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.