ER Doc give his advice to drug seekers.

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8'Duece

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Not like there's anyone here that drug seeks, but this was in our ACM (Advanced Clinical Medicine) in box this morning. :uhh::-x

This is supposedly from an ER doc at University Of Louisville and he posted this on Craigs Lists.

This is funny, so feel free to comment on your experiences if your in the Health Care field etc.


OK, I am not going to lecture you about the dangers of narcotic pain medicines. We both know how addictive they are: you because you know how it feels when you don't have your vicodin, me because I've seen many many many people just like you. However, there are a few things I can tell you that would make us both much happier. By following a few simple rules our little clinical transaction can go more smoothly and we'll both be happier because you get out of the ER quicker.

The first rule is be nice to the nurses. They are underpaid, overworked, and have a lot more influence over your stay in the ER than you think. When you are tempted to treat them like shit because they are not the ones who write the rx, remember: I might write for you to get a shot of 2mg of dilaudid, but your behavior toward the nurses determines what percent of that dilaudid is squirted onto the floor before you get your shot.

The second rule is pick a simple, non-dangerous, (non-verifiable) painful condition which doesn't require me to do a four thousand dollar work-up in order to get you out of the ER. If you tell me that you headache started suddenly and is the 'worst headache of your life' you will either end up with a spinal tap or signing out against medical advice without an rx for pain medicine. The parts of the story that you think make you sound pitiful and worthy of extra narcotics make me worry that you have a bleeding aneurysm. And while I am 99% sure its not, I'm not willing to lay my license and my families future on the line for your ass. I also don't want to miss the poor bastard who really has a bleed, so everyone with that history gets a needle in the back. Just stick to a history of your 'typical pain that is totally the same as I usually get' and we will both be much happier.

The third rule (related to #2) is never rate your pain a 10/10. 10/10 means the worst pain you could possibly imagine. I've seen people in a 10/10 pain and you sitting there playing tetris on your cell phone are not in 10/10 pain. 10/10 pain is an open fracture dangling in the wind, a 50% body surface deep partial thickness burn, or the pain of a real cerebral aneurysm. Even when I passed a kidney stone, the worst pain I had was probably a 7. And that was when I was projectile vomiting and crying for my mother. So stick with a nice 7 or even an 8. That means to me you are hurting but you might not be lying. (See below.)

The fourth rule is never ever ever lie to me about who you are or your history. If you come to the ER and give us a fake name so we can't get your old records I will assume you are a worse douchetard than you really are. More importantly though it will really really piss me the fuck off. Pissing off the guy who writes the rx you want does not work to your advantage.

The fifth rule is don't assume I am an idiot. I went to medical school. That is certainly no guarantee that I am a rocket scientist I know (hell, I went to school with a few people who were a couple of french fries short of a happy meal.) However, I also got an ER residency spot which means I was in the top quarter or so of my class. This means it is a fair guess I am a reasonably smart guy. So if I read your triage note and 1) you list allergies to every non-narcotic pain medicine ever made, 2) you have a history of migraines, fibromyalgia, and lumbar disk disease, and 3) your doctor is on vacation, only has clinic on alternate Tuesdays, or is dead, I am smart enough to read that as: you are scamming for some vicodin. That in and of itself won't necessarily mean you don't get any pain medicine. Hell, the fucktards who list and allergy to tylenol but who can take vicodin (which contains tylenol) are at least good for a few laughs at the nurses station. However, if you give that history everyone in the ER from me to the guy who mops the floor will know you are a lying douchetard who is scamming for vicodin. (See rule # 4 about lying.)

The sixth and final rule is wait your fucking turn. If the nurse triages you to the waiting room but brings patients who arrived after you back to be treated first, that is because this is an EMERGENCY room and they are sicker than you are. You getting a fix of vicodin is not more important than the 6 year old with a severe asthma attack. Telling the nurse at triage that now your migraine is giving you chest pain since you have been sitting a half hour in the waiting area to try to force her into taking you back sooner is a recipe for making all of us hate you. Even if you end up coming back immediately, I will make it my mission that night to torment you. You will not get the pain medicine you want under any circumstances. And I firmly believe that if you manipulate your way to the back and make a 19 year old young woman with an ectopic pregnancy that might kill her in a few hours wait even a moment longer to be seen, I should be able to piss in a glass and make you drink it before you leave the ER.

So if you keep these few simple rules in mind, our interaction will go much more smoothly. I don't really give a shit if I give 20 vicodins to a drug-seeker. Before I was burnt out in the ER I was a hippy and I would honestly rather give that to ten of you guys than make one person in real pain (unrelated to withdrawal) suffer. However, if you insist on waving a flourescent orange flag that says 'I am a drug seeker' and pissing me and the nurses off with your behavior, I am less likely to give you that rx. You don't want that. I don't want that. So lets keep this simple, easy, and we'll all be much happier.

Sincerely,
Your friendly neighborhood ER doctor
 
8

8'Duece

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I can tell you from shadowing the ER docs at my school that this paragraph is the absolute truth !!

I'm not advocating this behavior. This is for humor and humors sake only.

So if you keep these few simple rules in mind, our interaction will go much more smoothly. I don't really give a shit if I give 20 vicodins to a drug-seeker. Before I was burnt out in the ER I was a hippy and I would honestly rather give that to ten of you guys than make one person in real pain (unrelated to withdrawal) suffer. However, if you insist on waving a flourescent orange flag that says 'I am a drug seeker' and pissing me and the nurses off with your behavior, I am less likely to give you that rx. You don't want that. I don't want that. So lets keep this simple, easy, and we'll all be much happier
 

Dame

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Wow. That explains the Thorazine they gave me this weekend. Off label for migraine in a 9.5/10 pain situation (I was basically blind by the time I got in there) but the I.V. helped. I'm guessing it wouldn't have had that effect on my brain if I was addicted to pain meds. And it only helped my brain. My neck and shoulders still hurt like a sonofabitch. Almost over now thank goodness.
 
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8'Duece

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Wow. That explains the Thorazine they gave me this weekend. Off label for migraine in a 9.5/10 pain situation (I was basically blind by the time I got in there) but the I.V. helped. I'm guessing it wouldn't have had that effect on my brain if I was addicted to pain meds. And it only helped my brain. My neck and shoulders still hurt like a sonofabitch. Almost over now thank goodness.

That's just silly !!

I'm surprised they didn't just go for 2mg's Stadol from the start with 25 mg's of Phenergan. Some Docs practice what their tought through their rotations and others learn along the way that most migraines never respond fully to triptans and Thorazine. I have yet to meet a person that suffers from true migraines that is given any relief from Sumatriptan or other cocktails that do not involve narco therapy. If you have other experiences, please share them.

Hell, screw the IV, just hit your ass with 3mg's of Stadol or 2mg's of Dilaudid with 25 mgs of Phenergan and your out the door and home comfortable without the IV wait. Following protocol for wait time and BP and O2 sats.

The fact that you said "9.5" ont the pain scale is percieved pain. If you've never experienced a compound fracture of the femur then you don't know the pain relative to the injury, just that your head is about to explode and you can't see or stomach anything.
 
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8'Duece

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ADD:

The IV helped due to probable dehydration. I've seen migraine sufferers respond to IV therapy and pure O2.
 

Dame

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The 9.5 response was to the question, "Based on the worst migraine you've ever had..." not the worst pain. As far as the rest of the experience, you're right, it did not fully respond to the Thorazine and I had a minor reaction of throat and nasal cavity closing. I was able to vocalize it and it subsided quickly. Still on Percocet for pain and Prochlorper for the nausea/dizziness/balance issues. OK, I'll STFU now. I'm sure this is boring.
 

Muppet

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The 9.5 response was to the question, "Based on the worst migraine you've ever had..." not the worst pain. As far as the rest of the experience, you're right, it did not fully respond to the Thorazine and I had a minor reaction of throat and nasal cavity closing. I was able to vocalize it and it subsided quickly. Still on Percocet for pain and Prochlorper for the nausea/dizziness/balance issues. OK, I'll STFU now. I'm sure this is boring.

I am not bored. I learned something.

F.M.
 

policemedic

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The muppet is right; you're not boring us.

The truth is that migraines are fairly common (roughly 15% of the population experience them), so a decent knowledge of how to assess and treat one should be possessed by anyone in emergency medicine. Migraine is an interesting syndrome that is associated with a wide list of differential diagnoses, and as you can attest, the pharmacology involved in the treatment of migraine variant HA is fairly complex.

The thing about migraine is that (with some notable exceptions, such as first-time presentations), the diagnosis is based on a careful history. Imaging and other studies tend to be overused. It's one of the reasons migraines are interesting and not boring; proper assessment requires critical thinking instead of reliance on technological crutches.

Have you had Thorazine before? Reactions to meds that cause airway issues are worrisome.

Duece is right. Triptans and Thorazine aren't the drugs of choice. In fact, triptans are often contraindicated in several migraine variants, as are drugs containing ergot. Stadol may be effective, but can be addictive and can produce bothersome side effects in those persons who are not accustomed to narcs.

Anyway, I'm sorry you were suffering. Migraines suck. Feel better!
 

Manolito

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I am sorry for laughing but the Thorazine shuffle is the greatest thing to watch. Some Dr. that have a low tolerance for people will light them up with Thorazine and they will shuffle out of the room like they have large slippers on and are trying to keep them on their feet.
Sorry to hear about the migraine.
Bill
 

Dame

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Bill, if I could remember walking out of there I'd confirm or deny the shuffle, LOL. I was hoping no one would start to hypothesize why a drug that acts like a chemical lobotomy might have worked. I'm flying to Reno/Carson again today for govt meetings and I'm hoping the travel doesn't trigger anything more.

Policemedic, I've never had anyone give me Thorazine before which is why (despite the difficulty is forming a coherent sentence) I made sure to vocalize the difficulty breathing. They added more of the other stuff to the cocktail; triptans I guess. Eventually they gave me a pain killer but I'm not even sure it was the same stuff they sent me home with a prescription for.

Muppet, glad to be of assistance, LOL. Wish me luck today. I hate it when they schedule more than one meeting in a day for me in two different cities up there.
 

Headshot

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Many docs DO NOT know what to do with a migraine as they are a bit of a mystery given most fail to do a proper social history anymore on their patients. With that, many many docs will give a migraine sufferer something strong enough to put them out of their right mind long enough for the migraine to go away on it's own. Symptomatic cures as usual when it comes to a migraine. You will continue to have migraines until you find someone who is willing to do a proper social history workup on you and help you make the proper lifestyle changes that will bring about a cure rather than occasional relief.
 
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8'Duece

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The muppet is right; you're not boring us.

The truth is that migraines are fairly common (roughly 15% of the population experience them), so a decent knowledge of how to assess and treat one should be possessed by anyone in emergency medicine. Migraine is an interesting syndrome that is associated with a wide list of differential diagnoses, and as you can attest, the pharmacology involved in the treatment of migraine variant HA is fairly complex.

The thing about migraine is that (with some notable exceptions, such as first-time presentations), the diagnosis is based on a careful history. Imaging and other studies tend to be overused. It's one of the reasons migraines are interesting and not boring; proper assessment requires critical thinking instead of reliance on technological crutches.

Have you had Thorazine before? Reactions to meds that cause airway issues are worrisome. Good post Policemedic !!

Duece is right. Triptans and Thorazine aren't the drugs of choice. In fact, triptans are often contraindicated in several migraine variants, as are drugs containing ergot. Stadol may be effective, but can be addictive and can produce bothersome side effects in those persons who are not accustomed to narcs. Anyway, I'm sorry you were suffering. Migraines suck. Feel better!

Sever itching is the most commom side effect in just about all patients. Stadol is also available in a Nasal Spray for home use. This is what get's most people in trouble. It works so damn well !!

Headshot hit the nail on the head. A differential diagnoses by a Neurologist is called for in most cases. There are plenty of prophylactic drugs that can be taken on a daily basis to stave off migraines. Topamax, Beta blockers and a couple others that come to mind. Although these drugs seem to only prevent the number of migraines you may suffer over a given length of time. You may still require ER treatment a couple times a year for relief.

Honestly, the highlighted portion regarding the use of Thorazine has me wondering why they even attempt it. :uhh: It's totally off label for Migraine relief.
 

Marauder06

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And I firmly believe that if you manipulate your way to the back and make a 19 year old young woman with an ectopic pregnancy that might kill her in a few hours wait even a moment longer to be seen, I should be able to piss in a glass and make you drink it before you leave the ER.

lol :)
 
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8'Duece

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I don't mind off-label use (BTDT) but not without good evidence of safety and efficacy.

I'm gonna take an educated guess without looking up the class of drugs.

Good for nausea, vomiting and relaxing the patient ? It's usually a given for schizophrenia patients.

Why use it ? The ER doc here will give you 2-4mgs Stadol, 25mgs Phenergan and maybe 2mgs Ativan. You'll be damned comfortable by then.
 

policemedic

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No argument with that. My comment about off-label drug use was intended generally. Many drugs are used off-label to good effect. With that said, the clinician must have a solid understanding of the pathophysiology of the disease process they're attempting to correct and a good understanding of how the drug they've chosen will produce the beneficial effect they're seeking to achieve.

Thorazine isn't a drug I'd choose for migraine HA, just for clarity's sake.
 
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8'Duece

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Some docs just are too damn skeered to use narco therapy first. For good reason, but if the patient does not have any underlying conditions that restrict the use of narcotics then you can GOMER them out of the ER and both you and the patient have been served well. Beds need to be open for more serious cases coming out of triage. Assuming this is a typical migraine with no underlying causes that would require a CAT workup, blood cultures, etc.

It's ok to use lesser drugs, such as the triptans, but don't expect the patient to suddently say "Hey, feels better, I'm like new" when those have proven track records of poor perfomance for pain relief once the migraine has ventured passed the pain threshold, bell curve.

Tell tale signs are high BP, intense photophobia, nausea, gagging and muscle weakness. If my patient does not have any trauma related issues, respiratory distress etc or is on daily medications that are highly contraindicated to narco therapy then I'm going to get them the pain relief they need and get them home and out of the ER. It's good business. This is also assuming I've completed a proper neuro exam with expected results. If the patients eyes are not dilating properly I've got something entirely different and serious on my hands.
 

Headshot

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I get headaches from taking the vicodin. :uhh:

Of course I take more vicodin in a week than any drug addict crack head, but it’s due to actual severe pain…

You're dehydrated. Try hydrating till you piss clear (you know the drill); in the morning drink 2 tall glasses room temp water about 30 minutes before eating to get re-hydrated. Vicodin saps water from your system as quick as alcohol does, and if you go to be dehydrated the problem is compounded by moisture loss from breathing while you sleep. Also, if you find yourself hungry often then try drinking some water. Most people are dehydrated and confuse it with the feeling of hunger when they actually need to drink water. Stay away from the sports drinks for actual hydration (read the labels), nothing beats water. You are made mostly from H2O, not Gatorade. You can buy electrolytes to add to water without all sodium that most sports drinks have. Try it for a couple of days and see if the headaches don't disappear.
 
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