Posted by: medicblog999 | April 29, 2009

Feeling used and abused!

nelsonI know many of you (especially those in EMS) may find this unbelievable, but after 9 years in the job I have just been taken for a mug by a drug seeking heroin user. I can honestly say that this is the first time I have been aware that my good intentions and caring nature have been taken advantage off, and I feel a little used!

I was called to a patient 18yr old female, who was complaining of pain in her leg, on arrival at scene I was shown upstairs to her room by her mother.

Being the non-judgemental professional that I am, I didn’t look around the house on the way up, I didn’t look at the surroundings they were living in, and I most certainly didn’t look and make judgements on the patient herself (very unkempt, dishevelled, and looking like a stereo-typical heroin addict).

I asked what the problem was and she told me that she had developed pain in her lower left leg the day before, no history of trauma, and the pain had gotten worse overnight then became unbearable today. On examining her leg, it immediately looked like a significant DVT (deep vein thrombosis) with her calf swollen, tender and hot to touch. She looked in significant pain and scored her pain at 8 on a 0 – 10 pain scale.

Going off the provisional diagnosis of a DVT and knowing the pain and discomfort that these can cause, I get to work on alleviating her pain. The oral analgesia we use (paracetamol or brufen) probably wont be sufficient, so then we have to think of either Entonox (gas and air) or Morphine. In this case I opted to go for the morphine as I like to get the patient comfortable for the journey and more importantly have some semblance of pain relief to last whilst they wait to be seen and treated by the doctors and nurses in the A&E department.

I start looking for veins and notice track marks around all of the usual places that I would think of placing a cannula.

M999: “Are you still injecting?”

Pt: “No, been clean for the past three months, havent touched any since then”

Now, maybe naively, I tend to believe what people are telling me. There are sometimes when blatant lies are getting told that I will get the truth from someone in the house or on the scene. There are times when my spider sense is tingling and I know that something is a miss. Not this time though, she seems genuinely in pain, and has all the clinical signs or a raging DVT, so I want to help her,

I try 2 cannulation attempts, without success, then she tells me that she normally used her groin to inject her heroin.

M999: “Are you sure its been three months since you used? Because if you have been injecting into this side of your groin, then that could be what has caused your leg to swell so much? Both I and the hospital will need to know about that”

Pt: “Honest, I haven’t done it for three months”

Again, I choose to trust my patient.

Without IV access, I opt to give her Oromorph instead, which she takes easily and I explain that it should give her some relief, but will take a little while to work.

Shortly afterwards, the crew arrives to take over care of the patient. I give a brief handover and due to the fact that she is still in pain, we decide to carry her to the ambulance on their carry chair and transport her up to the A&E department.

I bid farewell to the crew (after restocking some supplies from their ambulance) and move on to the next job.

Later the same shift, the same crew back me up on another job. Once we have got the patient on the vehicle and just before they drive off, one of the paramedics comes over to the car.

Para: “You know that girl from before, the one with the swollen leg?”

M999: “Yeah?”

Para: ” She kicked off in the back on the way up to A&E, then she kicked off in the department too. She confessed that she only wanted some Morphine, and seemed pretty pleased that you had given her some. She admitted that she is still injecting 4-5 times per day, but she hadn’t had any that day, so called 999 so that she could get some Morphine”

M999: “She said she had been clean for 3 months!”

Para: “I know, but she said that she told you that because if she told you the truth, then you wouldn’t have given her the Morphine”

That’s not entirely true though. If someone is a heroin user, then they develop a condition or have a traumatic event that is causing them significant pain, they will get appropriate analgesia for their condition and pain score. I have never witheld analgesia from someone before who appears genuine and never will.

It has however left a bitter taste in my mouth. I don’t like being taken for a fool, but it wont change my approach. I think I have done pretty well for 9 years of service (or maybe I haven’t, only that this is the first one I am aware off).

I have read many different blog posts from EMS and ER bloggers on the subject of drug seeking patients. I have always maintained that I will always air on the side of giving a drug seeker something, rather than with hold analgesia from someone who is in genuine pain. I obviously make judgements on patients and their apparent pain scores, along with their physiological response to that pain (or lack of it), but I would hate to think that I left a genuine patient in pain just because of one experience of getting taken in and used.

Oh well, onwards and upwards.

P.s. What will be interesting is to see how I assess and treat the same patient again if she calls another time with a different “acute pain”. I really don’t know what I would do. The only thing I can hope for is that I make the right decision next time, whatever that may be!

 

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566242_balloonsP.s this is my 101st post already!! Ive only been going since January 1st. Think I had better slow down a bit or run the risk of either running out of things to say or having you all get fed up with my constant ramblings!!

Thanks for keeping reading though.

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Responses

  1. That is a tough call there, Bro. I think I would have elected to not give her MS, not due to her drug use, but the fact that she had been “clean” for three months. I was taught to avoid giving opiods to former narcotics abusers, as this may precipitate a relapse.

    What my big question is, how the hell did she fake a DVT?

  2. 999,
    It’s them, not you, remember that. She was the one who lied and fooled you. You didn’t fall for it, she made you jump.
    Unfortunately she doesn’t realize her error, which is the next person who needs it will get a minor hesitation from you.

    Personally, based only on your general description, she does not meet my protocols for MS, so O2 and comfort would have been on my list of treatment.

    I’ve had regulars lie to my face thinking they’ll get a different response than last time. The same way my mother in law’s dog always begs at the table, but never gets anything.

    Only 101 posts? You better keep them coming, need to keep in practice should anything get interesting.

  3. Ah that reminds me of one of our regulars with pancreatitis. He was in agony and I felt so sorry for him, so I got him in and asked the nurse to get him some painkillers as soon as she could. It was only when I started on his obs that he started shouting for morphine and was actually very abusive towards me. Don’t you just hate it when you’re wrong about them?

    Congratulations on your 101st post! Keep ’em coming. Considering you’ve only been blogging since January you’ve got over 20,000 hits, you’re doing better than I could ever hope to!

  4. If she is injecting 4-5 times a day, then she is probably getting through close to 1g of Heroin. It’s never 100%, and is usually cut to about 30%. So, she takes the equivalent of 300mg of diamorphine, the same as 600mg of morphine, a day. And you gave her how much? I always tell my junior staff that what we give them is such a tiny percent of their usual that they will get nothing out of it. So, you did exactly the right thing, which is to presume your patient is telling you the truth and is in pain. Consider the 2 options. If she is telling you the truth and you withhold opiate, she is left in pain unnecessarily. If she is lying and you give her opiate, she gets such a tiny proportion of her daily dose that she won’t get any benefit.

  5. Don’t feel bad- I once had a guy with an OBVIOUSLY deformed broken arm. I gave him appropriate morphine and transported him. The hospital gave him more pain killers, and sent him to X-ray. He vanished after the x-rays revealed it was an old break that he had allowed to heal crooked. (and use to his seeking advantge.)

  6. Our protocols allow us to administer up to 10mg MS (in 2mg increments) for cardiac patients and up to 10mg for burns 2nd or 3rd degree greater than 15% BSA and for isolated long bone Fx. (Which for the most part barely takes the edge of it.) Any other pain we would have to call the ER doc for orders but a lot of the time we have short transport times less than 10 mins. I would like to see other forms of pain meds carried on our units but for the most part cost is a consideration. Also i dont think they trust us…LOL

  7. As for someone from the North East (Ouston Near Birtley) i like reading your posts as there ” Closer to home”…I can't believe someone to be that sick to trick you into giving them morphine it's a disgrace. You do a great job i watched Emergency when it was on Tv shame it's not on anymore. Keep up the great work and keep the blog going :).Regards,Ben Stoves

  8. As for someone from the North East (Ouston Near Birtley) i like reading your posts as there ” Closer to home”…I can't believe someone to be that sick to trick you into giving them morphine it's a disgrace. You do a great job i watched Emergency when it was on Tv shame it's not on anymore. Keep up the great work and keep the blog going :).Regards,Ben Stoves


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