The slow progress from naive to bitter I expected, but the first patient who burned me I didn't see coming.

26-yo female came in with lower pelvic pain and bleeding that she truthfully attributed to endometritis, and had a long history of work-up for the same. I don't know about the literature, but I've seen a couple patients have significant pain from this condition, where implants of uterine lining in the pelvic cavity cause pain secondary to bleeding; though outside the uterus, they are hormonally responsive. It's not fun, partially because the pain and scarring isn't life threatening, so patients tend to feel their complaint is minimized.

The nurse, Robert, recognized her immediately and warned me that she was a 'frequent flier', and had been to the ED numerous times in the past six months. Her first request for pain medication was for Dilaudid, which I've seen used multiple times in my first ED but not at my second. It's considered overly strong. Too fast acting, too likely to cause respiratory depression. I'm sure the high is killer. I'm also sure that the pain relief is both quick and dramatic.

Most patients who are opiate-naive don't have a favorite yet; they may remember what they had last time, but they often mangle the name or just don't remember. The nurse was suspicious from the beginning that she was exaggerating her complaint to get more substantial pain relief.

The work-up, as expected, was negative for any of the more dangerous causes of bleeding and lower pelvic pain like an ectopic pregnancy or a ruptured ovarian cyst. I went to check on her, and sat down at the bedside. She was shaking, sitting curled up. She said she was frustrated by the pain she was still having and didn't feel like she was under control; we had offered a Percocet script to take with her and a dose of Toradol (similar to ibuprofen) before leaving, but that wasn't sufficient. She said she'd call for a ride if we could help her control her pain.

I walked back to the attending doc, who said he'd be willing to do that after she called for a ride. So I went back and told her and she said she'd call and picked up her phone. I went back and told the doc.

"Did she call?" he said.
"She was going to", I said.
"She can't have anything until she calls and her ride is on the way", he said. Then he looked at me. "Here's what's going to happen. She'll say she's getting a ride, get the shot, and take off. Then she'll drive herself into an abutment with narcotics in her system".

I didn't believe it. I thought she was genuine. Then I went back and talked to her again, and she said, 'Oh, did you want me to call? I wasn't clear'. The context made it suspicious. Maybe she was just gaming me into getting her high. The tricky part was that she did have genuine pathology; no one was arguing that. The argument was that she was way too into a shot of Dilaudid. By the time she finished her plea, called, and then 'couldn't get a ride', she would've had good relief from her oral pain meds.

So that plea, where she was shaking and frustrated and talked about how her pain had gotten worse after the pelvic exam, all calculated? Who knows? Perhaps all genuine but just accentuated. These are the drug seekers I have to get used to, the ones who are really sick. The most egregious are sickle cell patients, classically. They get so zonked out that they'll be close to respiratory arrest and still requesting meds. No one, however, will argue that a sickle cell crisis is faked. You try having your hemoglobin precipitate out in your peripheral arterial system.

The IV component can't be underestimated, either. Benadryl would never be considered a drug of abuse, but in the form of an IV push (given in one dose) it produces a high just because of the route.

I guess I'm a bit more cranky and jaded than before my shift started. I still believe pain must be treated, but, just as with every other complaint, the world is grey--or, in the case of the ED, a bit green.

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