A Comment on Drug Seeking Behavior

A while back I had the predictable response from one of my posts about drug seeking individuals; the respondent took issue with my attitude and begged me to consider that all patients with chronic pain complaints are not, in fact, drug seekers. My response:

"Yes, but why are you out of meds? Surely with a chronic painful problem you would make it a priority to contact your provider well in advance so you DO NOT run out; this is what reasonable individuals do who are taking responsibility for managing their health care. "I've run out of my meds and haven't had time to contact my doctor" is often how individuals seeking narcotics present to the ED. This is not to paint everybody with chronic pain issues with the same brush, I am merely pointing out why you may be treated like a drug seeker when you say you have run out of meds. You must understand that most of us working in emergency departments see the same individuals all the time with the same chronic complaints; most of these patients could be well controlled with medication if they are diligent. But that is my point, so many want only the narcotics. Their histrionics and constant drama suck the life out of us and take us away from legitimately sick patients. No, not everyone is a carbon copy, however when 9 out of 10 individuals with these chronic types of pain issues IS a carbon copy perhaps you can begin to see the problem".



For example:



Today a gentleman arrived with a complaint of "Getting a Migraine". No headache, but you know, he says, I've had these visual "bubbles" for a whole 20 minutes now and that's how it starts. He has had 25 ER visits in 2010 for pain-related complaints; most were without trauma, and those that involved a fall, lifting furniture, banging his thumb with a hammer were all without clinical findings. Of course the majority were for the Holy Trinity of pain complaints: Back Pain, Migraine, and Dental Pain. Amen. He had been prescribed 15 Percocet for 10 of those visits, 10-15 Vicodin for 6 visits, and Ibuprofen for 3 visits. He declined a dental block for two visits and just took the antibiotics.



Another well known individual with many, many visits for back pain always has the same story; my doctor is not available. In 18 of the last 19 visits, he has arrived at 5:15 pm ALMOST TO THE MINUTE. Of course his PCP's office is closed at that hour. He asked for oxycodone without the acetaminophen, which is oxycontin pretty much and very powerful stuff. He claimed that the Tylenol hurt his stomach; note that for 19 out of 19 visits he received a prescription for percocet. The ER physician informed him that she never prescribes pure oxycodone in the emergency setting and wasn't about to start now.



Both of these cases involve individuals with chronic pain issues who have either not been up front with their physicians about how much medication they are taking, or are simply lazy. Lack of planning on your part does not constitute an emergency.

Welcome to the Dark Side, Bobo

Apparently, Dr. Roboto has thrown in the towel, conceded my cynical superiority, and has decided if you can't beat 'em, join 'em.



Yep. He's rolled over and realized that I'm no pushover, have no respect for him, could care less if I am fired and, more importantly, my sucky attitude toward him has spread to the other nurses. Pied Piper rulz; no one has called him Dr. Roboto in weeks, we now all call him "Bobo".

Oh, Bobo is still going full tilt on the rapid door to doc. But, if the nurses are busy he will greet the patient at the ER door and see them before they are triaged. Great! Now you're beginning to understand teamwork! I am a powerful ally, but a formidable opponent as he has discovered. I have caught him trying to make jokes, along with uncharacteristic human emotion, an occasional eyeroll, and actually CHATTING with nurses. I told him, as he considered having one of us give a constipated individual and emergency enema, that there was a special place in hell for ER docs who order either ear irrigations or enemas in the ER. The son of a bitch actually laughed and didn't order it. Another social lesson well learned (or he is at least on the right combination of meds), but my work is not yet complete; now I just need to get him to talk to his clavicles a little less as he does occasionally backslide on that issue.
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I rarely work with Mikki, and had an opportunity to do so with her today on an infrequent day-shift appearance on another busy shift in which we ran our little legs off. Everyone got hydration, labs, meds and instructed in how to collect a sample of the alleged diarrhea that a many had claimed to have experienced for days, which somehow mysteriously resolved upon arrival to the ER. We had Dr. Cripes today, which was a happy bonus. Gotta love him. Working with Mikki is a trip because she has been very insecure in the past, and frequently looks to me for...I don't know, courage, leadership, approval-whatever. She gets better all the time though, I'm happy to report. I tell her the cool kids like her and not to worry about what Second in Command says or does, because she is unhappy, unliked, and uncool. Who needs her?

I had been given a yellow pen with a duck head that lights up and quacks when you push it on the noggin; very annoying, but I LOOOOVES me my ducky pen. It goes well with my yellow scrubs; the yellow submarine in da house.

I emitted a cheerful "quack" with my pen as I greeted Mikki and Cripes. "Hey, what's with the duck", Cripes asked. "It annoys Bobo, what could be better?" I asked.

"I used to be a wreck when you and I had to work with Bobo", Mikki said. "I'll never forget the time you said you wouldn't respond to anything he said unless he called you by name and looked you in the eyes".

Cripes and I laughed. "That was also the day I told him he was needy. And because he took the time to write 'suture set, 1% lidocaine, 4-0 nylon, normal saline, Zerowet and set up for sutures' on an order sheet which took 4 times as long as it would have for him to just do it, I put 1/2 the wrong stuff up on purpose".

"I wanted to disappear", Mikki cringed.

"Nurse Passive-Aggressive on the job that night?", Cripes grinned.

"Yep, guess you will never have to meet her since you are pretty much the pinnacle of ER physician role models. We all change shifts so we can get to work with you".

The highlight of the day was that my boss told me that I would be receiving the first raise of the new year since my anniversary date is January 4. WOOT!

"I Like the Christmas Jesus Best"

New Years Day was just as much fun as New Years Eve, with record numbers of patients. It was apparently a good day to take care of all of those annoying little symptoms people have had for months; colds, back pain, dental pain, rash. Not the most challenging night.

New Cathy, whose Christmas tree and decorations came down on Christmas Day before she came to work, was all about ridding us of the holiday decor. I spent about 30 minutes in triage and when I got through with about 6 patients, she had taken it all down. Most of the stuff is pretty old, so I 86'ed the wreath that looked awful; executive decision.

Of course, there was the scandalous Nativity Scene crime. It all started on Christmas night.

It was pretty quiet; we were hanging out in the waiting room watching a very boring movie and chatting when I noticed that the ancient, chipped Nativity set on the small table next to me seemed somehow incomplete.

"Hey", I said to nobody in particular, " did this Nativity come with a Baby Jesus?".

Ellen sat bolt upright. "What?! You gotta be kidding me. I put that out myself! Maybe it fell on the floor?"

We searched around, but it was nowhere to be found. "It's really gone! Who would do that? Who would steal the Baby Jesus? Who would be that low?", said Ellen.

"Well, maybe someone just took it for a joke; you know, like those lawn ornament thingies?", suggested Mary.

"You mean garden gnomes; people would pose them in vacation spots and took pictures? Then they sent the people pictures of their gnomes on vacation?", I said.

"Yes, just like that. Maybe someone took Jesus on vacation", offered Mary.

“Why not?" I said, "to quote my daughter K: 'I like to think of Jesus as wearin’ a Tuxedo T-shirt, ‘cause it says,‘I want to be formal, but I’m here to party too.’"


"That is just terrible. I'm very upset about this", said Ellen in a huff.

I just think it is kind of ironic that someone took the very symbol of one of the most holy days of the Christian calendar from a religious hospital. But that wasn't the end of it, which brings me around to the Christmas decoration sweep over the weekend. Not only was the Baby Jesus MIA, but so was the Mary figurine.

Now Ellen is nearly apoplectic.

"Oh, more crime; what kind of person steals pieces of a Nativity scene. REALLY! People will stop at nothing these days, it is so sad."

“Dear Tiny Jesus, in your golden fleece diapers, with your curled-up, balled-up little fists pawin’ at the air…”

But wait! There's more. During the Christmas cleanup it was discovered that the nativity scene was also missing a farm animal.

Where has Donkey gone? Is he on vacation as well?

Donkey: Oh, man! Where do I begin? First there was the time the farmer traded me for some magic beans. I ain't never gotten over that. Then this fool went off and had a party, and they all starting trying to pin a tail on me. Then they all got drunk, and started hitting me with sticks, yelling "Piñata! Piñata!" What the hell is a piñata, anyway?

This news nearly puts poor Ellen over the edge until Chris from the lab offered an explanation.

"Oh, that. The head broke off, so since I couldn't find the head, I threw the rest of it away".

It is with some effort that I restrain myself from any comments regarding the business end of a donkey. And we have not as yet received any vacation photos, just saying.

Still, I was a little surprised at the lack of quality of the entire sorry set anyway, it should have been long retired. No manger, just a bunch of wise men, a donkey and the holy family sitting on a TV table in the waiting room. Not even in a place of honor.

When I actually put up a nativity set in my house when my kids were small, it went on top of the piano (which I also no longer have). It was the highlight of the Christmas decorating routine, with my kids placing the figures in various positions which were rearranged on a daily basis.

You may recall that my mother was scandalized when the baby Jesus was found to occupy a position on top of the manger when I was a kid, however, that was normal for my family. Often, the scene was embellished with one of the many dozens of Fisher-Price doll people, as well as Match Box cars, Transformers, plastic toy soldiers, boats, china animals, and a fence from one of the 50-pack plastic farm animal sets, many of which also joined the fun. The 3 wise men were plenty crowded; it was quite a party in there. My mother just shook her head.

My daughter drew the line at the plastic He-Man and other Masters of the Universe that my son J would add. "That's not 'propriate", she would say.

"He's guarding Jesus", J would explain.

Usually, though, at the end of the day Jesus was on the roof, but He-Man was at his post protecting him, and all was right with the world.

Next year I'm gonna bring in that He-Man in case Jesus returns. Just sayin'.

Throw Out Your Dead (Year, that is)

Working holidays usually sucks, especially on Christmas; goes with the territory. The ones who get paid through a pea-shooter are forced to be away from their families at least half, if not more, of all of the paid holidays. Clip board nurses get every paid holiday off; every bean counter gets every paid holiday. Off. According to a notice on our bulletin board, the electricians, maintenance workers, and general stores people are also having a paid holiday. Forget that on New Year's Eve day, every single primary care office closes up shop and abandons refer their patients to the ER. As I frequently say, the usual sick and stupid become the very sick and the galactically stupid. Today's mixed bag included constipation, ear wax, spotting 4 days ago x 1 in a 24 year old who is 10 minutes pregnant (no insurance), vaginal bleeding in a 24 year old 5 weeks post partum who is not breast feeding, using birth control and who didn't tell me that she took Plan B 5 days ago. Also no insurance. Oh, and a little girl "rushed" in by her grandmother with fever. "101!!". "But I gave her Benadryl, and it was climbing before I left the house!". Trouble was, Grammy didn't know any of the girl's health information including the date of birth. She didn't notice that the kid's respiratory rate was around 50, and wouldn't have known anyway that her o2 sat was only 88% (should be over 95 at least). Fortunately Dad arrived shortly thereafter to add to fill in the blanks; what a brain trust that was I tell ya. Dad had to be told to carry the kid out to the car with her pneumonia; "yeah, Dad, you probably should give her little lungs a break for the next couple of days, maybe keep her quiet and minimize her activity? mmmkay?". Yikes.

So, I'm working New Years Eve and New Years Day (by choice to be honest; Mr. Ednurseasauras and I haven't been out in about 100 years, and I would prefer to actually be in the ER than out with the Crayzees). We had the good luck to work with The Talker, for whom commonsense rules in all things. Love it. We were busy all night though, but our Last Patient of the Night left before 10:30 PM so we did get out on time. Now, shortly before midnight I sit and reflect on the last 12 months (Mr. EdN has gone to bed). I am briefly distracted by New Year's Rockin' Eve, how can they allow that poor Dick Clark to continue? It is just so.....wrong. This has to be his last year, huh? Isn't he about 106 years old?

Anyway, back to my reflections. I rarely make New Years resolutions; it merely sets me up for failure. But I can think about changes without actually committing to them, that must count for something, right?

So, I imagined that I would have completed my BSN and be working on my MSN by now. I have 2 CLEP's and one course left to take. I WILL complete these in 2011, but as for the master's degree, forget it. Everything I have to teach is clinically oriented. I just couldn't imagine myself in a classroom. Therefore, teaching is down the drain.

I need to return to a busier ER before I become old, befuddled, and lose all of my skills completely. I have too much time on my hands, see way too many drug seekers and other pathetic souls, and lack an opportunity to use my clinical skills in a positive way. Besides, there is just way too much physician interference with the nursing part of nursing care at this facility; I understand the patriarchal culture of a religious hospital, but I have ever chafed at this kind of authority. I have become increasingly unhappy and will do my best to change that in the coming year. No promises, see.

I will try to keep my writing more positive, finish my novel (or scrap it and start from scratch), blog more frequently, read more books, and continue to get more exercise. I actually managed to lose weight during the holidays this year (5 pounds is not a big deal, but I see it as not weighing 10 pounds more, not too shabby). I will keep on making healthier eating choices because at my age, every calorie counts.

I continue to do synchronized skating, albeit badly; I expect every week for the coach to tell me I suck too badly to continue since I am probably the worst skater on the team. I cannot get any better at my age though, more's the pity. I do have fun though, most of the time.

I cherish my family; my husband is active and healthy, and we remain best friends after nearly 33 years of marriage. My kids are awesome; gainfully employed and doing well on their own, both college graduates. My four brothers and their families are happy and healthy, busy with their lives as my 10 nieces and nephews grow and thrive. My mom is 78 and has every last one of her marbles (not to mention her original teeth), is remarkably healthy and active, living on her own with a busier social life than mine.

I have wonderful friends, anyone of whom would be instantly by my side if I asked (as I would to them); the kind of friends who would wordlessly and without argument bring the lime along with the requested shovel. I laugh a lot with these girls; some were nursing school friends, some from various jobs, some from skating. Circles within circles within circles, what could be better. We might go weeks/months without hearing from each other some of us, so I will try to keep in touch more.



I could think about being nicer, stop terrorizing SIC, be less critical....nah. That's enough New Year's reflection for one night, besides it's almost 2011. Happy New Year!

12 Days of Family Christmas Sayings

After hearing the "12 Pains of Christmas" and getting a chuckle, here is a list of 12 quotes from my childhood, usually from my Mom. My four younger brothers will remember many of them I'm sure:

12. "Stop shaking those presents!"
11. "Don't you dare go into the attic / basement / bedroom closet / car!"
10. "Will you PLEASE stop putting the baby Jesus on TOP of the manger?!"
9. " Place the tinsel strand by strand, DO NOT just throw a handful!"
8. "Wait 'til your father gets home!"
7. "Please take the cat off the tree".
6. "Santa won't come unless you are asleep"
5. (On Christmas morning at about 5 AM): "NOBODY is to move past the top step and proceed to the living room until Daddy has turned on the (heat, tree lights, movie camera, coffee)"
4. "Unwrap your little brother right this minute; no, you can't give him to the Salvation Army"
3. "No, you can't eat chocolate Santas for breakfast".
2. "Please let the cat/your little brother out of that box right this minute, I don't care if it has air holes!"
1. "So much preparation, and it is over so fast"