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Post  milo on Wed 29 Jan 2014, 7:41 pm

Thought I'd post this because it makes me really mad but many of my non-migraine healthcare friends think it is hilarious.


Originally Posted: Tue, 27 Mar 09:56 PDT on Craigslist
Advice from an ER doctor to drug seekers

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 by 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 @@@@ 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.

Your friendly neighborhood ER doctor


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Post  Sara79 on Thu 30 Jan 2014, 1:10 am

Personally I agree with rules one and four, those are common sense, but so many people really are in the ED with 'the worst pain in their life', that I feel the rule about rating it a 10/10 is stupid.  I have told both the ED and our primary care docs that it may not be a true 10, but on my/DH's migraine pain scale, it's an 11/10, which is usually something most ED nurses hate to hear (11/10, not the pain level itself).  And if they really want the stupid MRI I'll take it, but this is just a migraine that's out of control, and I know it.  DH has declined the spinal tap, but that was after the MRI came back clean, and we promised that if the migraine didn't resolve in 4 hours that we would come back and get one.

About rule one- no ED nurse I've ever met would squirt pain meds on the floor.  One it's a slip hazard, two, it's illegal to document that you gave X amount of med, but really only give 2/3 of X.  They will and have however given 1/2 of the prescribed amount, waited a short while and seen how the pt responded.  When they chart, they'll document the actual amount given.  

They also won't ever ever give a 'fast push' in the port closest to the pt if they suspect drug seeking.  Many drug seekers request this, because it makes the high higher and quicker.  If they think the pt is seeking, they will put the drug in the largest amount flush (sterile saline filled syringe) their ED has, and push it as slowly as time will allow in the port closest to the IV bag, this way the med is diluted before it gets to the pt.  The pt will get the pain relief, but not the high, so it infuriates drug seekers, too bad.

Also, I've seen drug seekers request benedryl pushed (injected) as quickly as possible as close to the vein as possible...I don't get it, as I've never had that give me a high.  I did feel soothing relief the only time they've done this, but you could also trace my irritated vein up to my shoulder.  I don't remember what they gave me, but it HURT, and then the vein showed up right red under my skin.  

I will agree that drug seeking is a problem, and that the ED pros have to be careful.  As you all know, there are times that the only option left for help is the ED, and I hate that drug seekers have made it harder for legitimate migrainers, or suffers of any pain causing condition, to obtain the relief they need.

I will also agree that it's hard to think that the pain is really 10/10 when the pt is playing on the phone, or eating junk from the vending machine, which most ED pros have seen.  I think I've even had one nurse on a blog refer to it as Cheeto-itis, and rant that the pain cannot be ED worthy if you're yelling on your cell and eating Cheetos.

I know my perspective is a bit different, since I work in healthcare; however, I felt this way long before I changed careers.

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Post  7777Trinity on Thu 30 Jan 2014, 7:52 am

Actually, I have seen this write up before from a doctor. This one posted, has had a lot of derogatory remarks added to it.

The one I had read was this.

When you go to he ER be honest, be patient and don't ask for narcotics, even if you know which one you need. The ER will want to give you a muscle relaxer and something for nausea and an anti-inflammatory first.

You and I both know that won't work, but let them do it and ask to stay to see if the pain starts easing. In about an hour tell the nurse what your pain level is, if it is still the same, this is when a pain medication would be given.

ER doctors are placed in a very difficult situation and this Craig's list memo has been doctored by someone to offend as many people as possible.

22 million people in the U.S. use illegal drugs or misuse prescription drugs and the U.S. leads world wide in illegal drug use. This has to be a sobering factor in what ER doctors face.

I had a terrible experience in the ER in the summer of 2012, If I had known that I had to make every effort to appear sane and that would help me get treatment for the Migraine Monster, it would have changed that visit. That said, after 17 days in a row of a 8-9 scale migraine, I'm not sure I could have. However, I think I would have tried.

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