Thursday, January 27, 2005

The Case of the Strange Sprain

Two days ago a slender middle-aged man walked into a local emergency room, complaining of neck pain after taking a spill in his brother's front yard. X-rays of the cervical spine were unremarkable, and the patient was discharged with a standard information sheet for home care of a neck sprain and told to follow-up with his primary care physician.

He replied that he did not have a family doctor, and was therefore given the name, address and telephone number of the physician designated by the hospital to be "on-call" for emergency patients on that date, January 24th, and was instructed to see him the next day should his neck continue to hurt.

When he discovered that the doctor's office was twenty miles away from the emergency room he had just visited, the patient did not complain nor ask to see someone closer.

The following day the patient appeared unannounced in the follow-up doctor's waiting room wearing a bulky cervical collar and complaining of a sore neck. He asked to see the doctor and presented his E.R. discharge sheet as proof of his diagnosis. After a rather long wait, the doctor whose name was on that piece of paper walked into the waiting room and addressed the patient.

There are some days when the twirling roulette ball hits the chosen number time and again, when every bet placed brings in a winner. It is during such a streak that a person's confidence may mutate into thoughts of infallibility, that his ambitions may soar beyond the gravity belt of common sense that keeps him secure in his wits. The man at the window thought he was having such a splendid day as he greeted the doctor. He did not realize it yet, but his most recent wager was about to bust. By sheer coincidence the hospital had paired him with the worst possible doctor around when it comes to a pain in the neck - a completely unhelpful, ungracious, uncaring, inflexible creep.

The man in pain was about to meet the pain man - and get the old heave-ho.

Mr. Drug Addict, meet The Cheerful Oncologist.

If there ever was a specialty where a little training in drug-seeking behavior might be a good idea, it is medical oncology. We cancer docs dispense narcotics like the local movie house sells popcorn, and frankly, it is one of the most important treatments we can offer our patients. We are extremely cautious in our use of pain pills. Rarely, and I mean extremely rarely, we come up against a scam artist, and when we do it is up to us to slap our lethargic cheeks and recognize the start of the con game. I did not immediately sniff out the ruse being performed in my office, but as I interviewed the injured soul some curiosities about his story were raised, such as why he bypassed six hospitals to go to one located forty miles from his home. Possessing a naturally helpful disposition, I at first tried to find him a specialist who could treat his neck, but while sitting at my desk looking up telephone numbers I suddenly had the notion to follow one of the Basic Laws of Medicine:

Don't even attempt to make a diagnosis until you have all the facts of the case!

With such sage counsel bubbling throughout the cranium I decided to pay a visit, via the miracle of the Internet, to the patient's hospital records. After a couple of clicks my lips were lo-and-beholding with amazement. The unfortunate neck-twister had been to that very same emergency room last November, and the year before - always with the same complaint! In fact, he had received x-rays of his long-suffering neck on each occasion. "Well, I'll be a monkey's uncle!" was the phrase of the day at that point. I printed out his radiology reports and headed back out front.

It was a brief but emotional reunion for the two of us - he with an increasingly anxious look on his face, like one who has just walked into church without his trousers on - and me, the Perry Mason of medicine, cross-examining the witness until he abruptly paid his respects and beat a hasty exit.

All's well that end's well, I suppose - I avoided becoming another victim of a classic flimflam by a dope fiend, and perhaps my opponent will re-think his strategy of promulgating perpetual pain to every emergency room in town. The moral of the story is clear:

Learn everything you can about your new patient.

Sometimes the secrets to a successful outcome in medicine, like clues hidden around the old dark mansion on the night of the crime, require the protagonist to play dual roles - that of doctor and detective.


At 5:49 AM, Blogger Allen said...

OK, that's the single best reason for a universal electronic medical record I can imagine.

We get scammed in EM, a lot, by drug seekers. It's supposedly now illegal to keep files about drug seekers (so we don't), but the EMR might at leat put the brakes on some of this.

You patient will now choose an ED 80 miles away.

At 9:27 PM, Anonymous Anonymous said...

The flip side of this is of course the penalty these guys indirectly impose on J. Random Patient.

In grad school (math) I suffered a herniated disk. I got 30 Vicodins, my first narcotic analgesic ever, to tide me over until I could see the spine specialist - but THAT appointment wasn't to be had for two weeks. After 1 week, I was out of business for the following week; they wouldn't refill my scrip without another meeting with the PCP, which couldn't be had until the same time as I saw the specialist anyway. And when I asked, I was treated like scum. The reason I was sweating and shifting from foot to foot was because I could barely stand.

Of course, I still could stand to stand, which might be the point of it. But nobody explained this to me at the time and the front office woman sure wasn't even a nurse.

Indeed, perhaps in the end it was better for me as by the two week mark I could manage things fine with just Tylenol 3, and compared with what my thesis advisor's husband went through with his leukemia (in the end a win!) my discomfort was small potatoes.

Still, the experience has made me wonder if the emphasis on diligence in dispensing this stuff has been placed too much on 'preventing inappropriate dispensing' than 'ensuring wholly appropriate dispensing'. My experience has made me more likely to look toward gaming the system next time to make sure I have more than I think I'll need: not because I want to be hooked on hydrocodone or because I found it especially pleasant, but because I'm not sure that the process is oriented toward my best interests.


At 11:48 AM, Anonymous Anonymous said...

Same worries as the above poster

"We [oncologists] are extremely cautious in our use of pain pills" reads to me like
"all those studies showing cancer ( and other) patients are left in pain by doctors who are stingy with pain meds are true"

I don't want doctors to play the role of drug-batman, even if that means someone "seeks" and finds.

At 2:08 PM, Blogger Dr. Craig Hildreth said...

The above points are well-spoken and important, as no one with cancer pain should ever have to suffer. In contrast, the man in this anecdote was not a cancer patient and had no records to suggest that he required narcotics for pain relief. I even called an orthopedic surgeon that day, who informed me that narcotics are not used for a simple neck strain. We oncologists are cautious in determining who needs strong pain relief, but generous in the use of such meds once it is deemed appropriate.

At 4:56 PM, Blogger bronwyn said...

Many chronic pain patients that I have spoken with develop what I think of as, "The Squirrel Mentality," -- That is, they are so afraid of being left in a bind with no pain medication that they do whatever they can to stockpile meds. Sometimes this means 'rationing' their meds now and dealing with inadequate pain relief as a result, just in case things get worse down the road. *And if there's one thing I've learned as a patient, it's that no matter how bad you think things are, they can always get worse.

But, volunteering in a regional ER, I saw the flipside of things as well.. All kinds of people crawling out of the woodwork, looking to score some oxycodone or whatever they can get their hands on. It's sick and very, very sad.

At 9:52 PM, Blogger Dreaming again said...

That's what my doctor meant by 'stop squirrelling them' when talking about my pain killers.

I'd had an injury, and she'd given me some lortabs. 9 months later, I had another injury .. and she went to give me some and I said I still have plenty from before. She looked at me funny.

Then when I had a lupus flare, I said I was taking it, and apologized, she asked me if my neurologist had given them to me, I said no, their for the ones from my shoulder last year. That's when she said to stop squirrelling.

She's told me that she will write for what I need, and IF she thinks I'm even close to using too many, she will tell me.

In December, I fell, when I went to the ortho, and had an MRI and went back in 2 weeks ... found out my knee cap wasn't all the way in. I asked if I could have some lortabs to stop the severity of the pain ... he was floored I hadn't had any.

I don't know if I'm more paranoid of becoming dependant ...or having someone think I'm drug seeking.

At 1:07 PM, Blogger jon said...

I was looking at your posts about bone cancer and found a good article about the same bone cancer info too...

God luck with it : )

At 2:11 AM, Blogger amacdrummer said...

You might find this cancer rectal site interesting : cancer rectal

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