When I found J.M., he was wincing in pain on the ER stretcher. Attempting to get moderately comfortable, he shifted his position from side to side to no avail. I introduced myself. He was my age, clean cut and pleasant, resembling someone I might have been friends with under different circumstances. He explained his story. One year ago, he had fallen off a room and injured his lower back. With the help of his Orthopedic Surgeon, he was back to himself after a couple of months. Unfortunately, he recently re-injured his back and the pain was intolerable. I could see the discomfort on his face and tears welled up in his eyes as he told his story. “I can’t walk. I have to call the neighbor to help me to the bathroom. Do you know how embarrassing that is?” My heart broke for him. He was on an impressive regimen of Percocet and Oxycodone at home and it just wasn’t managing his pain. As I set out to examine him, no doubt a painful endeavor, I recalled something an ER Attending had said to me. “ER docs are notoriously bad at managing patient’s pain. So make sure you don’t forget to make a patient comfortable.” So, before I went any further, I said to J.M. “I’ll be right back with some pain medication for you and then we’ll finish the exam.” He looked at me with gratitude. “Thanks.” he said.
Four milligrams of Morphine later, I returned to his room. He was still writhing in pain. “Doctor, the medicine didn’t touch me. When I was in the hospital last time for this, they gave me Toradol and Dilaudid.” I gave him both. After examining him, I called the Orthopedic resident to come down to see him. Clearly this patient’s pain control issues and lack of mobility warranted his admission to the hospital. The Orthopedic resident did not agree. Our conversation went like this:
Ortho: “I know this guy. He’s had back problems forever. He just wants a prescription for pain killers and he will go home”.
Me: “You don’t understand. His pain medications are NOT working. He CANNOT WALK by himself.”
Ortho: “How did he get to the ER then?”
Me: “He told me his Dad carried him in!”
Ortho: “Allright fine. Get some X-Rays and I’ll come and see him”.
Long story short: Ortho came down. Saw that his X-Rays had not changed at all - meaning his back issues had not gotten, that we could see, any worse. Ortho found out he ran out of his Oxycodone last night. Offered to write him a prescription for new pain medications and send him home. The patient agreed. Ortho got him to demonstrate his ability to walk. Ortho also found out that he had been to 4 ERs in the span of 2 weeks asking for pain control. Needless to say, his story got fishier and fishier. And I got more and more embarrassed.
How could I have not seen this? Was it because he looked like someone I could relate to? Was it because he didn’t have a history of drug abuse, like so many of our other patients? As a physician, how do you balance being compassionate and being taken advantage of? How do you avoid enabling prescription drug abuse? Let me know if you have any ideas...