Seekers

The other day, I had a patient who hasn't quite reached our platinum frequent flyer status, but is steadily working her way up. About 20 visits over the last year. In with a headache today. Same headache she had two days ago when she was here. Told to follow up with PCP yesterday, who of course was impossible to get a hold of with that one call she made at 4:30 pm, so alas, it's Saturday, and the pain is unbearable.

I hadn't as yet had the pleasure of her acquaintance, so after our meeting, I offer her a shot for the pain (in my mind = benadryl + compazine). She asks for specifics (d#%! it...), and I find out this isn't what she had in mind:

"Yesterday, I got 2 mg of dilaudid and 50 mg of vistaril. Give me that and I'll be out of here in ten minutes."

I've treated plenty of sicklers who wanted to write their own orders, so the specific request wasn't too surprising; it was the offer that got my attention. This lady was speaking my language. Give me this, I'll cut your throughput, increase your patient flow, help your patient satisfaction scores. An administrator in patient's clothing.

I'm still fairly new out of residency, so I'm still sorting out how I'm going to treat the seekers. I used to think the answer was pretty simple until a patient I can recall in residency. Woman with HA, known frequent flyer in the neighboring town 30 minutes away. Called the ambulance from the ER (those of you in the hood won't be that surprised by this) for transport to our facility. Staff at said hospital alerted us of her impending arrival. When I get to her, I'm ready. Give her a shot of Benadryl. No effect (gasp!). Just wait, it will kick in (grinning inside...). Shot of compazine. "I'm allergic to compazine". "That's why I gave you the Benadryl--you'll make it."

Anyway, we did this little dance for a good hour or two before my attending steps in and reminds me that she's been here for two hours and I haven't done a thing for her. Wants me to give her what she's asking for. The idealist in me is going, "but...but..." "But nothing...treat her and move on."

Now I would write this guy off, but he was one of the best attendings in our residency. Always kept his cool, kept the department moving, and a great guy to work with. Nothing ever really seemed to get to him, a stark contrast to the slew of burned-out malcontents we usually had to work with.

So I'm finding myself increasingly following his advice. The battle just isn't worth it. I got into it with one of the nurses the other day who was irritated that I was giving this guy with back pain a morphine shot. "But he's here all the time!" Quick check to the records to see that "all the time" meant about every other week, and that with EVERY visit, the doc had done the toradol/flexeril/norflex thing, likely tying up a bed and a nurse for an hour, only to give him his drug at the end.

Why not just start at the endpoint? I don't KNOW the guy's not in pain. And even if he's seeking drugs, every other week ain't bad. Give him his drug, and save the battles for the platinum club.