Tag Archives: ER

How to Say No to a Drug Seeker

30 Oct

smoker blog

The reason why I chose the above photo is because many of us are addicted to substances.  Coffee, cigarettes, alcohol,  drugs, all can lead to unhealthy consequences.  That’s me up there smoking.  Just kidding.   I’d like to think that I looked that good when I smoked.   After recently quitting, I can tell you first hand that habits suck.  I always try to have compassion with my patients, but often fail miserably with drug seekers. When someone comes to the ER with the goal of getting narcotic pain medications to feed the “beast”, I have to take a breath and try to remember that they probably aren’t real happy with themselves either.

There are many legitimate reasons  for drug seeking at an ER.

1) Kidney Stones

2) Bear Mauling

3) Severing/Breaking of Limbs

4) Abscess (especially if in a “sensitive” area)

5) Rupture of Any Internal Organ

This is not an exhaustive list.  These patients have an underlying medical or surgical condition that require emergency intervention that will likely include pain control.  The people that come in for chronic issues, or for a fix,  push to the waiting room those who may have more serious illnesses.  (The little old lady with a red leg for 2 weeks is less of a priority than the 45 year old writhing and retching with three months of abdominal pain.) The person who comes in with abdominal pain for the sixth time that week may have developed a true surgical pathology, like an appendicitis, so the key is to push aside your bias and look at the patient with fresh eyes each time.  After you have ruled out any medical or surgical emergency, its time to give the patient the bad news.  The following is a  mock conversation to give you a few ideas about how to respond to the patient.

Practitioner: We found nothing in your work up today that requires narcotic pain medication.

Patient: But  I am IN PAIN!  Isn’t it your job to help people?!?”

Practitioner: I feel that the best way to help you is to encourage you to get to your (primary care, gastroenterologist,  neurologist).

Patient: The last doctor gave me Percocet!

Practitioner: I’m looking at your symptoms and concerns for today’s visit, and I don’t feel that narcotic pain  medication is going to be helpful in the long run.  Here is a list of things you can do at home to help with your symptoms.

This may be where things get really ugly.  My suggestion is that you remember that it is not the patient talking, but the beast that is their addiction.

Patient:  You are a #$%^@!  You don’t even understand what this feels like!  Have you ever been in pain?!?

Practitioner: I am sorry that you are in pain, but we are not sending you with narcotic pain medications.  If you are having chronic pain then you need to see a specialist for that.  I am going to get your paperwork for your discharge.

Mic Drop!  

Do not let this portion of the conversation go on and on.  You might cave and fuel the beast, which is actually hurting the patient.  Here’s the kicker.  Many times I have literally been walking out of a patient room when they throw out a new complaint.  I had a patient that came out of her room, followed me to my work station, and then complained of new chest pain.  I explained that if she is having new pain that we need to discuss that in her room.  The patient then stormed out and said that I wasn’t going to evaluate her chest pain and that I was going to be in “big trouble”.  I covered my bases, documented well, and let it go.  That’s all I could do.

To summarize, always treat a patient with respect, rule out any true pathology, stick to your guns.  There is a designer drug addiction epidemic in the US and as ER clinicians we are the first line of defense.  Use your best judgement, but sometimes you will have unsatisfied “customers” and that may be an indicator that you are doing a good job.

Have you ever had a difficult patient?  How did you respond?  Please comment below!


Blood, Guts, and Bones…Your ER Rotation

6 Oct

Medical research and studies

I must say that I have been working in the ER for 6 years now so I am a leeeeetle partial to this rotation.  My rotation was in a busy, level 1 trauma center.  It was an intense, mind blowing 6 weeks.   Stress levels run high and there is always a lot of action.  There is also a disproportionately large amount of bull crap complaints, which you will notice right away.

I had an interesting emotional response during my ER rotation.  We saw a few trauma patients with gun shot wounds.  These were young men who died of senseless violence.  One free Friday night my husband and I went to see the movie “Departed”.  I know, one of the best crime movies with some seriously gorgeous men.  Although I did enjoy Leonardo Dicaprio and Matt Damon, I walked out of that movie in a near panic attack.  The shoot em’ up scenes hit me in a new way.  I watched people die, in real life.  The violence and death I experienced in the ER shook me deeper than I knew.  The ER is a place where you see people at their most vulnerable and scary moments.  We are a key player in these moments and that can take a toll on you emotionally.

The following are some tips to get you through your rotation.

1.  Be on time…in fact, be early.  Shift changes are key times of sign out and you will be better prepared if you know what is going on with the current patients.  You will also likely learn something about diseases and treatments.

2.  Make your presentations succinct.  There is nothing more irritating then a long, drawn out, fumbling patient presentation.

3.  Know your differentials.  The ER is a little different than your primary care rotation in that the attending will want to know mainly the life or limb threatening possibilities.  Always have five possible diagnosis and say them with confidence!

4.  If you can be a part of an end-of-life discussion you should be there.  This is more of the “art of medicine” that we all need more practice on.

5.  Patient education takes a lot of time.  A LOT of time.  I had a patient who was scared because she thought she had “poop coming out of the wrong hole”.  It was not.  My cartoonish drawing helped clear that one up.

6.  ATLS, PALS, ACLS are all important to know.  When you are part of a code, try to think preemptively what meds and procedures should be done.  You will understand the process better if you try to think for yourself.

7.  In my ER, PAs do central lines, chest tubes, intubations, sutures, I and Ds, dental blocks, joint reductions, splint applications, among other procedures.  You will not get a hang of these in 6 weeks but its important to know the indications, instruments, and meds used.

8.  Nurses, Techs, Medics,  HUCs…They all make the ER roll along and most of them know more than you do.  Show respect.

9.  Be assertive.  There will likely be Med students, NP students, nursing students, medics in training all trying to get in on that code or procedure.  If you don’t get yourself involved no one is going to coddle you along.

10.  The ER may be the career choice for you if you enjoy fast paced, high adrenaline settings… and you don’t mind having a schedule that is opposite of all your friends’ and family’s.   PAs get to use a large skill set and it is cool to help save lives in real time.  You also see some really heart wrenching things and you have to be the type of person who can leave work at work.  Did I say that I love the ER?  Comment below if you have questions or great stories.

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