More on pain...

The surest and most reliable sign of a wuss is the statement "I have a high tolerance for pain."

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.

The pain scale

A word of advice: if you're asked to rate your pain on a scale of 1 to 10, choose a number between 1 and 10. 11 is not between 1 and 10. Neither is 15. I know you're trying to communicate to me the urgency of your headache. I know you're trying to impress upon me just how bad it hurts. But in reality, it's all I can do to not roll my eyes at you (or stab this 18-gauge needle into your leg and ask you where your pain is now...between 1 and 10). And the triage nurse, the registration clerk, the tech, and everyone else who treats you are all thinking the same thing.

Forgive what I'm sure you'll perceive as a lack of compassion, but every day we see people with severed limbs, broken femurs, or jagged rocks passing through their urinary tract, who all manage to pick a number between 1 and 10. And they rarely pick 10.

Oh...and it helps if we don't have to wake you up to pick your number.

I hate the pain scale.

The power of an apology

I recently treated two college freshman who had concocted this homemade brew of nutmeg and poppy seeds. The reason for the poppy seeds is fairly obvious, but the addition of the nutmeg puzzled me a little. Until I called Poison Control and found out that nutmeg has fairly potent anticholinergic properties--tachycardia, dry mouth, vomiting, hallucinations---aaahhh...that's it--hallucinations. Our two little scientists had come up with a brand new concoction that was totally legal and available at your local grocery store.

Well, since the safety of this brew hasn't been as well established as some of the more commonly used drugs we see all the time (crack, meth, marijuana, etc), we were obligated to give these guys charcoal, which they inevitably vomited all over the place (why didn't I put in an NG tube???) For non-medical folks, charcoal vomiting creates a mess that no commercial stain remover is designed to clean up. This mess then tied up not one, but both of our night nurses for a good hour. We then had to call the social worker to come see them in the middle of the night and arrange for their ICU admission.

The thing that makes this story unique (besides the novel use of nutmeg) is that towards the end of this, one of them tells me "I'm really sorry about all of this." Huh? You're sorry? I was speechless. Sure, patients have said this before, but it's usually the little old lady who's so sorry to be bugging everyone about this, but she's concerned about this tearing sensation in her chest that turns out to be an aortic dissection. It's never the people that really should be sorry.

But you know what? The two words "I'm sorry" made everything--the charcoal mess, the tired social worker, the ICU admission--a little better for everyone. I guess it's because we've all done really stupid things in our lives, things that create bigger problems than a little mess on the floor. Thank goodness for the words, "I'm sorry."

Last night, I discovered the world of medblogs, and now I'm hooked. (Thank you internet, for stealing yet another day of my life.) Some of my favorites:

M.D.O.D. www.docsontheweb.blogspot.com
Musings of a Highly Trained Monkey www.highlytrainedmonkey.blogspot.com
Scalpel or Sword www.scalpelorsword.com

It got me wondering about what I'm writing this for, who I'm writing it to, etc. The idea of writing a medblog is appealing in a sense. I could use an outlet for venting--try as she might, my wife just doesn't always get it. I also work in a single-coverage ER for the most part, and I sort of miss having other docs to talk to. On the other hand, I spend enough time at work, that when I get home, medicine is often the last thing I want to think or talk about.

I want to write about what I'm thinking, which more often than not is not related to medicine, and may or may not be all that interesting. I would love for my friends to stop by and read a few posts, but most of my friends aren't in the medical field and aren't the blogging type, if there is such a thing. And with such a lack of direction, I'm not sure I can count on any consistent audience of strangers out there.

So, I guess I'm settling on this blog being for me. Well, me and that faceless stranger I'm talking to in these posts who always cares what I have to say, no matter the subject, and is intensely interested.

For anyone else who happens to wander by this blog, deal with it.

Oh...and feel free to leave a comment...

Tired

Just finishing a week of 12's--2 nights followed by three days. As any ER doctor knows, a 12-hour is really a 13-hour shift by the time things get all wrapped up. So, it's a 65-hour week. I used to pull those all the time in residency--I'm getting soft.

I'm not so much tired as I am annoyed. For me, annoyance with patients is my first sign of burnout, a sign that I need a break. I caught myself several times getting bored as the patient is talking to me, wondering in my head, "why in the world are they telling me this? Do they really think I care? Why on earth is this relevant?" Which is sort of dangerous, because on more than one occasion, a patient has volunteered a detail I never would have asked about that's been the key to their diagnosis. The problem is, for every one of those facts that saves your butt, you have to wade through 20 ramblings about a patient's tingling sensation in their left pinky.

It's flu season, which adds to the fatigue. Besides having to listen to the same constellation of symptoms over and over (and over...), I end up having to tell them that despite the fact that they're absolutely miserable, there's really nothing I can do that they can't do for themselves by a quick walk through the pharmacy. And even after my lengthy explanation that their illness is due to a virus, they inevitably ask, "Are you going to write me for something?" Yes, "something" means an antibiotic.

Did you hear a word of what I just said? YOU DON'T NEED AN ANTIBIOTIC. I don't care if your doctor gives you a Z-pack whenever you get this. You could take a pack of jelly beans and get better just as quickly. Here...I'll even put them in a pill bottle for you.

As you can tell, I'm not very good at the kind doctor comforting thing. It's actually much more tiring to me telling 20 people they're fine (without ticking them off) than treating 20 MI's. Wow...it's really a good thing I switched residencies.

Good news, I have a good week ahead. Only two shifts. Such is the beauty of 12's.

The strike must end!

My favorite shows:
1) The Office
2) (a very close second) Scrubs
3) 30 Rock
4) My Name is Earl
5) A bunch of others - Pushing Up Daisies and Big Bang Theory are recent finds that are pretty good.

Guilty pleasures - So You Think You Can Dance, Biggest Loser

Show that must die soon...
American Idol. How does this show get 4-5 hours every week?

The writers' strike needs to end. If I miss the final season of Scrubs, I'll be ticked.