I think it’s called Deluded?

They say you always remember your first drug seeker.  I think they’re right. 

I was working a shift in the middle of the afternoon when the triage nurse rolled this young guy through the ER.  He was shaking, crying, and moaning in pain and even from where I was sitting it was obvious there was some blood pouring out of his leg.  Now the ER I was in that day wasn’t a Level One Trauma Center, but we have the occasional gun shot wound that’s dropped off at our door step by someone’s concerned friends.  I figured he either caught a bullet through his leg or had an open traumatic fracture.  Usually neither would be the case for an intern to grab, but all the seniors were busy so I decided to overstep my bounds a little.  Plus, the guy was still audibly moaning and I figured he could use some immediate pain control.

I walk into the room with one of our medical students and the guy immediately begins asking for pain medicine.  Now that’s not so unusual and as I gave him a quick once over I figured we’d start with some morphine.  I took a look at his injured leg.  There was a large knot a few centimeters beneath the knee that was heavily abraised but most of the bleeding had stopped.  He was complaining of a lot of back pain so I asked what exactly happened.  (Be sure to add in the gasping and tiny yelps of pain for the full effect).

“I was in the shower and I spilled some shampoo.  I slipped and literally flew up in the air and landed right on my back.  My leg scraped the faucet and that’s how it got cut.  I’ve had a bad back for the last couple of years and now I have sciatica.  I’m actually supposed to get some sort of surgery next month to fix everything.  I’m in a lot of pain, Doc, please give me something.  I was in the hospital a few months ago and I think they gave me something that began with a ‘D’?  Maybe it was duh… duh… deluded?  Is that right?  I just remember they gave me 4mg of it before it got better.”

And that’s when the red flags went up.  I had actually just finished a mandatory online course about respecting patient’s need for pain control and how physicians have preconceived notions about drug seekers, specifically that we judge people who ask for a particular drug and a particular dose.   I didn’t want to unfairly judge this guy.  He was shaking and crying so much that my student said it made her nauseous just being in the same room as him because he seemed like he was in so much pain.  But something about the story itself sounded fishy not to mention him pretending he didn’t know the proper pronunciation of Dilaudid (duh-laud-ed).  I went over and grabbed an attending and asked him to come take a look to make sure I wasn’t missing something.  He told the same story and we walked out telling him that we’d get him some pain medication immediately.

The attending asked me what I thought and I said “Well… the pain seems pretty legit, but the story doesn’t seem right and I don’t like that he’s asking for 4 of Dilaudid off the top.”  He agreed and said there’s no way he would have gotten the abrasion on the leg from a faucet while falling and that it looked more like a motorcycle road rash.  Plus, he had some scratches and redness over the back that didn’t fit with falling in the shower.  We agreed to give 4mg of morphine and see how it went.  

In the meantime, I went to see if I could find any other ER records.  Lo and behold our friend had visited the ER twice in the last 5 months.  Both times he had similar stories to today and similar physical finding and both times he left after eventually getting 4mg of Dilaudid.  The first time he left AMA (against medical advice) because he had “a cooking class he had to get to and had sunk too much money and time into it to miss it”.  Now I don’t care how expensive the damn class was.  If you’re in so much pain that it only goes away with 4mg of Dilaudid you don’t just up and leave the ER if you’re really injured.  Plus, this residents who saw the patient in his previous two visits described the same abrasions over the lower back and over a knot below his right knee.  That’s just strange.  

By that time about a half hour had gone past and I went to see how the morphine worked.  The patient was still writing and crying in pain.  He again asked for the ‘deluded’.  I told him I’d talk to the attending and let him know what we were going to do. I went to talk to the nurse who told me that the patient almost wouldn’t let her push the morphine.  He asked what the medicine was and how many milligrams she was giving.  I was more or less convinced at this point, but I felt bad for the guy since he had went to so much trouble to get his narcotics.  I talked to the attending and said I wanted to give 2mg of dilaudid and see if that helped at all.  I also figured I’d order X-rays of the lower back and the right leg to make sure he had injured himself too vigorously.  

About a half hour later I hear a big ruckus being made over by X-ray.  The patient was refusing any X-rays because he was still in so much pain.  He accused me of not taking his sciatica seriously.  I assured him we were which is why we had given him 4mg of morphine and 2mg of dilaudid which is more pain medicine than I had given any other patient that month.  I asked if I could call his doctor who was managing his sciatica and planning on doing the surgery and get some better direction on how to best handle his pain.  He told me he had a chiropractor but no doctor.  

And that’s when I was done.  

Chiropractors do not do surgery.  I decided he had gotten enough pain medication from us until I was able to get to the bottom of his injuries.  I told him we needed to get x-rays to determine the extent of his injuries.  He told me he was going to ‘sign out’ if he didn’t get more Dilaudid.  I said I wouldn’t be able to give him more pain medication because I was worried that that much narcotic would depress his respiratory status and stop his breathing (a very real and very serious side effect of narcotic overdose).  He said he wanted to leave.  I asked where he was going to go and what he’d do for his injuries.  He said he’d just go to another ER where his condition would be more respected.  I again assured him we respected his pain and his condition and that I wanted to get an x-ray because someone in so much pain might have fractured something during a ‘fall’.  He said he wanted to ‘sign out’ and I asked him what he meant.  “I want to sign out AMA”.  Well, not everyone can let that roll off the tongue; you have to be a pretty savvy ER customer to know about AMA.  I agreed to get the forms together and told him the nurse would be by to clean up his wounds.  Magically, the crying, moaning and shaking all stopped and we didn’t hear another peep out of him for the rest of his short stay.

After everything was signed and cleaned up he asked for some apple juice.  He drank it, grabbed his cane, and then hobbled out of the ER with no drama or obvious pain in his movement.  My attending congratulated me for handling my first drug seeker and not succumbing to his demands.  We were both hopeful that he wouldn’t be coming back to our ER anytime soon since he never got his full 4mg of Dilaudid.  

I expressed my concern for the patient’s narcotic addiction to the attending, “Is it ever worth while attempting to acknowledge their obvious lie and ask if they’re interested in a treatment program?”  He said that the patient was most likely beyond anyone’s help if he was going to the great lengths of self inflicted injury to make his story more believable.  Plus if he really wanted help, he wouldn’t be bouncing in and out of ER’s looking for Dilaudid, he’d be looking for a treatment program.  I realized while a bit jaded, my attending was probably right.  But it didn’t leave me feeling any better about the whole thing.  Even though I ended up being right, I felt bad I had judged this guy as a drug seeker from the beginning.  On the other hand, I was pretty satisfied with my good instincts and I felt a small moral victory was achieved by not allowing the patient to get all the Dilaudid he was looking for.  

It still sucks though.