ERP here from ER Stories. I hope you enjoy my ramblings.
You might also call these three diagnoses all together “The Bermuda Triagnle” or “Triple Threat”. All I know is that when they all appear on the chart of an ER patient, you just gird your loins (like the two Roman references?) before you go in. You know it is going to be painful.
I experienced the wrath of the Triumvirite the other night – blindsided as I walked into the room.
The triage RN wrote: 50 year old woman c/o headache, vomiting, abdominal pain, body aches, and maliaise. Fine, I thought, probably a viral syndrome or the flu. Vitals were fine. But then I looked down the triage sheet and saw them. Those three diagnoses staring me right in the face. My mood sank, dreading the fact that it was really busy and that I had been really hoping for a few quick, easy patient encounters. The med list that followed confirmed my suspicions and I felt like the knife was being ground in a little further.
Past Medical History: Migraines, Fibromyalgia, Irritable Bowel Syndrome
Meds: Dilaudid, Imitrex, Topomax, Klonopin, Soma, Lyrica, Trazadone.
Allergies : Compazine, Reglan, Toradol, Steroids
It was a painful encounter. Demands for narcotics, histrionics, exaggerated wretching, and constant pestering of the nurse and secretary. I am ashamed to say, I lost my nerve. I was really busy with sicker patients and threw in the flag. I called the patient’s PMD’s service and admitted her. Sometimes you have to know which battles to fight. I will live to fight the triumvirate another day when I am emboldened with more energy.
This is a bad post to read just before you start your shift.
It’s easy, the order sheet looks like this:
Dilaudid 2mg IM
Discharge Home
Droperidol!
So you dumped it on the hospitalist? That’s fine, just remember that the next time you want to complain about them.
Nah. If it’s a Happy-style Hospitalist, she’ll get a useful lecture on weight loss and smoking cessation (or the evils of second- and third-hand smoke) and a shit of saline in the arm to discourage further ED visits.
Er, “shot.”
Dr. Freud, your slip is showing!
I was close- I was gonna guess the trifecta as migraines, fibromyalgia and chronic fatigue.
Reminds me of a lecture on EM rap from a while back…
“You have two charts in the rack, one is an elderly female who needs disimpaction and the other is a young female with chronic pain. Which one do you pick up? I think we all know the answer to that- you glove up, smile big, and introduce yourself to the patient”
That’s so sweet of you. Or, you know, NOT.
Clearly, you don’t know enough about fibromyalgia. If only it -were- imaginary, my lovely, bubbly, intelligent and emotionally independent best friend would not be forced to live at home with her parents because she is too ill to take care of herself.
No, if the variety of depressed patients who are somatizing their mental illness but refuse to admit it hadn’t subverted medicine into creating this diagnosis in the name of patient satisfaction, we could, perhaps, figure out what actual illness is leaving your best friend so debilitated.
…functioning brain cells. get some. seriously. how are you this insane and still breathing?
You remind me of the docs of 20 yrs ago who use to tell us Arthritis sufferers that it was all in our head, that our symptoms were caused by too much stress, yada yada yada. You should’ve hung your coat up a long time ago.
You must me a psychiatrist. I was told everything was all in my head. That I was somatizing all my symptoms until I walked into my psych’s office one day so white from being obviously anemic that he almost turned white as a ghost himself. I’ve never seen a dr with such a look of shock on his face. I was pasty white. I mean SNOWFLAKE white. Labs were normal. Go figure. Well, actually now I can. Blood volume, not CBC, but actual volume is low. Funny how after starting iron and being on it for 3 months every single symptom I was experiencing disappeared. Not only that it was visibily apparent to others as well, including my drs. That was 5 years ago. Same thing happened this year too.
My point, patients aren’t always somatizing, sometimes drs just aren’t knowledgable enough to know what additional tests to run. Often it takes patients years of searching and finally find a dr who figures it out. There’s no informing/reporting method to make you incompentent drs aware of your incompetence once it’s figured out. *sigh*
Diva,
You completely miss my point. I AGREE with you. Some of the people with what is being called fibromyalgia have some real pathology that is not being worked up because we have thrown them into a “catch all” diagnosis of fibromyalgia. The problem is that the only effective drugs for the majority of fibromyalgia sufferers are anti-depressants. We have known for years that somatization exists and usually is exquisitely painful. Unfortunately, mental illness comes with a huge social stigma, so we, in medicine, began to call this fibromyalgia, just to make our patient happy that they have a diagnosis.
Now the problem occurs when one of the many OTHER, more seated in the objective, illnesses strike a patient, inflicting signs and symptoms similar to fibromyalgia. What do we do – give them lyrica and send them home with the fibro diagnosis. It is a shame but the definition of the disorder has become so blurred that meanful research can not be performed because cases can not be defined. Look, I do believe some of these patients have real pathology, and I’d love to help, but to do so in a scientifically meaningful way we need to clear somatization away.
Brain cells, I’ve got them M. Do you? If you can not see that creating an ill defined diagnosis that consists of essentially renaming a known, but stigmatized, illness is bad for the population as a whole, and even worse for those actually suffering from different pain syndromes, then I feel sorry for you.
No I did get your point. After I submitted and reread your post I realized that my post was in the wrong place. Should have be posted in reference to a different post.
Are there other docs who believe like you? I mean, that some fibro patients have a real pathology? Ugh! I’m on different online support group boards and I’m in disbelief at how many have this dx.
I thought fibro was suppose to be a dx for those who don’t have another serious condition, i.e. one w/identifiable pathology. Many of these patients have serious conditions like liver disease, lupus, etc.
I don’t know if you are an ER doc or some other specialty, but from my experience if a patient complains about pain, they get fibro dx. Hunh?
This does us a greater injustice. It seems most docs practicing today suffer from “zombie dr syndrome”. They run a CBC, CMP, & urinalisys. When they come back normal, they just dx patient w/fibro.
There’s a saying…live by the numbers, die by the numbers.
I was one of those patients who got labeled w/fibro. (BTW I just ignored the dx and kept searching for a doc who could figure out what was wrong w/me.) It definitely set me back. While it’s not all completely figured out w/me, some of it is. I’m no longer in pain. Where I use to live daily with pain at 8, 9 or 10, now its 0, 1, or 2, b/c I am receiving proper care. Won’t go into specifics, but no antidepressants, lyrica etc.
I hate that others might have a condition other than fibro, that w/appropriate treatment, might improve and low & behold live w/o pain.
What are your thoughts on how to change this?
Yes, there are other physicians who think like I do, but I have no idea how to change things because I am an emergency physician and my research interests lay elsewhere. I don’t think there is any question in medicne as a whole that some of these folks are misdiagnosed – but there isn’t an easy answer that I can see. As long as physicians are being forced to do more exams in less time and with fewer resources, the problem will only get worse…
I’m glad you found a physician to give you the help you needed.
(more in reply to your explanation – but I can’t figure out how to reply down there…)
I’m not a doctor – just a patient (non-fibro). But I’ve often gotten in trouble with friends for what they hear when I say something similar. I really and truly hate the diagnosis of fibromyalgia. I lived in fear of being told that’s what I had whenever I complained of constant abdominal pain* – but I’m thankful I had doctors that didn’t “give up” and diagnose me with the “we can’t figure out why you’re hurting – you have fibro” diagnosis. I do not doubt at all that the person is in pain – whether physical or mental or emotional or, or, or… But I feel like all too often it really is a tired-of-your-bitchin’ catch-all. In a small sub-community where we used to live and work, there were about 5 or 6 fibro diagnoses (that we knew of) in a population of about 80-100. That’s HUGE!
*celiac disease and crohn’s disease… and knowing was WAY more than half the battle!
Somebody help a non-medical reader out here and explain all that. I’m thinking somebody only thinks she’s ill and likes attention.
Unfortunately, if you actually have those diagnoses legitimately, it’s not the case. This so-called “doctor” is being an idiot and talking against about 80% of the research out there nowadays.
Fibromyalgia confers chronic pain and fatigue with very little effective treatment – recent studies appear to show it has a neurological aspect and that it may have to do with pain-registered synapses in the brain being “always on”. It also has with it a heightened pain response and a lowered response to opiate painkillers – which is a lovely recipe when one has a migraine and may not be able to keep any painkillers down anyway. IBS frequently comes with fibromyalgia, as do migraines because of the muscle tension that mounts up during flare cycles.
Actually the research on fibromyalgia is incredibly poorly done related to difficulties in case definition and reporting biases. Any subjectively defined illness is very hard to study. Please do not confuse a paper being published and it being a reason to change practice. Unfortunately, lots of mediocre research is published.
Wow! As an ER Nurse who also suffers from FMS, CMS and severe Migraines that have left me so dehydrated that I’ve had to have IV fluids, you’re lack of sympathy and compassion is disgusting. You really should be reported to your Hosp. Admin, as well as thinking about taking up a different profession.
Somebody is off of their TCA’s. You chronic pain junkies get butthurt too easily. Get a grip, seek some therapy, and give me something better to work with than your pseudo disease process(s).
For the record, I am seeking a different profession. You better hope someone is still around to take care of you when the time comes, I am not the only one going this route.
What makes you think all chronic pain conditions are pseudo diseases???
I have Reflex Sympathetic Dystrophy (RSD) and it is NOT a pseudo disease, it is a disorder of the sympathetic nervous system.
Those with chronic pain are NOT junkies and in fact do NOT get high or a buzz from there meds at all as the meds are being used to control the pain, you only get high if meds are taken when there is no pain for them to work on.
There is a difference between addicted, dependant and medically necessary medications.
Do you give the same grief to a diabetic about them taking insulin (they don’t have a choice nad neither do I).
Youu have no compassion and assume becasue you cannot deal with it or understand it that it must not exist and must be psychiatic in nature, or histrionics from an overanxious female/ male who just wants meds and attention.
I tell you what – try this and then tell me if you think you would want meds.
- Get the flu, then while you are felling sick, have someone douse you in hot cooking oil, pour it over you, maybe just one arm or leg, or maybe more – depneds on wherre your RSD is, then during this have someone put a TENS machine on you turn it on full so that youget electric shocks nad sevee painful tingling from it and give them the controls so they can have the underlying run all the time and then shock you at random inveralls, and while this is happening with the other stuff have someone jump up and randomly hit you with a hammer. Then tell me is all in your head or a pseudo feeling or you don’t need to take anything to deal with the pain.
Just becasue you can’t see it, and the tests that we have YET don’t show it does NOT mean it doesn’t exist, it just means our technology isn’t good enough yet to work out more about it and to find a definative test to prove it.
I hate that people (especially some in the medical field) think that they know better than a persons body and they becasue they have a chronic pain diagnosis they are somehow psychiatric patients or second class citizens, we did NOT ask for these conditions, and 99% of us are NOT drug seekers and if we could would give up our illnesses and meds in a heart beat (I know I would, I have tried and managed to lower my pain meds at times, but only becasue I am willing to live in more pain.
Unless you have lived it then you have NO IDEA.
Give people the benefit of the doubt.
Sure there are some people out there who are drug seekers but most are NOT they have real diseases but are fobbed off by medical so called professionals becasue of a one word diagnosis or because we are too hard, misunderstood, or assumptions are made that are incorrect.
Sorry aboutt his rant and yes we tend to get butt hurt easily becasue d!cks like you tend to run there mouths off thinking they know everything and that all chronic pain people are junkies with psychiatric disorders who are just to hard to deal with, when a small about of medical help and understand and trying to get to the bottom of things could go a long way.
What if the women mentioned above had of had something serious, and you just fobbed her off becasue you saw the word Fibromyalgia on her forms, if it had of said, Duodenal ulcer instead would you have treated her differently (YES), but no you see these words like Fibromyalgia, CFS, Chronic Pain and think they are making it up and couldn’t really be sick, they just want meds or attention or some such cr@p.
People with these chronic pain disorders get sick with more common issues too, like that viral syndrome of flu that was expected first, until you saw the word Fibro and thought she was a drug seeking psychiatric junkie. Not only do they tend to get sick witht he common issues as well but these can hit them harder due to there body working so hard to try to deal with what they aleardy have that they do NOT have the ability to deal with more, it can cause these conditions to flare as well…
So next time you see someone with a chronic pain diagnosis, give them the benefit of the doubt and treat them like a human being.
Thank God for that, as it is obvious you have no business in the medical profession. I Hope you never have to deal with a chronic illness.
Props to you though for not being afraid to show your ignorance. TCA is an antiquated treatment for FMS and CFS.
And as for your chronic pain junkie comment, the only med I’m on is Melocicam 7.5 mg 2x. As I’m sure you know, it’s an anti-inflam, not a pain med.
Seriously… before passing judgement, you might want to educate yourself on the topic.
Me, ERP said she was demanding narcotics. The majority of people don’t demand narcotics for the flu. Drug addicts demand narcotics for the flu.
ERP, you didn’t lose your nerve, you were overcome with Zombie Doctor Syndrome–we don’t need a stinkin ED doc who admits because he is too lazy to do the right thing. Go home, have 3 beers and watch the football game (or other useless but enjoyable task that you wish) and rev your engines so you can be a better doc next shift.
I did not admit her to the hospitalist. Amazingly, the private doc covering her PMD realised it was easier to admit her than field phone calls all weekend.
Be very careful when examining a pt. with the big three…we had a patient go comatose from adrenal insufficiency…pesky little things we miss almost cost pt. their life. Maybe it is a good thing to admit and let someone else deal with it.
Oh, wait… could it be… no… you mean a patient with the trifecta was… no… ACTUALLY SICK?
Please don’t misunderstand, I realize that you must see people that are merely seeking opiates, but many people, including myself, only seek treatment at the ER when it is necessary.
I’ve been to the ER about 3 times in the last 10 years because of a migraine. I was vomiting so much that I became dehydrated. They re-hydrated me, injected me with something for the pain and something for the nausea, and in 2 hours, though groggy I was on my way.
I don’t know… can you die from dehydration? Hmmm…
As a medical PROFESSIONAL, you should know better than to just lump everyone presenting with the Big Three into the same catagorie. Not only does it show your lack of compassion, but it shows your ignorance.
Would love to know what medical facility you’re working at. I’m sure admin attys would find your postings interesting…
[...] and go check out my post over at EP Monthly’s WhiteCoat’s Call room Canadian Pharmacy – [...]
Interesting. Every time I post something like this people come out in droves in one of two ways. Health care providers who either laugh along with or berate me for not throwing her out of the dept and presumed sufferers of the condition(s) who berate me for being callous. Clearly a disconnect between patients and providers exists.
Consider the possibility that professional whiners just stick together. After all if they let you figure the racket out on *one* of them they all lose a profitable line.
Seriously… you’re in the medical profession?! You can’t possibly believe that every pt is only seeking pain meds, can you? Wow.
ERP…in all seriousness…do you believe that patients that present with the “trifecta” can’t develop conditions such as those mentioned by oldskoolnurse that can be life threatnening and thus require ER services? If the answer is yes, I would like to know how you, yourself, figure out if these patients when they present to you, are just in need of pain meds or something that requires advanced medical intervention? From your intial postings it sounds like to you do NOT do any due diligence in making a differential and just go on seeing the “trifecta” notation in a patients chart? Do I understand you correctly?
Of course you evaluate patients for an urgent condition – however, it usually doesn’t take much to realise that one does not exist. By and large (oops Kathrine, I typed this fast and the spell checker corrected it to “enlarge”), patient’s like the one I encountered do not want large workups (they’ve already been done and they carry these diagnoses of exclusion). They want pain meds. They often say something like “I won’t let you draw any bloods until I get some Dilaudid”. My next response is : here is the AMA form. Please sign on the dotted line.
“by enlarge” = by and large. “patient’s” like this = patients like this.
I know you’re busy, I just can’t help myself. Feel free to delete my comment but while you’re there can you fix yours?
That’s petty Katherine,
This blog does not offer an “edit” function. Pointing out errors in spelling and word choice is poor form – even if those errors are in the post of a guest blogger….
I understand that in most cases chronic pain patients who end up in the ER won’t have an acute condition outside of their chronic pain/condition.
Please understand that from your OP it does sound like you suffer from “zombie dr syndrome.” Be careful as oldskoolnurse illustrates, this can be deadly for patients. Don’t be one of those docs. You may never know it, but your patient will remember you forever…
I think there are 3 categories of patients here, and only 2 are acknowledged.
1. Acutely ill patient in pain
2. Chronic pain sufferer in acute pain
3. Addicts
Group #2 does not show up in ER unless it is so severe they can’t handle it anymore. They live w/pain often at a level 10 daily. When you live day to day like this for any length of time, you learn how to handle it. Suffer through it. Go through the night or weekend w/extra bad pain w/o going to the ER, and wait until Monday when they can get a hold of PMDr. If they end up in front of you…the pain is indescribable. So bad you can’t imagine. They can’t function. Barely think. It’s acute.
Interesting.
The providers who are constantly inundated by the worried well & the drug seekers, the frequent flyers who know about the squeaky wheel. Who need a place to joke/vent/discuss.
The patients, with painful illnesses, frustration, and irritation at being labelled a frequent flyer drug seeker, reading blogs because y’all are popular and health care is a part of their lives.
BOTH read and respond to this blog with biases.
What’s missing?
Hmm… the drug-seeking frequent flyer patients who don’t give a damn about the doctor or patients in actually pain?
They don’t give a damn.
So we’re left fighting each other & arguing over receiving care, diagnoses, and etc, while the genuinely hurting person, who refuses to call something a 10 b/c they can talk, is sent home with 600mg IBP and the drug-seeker on the cell phone with her Micky D’s is getting a shot of dilaudid.
*Thank you for this post. It really clarifies why it took 2 doctors and 3 er visits in a week, for me to be diagnosed, and successfully treated for a painful condition that resolved after appropriate medical intervention. I am so less bitter now.
The problem is, chronic pain shouldn’t be managed by emergency department visits. The people that get posted about in emergency department blogs walk in demanding narcotics with a list of made up allergies to everything that’s not a narcotic, for NON-EMERGENT conditions. Then people who probably don’t show up in the ED for their pain get all offended, type their life story into the comments and inform the blogger they should quit medicine.
Guess what, ED’s treat ACUTE conditions. ACUTE is different from CHRONIC.
If a doctor specialising in chronic pain was putting up a rant like this about all their patients, then that would be fair enough. That’s their job. Emergency doctors do not specialise in chronic pain. The ED is not for chronic pain. ED docs (and nurses) get to bitch when people with a chronic condition come in demanding drugs.
Absolutely!
When a chronic or drug seeking condition comes in to the ED, it detracts from other patients, jades physicians response towards pain and creates suspicion, NOT to mention the time/space/testing/staffing costs.
From the patient or family member side, it creates anger and frustration, feelings of invalidation, doubts of the physician’s skills, and, additional fear that something was missed or really wrong, because xyz, was not addressed.
And… I may be naive here… the people I saw waiting with me, with their soda, 3 generations worth of relatives, cell-phone talking, pill popping, outside to smoke walking, talking on cell-phone, ‘patients’ reporting a 10/10.
Those people? Somehow I really don’t see them reading this blog…
but then, I may be biased, I don’t have enough knowledge to determine the actual severity of my issue, nor to determine if my experience was unique. I do know how I felt &
w.r.t. the PROBLEM however, is this persistent situation. Doctors and Patients are frustrated, angry, blaming, doubting… and the people causing this rift, are blindly sucking on their dilaudid lollipop
(ps, I didn’t get a damn lollipop)
So what’s the solution when the specialist says, “I can’t see you – go to the ER (his abbreviation – not mine) if you can’t wait 6 weeks for an appointment” for a diagnosed chronic condition?
I don’t think there is one. You have the overly frustrated ED physician who sees another chronic patient instead of an MI or accidental amputation… and you have the specialist who can’t be bothered to field a question. Where does that leave the patient?
(Not a butt-hurt patient… but a patient who refuses to go to the ED unless, you know, it’s **actually** an emergency and is tired of just slightly more important than God specialists.)
Samantha,
Thank you for the most even and reasoned response yet.
William sends.
Uh-oh ERP, you’ve upset the chronic paineurs. If only they’d read the full post instead of going into a rage and typing their life story into the comments. Guess what guys, viral conditions don’t require narcotics or the nurse to hold your hand for their entire shift. They definitely don’t require an ED visit. Suck it up, and take some paracetemol/ibuprofen like the rest of us.
Some chronic painers do need to visit ED’s due to many reasons, from simple everyday issues that everyone gets to things like pain flares s out of control at times when they can’t get into contact with there treating Dr’s that they have no other choice but to go to an ED.
I am sorry that you take exception to my “Life Story” but when you have been through comments and treatment like this from Medical professionals for many years then yes you do tend to get your back up.
Personally I have NEVER been to an ED for the flu or demanded ANY medication EVER, I have my own pain meds and unless it is something out of the ordinary, like dislocating a shoulder (before i had it fixed) then I rarely went to the ER, I only every attended an ER for an acute condition (and if for an unknown reason my pain suddly doubles in intensity and it is night or a weekend and I can’t get hold of my own Dr’s and the med’s I take daily and any breakthrough meds I have have been taken and I am going out of my mind after trying everything else then yes I might go to the ER BUT I would NEVER EVER demand any med’s I don’t care if the treatment is to stand on one leg while going crosseyed, or ice on 1/2 my body and heat on the other, if it works I am HAPPY.
I did read the whole story, and while this was mostly about the one woman who yuo said demanded narcotics it also was generalised about chrnic painers.
The comments I made above was actually in response to Cynic as well as ERP.
I just wanted people to realise that not everyone with a chronic pain condition is a drug seeker or junkie, or demanding of meds or anything, many or in fact most of us have tried EVERYTHING to live our lives as best we can and take eception to being accused.
I am going to make this my last comment and will not be looking at this post/ forum again as it seemes that peple who have an ulternate view only get bagged and nothing comes from making comments trying to explain it from the other side, so why bother…
The point is, the people with chronic pain who turn up in ED’s that get bitched about on blogs do go into the ED demanding narcotics for non-emergent reasons, and all the offended comments come from people who DON’T go into the ED for non-emergent conditions. Chronic pain needs to be treated by a pain specialist, not an ED physician.
Yep. The chronic pains are out in force as usual. Something about hearing medical folks vent gets them all butthurt. Fibro is a disease of motivation. That’s why the treatments are anti-depressants, not pain meds. Lay like a slug in bed for a few days because you’re too achy, and what do ya know, you get more achy. Quads get nasty muscle cramps, and need muscle relaxants, and pain meds if they can still feel what’s going on, but they don’t have a choice. Get out of bed, stretch out, make yourself get active, and you’ll feel a lot better.
I suffer from chronic pain, it is called marriage.
When do I get to sign up for that dilaudid gravy train ?
CB
Katy, that has been my (and most other ER provider’s ) point all along. We are not a place for flare ups of chronic pain. We simply have more significant work to do – we have people who are having life threatening conditions. We are swamped with sick paitients. There are doctor’s offices out there (and clinics) where appointments can be made and you can get your supply of your pain meds. Your visit will be much more pleasant than waiting in the ER. The doctor you see will be much more receptive to your complaints because this is what they do. We as ER doctors did not train for this. Encounters like the one described above are not remotely enjoyable for us (as for you I am sure), and they delay us from treating people with real or impending emergencies. We know immediately that an emergency does not exist and we go on our way. In our mind, you are discharged 2 minutes after we see you.
“There are doctor’s offices out there (and clinics) where appointments can be made and you can get your supply of your pain meds.”
Congratulations, you missed the point again. Chronic pain patients go to the ER, as “Me” said, because they can’t get hold of their usual doctor and the meds they normally use ARE NOT WORKING. When the pain reaches the point where it starts to pry your grip off reality/impedes your ability to breathe/makes you puke your kidneys up, guess what? THAT QUALIFIES AS AN EMERGENCY. It goes back to the old chestnut: until you’ve actually been in the mind-bending levels of pain we have, you have no business telling us what’s real and what isn’t.
Suck it up, do your damn job, medicate us, then you can send us home. If you’re not willing to do that, find another career because having a medical degree does not make you God.
Actually perihelion, it is not an emergency. It is an urgency at best. You are not in imminent life-threatening danger. Thus it can wait. Also, why is it that these folks always seem to “run out” of their “Dilauded 8mg Q4hours” on a Sunday? In my opinion, if you are having a legitimate pain flare at home, you should anticipate increased use of your meds and call your MD BEFORE you run out.
*dodging incoming flames*
I’m the mother of an adolescent female diagnosed with “chronic headaches” along with neurological diagnoses. Could have something to do with the four brain surgeries she has had to date. Here’s the problem from our perspective. We know the ED is not the place for chronic pain management. We know the ED is not really the place for non-emergent lumbar punctures (especially ones that must be performed sedated and under fluoroscopy). We know the ED isn’t always the place to get the xray for the suspected shunt malfunction.
But the ED is where we are told to go by both our pain management doc (for pain flare ups) and by our primary care doc (for almost everything except med refills) and by our neurosurgeon (just call the ED his clinic-West). You guys in the ED are supposed to evaluate and treat emergent issues, but our private doctors are sending us to you for urgent care/”I don’t know what to do” issues. What are we supposed to do when everyone is saying “don’t come to us, go see the other guy”?
*will now accept flames for responding to the comments and not necessarily the post*
Ohhh, please. Don’t kid yourself about this. There’s not a chronic pain patient on the planet who would willingly risk dealing with your phoney politeness and complete incompetence at handling this kind of case unless it was absolutely necessary. See, what you do amounts to nothing less than purposely torturing a suffering patient rather than stick your head back into the more recent legitimate literature and learn that part of your business a little better.
I know, I know. You wanted to treat trauma and all. Laudable, no doubt. But that’s not the reality, and these patients didn’t invent this system just to annoy you. What you don’t grasp is that the incidence of suicide and abuse of street drugs in this particular patient population is not caused by some pansy neuroses. It’s caused by…you, and others like-minded. You become the trauma. Learn to treat, do it efficiently and effectively, and everyone can get back to their regular life without all the unnecessary drama and suffering.
And we all know that people with chronic conditions are immune to acute conditions, so anyone with the three diseases you mention will never have been involved in any emergency…. oh wait, maybe that’s wrong.
Um, of course they can have emergencies. I never said they can’t. We screen them for emergencies and see that they have presented with the same complaint every week for a year and the vitals are OK. Recently I had a well known chronic paineur present with a fall and a broken femur. She obviously got pain meds and admitted for surgery.
The fibro/IBS/Chronic migraine/depressed folks are frustrated that modern medicine does not ‘cure’ them. ER docs are frustrated they can’t fix them in the span of a TV sitcom.
Well then, fine. They should go elsewhere. See a Shaman, or a homeopathic quack, or an Indian medicine man. Go exercise. Join a support group. Find some spiritual meaning in life. Meditate. Just don’t freaking think you are going to find someone in the ER to hold your hand and lovingly get you stoned.
Busy as hell in the ER with critical patients. Thank Goodness! Let the ER be what is was meant for critically ill people. Some Er’s have become the CODEPENDENT helper of the drug seekers. Just say, “No”. I wish it was that easy. Sometimes it’s just easier to medicate, and street or admit. UGH.
Again…
As I have no medical knowledge and my limited ER visit(s) to draw from, I find myself asking what is probably the million dollar question…
How can a medical professional tell? When is a flare-up a flare-up, when is it indicative of an acute situation, when is it the worried-well or a drug-seeker?
Does it come down to accepting that in a short-term acute environment, there will be cases that are misdiagnosed/misunderstood, while filtering out the other, similar sounding, non-emergent situations?
Or is it a matter where countless resources should be wasted to assure the situation above does not arise?
and finally…again, hypothetically,
Does that discharge diagnosis/details/whatever of the ER professional, and patient interpretation, and relation of those facts, then factor into the primary physician’s or clinic future care decisions?
Does this contribute to conditions being missed, or overlooked? & if so, how can situations like this be better addressed?
I discovered this blog and many other fascinating medical professionals, by way of a certain well-written and engaging WhiteCoat Trial…
Sorry for the double-post, but I wanted to reiterate that:
The above post was asking how to eliminate some of the anger/frustration/disconnect between many of the readers I see here, and not intended to:
place blame on any person or entity either online or in real life, or question standards of care…
Please, if you do choose to respond, do so in a reflective, productive manor. =)
I have been watching this thread unfold since yesterday and as someone with multiple health problems, of which fibro is one of them, I find this thread very disturbing.
Since it seems to be established by the OP, Katy and a few others that chronic pain patients or people with fibro don’t belong in an ED, I have a question. Based on the OP it would appear that a judgement is made about the patient by scanning through the admit sheet before even laying eyes on the patient. So, in order to have my illness to be considered on merit and not be discriminated against for having a diagnosis deemed as “inferior”, am I supposed to go in and lie about my medical history? Should I not tell my diagnosis and medications just so I am not judged as a frequent flyer, drug-seeking, hypochondriac fruitcake before the jaded and prejudiced doctor even lays eyes on me? That’s the picture I’m getting here.
I already hate going to the ED and I don’t go unless something is going on that I or my doctor deems is an emergency, otherwise I do utilize urgent care or suffer through til the following day when I can see my Neuro or Primary. Having said that, on the rare occasions that I may show up in your ED I would be there for help, not judgement. I get judged enough by the mainstream society who has no concept of chronic pain but it’s a crying shame when that same judgement comes from the people I am turning to to possibly save my life.
For those that are so cynical, perhaps you need to walk in my shoes or those of the other posters for 30 days or so. Perhaps then you might have a little more compassion.
While I realize this is a place to vent, because people on the “outside” are able to see it and read it I guess you get to hear both sides instead of just getting high-fived by people who feel the way you do. Oh well. I’m just glad to know that not everyone feels the same as you.
Another hallmark of the Triumvirate. The assumption that the observations of an experienced clinician who’s seen hundreds of patients is in error, caused by incompetence, laziness, callousness, etc. Takes alot of ego-centrism to come to that conclusion. Hence multi paragraph, painfully detailed tomes with the object of a come-to Jesus Aha moment. Now that the cottage industry of Triumvirate related trappings has blossomed, there’s plenty of “ammo” to give legitimacy to this crap. I know sometimes real diseases are mis-diagnosed, that is the exception, not the rule.
+1
Indeed the Triumvirate can have life threatening issues. But 99% of the time they go through an evaluuation with potential dangerous radiation and procedures to prove they don’t. Normal vital signs, normal exam, normal labs, +/- normal CT scan and it is time to leave the ER. You may have something from the x-files but it won’t be solved by the ER doc trying to keep patients alive and wade through the 25 patients ready to be seen.
Speaking from an ED point of view:
How does a medical professional tell the difference between emergent and nonemergent?
Emergent patients act emergent. So do their vital signs.
Nonemergent, drugseeking patients demand everything: narcs, water, ice chips, food, and warm blankets from the minute they get to a room/walk in the door. They abuse the staff, mostly verbally, but it can get physical. They put on a big show, including but not limited to “passing out” on the floor, vomiting/retching/gagging (vomiting is not an emergency, kids), screaming, moaning, and squirming around in bed. They are unable to answer the nurse’s triage questions, but if their phone rings they can pick it up and tell their ride that they’re in the emergency room. Their vital signs are stable, and if you make them mad enough they will get up and miraculously acquire the ability to walk out the door.
So the answer is, their behavior is what tells us if they’re someone to worry about or not. As with anything, there are exceptions to the rule, but for the most part, working in the ED makes you intolerant of drama queens and kings, when you deal with the reality of what a real emergency looks like on a daily basis.
Well put Stephanie.
Exactly.
Also, just have to add… I find the vitriol with which frequent flyers reply to articles similar to ERD’s, to be quite revealing in itself.
Here is a solution to the problem. Set up a 24hour staffed pain management clinic. You could make a killing! I guess some people have been arrested for doing this in a fraudulent way (ie, not keeping good records or doing an exam) but if done properly, the Triumvirate would spend all its time there instead of the ER.
I find TK’s idea both attractive and quite reasonable. I do NOT happen to be a frequent flyer. But I have walked a few thousand miles in the fibro patients’ shoes, owing to a repeatedly missed dx and getting stuck in the grab bag myself. I support them because I know firsthand what they go through. I also hear what the ED staffers are saying – they aren’t happy with this patient population, and aren’t geared for handling stuff that doesn’t bleed. OK. That’s fine. You guys aren’t good at what we need, and we aren’t about to die in the next 5 minutes.
Problem is, pain flares and such can happen at any time and there is no acceptable reason for leaving the patient to suffer. So, why NOT refer to a 24-hour pain management clinic? None of these patients are asking for a new dx. They aren’t asking for a cure, judgment, or medical neglect. Few are merely the drug-seeking flakes you seem to think. But they ARE asking for immediate help until they can see their regular attendings, and there’s nowhere else to go. TK’s idea would make everyone a whole lot happier.
Then you’ve got an outfit dedicated to keeping a lid on any actual drug-seekers wasting your time, and (hopefully) one that’s well enough educated in management of chronic pain to help the patients better.
Sounds like a winner to me….
Serena, thank you for your post that lays out both sides very well. I, like you, am no frequent flyer. I have been to the ED a grand total of one time since receiving my many dx. That’s ONE time and it wasn’t for pain meds, it was on the orders of my neuro. I totally understand the ED docs side although the way the OP put it just totally upset me. But I get it, I’m not stupid. But consider this. WE DON’T WANT TO BE IN HIS ED ANY MORE THAN HE WANTS US THERE! So, yeah, if there were such an animal as a 24 hour pain clinic for those who have pain flares it would go a long ways towards letting the ED treat emergencies and chronic pain sufferers be treated with dignity instead of derision.
But wait a minute. Even if you get rid of all the chronic pain people is that the solution to all the ED docs problems? What about the people who bring their kid in with a runny nose because they don’t have insurance? They treat the ED as their own personal physician. But I guess that’s ok, huh? Just get rid of the chronic pain people and all ills will be solved.
That wasn’t directed at you Serena, that was just more of my thoughts on this whole subject. I’m glad you were relieved of your fibro title and given a correct dx (if I read that right). I hope to be able to say the same one day!
The original post is intended to highlight 2 aggravations: having to admit a patient with a viral syndrome for which there is no treatment except supportive care and having an unpleasant encounter with a chronically ill patient for whom there is no treatment except supportive care. And ERP wasn’t feeling very supportive, I get that. There was a primary doc who stepped in to hold the patient’s hand (or admitted her to the floor so nurses could do it) because that is what the patient appears to be seeking: someone to hold her hand because she feels crappy, is upset & worried. Heck, I once checked into a luxury hotel when I was alone & had a nasty flu so someone would be at my beck & call, come & change the linens, bring me meals & notice me passed out on the floor if I got too dehydrated. When you’re that sick, you are suddenly willing to come up with unthinkably complicated ways to get help. This patient getting admitted sounds no different than my hotel experience except that I paid out of pocket for my care, she probably didn’t. Let that be aggravation #3.
red65 questioned “Should I not tell my diagnosis & medications so I’m not judged as a frequent flyer, drug-seeking, hypochondriac fruitcake?” I’ve wondered that myself since I also have a chart full of vague, chronically painful diagnoses. It just means you have to work harder to be a responsible patient & your MD has to work harder too. My problems are the aftermath of a serious car accident with closed head injury, surgical & orthopedic nightmares so at least I have some visible legitimate complaints. I also get told by my neurologist to go to Emergency if I have sudden onset head pain with vomiting or other symptoms outside my normal complaints because they want me evaluated for clots or bleeds. Most Urgent Care centers can’t handle the labs & imaging so I might end up at the nearest ER. I apologize profusely & try my best to be behave the opposite of the usual chronic paineurs. I also call my doc ahead of going in so they can talk directly to the ER, I have a narcotics contract that outlines what I can have & how much, I have a list of drugs & treatments that HAVE worked in the past (and actually ice on one spot, heat on another improves my headaches!). THIS is the approach a chronically ill patient should take. I’ve never encountered anything other than polite, prompt treatment, regardless of what prejudices the attending physician might have when he first reads my chart.
Wow. Quite a little hornet’s nest that someone kicked. I’m not going to get into the middle of things other than to make a few points.
First, when people ask how we’ll make sure that we don’t miss adrenal insufficiency or other things masquerading as one of the “trifecta” diagnoses, don’t worry. When health care reform comes around and provides “insurance to everyone,” it is likely that repeat testing to question established diagnoses will be considered “unnecessary” and won’t be paid for by insurance. But hey – everyone will be insured.
Second, I think that most docs (but certainly not all of them) give patients in pain the benefit of the doubt … initially. If you meet the “frequent flyer” definitions, then you won’t get much sympathy from anyone in the emergency department for chronic pain complaints and you need to question yourself as to whether you really deserve the sympathy.
Finally, I’ll summarize a story I posted on my old blog. A friend has a pit bull that is the best family dog that you could ever ask for. Kids poke him in the eyes and pull his whiskers and he kisses them. But anyone that sees the dog is scared to death of him … because he’s a pit bull. Who do we blame for those people’s fears? The people for having the fear or the actions of all the other pit bulls that lead to those fears?
To me, the anger of people who suffer from chronic pain is misplaced. Some doctors can be jerks, but when you’ve been lied to so many times before, some tend to look at chronic pain complaints from a different viewpoint.
And just in case you’re assuming that I’m another one of “those” kind of doctors, think again. I have chronic pain.
I suppose I am annoyed because I have Fibro, but wonder whether an ER doc would look at me the same way. I also have Lupus and an RA overlap, and fibro is secondary. These conditions are painful, and before I started Orencia, I hade MAJOR pain from pleurisy, pericarditis, and generally just the arthritis. I have ended up in the ER at 2 a.m., because of pain, and because having these conditions, can generally freak a person out. I am 27, am being seen by a psychologist for the underlying psychological issues that these diseases can bring with them, including depression, and would hate to think that if I were to go the ER again, that I may be “discharged” from the beginning.
On the other hand, being 27 and having the fibro diagnoses thrown in, can be extremely frustrating, too! I have been thrown the diagnoses of Fibro for pain, that later will be seen as my RA by my rheumatoligist.
I can see the frustration on both ends.I personally will not say Fibro is all in the head, but it definately get thrown around a lot more than it should. I blame it on big Pharma.
It is hard for all around for those with invisible illnesses (ones that have no signs on the outside) and those treating or seeing them in ER’s.
In Australia we do no have urgent care clinics are are told to go to the ER if we are concerned, we do now have a 24/7 phone line staffed by nurses who you can call day or night to see if your symptoms are something that is an emergency, urgent, can wait etc.
I have used this many times and have also set in place community nurses to be available to give me my migraine shots (which i can no longer do due to injury(s) to both of my arms, they are also training my husband to give them to me, so that I do NOT have to go to the ER).
It is also hard in that from what I understand people who live in chronic pain (TRUE chronic pain) can have abnormal responses when there vitals are checked, ie. they may not show the “normal” responses to pain such as increased BP, respirations, sweating etc etc, and the medications they take daily may also interfere with these responses. I may be WRONG about this but it is what I have been told by my Dr’s.
I also understand that Dr’s in the ER are NOT trained and shouldn’t have to deal with chronic pain patients with non life threatening issues and shouldn’t have to. But if the patient is told by there Dr etc to go to the ER in certain sets of circumstances, and they go, but are then told by (or thought)the ER Dr that they shouldn’t be there that is hard for all concerned.
I truly wish there was an alternative, and that drug seekers didn’t seek drugs and use chronic pain conditions as there reason for it.
After seeing thousands of patients seeking pain medicine, one becomes attuned to the nuances. While real pain exists, so too does neurosis, hypochondria, anxiety, and personality disorders. Unfortunately, if army generals are unwilling to call a terrorist on a shooting spree a terrorist, what hope is there for a poor hapless doc to tell it like it is? Listen, if you don’t like your treatment, go find another doc. It is a free country. When I go to a restaurant and am treated poorly, I don’t go back. You are free! For a little while longer, that is.
The problem is NOT that emergency physicians “are not trained” to deal with chronic pain. We are (as much as any other non-pain specialist is). The problem is in the approach to a patient in emergency medicine. Simply put, I do not care what my patients have (i.e., what their diagnosis is). I care what they DON’T have. Let me explain. When a patient presents to the emergency department, I assess them not for what I think might be wrong, but rather for the 5 or so things that present with those symptoms that may hurt or kill them before they could conceivably follow-up with their primary physician. I examine and perform tests to rule out these “bad things”. If I can not safely exclude them in the department, I admit the patient for further testing. If I stumble across the diagnosis and it requires admission, I admit. If the testing safely excludes the harmful, I send the patient to follow up, even if I have no idea what is wrong with the patient. This approach is the most efficient way to exclude emergent situations, but for diagnosing injury or illness, it is horribly inefficient.
Let me give you an example. If a person comes in with a headache (and never gets headaches), occurring suddenly, which is maximal at it’s onset; I work to rule out a sub-arachnoid hemorrhage, meningitis, hydrocephalus, encephalitis, glaucoma, arteritis, hypertensive emergency, stroke, or brain neoplasm, all while treating the patient’s pain. All of these things are very rare (some, very, very rare). If, through my history, physical exam and testing, I exclude these entities (and even if I find a few of them), I send the patient home. What caused the headache? I don’t know, but I know it is not one of those concerning problems.
Now take a chronic pain patient. If they are having a flare up of pain that they have had for a long time, unchanged in character but more severe than usual, the likelihood that I am going to discover some new emergent pathology in my emergency department that has gone undiscovered by the extensive work-ups that preceded their visit, is unbelievably small. So yes, I mentally prepare to discharge the patient. If this is “the same pain” they always have, I will usually treat their pain, as best I can, and send them back into the grind of their primary physician and specialists. Why? Because I am not set up to discover their source of their pathology. I am set up to exclude life or limb threatening pathology. If they have already been worked up extensively for this exact pain and no source found, my job is already done. If there is some new or concerning feature to their pain, I will begin my “exclusion” work up – so as not to miss the new pathology in the chronic pain patient.
Unfortunately this leaves the patient unbelievably frustrated as all they want are answers. It leaves me frustrated because all I can offer are drugs to mask the symptoms (and in my mind they become sort of “drug seekers” because I know that they know that all I can do for them is provide narcotics). Thus, no one is happy. It reminds me of the unofficial motto of the the FAA “We’re not happy until you’re not happy” (which I realize applies to BOTH sides of these encounters).
That makes sense. And within that context, it helps me to understand my experience.
As a patient, I certainly did not know this. As a patient, I come in, ’something is seriously wrong’, and expect to come out with a diagnosis.
I then expect to give the discharge sheet to my pcp who continues to treat me based on these results, and when I fail to improve, I hear him state: “either the er missed something, or you need to see a shrink”
So back to the hospital i go for his ordered tests, and something is determined.
I walk away, angry at the ER for putting me through this.
~~~
*angry at the er* – where if your description is correct, did exactly what should have been done…
Leaving me asking, how – in my late 30’s, did I not know this about emergency rooms? And, does my physician really understand this either?
Is it society? Generational messages? Patient education? physician education?
or does “follow-up with your doctor” Those 4.5 words, explain the above?
Sam
Sam,
As a specialty in medicine, Emergency Medicine shares something with Sesame Street – it’s age. EM came about formally 40 years ago with the founding of the American College of Emergency Physicians. And it was 20 years ago, Sept. 21, 1989, that emergency medicine became a primary specialty in the House of Medicine with acceptance of the American Board of Emergency Medicine by ABMS. So it is not uncommon for the use and limitations of modern emergency medical practice to be lost on not only the public, but also the majority of physicians. “In the old days”, before EM was a specialty, ERs were staffed by primary care providers who ran them like clinics, and in that framework the “ER may have missed something”. It is a slow process for us to get not only our colleagues, but the public as a whole, to understand what we do.
Try http://www.emergencymedicinerealities.com/myths.aspx as a resource.
I had to sit back and think really hard about the subject in this blog. I am also a chronic pain sufferer. I have severe osteoarthritis, had my right knee replaced, my left knee is shot and needing replaced, both hips are in need of replacement and both shoulders also. My right thumb is broken away at the base because of the osteo and hurts like 4 kinds of h3ll!! and I also have Fibro/Chronic Fatigue Syndrom. I live in a small town on the outskirts of Houston and our hospital is in the top 10 heart and stroke centers in the country.
I was more saddened than anything to read that a person who holds the life of patients literaly in his hands speak with such negativity. I have had to go to the ER twice since my Dx and I was treated with respect, and compassion. My doctor met me at the ER because it was 2 am and my husband had called him before we left.
The doctor and staff treated me quickly and I was able to go home in a couple of hours. I didn’t need a script for pain meds, I have my own at home. I am not a drug seeker, nor have I ever been. I am a person with multiple health problems, fibro being one. When the pain gets so excruciating that thoughts of suicide as a way to stop the pain comes into my thoughts, I need to see a doctor and if it’s at night, then the ER is the place to go. You should be ashamed to lump us all in the same pot, drug seekers are as low as they come, and have made my life miserable in the process.
Tell me, is there someplace in your oath that says” If you have a trifecta diagnoses, I am not responsible for treating you like a human?” Think about it.
What I truly don’t understand is if I am supposed to ‘figure out’ what is wrong with me when I have severe acute pain, in, let’s say, my chest and jaw.
I have gone to the ER for these exact things, and got an elevated D-Dimer, and at that point, they take it more seriously. It turned out that there was nothing they could see in my CT, and they made me comfortable, and sent me home.
Was I supposed to know that it was an RA flare and costochodritis, and that it was not something more serious? Should I have stayed home, and “toughed it out until I could see my regular docs?”
I have also been in similar pain in the chest, and went to the ER with it, and it turned out to be pericarditis. Had I have elected to stay home on either of these occasions, then it could have been very bad for me on that one occasion.
I just do not know at what point I should stay home, in fear that I will be dismissed as “drug seeking.”
Well, basically, if you walk into the ED demanding drugs, abusing staff, talking on your phone, saying you have nausea while eating a burger from McDonalds, with normal vitals and lab results, then that’s drug seeking.
If you have pain that’s unlike a normal chronic pain flare up, then that could be considered emergent. Obviously chest pain is cause for concern.
While I don’t believe the ED is the place for chronic pain patients, I’m sure any patient that explained the situation, was patient and polite would get the same respect from the doctor. That obviously wasn’t the case in ERP’s post.
Don’t fear it. Come in, be honest with us and realize our limitations. If you come in and say “Listen, I don’t come here often, and I know there is little you are likely to find today that will change my overall course of illness, but my pain is really out of control and I need some help” you will find us most accommodating.
If you do that daily (I have one patient who has been transported by EMS 187 times so far this year), expect that we will get a little annoyed.
“I have gone to the ER for these exact things, and got an elevated D-Dimer, and at that point, they take it more seriously.”
That is my point. You had severe, acute pain, different from that which you normally had. Tests were done and the more serious problems excluded.
No one is asking you to figure out when your pain is caused by something serious. Come to the ED. If the pain is the same as usual, just out of control, come and tell me. I’ll help you control the pain. I will get frustrated if you lie to me, or try and magnify your symptoms so that I will take you more seriously. If the pain is unusual, or different, I will do tests to help make certain it is safe for you to go home. But please do not expect that I can solve in one visit what 10 different specialists have failed to find in 50 visits.
Frydoc, your approach to patients sounds different than the OP’s. We might actually stand a chance of getting to speak to you BEFORE you made any judgements about what could or could not be wrong rather than seeing our history on an admit sheet and walking in with a stick up your butt at having to deal with one of us.
I can’t speak for anyone else but that is what I found so upsetting and offensive is the over-generalization, the assumptions and pre-conceived ideas that were made before the OP even walked in to see a chronic pain patient. Is it true of some patients? I’m sure it is, but at least talk to the patient and see for yourself if you think it’s legit or a PITA and THEN act accordingly. Is that so much to ask?
Wow, I always thought some of you physicians were needlessly personal in your attacks on lawyers. I didn’t realize you had a whole other level of vitriol and contempt for some of those who utilize your services.
I’m pretty sure the problem isn’t ulitisation of services, but MISUSE of services.
Actually Matt the difference is that these patients you think we have “vitrol” for we don’t. What we have is an incredible sense of frustration at a system that routinely fails some of it’s most vulnerable members. The cognitive dissonance this creates in us sometimes manifests in less productive ways. But in the end, I don’t know of a single physician who doesn’t wish there were a better way to help these folks.
I also don’t know of a single physician who wouldn’t wish all of the pain and suffering these innocent folks suffer from be visited on every lawyer in abundance (for starters).
You know, just sayin’.
Your continued whining about the “system”, as if you’re not an essential part of it and not responsible for it’s present state, is disingenuous. Stop blaming everyone else for failures you are complicit in creating.
Your hatred of others simply because of a degree they hold continues to speak volumes about your own weaknesses as a professional.
Just sayin’.
Matt,
I don’t hate the degree. There are medical doctors who carry JDs whose company I enjoy very much. I have friends who hold JDs and are CPAs working for financial service companies. None use their JDs in the practice of law put rather as a means to understand a myriad of regulations, rules, etc. that control their professions. And no, if involved in legislation they do not represent their companies or themselves. I don’t hate them. I hate lawyers – the soul sucking leeches on society. Like you.
Hopefully you’ll never need one. I guess I just lack your hatred for those who help people collect debts, get protective orders, protect their assets, provide for their heirs, paybtheor bills, and adopt children. I assume you and yours are immune from breached contracts, car wrecks, death, disability, false arrest, taking of your property by eminent domain, divorce, wrongful denial of an insurance claim, domestic violence, theft, etc. I and those I love are not, so I find it hard to hate those who might help me with those problems, especially when I’ve never met them.
But what we both know it really comes down to is your simple insecurity. It’s why you hate those you don’t know. It’s why you insist on reminding us all how smart you are. It’s why you felt the need to give me your CV even though I don’t even know your name.
And really, I don’t blame you for being insecure. Your profession has handed over it’s future to the insurance industry and the federal government. And of course the AMA. I would feel insecure if those players were controlling that much of my professional life too. I understand that’s why you lash out at people who dare to practice law. After all, how do you lash out against the insurers or the government when they hold your livelihood in their hands?
You’re looking for a scapegoat, and I don’t mind being it. Honestly, I sympathize with you. I realize it was your predecessors who started down this third party payor road and you don’t know how to get off. As a patient and someone who appreciates better than most the regulatory burden your had to take on I am inclined to sympathize with you. But at a time in your professional life when you need all the people who believe in the free market on your side, you make it hard for fellow believers to back you when youso easily demonize them while knowing nothing about them.
Matt,
While that is the most cogent, almost real post you have made here yet, it still belies a simple point. One can hate what they need. There are plenty of bleeding hearts protected by a military they loathe. Drug dealers, arsonists, pedophiles, etc. are kept safe at night by police, who loathe the need to protect these “citizens” as much as these lowlifes hate their protectors.
And I’ve yet to post my CV. I’ve discussed areas of my training or experience to provide a basis for my point of view. As an academic physician, my CV extends far longer than would be worth publishing here and in fact the experiences I’ve discussed here (such as working with the innocence project as an undergraduate) are not on it. This is no different than you explaining that you are a pox on the soul of society (I mean practicing attorney).
And from your previous posts, I know all I need to know about you.
You’re a good, if misguided, person I think. I hope you don’t come just another federal employee under single payer. Please, put aside your insecurity masquerading as arrogance and your silly prejudices and focus on what’s really going on in your industry before you’re just another member of a federal employees union and not an independent professional.
YAWN! Needless fear mongering. Dr. Ian Stiell is perhaps one of the best emergency physicians in the world. He is responsible for a large portion of the research that defines EM and EMS practice. And he is a federal employee in the single payer system of Canadian medicine. I should hope to enjoy a tenth of the successes he has enjoyed.
As an academic physician, my salary would change very little under any of the proposed “reforms” or a single payer system. In fact, if single payer were passed and the reimbursement to emergency physicians cut by 25%, most emergency departments would still be ahead by 10-15% as they would be paid for the entire population of patients they see.
You constantly argue that we physicians are not doing enough to change the system. Don’t you realize that YOU are part of the problem? The problem with the reforms being suggested is that allowing health insurers to continue to exist continues to remove billions of dollars from the system as profit each year. Likewise, medical malpractice attorneys remove billions from the system annually. How much medicine could be paid for if the malpractice and class action pharmacy suit non-economic damages and lawyers fees were returned into the medical system along with the profits from all of the health insurance companies?
The problem is not that we spend too much on health care in this country, the problem is that we spend it poorly!
Sorry, i keep forgetting you’re an academic, and thus Have little practical knowledge of the free market.
Incidentally, those lawsuit do not remove money from the system. That money was never in the system nor being used to pay for medical services. Again, though, I understand that the ivory tower doesn’t give you much exposure or opportunity to economic realities.
Frydoc,
It makes sense. I think people reacted negatively, because the initial responses, seemed so callous.
I have never exaggerated pain, and actually probably under report it severity. I’m afraid that I will be deemed a hypochondriac if I tell them the real level of pain. For instance, last night I had a true level ten pain that induced vomiting, and had me blacking out. I didn’t head to the ER because the pain was intermittent, and I can take that pain, as I know it will go away.
It is the level 6-8 pain that is continuos that makes me crazy and will send me to the ER. Does that make sense?
Sure, that makes sense. No physician I know is bothered by that. Just be up front with us. I have chronic pain patients that I see regularly – they come in, the exam and interaction takes out two seconds (”Had it before, got it again”). The best part, when something really is wrong, I find it quickly because they are honest with me and we have an understanding.
So, again, it seems that what we need to do as part of healthcare reform is set up 24-hour “non-emergent clinics”, for the worried well and drug-seekers to visit.
Please everyone, lets stop the personal attacks. Comments should be at least somewhat constructive….
DensityDuck,
I am far from the worried well, or drug seeking. Don’t know if you know very much about organ involved SLE, but if I have a source of pain that is worrisome, then it is smarter for me to get it checked out, even if turns out to be nothing. A headache for me could turn out to be life threatning, or it could turn out to be a headache. A fever for me could also be a life threatning infection, or just be part of my disease process. Yes, I do worry about things sometimes, but it has been experience that has shown me that I can’t just sit back and be non-chalant about it. As for the pain last night, dare I say it, was part of my IBS. I know the pain well, and had managed to have not had a flare for a few years, through diet and stress control, and since becoming poor, my diet has turned to shit. Let me also say that stress is a huge cause for lupus & RA flares, as well. So maybe lupus and RA are all in my head too! You could be referring to all commenters as a whole, but you don’t know anything about their circumstance, and pain flares have often made us suicidal, and I think that suicide constitutes as an emergency. But what I do I know, I’m just a chronic pain patient.
Everyone needs to calm down and read the OP again.
“It was a painful encounter. Demands for narcotics, histrionics, exaggerated wretching, and constant pestering of the nurse and secretary.”
This is what the concerns of ERP (and most emergency physicians in general) are about. If you have chronic pain, just come in and tell us. Tell us if it is your usual pain but out of control (what I like to call “same song, louder volume”) or if it is something new that has you worried. Realize that we have routinues to follow, estabished for the safety of all of our patients, and even if you are certain of your diagnosis and needed treatment, we still must go through them. The squeaky wheel doesn’t necessarily get the grease in the ED. Now, if you are a chronic pain sufferer, who does not frequent the ED, and is civil when you do – ERP WAS NOT TALKING ABOUT YOU! But we have all seen chronic pain patients who are really unreasonable and demanding. I even had one who barged in while I was explaining to a family that their father had just died. Her response, “Well he is already dead and the damn nurse {who had been busy doing CPR – FD} missed my last dilaudid dose”. Now we understand this isn’t the norm. It just seems to happen more often with chronic pain patients. And this is a place for us to vent – the same as I am certain that many chronic pain suffers share their stories of awful ED care in their support groups.
Well said, that about sums it up.
Fry,
I totally get your point because you make yourself very clear. DensityDuck just seems to have a vendetta. That is all I am saying to him.
:rolleyes: Dude, whatever. I’m just saying that there needs to be an option for nonscheduled treatment that *isn’t* the ER. It says a lot about you that you would immediately post your life story in response.
[...] is a repost of an old post – coming on the heels of the post I did on WhiteCoat’s blog that caused quite a [...]
wow erp really opened a can of worms with this one. still, what can you expect with such a thriving online chronic pain community? my 2 cents?
in my experience there are certain diagnoses which seem to coincide with psych problems, or at least with difficult personalities. crohn’s disease, multiple sclerosis, and diabetic gastroparesis for example.
then there are some diagnoses that seem to span a wide spectrum from clear-cut disease with objective physical findings to very questionable patients that claim to carry the diagnosis but who knows. migraines, reflex sympathetic dystrophy, cyclic vomiting syndrome.
finally there are diagnoses that completely mystify me, in that as far as i can tell there’s no way to prove conclusively that you have it or you don’t. fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome. i mean not even an elevated esr? of course one of my mentors used to say every patient needs an esr or a doctor but never both… but i digress.
in our line of work, this is complicated by the fact that chances are we’ve never seen you before, and never will again. now i believe that anyone who feels they are in pain or suffering, regardless of the underlying cause (psychiatric or otherwise), are actually suffering and deserve the appropriate compassion and treatment. but you have to realize that you are mixed in with a steady stream of people who are just trying to scam us for narcotics, work notes, what have you. if you have some chronic condition that is debilitating and constantly impacts your life, it is imperative to be locked into a pcp or chronic pain doc or whatever that helps you manage your condition without going to the ed where you’ll be seen by a doc who doesn’t know you and just saw a scam artist with the same complaints and the same paucity of objective findings.
i like to think i’m experienced enough to have a decent bs radar but it can be difficult, especially when the volume is high and some of the other patients have more pressing emergencies (in the sense that they’ll die without immediate attention). very easy for people not in the trenches to claim the docs on this thread are lacking in compassion or “have no brain cells” but when the shit hits the fan i would choose the jaded ed doc who manages my emergency competently over the touchy feely doc that treats fibromyalgeurs with respect. (of course, the ideal doc can do both…)
Paul, that is a decent 2 cents.
My 2 cents? I’m an ED Nurse who also has chronic pain. I see my pain doctor and get my pump filled every few months and life is good. When I was on oral medication, and I started to get low, I contacted my physician and he treated me. I have seen folks jump out of the tricked out jacked up pickup truck, walk half way across the parking lot then double over and complain of pain they just happened to run out of their dilaudid for on a weekend. I have seen folks tear up scripts of pain medication because it’s not “what they want”…. ummm… I mean what works for them. I have seen them walk out of the ED refusing care because we were going to give antibiotics for the abscess they had instead of giving them a pain shot – when they were in for the same problem 3 days earlier and did not fill the antibiotics but did fill the pain medication and used it all up.
I have seen, have helped treat and have felt sympathy for folks who have come into my ED at 2am with an exacerbation of their chronic pain. They have taken their pain pills, brought in the bottle (with plenty left by the way), letting me know that it’s just not touching the pain.
I feel for those in chronic pain, I’m actually one of you. However, you don’t come into the ED weekly or even more often, with a chief complaint of migraine, or fibromyalgia pain or IBS. The folks who generally get talked badly about are those who present weekly or there abouts. You know them by name. They are given scripts for 30 or 60 pills and blow through them within a couple of days. They never follow up with their primary physician for their care. The ED physician is their doctor. These are the folks who are allergic to everything EXCEPT their drug of choice – usually an extremely potent narcotic. These are the folks who are allergic to new pain medications DAY’s after they are released (anyone remember when Toradol and Ultram were released?… I do. I remember folks being allergic the first day we had it in the ED to give). Please don’t take these rantings personally – no one is looking at you and clustering you in the drug seeking group. Unfortunately though, when you come to the ED weekly, allergic to everything but Dilaudid, do bring your screaming kids with you (and you drove yourself), talking on the cell phone, DEMANDING (yes, not asking, DEMANDING) your pain shot before you are even seen, refusing any other therapy or exam along the way – you might be classified as a drug seeker. Even joking. You are what you present yourself to be. If you are honest, upfront and work with the system you will be rewarded with being treated with compassion and respect.
Wow. Just wow. One look at the patient’s history and you formed such a negative opinion?
I haved been diagnosed w/2 out 3 of those. I have never asked anyone for a pain shot or anything more powerful that some Gabapentin and once some Imatrex. I fought hard against getting the label “fibromyalgia” because I knew how that would be perceived. Seems I was right.
Last night I went to the ER with the worst stabbing stomach pains of my life. After looking over my chart and taking my temp, I was sent home with a bottle of Mylanta. Obviously that has not helped. THe thing is, doctors like you are the reason why I avoid ERs like the plague that they are and I’d rather writhe in pain than encounter your type again.
“Last night I went to the ER with the worst stabbing stomach pains of my life. After looking over my chart and taking my temp, I was sent home with a bottle of Mylanta.”
I call BS on that. Almost everyone with abd pain gets a work up with lab tests and imaging that usually is not needed. You would have to look exceptionally well if that is all you got.
I agree with Brett. It would be extremely strange that you received no work up for severe abdominal pain. I have only done this with patients who have had large, recently negative workups.
This may help….
http://www.wikihow.com/Overcome-Martyr-Syndrome
Not to be a huge bitch…..But I will anyway:
For those who suffer from chronic pain, fibro, IBS, etc…who seem so upset by the observations of ED physicians and nurses posting here, I have this to say:
Realize this ain’t about you. You are taking the stated observations of people who work with hundreds of patients per week too personally. Each person is an individual, however, these smart people who have medical degrees and nursing licenses are sharp enough to be able to synthesize the trends they see week to week. As another nurse described earlier, crazy is as crazy does. Not all chronic paineurs are lying sacks with somatoform d/o’s. That is evident by the way they behave (subjective) and data like vital signs, lab results, and physical exams (objective). I believe the term is “down the hall diagnosis.” Most of the time, the combination of behavior, allergies, PMH, and currents meds is enough to see these people coming from a mile away. Does that mean that staff do not make the effort to rule out emergent problems that could still be legitimately occurring? Of course not. But it doesn’t mean that staff should be kissing their asses and putting on their kid gloves to pass out the vitamin D.
Since I’m willing to give *most* doctors the benefit of the doubt, maybe you should understand that when doctors generalize about a certain subset of patients, it ain’t about you. It’s a generalization based upon the thousands of patients these people have treated through the course of their careers.