Tuesday, November 3, 2009

The Patient is the One With the Disease

The lady who rushed into the ER last night after having her forearm punctured by her cat's sharp little teeth was in the department again less than 24 hours later when I got to work. She had gotten her wish: because she neglected to take the proferred antibiotic for 15 hours she developed the cellulitis that she insisted she was going to get. This was fairly predictable since she pretty much wanted to be admitted last night when she came in. When there was no redness or swelling. She wanted to be admitted prohylactically. I don't know about you, but such individuals just creep me out. There is an alarmng population of individuals who revel in their illness, delight in their disability and can't wait for complications. It is all about the attention, either from health care workers or family and friends.

Lots of people will fake pain so they can get narcotics; some are addicted, some sell them to get other drugs. The majority of these adopt a "pitch 'til you win" strategy. They make the rounds of every ER until they get what they want. Since we close at 11 PM, unless we have patients in the department, many have figured out that if they come in at 10:50 PM we will be more likely to give them the Vicodin or Percocet. Sometimes it backfires. One of the docs will only give Tramadol, which is fairly useless to the hard-core narcotic seekers. Let me assure you, though, we do evaluate everyone individually for their pain issues; sometimes we actually get someone who has 1) legitimate pain, which we 2) relieve

Still, some people have some pretty elaborate stories; it goes like this:

"So I've had this pain in my tooth for about 2 weeks, tylenol doesn't work, aspirin doesn't work, ibuprofen doesn't work (fill in time of last over the counter pain med administration, usually sometime yesterday). I have an appointment with the dentist next (fill in the day and date) because I had to reschedule from (fill in the last 6 dates for alleged cancelled appointments). The pain is really bad, it goes into my jaw and into my neck. It's 10 out of 10, I can't eat or sleep. I had some Percocet but i finished them. Does my face look swollen? It feels swollen. If I could get some more Percocet to tide me over until I see the dentist that would be great. Did I mention my pain is 10 out of 10? It's really bad No, I didn't call the dentist to see if I could get an earilier appointment"

Because I have many years of experience and generally know how to synopsize most complaints, my triage not says simply:

"Dental pain. Requests Percocet"

That about covers dental pain. It makes me lose interest really quickly, especially when we've seen the patient 5 times in the last 3 weeks, and it's always the same story. Many times the patient will get a 'script for Vicodin AND Penicillin. Guess which 'script never gets filled?

My favorite doc is keenly interested in relieving dental pain; he will do an injection of local anesthetic just like the dentist does. Not all of them do this, but I think for the legitimate dental paineurs it is a great option to buy them some time to get to the store for one of those temporary filling kits. Alas, some people refuse this option as you can imagine.

Not all the docs have the training to do this, which is why I think my friend Debbie, who teaches this skill to hygienists and dentists, should come up and do a training session. She could clean up $$ wise. Must remember to talk to her about it, several of the docs were very interested. It sort of seperates the wheat from the chaff if you get my drift.