Archive for category Pain Management

Makes Me Wonder

Sometimes I have a hard time trying to separate fact from fiction; especially when patients start giving me a back story to explain why they haven’t had follow up for a medical problem, or how their narcotics got stolen/lost/misplaced, etc. I sometimes think, seriously? Is that really how bad your life is? Come on…

I know times are hard for a lot of people, but when you’re a 30-something, insulin-dependent, right AKA with non-healing wounds who social work bent over backward following your last admission to get you a clean place to live, home health care visits and arranged for a primary care physician so that you could regularly get medical care and, more importantly, your prescriptions, it’s poor form to miss appointments and get dropped from the practice.

Yes, I know it’s easy to get kicked out of your place within a month for having a dog which wasn’t allowed in the first place and which you acquired AFTER you moved in. What home isn’t complete without a loving pet? And, since you couldn’t afford a place before because of your limited SSI, I am sure adding vet bills, dog feed, and vaccinations to your budget will be no problem at all. And, sure, having a significant other who doesn’t work and who smokes despite the no-smoking policy of the building management is a problem especially when they’re not supposed to be on the property either. Yes, darn those apartment landlords and their stupid rules.

Now, I understand that you had previously been living in your car and had been lucky to have a nice place to live, but why couldn’t you drive that car to the appointment again? I’m sorry, you’re now having to live in it again… is it in working order? How did you get here again? What? It’s a legitimate question since you came 20 miles out of your way from your hometown to our E.D. Sure, yes, well, you’re in luck, we have no beds and are having to send all of our admissions north to our sister hospital. So, you’ll be closer to, um, home… and, besides, those social workers already know you and have done all of the leg work already, so there’s that too.

Then there’s the “I need a drug refill because my meds were stolen after I moved out from the last place I was in.” My answer is simply “drugs and scripts are like money, if you lose it, it’s gone and there’s no replacing it.” Besides, we have pain contracts with the local primary care M.D.’s, and they say, “No.” I still get some interesting stories, though, of backpacks being left “for just a second,” or of drugs disappearing “while I was taking a nap” or of pills in a lockbox in someone else’s house that mysteriously disappear when the person with the key leaves the house to go out to get some smokes. My favorite is the “I left them at my ex’s house, and now I can’t get them back.” “Did you file a police report?” “Well, um, yeah.” “Ok, let me talk to the police department and confirm the report number.” “Yeah, well, um.” “So, which police officer was it again..?” “Um, well, yeah it’s kinda like this…”

Mark Twain once said, “Truth is stranger than fiction, but it is because Fiction is obliged to stick to possibilities; Truth isn’t.” Twain must have worked in an E.D.

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Pain and Prompting

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It’s funny how you can walk into a room, think you have a pretty clear history of what’s going on with the patient, and 30 minutes later your attending comes up saying, “No, he’s telling me it was crushing substernal chest pain with trouble breathing, NOT 2 seconds of pain when he moves his left arm.” Yessirree Bob, the attending effect is real: but I’d like to challenge its origin.

First, some disclaimers: some patients are, simply, crazy. (And I’m not talking psychiatrically crazy, I’m talking dramatic, emotional, over-the-top, and hard to pin down on a clear story. Okay, maybe psychiatrically Axis 2.) And some doctors are, simply, bad listeners. They will never get a good history, because they don’t know what questions to ask, or how to ask them, or how to tease out the important parts of the story from the rest. But besides these caveats, I’d like to hypothesize this: the attending effect is primarily due to pain, or prompting.

Pain’s an easy one. We see this all the time. You have a patient in pain, or nauseous, or angry, or — in any way, emotional — and you might as well kiss most of your history-taking goodbye for the time being. This is no Mt. Everest for us in the ED. This is just how it goes. You get a little story, you treat the pain, you start your workup, you go back once the morphine’s kicked in, and you get some more story. The more calm and rational the patient is able to be, the better history you’re going to get. I find this to be the case all the time when I’m admitting patients: the history of present illness I’ve initially written has evolved over the course of the stay. I’d like to also posit that this is why the medicine resident comes down and thinks I’m an idiot: the story they get from the patient sounds nothing like the one I documented in the chart. (Other possibility: I am actually an idiot.)

“Prompting” is the other big cause (in psychology, they call it “priming“): when you do the initial history and ask the initial questions, the patient may not remember every detail of his or her history. You zip in, get your story, do your exam, zip out, and start writing your orders, while the patient in the mean time has a chance for those questions you’ve asked to simmer a bit in their cranial Crock Pot. Case in point: 28 year-old guy in the ED last night with urinary obstruction. Said he’s never had an STD that might predispose him to this. Urology comes in after multiple failed attempts to Coudé the poor guy, and he freely acknowledges having chlamydia a few years back. So thank you, Urology, for the consult, but I swear we’re not lying: we just primed his brain to remember!

So there’s no reason to be ashamed if you get a different history from someone else — especially if their history comes later than yours.

That is, of course, unless you’re an Axis 2, crazy, dramatic, bad-listening doctor.


Best Pediatric Sedation Technique Ever

In my short Pediatric Emergency Medicine career, I have successfully:

  • burrito-wrapped my fair share of pediatric laceration patients;
  • debrided 3rd degree burns with IM ketamine;
  • removed cockroaches from ears, and
  • sutured a sleeping child.

But never, ever in my career have I sutured a child without them screaming bloody murder. Until today, ladies and gents.

God bless you, Spongebob Distractionpants. For the low price of $1.99 (and your iPhone service plan, of course) you can download an episode from iTunes and totally distract a kid — without any respiratory depression or squirming!

It did absolutely nothing when I tried to distract the kid during the lidocaine injection, but once he was numb, I was suturing up his lip, dragging suture material along his face and waving suture instruments near his mouth and eyes without an ounce of fear — or even interest. He was totally, absolutely, completely fixated on my iPhone showing the SpongeBob episode. (And works faster and more reliably than PO versed.) Thank you, inherent distractability of the immature mind!

(The febrile 2 year-old tonight with otitis would have none of it, despite me going for a Yo Gabba Gabba episode, in case you’re wondering.)

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A Simple, Powerful Pain Protocol

Even when we can’t cure a patient, we can relieve suffering. On average, we kind of stink at pain control in the ED. One physician, Dr. Ed Gentile, has created a simple path to optimal acute pain control in the ED. I heard this lecture on the EM:RAP podcast and got permission from Drs. Gentile and Herbert to repost it here. This is not a critical care topic per se, but it is applicable to the critically ill, the non-critically ill–-basically any patient who is in pain in the ED.

[Click here to read more and hear the podcast]

photo by Azarius