We find our patient by the elevator doors in a public building. He is on all fours, dry heaving, and shaking. He says he is in terrible pain. Security tells us he is a visitor to this public building. They don't know anything about him other than that he has been screaming that he is in pain. I do my best to assess the patient. He is alert, with warm, dry skin. His pulse is in the 90's. His abdomen is soft. I tell him we are going to get him on the stretcher and examine him further, and depending on a number of things, we hope to be able to help him. He continues to squirm. He is in his forties, wearing, shorts and sneakers and a tee-shirt. He seems oddly out-of-place. I ask him if he has ever felt this pain before. He says yes. I ask him what caused it on those occasions. He says he has gastroenteritis. In the elevator, he tells me he has no allergies. In the ambulance, I take his pressure and find it within normal limits. I am going to give medicine. I take my patients (for the most part) at their word. Yet, my twenty years experience suggest to me that this man falls into the category of drug-seeker.
I have no doubt but that he is in pain, and as I said, I am going to medicate him. I just wonder at the quality of his performance. The manner that he contorts himself and screams that the pain is killing him and that he is burning are both true to real pain and true to performance pain.
He seems almost like a dog who knows he has to perform in a certain way to get his bone. Or a court jester who has to put on a good show to avoid being kicked by larger men. I get the feeling that while there is passion in his performance, there is no joy. He is doing what he does in order to survive.
"What are you giving me?" he says as I slowly push the plunger on the syringe. "I like Morphine."
"Well, too late. It's Fentanyl," I say. I give him a 100 mcgs, and I watch his whole body relax and he slumps back on the stretcher, and closes his eyes. This is truly one of the better responses to Fentanyl I have seen.
I was expecting to give him at least 200, but the 100 does the trick. In the ED, he sleeps curled in fetal position in dreamland.
I have to say, I have rarely regretted giving pain meds to any of my patients. And I have no doubt medicated many a "drug-seeker."
Do I care if I have been played?
I don't. My job is not to be the Judge Wapner of Drug Seeker Court. My job is to treat my patients as compassionately as I can and bring them to the ED where if they are a drug abuser, they can hopefully get more detailed care aimed at breaking their cycle of dependence. And if they are not a drug abuser, then I have not withheld treatment.
I write about this case in particular because of a pain policy I read recently that comes out of LA. Here are two passages I find striking.
1). Pain changes human behavior. People performing torture have long known that the intentional inflection of pain can cause a person to behave in ways that they normally would not behave just to avoid the pain. Pain is very powerful. Chronic pain changes personalities. People who have been happy and kind their entire life before being subjected to chronic pain (such as arthritis or an old injury) have been known to become irritable, angry and unsociable.
2). Addiction is a very real problem and treatment is very complex. One thing is certain, the treatment of drug addiction is not in the paramedic scope of practice and the withholding of narcotics by a paramedic is not going to end an addiction. It is better to give narcotics to 100 addicts than to deny pain management to a single patient who is in real pain.
Watching my patient contort and squirm and cry out for his medicine made me wonder what he was like before pain got a hold of him, before pain broke him, and turned him into what he was there before us. How often has he had to perform? How long as he had to find creative ways to get the medicine to fill that broken space in him where once he was whole?
Read this document:
Los Angeles Prehospital Pain Management Policy
Bravo to its authors! And while maybe they might want to consider letting their medics give narcs on standing orders, their policy has much in it to emulate.
***
I hope to write more about pain in the coming weeks, including about the raging war between the anti-drug overdose group and those who advocate for humane treatment of those in chronic pain.
