wasted your time, and the time of other patients : /
I always had a pretty good idea why docs don’t like giving pain medication…my mom is one of those women who is “always” in pain. I grew up on phrases like “I feel like someone took a baseball bat to my head” all the while thinking to myself…you have no idea. Just this past year she spent 3 days in the hospital “dying” with doctors too scared to let her leave because they couldn’t figure out what was wrong with her and she of course was in “SEVERE pain” they sent her home once…she came right back and started dropping hints about lawsuits for malpractice. So they ran test after test after test (all at the states expense of course) only to send her home under the assumption that she may have had a kidney infection. I think at that point they just wanted her to leave.She gets migraines and has anxiety and has a mile long list of painful illnesses. They even took out her completely healthy appendix because she was wailing about severe abdominal pain. As a result of my mother I grew up staying as far away from medicine as I could. I don’t even take midol. Unfortunately however I got shingles twice my doctor thinks my body is just more prone to getting it which I think is odd since I had chicken pox three times as a kid. The first time they put me in the hospital for eight days (I was pregnant with my third child and they were worried about my immune system) don’t ask I’m not a doctor and I have no idea. They offered me just about every pain medication under the sun which I was unwilling to take because I was 5 months pregnant. The second time I got it, a year and a half later, on two seperate nerves on exact opposite sides of my spine which my doctor says it’s extremely unusual not unheard of just rare (for those of you that don’t know shingles usually follows one nerve) Again I was in extreme pain this time with headaches (I had never had a headache before this) and they were really bad, they did a spinal tap, not fun at all. The thing that really got me was Shingles is something you can SEE, you get little blisters all along the affected nerves. It’s not something you can fake but the emergency room doctor refused to give me anything other than gabapentin I have no idea what that is but it didn’t help one bit. When I told the doctor this he gave me 800mg ibuprofen. I didn’t even bother asking for something else I just spent the next three weeks in a lot of pain. I agree with SarahW about it being better to err on the side of giving pain relief, in my case I’m sure I got the doctor that had come across so many drug-seekers that he assumed everyone in “pain” are just looking for drugs. It’s not right to cause people who are legitimately in pain to suffer because there are people out there just looking for a high. Hopefully, doctors will keep this in mind the next time a patient comes in your ER in pain.
Just a quick note to those in the “Just give them pain meds” contingent. Narcotics are not benign meds. They have serious side affects, not the least of which is DEATH. And you can die a lot of ways with narcotics… respiratory depression, anaphylaxis (true allergic reaction), liver failure (not from the narc, instead getting too much Tylenol (the “-acet” in Percacet, Darvocet, etc)- and this is not a very good way to die; driving into a faily of 5 (perhaps your parents or your brothers family) while their judgement is impaired on meds (often these patients drive themselves to the hospital or to your office, get the meds on the way home, take them then finish driving home). And, then, when they are out, they come back to that nice doctor who gave them narcotics for more, again, and again, and again. Denying other patients (again maybe you) from seeing that doctor.