Beginning to take the shape

On Friday, I did something I never thought I'd have the guts to do: I looked a patient in the eye and told her I was not going to treat her pain. It was hard.

She had been admitted the previous day with nausea, vomiting, and epigastric pain. Although she had some marks of a drug seeker--she was rude and demanding, she had a long history of vague chronic pain syndromes, and she had a habit of switching doctors--her initial bloodwork showed an indisputably real and concerning abnormality. "Even crazy people get real disease," said my upper level resident, and we offered her the diagnostic workup she deserved.

At home, this patient had been taking a very large daily dose of narcotics to manage her pain. In the hospital, she was started at twice her equivalent daily dose of an intravenously administered narcotic. As results came back, her disease was beginning to take the shape of the most benign entity on our differential diagnosis. Yet her pain, she said, was worse. By Friday afternoon, she was insisting on big increases in her narcotic doses.

When I asked her where her pain was, she replied that it was in her legs, her back, her arms, and her stomach: everywhere. "But it all starts in my stomach," she said. She had several reasons to have stomach pain, but not the kind of stomach pain relieved by a narcotic. She refused oral medications like antacids and gas reducers, saying they just made her sicker. Besides, she said, she felt like she would throw up anything she swallowed. ("Another reason I can't go home," she said. "I'm not ready to try drinking anything. And don't push me!")

I began to get the distinct feeling I was being played. She had a normal heart rate and blood pressure. When not hurling insults at nurses, she peacefully watched television for hours. But even without the unimpressive physical findings, I would have felt that something was wrong; she was setting up a series of obstacles that together pointed to only one potentially successful intervention: more narcotics.

Knowing what I knew about her condition, and having discussed what I was thinking with my team, I wasn't buying her obstacles. I didn't think I'd be doing her any favors by fueling her addiction, and although I wanted to keep her comfortable, I didn't think narcotics were the best way to do that. I told her this nicely while she threatened me, compared me to doctors she liked more, and called me names. "I'm sorry you feel that way," I said, and with her sobbing at my back that I didn't care about her, I left the room. I documented our conversation, signed out my patients, and went home.

All night, I worried that I had made the wrong decision. I was sure that on Saturday--my day off--her attending physician would read my note, think I was a bad doctor, and give the patient what she wanted. I thought back to criticism I've dealt out to poor judges of drug-seeking behavior, and worried that I'd been a poor judge. But to my great relief this Sunday morning, I saw that while I was away, the team stayed the course. When I talked to the attending, she said I'd done the right thing.

As I get closer to the end of intern year and to being a senior resident, it's moments like these that are especially validating. Very soon, I will be the intermediate point at which the buck stops. I will have to have the uncomfortable conversations and make the uncomfortable decisions, and to know I can do both at least once without leaving a path of death and destruction in my wake is satisfying. At least, until I have to do it again.

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Good grief - what a tough call but well-managed by the sound of it.

It's a very difficult conversation and you managed it with grace by the sound of it - the recipient is rarely going to be open to hear what you (and all of the people who have delivered similar news) are saying.

I had a similar "you did the right thing" moment today. When I came home and told my better half, the A Train said, "You never would have done that 10 months ago." And, you know, he was right! It feels good to be almost not The Intern!

I had almost this exact patient during my entire ER shift last night. Miserable. Classic borderline personality you are describing. Borderline patients, according to my psych attending in med school, are the patients that you dislike immensely on meeting them. You did the right thing. Last night I was very busy, so I ignored her when I could, fed the bear when I had to. Upside was, she told me how gorgeous I was every time I left the room. Crazy. Good to know I still have it with the crazies. Steve

Aw, Shinga. You are extra-validating.

I had a psych attending once, too, who said of borderline patients that you know them from the urge you get within minutes of meeting them to "kill kill kill."

EGM: You went home and A Train was there? Wait, I am SO confused.

Tough crowd.

I'm not Jesus, man. Although this guy kind of was, and when the time comes for me to have that conversation, I'll model everything I do after him.

re: A Train: Well, he comes home in between Gigs. I get to see him occasionally :) As for Bryan's comment: I'm a sucker (S U C K E R) for kids in pain. I'll give 'em anything (except IV Benadryl). Until the age they learn to lie. Like Dr. S said - normal vitals are often the best indication of a person who's not really in pain. And kids are great liers, but even they can't fake their heart rate and BP! And the ol' distract'emwhileyoupressreallyhardontheirabdomenwithyourstethoscope technique works wonders in finding the fakers!

eh, this can be a tough a call, and perhaps you did the right thing. but as someone who recently had doctors repeatedly tell me nothing was wrong, and say my stomach pain was caused by everything from stress, a virus, possibly an ovarian cyst,to Irritable Bowel Syndrome...i'm glad to see that you at least did bloodwork before declaring it was all in her head.

after 3 months of dealing with intense pain and almost having the doctors send me home again, they just happened to do bloodwork at the right time and is it possible that you are even conscious? your levels are incredibly high. you are really brave...blah, blah, blah. some people just don't show physical symptoms, none of the physical exams they gave me showed much, and i just don't exhibit my pain as much as other people.

it turned out i had pancreatitis and my gallbladder was falling apart. i'm doing better now, but just be sure to exhaust every possible test before declaring it is all in someone's head.

I think people differ greatly on this issue. For example, if it were completely unidentifiable as my own, I would have no problem with a picture of my naked ass being posted on the Internet. Others would be absolutely horrified by the prospect.

He brought up the code I mentioned here, and was appalled by the fact that procedures were still being done on a patient long after he'd died because the practitioners needed practice.

Borderline patients, according to my psych attending in med school, are the patients that you dislike immensely on meeting them.