If you’ve worked in an ED, you have a list. It may be written or it may be kept in the back of your head somewhere, but you have a list.
You always give the benefit of the doubt to patients in pain, but there are a few that keep coming back that make you say “hmmmmmm” to yourself. After a while, the “hmmmmmmm” turns from a little whisper to a Sam Kinison scream (this YouTube video is way more amusing than this post will ever be). They have chronic pain, ran out of their medications two days ago and come in at 6PM Friday night after their physician’s office has just closed and another doctor in the office just happens to be on call that weekend. Or they’re visiting from out of town, their physician doesn’t carry a pager, and they can’t remember what hospital their physician works at. Perhaps they have been diagnosed with temporal arteritis, but when you try to find the biopsy results there aren’t any – the patient refuses surgery because there are too many risks. The story just doesn’t quite fit.
You call the pharmacies to get an idea of what the patient’s medication history is like and the pharmacists can tell you what clothes they are wearing that day — because they’ve been there already to pick up a prescription from another physician.
You’re torn, because you want to alleviate pain, but you don’t want to be taken for a sucker.
Well, a lot of people have been making my List lately. Some of them haven’t even been ED patients.
One patient made it after being in the ED with a friend. It was a busy day, so the patient and her friend were waiting in the room reserved for critically ill patients. After they had left, we got a call later that day and it was the friend’s mother. She wanted to know if we gave her daughter medications even though she had not been seen. Her daughter had a bag full of a medicine packets labeled “Dop-a-min” in her room and was trying to figure out how to use it.
Another patient had been to the ED in the past, but was recently admitted directly to the floor. The nurse came and offered the patient’s roommate pain medications. The roommate refused. Later that evening, her roommate went to the nurse’s station and told the nurse that the patient told her to call the nurse back, ask for the pain medicine, and give it to her.
Another patient made my list last night. Chronic pain after surviving a helicopter crash years ago. The site of pain keeps changing, though. He’d been in previously for headaches, neck pain and back pain. He had picked up prescriptions for Fentanyl, Vicodin, Dilaudid, and Valium two days ago and immediately afterwards, someone broke into his apartment and stole his bottles of medications. Only the medications. Not his computer, his TV, or his watch. Only his medications. It was after hours and he wanted me to refill his prescriptions for the medications to relieve his severe back pain. We ended up finding out from a family member that the patient filled a prescription for 30 Valium tablets 8 hours earlier. Went back and asked the patient about the pills. “I took most of them. The rest are in my pants pocket.” Twenty tablets of Valium 10mg were missing. Three to four hours after ingesting 200mg of Valium and you’re still vertical? I don’t think so.
“Sorry, but you’ve been here multiple times for multiple pain complaints and frankly, I don’t believe that your medications were stolen. Besides, if you did take all those Valiums, you have a drug problem that needs to be addressed. You’re going to have to see your physician in the morning and explain it to him.”
“So you’re not going to treat me?”
“I’ll be happy to treat you, but you won’t receive narcotics from this emergency department any more.”
He got a shot of Toradol and his back pain suddenly improved to the point that he was able to stomp out of the emergency department in a gait that wasn’t possible only 30 minutes before.
Several people have been able to have their names taken off The List. Last year two of them died from drug overdoses. This year two have been arrested on drug charges. One was sentenced to 3-5 years in prison, the other to 2 years in prison.
The good thing about The List is that once people know they are on the list, they don’t visit the ED nearly as much.
The sad part about the list is that we have to have a List at all.