So this man is, based on my experience, a drug seeker. This is not a first impression or an instinct. I say this based on seven or eight years of transporting this patient (our service transports the patient anywhere from one to four or five times a month) to multiple hospitals. The calls are not all for pain or migraines. Some of them are for altered mental status because the patient has taken so much medication (somehow he manages to order Fiorinal over the internet) he is stuporous, drooling and unable to walk. The man does not have a general doctor because no one will take him his reputation is so well spread. When he is in pain and not stuporous, he becomes very whinny. He has a migraine. He hurts all over. His pain is always 8 or 9 on the scale. His gait is slow and tortured.
I try to be compassionate, and compassion for me with this patient is to merely ask what hospital he wants to go to today, and then to put him on the stretcher and take him there without getting into why don’t you want to go to the closest hospital or why are you such a drug-seeking loser.
This patient has called me an asshole before. This comes after I interview him trying to find out why his prescription bottle is empty when it was just filled five days ago or what the doctor said the last time he was at the hospital. The whining comes off and the patient soberizes with anger, and he calls me an asshole. So now I don’t even get into it anymore.
He will display this anger at the hospital as well. The patient will lay there all helpless and whinny while being examined by the nurse and doctor, and then when the doctor gives him a prescription for only two Percocets, he will tear his IV out, call the doctor a motherfucker and then storm out of the ED without a hint of feebleness.
Part of my reason for writing this today comes from the dilemma of how I describe this patient at triage. Sometimes it is easy. The nurse will look at the patient and say, okay, him again. And I don’t have to say anything. But what has been happening lately with the tremendous staff turnovers in the EDs, I often get nurses, and later physicians, who neither know the patient or me despite the fact I have been bringing patients to area hospitals for twenty years.
I try to be nonjudgmental at all times when giving my reports. I try to stick to the facts. I never say he is a drug seeker. I say patient complains of a migraine and pain all over. Patient has been transported to multiple hospitals multiple times for the same issues. Maybe this last bit about the multiple hospitals is a code for "he is a drug seeker." I find sometimes when I say that, while some nurses will nodd knowingly, other nurses will look at me like I lack compassion, like I have no idea that a migraine or chronic pain is a true medical problem. I just shake my head.
On times when I have brought this man in when he has been stuporus and drooling, I have had the staff call stroke alerts or doctors want to intubate. I used to say give him a good sternal rub and then tell him he can’t have any more percocets and you’ll have one less patient in the ER. Read his chart, I will say.
I just shrug most of the time now. If they want me to go into all my experiences with the patient I will do so, but some people just aren't interested. So pain all over, I say, been here before for same complaint. same condition.
***
There is another patient in town who we transport almost as frequently. Elderly woman with severe arthritis and chronic pain. She wears a Fentanyl patch and takes Percocet. Sometimes she just can’t take the pain anymore. I find her in her small apartment crying. I usually give her morphine. When I leave her in the ED she is at peace. History of chronic pain, I’ll say, was crying ten out of ten this evening. I gave her five of morphine. She’s down to a three and comfortable.”
“You know she’s a drug-seeker”’ a newer nurse told me once.
“Yes, she seeks drugs because she’s in pain,” I told her, but the nurse didn’t seem to understand that concept.
Maybe some of you are thinking to yourselves, "So what is the difference between these two patients?"
I ask myself that as well. Aren’t there needs really the same?
Do I treat one better because she is sweet and helpless? Do I treat the other worse because he is a miserable jerk?
If I met the man for the first time, I think I likely would medicate him as well, but time has taught me he is deceitful and abusive, so I do not. The old woman, I believe, is merely suffering, and so I try to ease her pain. At least that’s how I see it.
At triage, I don't preface by saying "sweet old lady" or "miserable drug-seeking loser." I try to stick to the facts. Let the hospital decide for themselves.
Still, something here is gnawing at me.
I want to provide relief to all my patients, and there is a possibility that this man is truly suffering as well. But it is hard for me to view him with unbiased eyes.
Sometimes I wonder what he was like years ago before pain and need and abuse found purchase in his soul.
