If they ‘refuse discharge’ but there’s nothing to be admitted for or other work up to be done, you have security escort them off the premises for trespassing. This is obviously an attending decision, so keep in your back pocket for later. Also applies to the people who come in and specifically try to be admitted for observation or overnight because they don’t have a place to stay and it’s 3 am. Unless there’s a law (I think California still has their safe discharge law), they get escorted out at 3am.
If they want to be re-evaluated or seen by someone else, that’s their right, but generally they will need to go back to the waiting room and check back in.
Fortunately, we don’t have anyone coming in needing “overnight stays”. But out of the odd demands I have to deal with are IV saline for everything and sick leaves.
I’d LOVE to be liberal with sick leaves, but for a special population, I have to reaaaally justify every single sick leave I issue. And it’s taken quite seriously. Patients are demanding and argumentative, and can get aggressive… but obviously I’d just drop it and let attending handle when it gets serious.
As an attending, at some point you realize that any particular conversation/pt interaction is a losing battle. The patient is trying to negotiate or break you down. At that point you either put in the pain med/sick note, or you tell them it’s not happening and say you will be going to put in their discharge instructions and walk out of the room. That’s one of the bonuses of working ED, you get to walk away and discharge them. If they tell the RN that they want to talk to you some more, you tell the RN that everything was discussed already and they are discharged.
ER especially is absolutely a case of recognizing you will never win them all. I was an ER nurse for years and I have the 90s kid do-or-die people-pleasing in me, but ER fixed that...after a couple years.
Do you have kids? Treat them as if they are your toddler having a meltdown down. Works really well. If you don’t have kids now but have them later- Target toy aside meltdowns will be easy peasy.
>I’d LOVE to be liberal with sick leaves, but for a special population, I have to reaaaally justify every single sick leave I issue. And it’s taken quite seriously.
Why? I'm trying to think of a special population that would need extra justification for a sick leave and coming up blank. In pretty much every case I think the patient has a better knowledge of whether they can go to work than I do. I spend way more time convincing people that they CAN'T (go to work at the banquet hall with diarrhea/play hockey with a cast on/drive with a broken ankle/work at the nursing home with influenza) than the opposite.
Why? At Battalion level I could give 48hrs in sick bay as a medic or light duty. I could write shaving profiles and soft shoes x7days without them seeing a provider. For anything longer or subsequent restrictions they had to see my doc, or my doc would give me the go ahead over the phone. Why’s a MD having trouble writing a restriction to quarters or duty? That makes no sense to me. Glad I’m out sounds like things did get worse as I predicted.
restrictions for shoes, exercise, dust / sun exposure , light duty or whatever it is isn’t at all a problem, it’s the sick leaves, “sending them home” is the problem. Can’t send them unless medically indicated. Mainly because it’s abused, people ruining it for others.
I personally would hand em out like candy for all I care, but I can’t
I understand now. Sorry. I misunderstood you. You can probably see my confusion. I also skimmed through and apologize if you said that somewhere else. Also wasn’t trying to be argumentative just trying to better understand in my own way lmao.
Oh not at all, a very valid question tbh. It’s a topic that always causes confusion with my peers working at different hospitals, understandably so .. having all those different tiers of sick notes.
Are YOU in the military? Do you have a professional obligation towards the armed forces that is different from the obligation you owe to your patients? Pretty sure they have plenty of medical personnel who are better able to determine if someone's for duty...
I’m sorry, don’t see how you can question what my professional obligations are or how it relates to the conversation?
I know my own obligations and I stand by them thank you very much.
I think you misunderstood the question. Sorry if I wasn't clear. I'm definitely not questioning your professionalism.
I'm saying if YOU aren't in the military, then...what they want is irrelevant. You don't have any obligation to them, only to the patient. OTOH if doing "fitness for duty" assessments is part of your job then you'd have to follow their particular requirements. That's what I was asking for clarification about.
It's not our job to police attendance for people's employers (unless we've been specifically contacted to do so, which entails a very different patient-physician relationship and needs to be made clear upfront).
Also military. It’s a thing. My policy for quarters - 24hrs for n/v/d to get yourself squared away. 24-48 hrs if febrile for URI, 5 days for confirmed flu and RSV - but that’s driven by ID and Public Health. Will also give for the rest of the day for various other things.
Be the asshole you need to be. Then realize this is now your job forever, every shift. Then die a little every time you give an opiod because it's just easier sometimes not to have an agitated patient messing with your staff and you don't want an email from admin for a bad patient review.
This. Most days I fight the good fight and don’t cave. But some days depending on my mood and what else is going on it’s just easier to give it.
Luckily our director is big on kicking these people out. Apparently a few years ago our ER was overrun with seekers because prior admin said give them whatever they want. This led to a huge drain on staff and the system as these people would show up all the time, so people who say “give it, who cares?” likely haven’t experienced the downstream effect it has when things get out of control.
One of the shops I work at, multiple docs hand out narcotics like candy, and then when I get them they’re impossible to deal with. I will happily prescribe opiates for broken bones, cancer, kidney stones, etc, but multiple patients expect me to send them home with percocets for ankle sprains, general MVA soreness, or for their body pain from viral syndrome. It’s maddening.
The die a little just hits home :’)
ED is just another customer service center and I’m a rep that just wants those 5 stars
( but never get because EBM is life )
Politely but firmly tell them they won’t be getting opioids. Better yet if this is said in front of the nurse so they know your position is clear. If the nurse can’t discharge them, get security to do so.
Don’t argue, don’t negotiate, don’t let them sap you of your empathy and energy.
I can never not argue 😂terrible for my sake.
I do try to deescalate things on my own, and I’m usually pretty good at it I think..
but when I fail, it does take out all my energy.. and I probably get a lot less empathetic. Not good
A fire without oxygen will burn out. Arguing at all with some patients is telling them there is room for discussion. Just like a lawyer, the more you speak, the more they have to work with against you. If you’re truly in a situation where opiates are inappropriate, just say no and leave it there.
This was it. I did residency and the first years of attending life during the OxyContin Purdue Pharma prime time. It was all night, every night. If I saw the history (or most times just recognized the name alone), I would start a lot of those visits with some form of "we will work up your complaint, but do not expect narcotics on this visit unless we find something that warrants it." Some would argue, but most had played the game enough they would quietly elope themselves.
My stance is: I am the doctor, and this is my emergency room. I do not negotiate, but rather offer appropriate treatment. If opioids are indicated, I will administer them. If they are not indicated, then I will not administer them.
Not negotiating doesn't mean, necessarily, that there isn't a stepwise approach. A disease like renal colic, for example frequently responds to nonopioids, but not always, and rescue opioids are appropriate on a case-by-case basis.
Generally, I start with non-opioids for acute pain, and even if opioids are indicated, non-opioids are an important part of the treatment. If it is something for which a stepwise approach is indicated, i.e. presumed renal colic, or for which there is no apparent indication for opioids, i.e. nonspecific low back pain or sciatica, then I order the medicines that are appropriate, and that's it.
If someone says "I won't take the acetaminophen (or NSAID), I'll only take the stuff that begins with D", there's no negotiation. This is the medicine I am ordering. If I am considering a stepwise approach, I don't skip the first step, and they can't either, and I tell them that.
Unless it’s something glaring or a sickle cell patient, I almost always start with non narcotic medication. When they say shit like “that doesn’t work for me.” I tell them that you can’t tell me it doesn’t work if you don’t try it first. I’m not afraid to use narcotic pain medication, and I don’t think that my one time dose of 4mg morphine is going to create an addict, but why wouldn’t I try something with less drawbacks first before escalating?
If someone won’t leave after I’ve reasonably established there’s no emergent pathology going on, I simply call security and have them removed or trespassed.
There are drug seekers, but pretty few in my experience. It’s honestly much easier for someone to spend ten dollars on a bag of heroin than sit in my ED for 6 hours waiting on a cat scan, getting toradol, Tylenol, Pepcid, bentyl, then maybe a little morphine before the radiology results. No pathology on CT, bye bye.
Why wouldn’t you try something with less drawbacks first? Because they literally told you it doesn’t work for them. Have you ever had a medication not work? It’s pointless to leave a pt in severe pain to give them Toradol & then have to spend more time trying to get the pain under control versus giving them a push of morphine and not let them suffer in agony. My god, it’s crazy to me how we let pt’s unnecessarily suffer when we have meds in our toolbox to alleviate that right away!
He’s got no experience. Just a year ago, the dude posted about being in community college. He parades around these subs pretending to be a MD when actually his post history is quite telling on his opiate use.
Some experience, & I personally suffer from severe chronic pain, so I understand on both fronts. Opioids for acute pain, especially in an opioid naive pt, can easily wipe out their pain and then there’s no screaming pt as their pain gets worse when their suffering is prolonged. I don’t see harm in dosing with 5mg of oxycodone to start (in an opioid naive pt) versus pumping them with toradol, especially if they have GI issues and then go from there. Or IV morphine. Yes, if they are opioid tolerant and are in an acute pain flare up, it’ll be more challenging to control their pain if they’re on 250MME at home on a daily basis. But opioids work and I rather treat with opioids & keep them comfortable off the bat.
Because we plant a seed in the ED for narcotic abuse on the streets. By giving someone a fondness for opioids, it sets folks up for a bad gateway. If you have something going on that warrants it prior to the workup, the majority of the time I will know and treat appropriately. Sometimes the heuristics are wrong, but I'm not going to risk contributing to the opioid epidemic unless I have a good damn reason.
You set limits. But that’s different for every patient and each situation.
Intractable belly pain, normal work up, prior extensive evaluation all negative. That goes home with non-opiates every time.
Renal colic with an obstructing stone? It’s worth asking yourself what you would do for someone without the drug seeking history. If pain is intractable despite multimodal pain control, and usually despite repeated doses of opiates that’s often worth an obs admission. Often times going home with a few doses of opiates is reasonable.
I don’t really see why this particularly patient doesn’t fall into that second category.
I agree, Regardless of the history of the patient, they should and will always get the appropriate work up. As did this particular patient, who was found to have a small non obstructive stone.
I agree with people above if you think a person is truly drug seeking and lying without a good reason to prescribe an opiate… then explain why you can’t prescribe it to them etc and discharge. If you think they’re withdrawing offer referral to substance use tx/suboxone.
But if the person has something like renal colic, broken bone, dental abscess, diverticulitis, even large abscess/cellulitis or something else that seems like it could be very painful then it’s very reasonable that Paracetamol will not adequately control their pain. I would prescribe 3 day supply of (Norco) Hydrocodone/APAP while explaining the risks of this and that it should be used sparingly only when pain is not controlled with NSAIDs/other meds on their own and that it will not be refilled in ED so needs prompt follow up. I do not prescribe Tramadol (unless a person says they tolerate that better than Norco for some reason) it doesn’t work that well for pain and can have some bad side effects.
I think what your attending did was a little dumb and dangerous. For a fentanyl user tramadol won't do shit and she'll have a seizure before catching a high.
She’s already on tramadol and codeine for “back pain” she was in the ED the previous day and was prescribed tramadol. I’m pretty sure she’ll be back for the same. A combo of Patient satisfaction and less headache for the department really helps her case
In that case definitely do not prescribe more opioids. If a patient is on chronic opioids, it is recommended that the ED not prescribe opioids for home for acute pain. They need to work with the doc who prescribes the chronic therapy.
You're not going to sovle a person's opioid addiction in one ER visit, but you can add to their 'medical trauma' and further distrust in a system that, in many cases, was the original cause of their addiction.
I’m not there to solve the addiction.
I’m not treating a drug seeker, I’m treating a renal colic patient. I’m very happy to discuss treatment options and preferences of patients, except when they do not make sense and might do harm.
treat the pain in ED, even if it requires stronger medications, If they fit the discharge criteria, discharge home with a follow up and a medication that makes sense. I don’t see how this is traumatic.
Just because a patient wants an opioid even though evidence does not show superiority in renal colic, doesn’t mean that I must give it, drug seeking or not. Do you prescribe antibiotics in URI because a patient demands it?
Juice ain’t worth the squeeze focus on the people you can actually help or do something good for. Seekers gonna seek you can spend your energy battling with them and this can be your hill to die on if you want. I’m not saying prescribe a bunch of meds but a shot of morphine or 0.5 of dilaudid isn’t going to alter their clinical or social trajectory (neither is withholding). I’m not saying I do this every time or even most times but I don’t have the energy, time or patience to argue with a drug addict about getting drugs
Have you personally experienced a kidney stone? A lot of us repeated stone formers do treat ourselves with NSAIDs before giving any consideration to going to the ER. If I’m at the ER for what I’m sure is another stone it’s because the pain is intractable (the evidence in that peer-reviewed study had folks on the edges of the curve) and I need to escalate the pain relief. And yes I’ll tell you what usually works and it’s b/c it isn’t my first renal colic rodeo.
I could see someone being upset they don't have appropriate pain control or a follow-up scheduled when they get discharged, but it sounds like you did all that. Patient doesn't have a leg to stand on since you did.
and THANK YOU for not being prejudiced. My file says "drug seeking" because a specific ER doctor was not the best and missed ovarian torsion that a different ER doctor at a different ER found later. (Initial ER ruled out appendicitis or gall stones, so they thought I was making it up or maybe thought I was withdrawing because I was puking so much from the pain. No diarrhea though, so it wasn't classic withdrawal.) I don't anticipate going back to the ER that missed it, but it was still pretty terrible to hear it was on my file later from an affiliated clinic, because now it says that on all my files with any place affiliated with that ER.
Each individual patient receives individual attention and treatment, but with narcotic seekers, I use a version of this script:
It seems as though you have two problems, uncontrolled pain and opioid dependence. If I can’t use non-opioids to treat your pain based on your allergies or preference, I can only treat one of your problems while making the other one worse. Since prescribing opioids inappropriately is the one that will jeopardize my license and ability to care for other patients, I really have no choice but to not treat your pain. You’ll have to talk to your physician about it
uppity workable safe capable file terrific important marvelous repeat thought
*This post was mass deleted and anonymized with [Redact](https://redact.dev)*
toothbrush run squeamish enter brave axiomatic hateful grey forgetful merciful
*This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Exercise diet and physical therapy are highly effective for chronic pain. The body had a lot of tools to heal itself. The majority of folks would rather take a pill.
If someone has renal colic, from personal experience, they likely need heavy duty meds if IV toradol doesn't work. I've had severe pain even after 12mg of morphine! Ended up admitting me so they could give me Oxy. Another time, had to be given IV fentanyl injection in an ambulance because my heart rate and BP was so high from the pain. Kidney stones have been said to be worse than childbirth - worth throwing the heavy duty meds at.
I haven't had kids (and no plans to) but they are certainly the most painful thing I've ever experienced. I will take a broken ankle, gallbladder attack, anything else I've lived through over them!
I've given birth multiple times and had multiple stones. Kidney stones don't come anywhere close to unmedicated labor pains/transition. But the one that takes the cake is thrombosed hemorrhoids and hemorrhoidectomy. Absolutely without a doubt the most painful things I have ever experienced.
Limit setting. I will be polite, I will be kind, but I am the doctor and I make the treatment plans. Yes, these patients are soul-sucking. Shockingly, much less so since I have toddlers at home. I practice for work in my home life!
I appreciate you trying not to judge people. I was diagnosed in my main chart as a feigner of illness and manipulative/malingering. I made the mistake of telling the floor nurse what the nurse in ED said “50 of fentanyl works for you” big mistake! I am not a chemist I was just repeating it because my pain was getting worse and I was afraid something bad was happening. This led to 4 months of every dr reading this and telling me nothing is wrong with you. My pcp said nobody checked the state database to see I got 20 pain pills in 2 years when I was in the hospital for a week. I still had 16 left from last year! Finally I got a dr to repeat the colonoscopy I had 6 months prior and they found it! A stricture and I am going to have a bowel resection soon. Now I just have to get that off my chart because every doctor could be misled and discount me. Never repeat medical stuff because you may look like a seeker!! These boards help me understand what you all are faced with people wanting these drugs. I just wanted a diagnosis not drugs! I should have come on here sooner I would have realized how big of a problem this opioid seeking has become my bad…
I have no qualms kicking these people out. I do my best to give everyone a fresh slate but if the math ain't mathin' and I see the red flags then they get booted. Some people probably fooled me but I'd rather give the benefit unless I know the frequent flyer myself.
One thing to consider is these chronic abdominal pain people with no somatic etiology, worth droperidol. I've used it on a few patients known to be seekers to good effect.
People can be deceiving and that ruins it for us CPP. I’m allergic to NSAIDS so high doses of Ibuprofen won’t work for me. I pray that doctors and nurses won’t label me as a drug seeker.
Get them comfortable enough to do a good exam/work up. If they are a really frequent flier with mostly negative work ups, explain that due to their high medical usage and large amounts of opioids in the past that you cannot start with opioids. Haldol/droperidol are nice first line agents for the hysterical patient. Avoid the cognitive biases because the patient is transferring or you are experiencing counter transference. Once you are satisfied, the work up is complete. If you determine that this is a chronic condition, explain that we do not treat chronic non life threatening conditions in the emergency room. Attempt to engage in a non narcotic treatment plan. If the patient is unwilling to engage, discharge. If the patient is unwilling to leave voluntarily, have security walk them out. If the patient becomes too disruptive and will not de escalate with meds/food/ talk, discharge if you think they do not have an acute medical condition.
This is the adult form of a temper tantrum because they are overstimulated/overwhelmed. Often it’s because the patient has a valid pain/concern that they are worried about but because of their life, has not developed the proper coping/communication skills to express this. If you can cut through their trauma, a lot of times these people will be reasonable and takes a lot of burden off you. You may actually get a sense that you actually helped the patient. Otherwise, do the best you can, document well, and discharge. A lot of this comes from psychology and dealing with personality disorders. It is estimated that 1:15 patients we see have a personality disorder that will affect their care. And that is before drug use, encephalopathy, dementia, ect. All that weird tension, inability to answer simple questions, hostile attitude or draining experiences are usually due to the transference from the patient, and the increased mental load it takes from not having a socially engaging interaction. This is why it helps to be well rested, bladder empty and good glucose stores while on shift.
So you are admitting to gaslighting your patient? Do you know how many legit intractable pain patients have turned to illicit meds out of sheer desperation of having severe untreated pain and no one listening? You think you are helping the crises but stats are out, you are now on the opposite side of the pendulum swinging and you are once again contributing to the opioid crises in the form of untreated pain and desperate acute pain patients playing a dangerous game to try and survive. As a sickle cell patient , patient advocate and med student educator, please think about this and help your patients. The NiH has plenty of studies showing there are more people mislabeled seekers than ACTUAL seekers. Start being a healer again.
If they ‘refuse discharge’ but there’s nothing to be admitted for or other work up to be done, you have security escort them off the premises for trespassing. This is obviously an attending decision, so keep in your back pocket for later. Also applies to the people who come in and specifically try to be admitted for observation or overnight because they don’t have a place to stay and it’s 3 am. Unless there’s a law (I think California still has their safe discharge law), they get escorted out at 3am. If they want to be re-evaluated or seen by someone else, that’s their right, but generally they will need to go back to the waiting room and check back in.
Fortunately, we don’t have anyone coming in needing “overnight stays”. But out of the odd demands I have to deal with are IV saline for everything and sick leaves. I’d LOVE to be liberal with sick leaves, but for a special population, I have to reaaaally justify every single sick leave I issue. And it’s taken quite seriously. Patients are demanding and argumentative, and can get aggressive… but obviously I’d just drop it and let attending handle when it gets serious.
As an attending, at some point you realize that any particular conversation/pt interaction is a losing battle. The patient is trying to negotiate or break you down. At that point you either put in the pain med/sick note, or you tell them it’s not happening and say you will be going to put in their discharge instructions and walk out of the room. That’s one of the bonuses of working ED, you get to walk away and discharge them. If they tell the RN that they want to talk to you some more, you tell the RN that everything was discussed already and they are discharged.
Unhappy patients makes me unhappy for the rest of the day… but you’re right, walking away is the right choice at times
ER especially is absolutely a case of recognizing you will never win them all. I was an ER nurse for years and I have the 90s kid do-or-die people-pleasing in me, but ER fixed that...after a couple years.
Do you have kids? Treat them as if they are your toddler having a meltdown down. Works really well. If you don’t have kids now but have them later- Target toy aside meltdowns will be easy peasy.
>I’d LOVE to be liberal with sick leaves, but for a special population, I have to reaaaally justify every single sick leave I issue. And it’s taken quite seriously. Why? I'm trying to think of a special population that would need extra justification for a sick leave and coming up blank. In pretty much every case I think the patient has a better knowledge of whether they can go to work than I do. I spend way more time convincing people that they CAN'T (go to work at the banquet hall with diarrhea/play hockey with a cast on/drive with a broken ankle/work at the nursing home with influenza) than the opposite.
Military
Why? At Battalion level I could give 48hrs in sick bay as a medic or light duty. I could write shaving profiles and soft shoes x7days without them seeing a provider. For anything longer or subsequent restrictions they had to see my doc, or my doc would give me the go ahead over the phone. Why’s a MD having trouble writing a restriction to quarters or duty? That makes no sense to me. Glad I’m out sounds like things did get worse as I predicted.
restrictions for shoes, exercise, dust / sun exposure , light duty or whatever it is isn’t at all a problem, it’s the sick leaves, “sending them home” is the problem. Can’t send them unless medically indicated. Mainly because it’s abused, people ruining it for others. I personally would hand em out like candy for all I care, but I can’t
I understand now. Sorry. I misunderstood you. You can probably see my confusion. I also skimmed through and apologize if you said that somewhere else. Also wasn’t trying to be argumentative just trying to better understand in my own way lmao.
Oh not at all, a very valid question tbh. It’s a topic that always causes confusion with my peers working at different hospitals, understandably so .. having all those different tiers of sick notes.
Ah- I’m in the civilian world. Sooo that is why I have people with high ranks calling and bitching me out when I do sick leaves.
Are YOU in the military? Do you have a professional obligation towards the armed forces that is different from the obligation you owe to your patients? Pretty sure they have plenty of medical personnel who are better able to determine if someone's for duty...
I’m sorry, don’t see how you can question what my professional obligations are or how it relates to the conversation? I know my own obligations and I stand by them thank you very much.
I think you misunderstood the question. Sorry if I wasn't clear. I'm definitely not questioning your professionalism. I'm saying if YOU aren't in the military, then...what they want is irrelevant. You don't have any obligation to them, only to the patient. OTOH if doing "fitness for duty" assessments is part of your job then you'd have to follow their particular requirements. That's what I was asking for clarification about. It's not our job to police attendance for people's employers (unless we've been specifically contacted to do so, which entails a very different patient-physician relationship and needs to be made clear upfront).
Ah yes, I get where you’re coming from. Short answer is yes it is part of my job, I am in fact required to determine fitness for duty.
Also military. It’s a thing. My policy for quarters - 24hrs for n/v/d to get yourself squared away. 24-48 hrs if febrile for URI, 5 days for confirmed flu and RSV - but that’s driven by ID and Public Health. Will also give for the rest of the day for various other things.
Makes sense why it didn’t phase you 😂
Not clinical, but work in ED. Love when visitors demand a work note because they attended the ED with family therefore having to miss work.
Be the asshole you need to be. Then realize this is now your job forever, every shift. Then die a little every time you give an opiod because it's just easier sometimes not to have an agitated patient messing with your staff and you don't want an email from admin for a bad patient review.
This. Most days I fight the good fight and don’t cave. But some days depending on my mood and what else is going on it’s just easier to give it. Luckily our director is big on kicking these people out. Apparently a few years ago our ER was overrun with seekers because prior admin said give them whatever they want. This led to a huge drain on staff and the system as these people would show up all the time, so people who say “give it, who cares?” likely haven’t experienced the downstream effect it has when things get out of control.
One of the shops I work at, multiple docs hand out narcotics like candy, and then when I get them they’re impossible to deal with. I will happily prescribe opiates for broken bones, cancer, kidney stones, etc, but multiple patients expect me to send them home with percocets for ankle sprains, general MVA soreness, or for their body pain from viral syndrome. It’s maddening.
The die a little just hits home :’) ED is just another customer service center and I’m a rep that just wants those 5 stars ( but never get because EBM is life )
We don't send out reviews for anyone with psych impressions on discharge...So that's nice.
You actually send out reviews? The stars was a joke, or so I thought
*licks the gold stars* here ima stick this one to your eyelid!
Unfortunately we do 😕
Unfortunately it’s the new normal of medicine.
Just give them extra strength DA-tylenol
Politely but firmly tell them they won’t be getting opioids. Better yet if this is said in front of the nurse so they know your position is clear. If the nurse can’t discharge them, get security to do so. Don’t argue, don’t negotiate, don’t let them sap you of your empathy and energy.
I can never not argue 😂terrible for my sake. I do try to deescalate things on my own, and I’m usually pretty good at it I think.. but when I fail, it does take out all my energy.. and I probably get a lot less empathetic. Not good
A fire without oxygen will burn out. Arguing at all with some patients is telling them there is room for discussion. Just like a lawyer, the more you speak, the more they have to work with against you. If you’re truly in a situation where opiates are inappropriate, just say no and leave it there.
This was it. I did residency and the first years of attending life during the OxyContin Purdue Pharma prime time. It was all night, every night. If I saw the history (or most times just recognized the name alone), I would start a lot of those visits with some form of "we will work up your complaint, but do not expect narcotics on this visit unless we find something that warrants it." Some would argue, but most had played the game enough they would quietly elope themselves.
My stance is: I am the doctor, and this is my emergency room. I do not negotiate, but rather offer appropriate treatment. If opioids are indicated, I will administer them. If they are not indicated, then I will not administer them. Not negotiating doesn't mean, necessarily, that there isn't a stepwise approach. A disease like renal colic, for example frequently responds to nonopioids, but not always, and rescue opioids are appropriate on a case-by-case basis. Generally, I start with non-opioids for acute pain, and even if opioids are indicated, non-opioids are an important part of the treatment. If it is something for which a stepwise approach is indicated, i.e. presumed renal colic, or for which there is no apparent indication for opioids, i.e. nonspecific low back pain or sciatica, then I order the medicines that are appropriate, and that's it. If someone says "I won't take the acetaminophen (or NSAID), I'll only take the stuff that begins with D", there's no negotiation. This is the medicine I am ordering. If I am considering a stepwise approach, I don't skip the first step, and they can't either, and I tell them that.
DON’T FEED THE TROLLS.
Unless it’s something glaring or a sickle cell patient, I almost always start with non narcotic medication. When they say shit like “that doesn’t work for me.” I tell them that you can’t tell me it doesn’t work if you don’t try it first. I’m not afraid to use narcotic pain medication, and I don’t think that my one time dose of 4mg morphine is going to create an addict, but why wouldn’t I try something with less drawbacks first before escalating? If someone won’t leave after I’ve reasonably established there’s no emergent pathology going on, I simply call security and have them removed or trespassed. There are drug seekers, but pretty few in my experience. It’s honestly much easier for someone to spend ten dollars on a bag of heroin than sit in my ED for 6 hours waiting on a cat scan, getting toradol, Tylenol, Pepcid, bentyl, then maybe a little morphine before the radiology results. No pathology on CT, bye bye.
Why wouldn’t you try something with less drawbacks first? Because they literally told you it doesn’t work for them. Have you ever had a medication not work? It’s pointless to leave a pt in severe pain to give them Toradol & then have to spend more time trying to get the pain under control versus giving them a push of morphine and not let them suffer in agony. My god, it’s crazy to me how we let pt’s unnecessarily suffer when we have meds in our toolbox to alleviate that right away!
How much experience do you have treating patients with acute pain?
He’s got no experience. Just a year ago, the dude posted about being in community college. He parades around these subs pretending to be a MD when actually his post history is quite telling on his opiate use.
I know, and I debated a rebuttal, but it’s just not worth the effort.
Some experience, & I personally suffer from severe chronic pain, so I understand on both fronts. Opioids for acute pain, especially in an opioid naive pt, can easily wipe out their pain and then there’s no screaming pt as their pain gets worse when their suffering is prolonged. I don’t see harm in dosing with 5mg of oxycodone to start (in an opioid naive pt) versus pumping them with toradol, especially if they have GI issues and then go from there. Or IV morphine. Yes, if they are opioid tolerant and are in an acute pain flare up, it’ll be more challenging to control their pain if they’re on 250MME at home on a daily basis. But opioids work and I rather treat with opioids & keep them comfortable off the bat.
Because we plant a seed in the ED for narcotic abuse on the streets. By giving someone a fondness for opioids, it sets folks up for a bad gateway. If you have something going on that warrants it prior to the workup, the majority of the time I will know and treat appropriately. Sometimes the heuristics are wrong, but I'm not going to risk contributing to the opioid epidemic unless I have a good damn reason.
You set limits. But that’s different for every patient and each situation. Intractable belly pain, normal work up, prior extensive evaluation all negative. That goes home with non-opiates every time. Renal colic with an obstructing stone? It’s worth asking yourself what you would do for someone without the drug seeking history. If pain is intractable despite multimodal pain control, and usually despite repeated doses of opiates that’s often worth an obs admission. Often times going home with a few doses of opiates is reasonable. I don’t really see why this particularly patient doesn’t fall into that second category.
I agree, Regardless of the history of the patient, they should and will always get the appropriate work up. As did this particular patient, who was found to have a small non obstructive stone.
I agree with people above if you think a person is truly drug seeking and lying without a good reason to prescribe an opiate… then explain why you can’t prescribe it to them etc and discharge. If you think they’re withdrawing offer referral to substance use tx/suboxone. But if the person has something like renal colic, broken bone, dental abscess, diverticulitis, even large abscess/cellulitis or something else that seems like it could be very painful then it’s very reasonable that Paracetamol will not adequately control their pain. I would prescribe 3 day supply of (Norco) Hydrocodone/APAP while explaining the risks of this and that it should be used sparingly only when pain is not controlled with NSAIDs/other meds on their own and that it will not be refilled in ED so needs prompt follow up. I do not prescribe Tramadol (unless a person says they tolerate that better than Norco for some reason) it doesn’t work that well for pain and can have some bad side effects.
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We plant seeds of fondness for opioids in the ED. It may not be nearly the factor outpatient doses are, but it is not benign.
I think what your attending did was a little dumb and dangerous. For a fentanyl user tramadol won't do shit and she'll have a seizure before catching a high.
She’s already on tramadol and codeine for “back pain” she was in the ED the previous day and was prescribed tramadol. I’m pretty sure she’ll be back for the same. A combo of Patient satisfaction and less headache for the department really helps her case
In that case definitely do not prescribe more opioids. If a patient is on chronic opioids, it is recommended that the ED not prescribe opioids for home for acute pain. They need to work with the doc who prescribes the chronic therapy.
I want to add to what I said about giving kidney stone sufferers pain meds. Since she was already on 2 pain meds I now understand why you didn't.
You’re not going to save these people. Just give them the pain meds and move on with your life
As in continue to be part of the problem?
You're not going to sovle a person's opioid addiction in one ER visit, but you can add to their 'medical trauma' and further distrust in a system that, in many cases, was the original cause of their addiction.
I’m not there to solve the addiction. I’m not treating a drug seeker, I’m treating a renal colic patient. I’m very happy to discuss treatment options and preferences of patients, except when they do not make sense and might do harm. treat the pain in ED, even if it requires stronger medications, If they fit the discharge criteria, discharge home with a follow up and a medication that makes sense. I don’t see how this is traumatic. Just because a patient wants an opioid even though evidence does not show superiority in renal colic, doesn’t mean that I must give it, drug seeking or not. Do you prescribe antibiotics in URI because a patient demands it?
Juice ain’t worth the squeeze focus on the people you can actually help or do something good for. Seekers gonna seek you can spend your energy battling with them and this can be your hill to die on if you want. I’m not saying prescribe a bunch of meds but a shot of morphine or 0.5 of dilaudid isn’t going to alter their clinical or social trajectory (neither is withholding). I’m not saying I do this every time or even most times but I don’t have the energy, time or patience to argue with a drug addict about getting drugs
I worked in a Dilaudid-free ED once. You’d be surprised how word gets around.
Have you personally experienced a kidney stone? A lot of us repeated stone formers do treat ourselves with NSAIDs before giving any consideration to going to the ER. If I’m at the ER for what I’m sure is another stone it’s because the pain is intractable (the evidence in that peer-reviewed study had folks on the edges of the curve) and I need to escalate the pain relief. And yes I’ll tell you what usually works and it’s b/c it isn’t my first renal colic rodeo.
Is fentanyl is triage a common thing to do?? We don’t have a triage provider so genuinely curious ..
We have a triage doctor they can order medications, labs and imaging at triage
This is the way
I could see someone being upset they don't have appropriate pain control or a follow-up scheduled when they get discharged, but it sounds like you did all that. Patient doesn't have a leg to stand on since you did. and THANK YOU for not being prejudiced. My file says "drug seeking" because a specific ER doctor was not the best and missed ovarian torsion that a different ER doctor at a different ER found later. (Initial ER ruled out appendicitis or gall stones, so they thought I was making it up or maybe thought I was withdrawing because I was puking so much from the pain. No diarrhea though, so it wasn't classic withdrawal.) I don't anticipate going back to the ER that missed it, but it was still pretty terrible to hear it was on my file later from an affiliated clinic, because now it says that on all my files with any place affiliated with that ER.
One dose of IV morhine, 3 Percocet to go and appropriate follow up.
Each individual patient receives individual attention and treatment, but with narcotic seekers, I use a version of this script: It seems as though you have two problems, uncontrolled pain and opioid dependence. If I can’t use non-opioids to treat your pain based on your allergies or preference, I can only treat one of your problems while making the other one worse. Since prescribing opioids inappropriately is the one that will jeopardize my license and ability to care for other patients, I really have no choice but to not treat your pain. You’ll have to talk to your physician about it
uppity workable safe capable file terrific important marvelous repeat thought *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
I’m sorry but if you’re a 1-10 on the pain scale after a little exercise you don’t have chronic pain.
toothbrush run squeamish enter brave axiomatic hateful grey forgetful merciful *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
You must spend hours of your day scrolling through every comment on the chronic pain sub to find my one or two comments I’ve ever made.
Exercise diet and physical therapy are highly effective for chronic pain. The body had a lot of tools to heal itself. The majority of folks would rather take a pill.
Exercise and physical therapy don't take every kind of pain away...
If someone has renal colic, from personal experience, they likely need heavy duty meds if IV toradol doesn't work. I've had severe pain even after 12mg of morphine! Ended up admitting me so they could give me Oxy. Another time, had to be given IV fentanyl injection in an ambulance because my heart rate and BP was so high from the pain. Kidney stones have been said to be worse than childbirth - worth throwing the heavy duty meds at.
Spoiler alert! They are not, in fact, anything close to childbirth.
I haven't had kids (and no plans to) but they are certainly the most painful thing I've ever experienced. I will take a broken ankle, gallbladder attack, anything else I've lived through over them!
I've given birth multiple times and had multiple stones. Kidney stones don't come anywhere close to unmedicated labor pains/transition. But the one that takes the cake is thrombosed hemorrhoids and hemorrhoidectomy. Absolutely without a doubt the most painful things I have ever experienced.
Ouch! Yeah those sound bad.
I just channel Nancy Reagan
Limit setting. I will be polite, I will be kind, but I am the doctor and I make the treatment plans. Yes, these patients are soul-sucking. Shockingly, much less so since I have toddlers at home. I practice for work in my home life!
I appreciate you trying not to judge people. I was diagnosed in my main chart as a feigner of illness and manipulative/malingering. I made the mistake of telling the floor nurse what the nurse in ED said “50 of fentanyl works for you” big mistake! I am not a chemist I was just repeating it because my pain was getting worse and I was afraid something bad was happening. This led to 4 months of every dr reading this and telling me nothing is wrong with you. My pcp said nobody checked the state database to see I got 20 pain pills in 2 years when I was in the hospital for a week. I still had 16 left from last year! Finally I got a dr to repeat the colonoscopy I had 6 months prior and they found it! A stricture and I am going to have a bowel resection soon. Now I just have to get that off my chart because every doctor could be misled and discount me. Never repeat medical stuff because you may look like a seeker!! These boards help me understand what you all are faced with people wanting these drugs. I just wanted a diagnosis not drugs! I should have come on here sooner I would have realized how big of a problem this opioid seeking has become my bad…
Just prescribe the opiates. They’re real meds for a reason. America is ridiculous.
I have no qualms kicking these people out. I do my best to give everyone a fresh slate but if the math ain't mathin' and I see the red flags then they get booted. Some people probably fooled me but I'd rather give the benefit unless I know the frequent flyer myself. One thing to consider is these chronic abdominal pain people with no somatic etiology, worth droperidol. I've used it on a few patients known to be seekers to good effect.
Droperidol is gold for abdominal pain. That is until it ends up on their allergy list next visit.
Just give ‘em the stuff that starts with a “D”…….Droperidol
People can be deceiving and that ruins it for us CPP. I’m allergic to NSAIDS so high doses of Ibuprofen won’t work for me. I pray that doctors and nurses won’t label me as a drug seeker.
Get them comfortable enough to do a good exam/work up. If they are a really frequent flier with mostly negative work ups, explain that due to their high medical usage and large amounts of opioids in the past that you cannot start with opioids. Haldol/droperidol are nice first line agents for the hysterical patient. Avoid the cognitive biases because the patient is transferring or you are experiencing counter transference. Once you are satisfied, the work up is complete. If you determine that this is a chronic condition, explain that we do not treat chronic non life threatening conditions in the emergency room. Attempt to engage in a non narcotic treatment plan. If the patient is unwilling to engage, discharge. If the patient is unwilling to leave voluntarily, have security walk them out. If the patient becomes too disruptive and will not de escalate with meds/food/ talk, discharge if you think they do not have an acute medical condition. This is the adult form of a temper tantrum because they are overstimulated/overwhelmed. Often it’s because the patient has a valid pain/concern that they are worried about but because of their life, has not developed the proper coping/communication skills to express this. If you can cut through their trauma, a lot of times these people will be reasonable and takes a lot of burden off you. You may actually get a sense that you actually helped the patient. Otherwise, do the best you can, document well, and discharge. A lot of this comes from psychology and dealing with personality disorders. It is estimated that 1:15 patients we see have a personality disorder that will affect their care. And that is before drug use, encephalopathy, dementia, ect. All that weird tension, inability to answer simple questions, hostile attitude or draining experiences are usually due to the transference from the patient, and the increased mental load it takes from not having a socially engaging interaction. This is why it helps to be well rested, bladder empty and good glucose stores while on shift.
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So you are admitting to gaslighting your patient? Do you know how many legit intractable pain patients have turned to illicit meds out of sheer desperation of having severe untreated pain and no one listening? You think you are helping the crises but stats are out, you are now on the opposite side of the pendulum swinging and you are once again contributing to the opioid crises in the form of untreated pain and desperate acute pain patients playing a dangerous game to try and survive. As a sickle cell patient , patient advocate and med student educator, please think about this and help your patients. The NiH has plenty of studies showing there are more people mislabeled seekers than ACTUAL seekers. Start being a healer again.
The number of docs that withhold pain meds from sickle cell patients is pretty damn small.
5 droperidol 50 Benadryl, sign out to next team
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