Sunday, January 15, 2006

Hobbyists, part one zillion

This is the time of year when, if you work in the typical hospital, the patients who come to you are either very sick or very weird. Sick, because everybody who had a choice about having surgery came in before the end of the year, so as not to have to pay a huge deductible; weird, because the post-Christmas letdown brings in the folks who really, really love their narcotics.

We've got 'em all over the spectrum this time. The one who mixes up whatever liquids are left in the room, complete with pills he's cheeked, to simulate vomit. The one who's complained for so long of pain at 10 on a 1 to 10 scale that she's become addicted to strong painkillers, yet can wander outside, complete with IV pole full of stuff, to smoke during the worst pain crisis. The one who Munched himself into four unnecessary surgeries, years of heavy steroids, and finally, an almost-complete dehiscence of his gut.

I want to put the new Munchers into a room with the experienced Munchers so that they can see what they're getting into.

If you're a Hospital Hobbyist, there is a possibility that you will eventually make yourself sick. Since we deal with people who have diseases that have to be diagnosed by exclusion and that often have wierd and vague symptomatology, we get a fair number of hobbyists. We also get a fair number of folks who started out as hobbyists but have actually become ill. Whether they're injecting Dilaudid and Demerol through their own implanted port at home, or simply going from doctor to doctor to get Vicodin until their livers give out, they will come to us at some point.

Yes, yes, I know: another person cannot rate your pain for you. A nurse has to believe that a patient is really experiencing the pain they say they are. Pain is the fifth vital sign, and should be treated with effective drugs, not shots of saline.

Please. There's a limit.

If you're in pain, you generally don't wait until the nurse is in the room to act like it. (Same with seizures: if you're lying there watching TV while I'm spying on you from outside, only to seize when I walk in the room, I'm going to wonder.) If you're in pain, you generally don't have the energy to steal vials and ampules of goodness from other facilities and stash them in your room when you're with us. If you're in pain, you sure as hell won't have the energy or desire to hang out in the smoking court for four hours, bringing a wide variety of interesting individuals back with you for a little tete a tete.

Eventually, if you complain of severe and unremitting pain long enough, we're going to start using non-narcotic drugs to treat that pain. It could be steroids, which thin your skin and leave you moon-faced and irritable. It could be immunomodulators, which leave you open to lovely infections. It could even be surgery, rather than drugs, as a last-ditch effort to relieve that headache, gut pain, or back pain you've been complaining about for years. You might end up with a shunt here, a colostomy there, or a hunk of metal somewhere else. Is it worth it?

On the other side of the unit is the patient who's really, really fucking sick. She might've had an aneurysm diagnosed shortly before Katrina wiped out the CT scanner; maybe he woke up one morning with CSF pouring from his ear. Could be fulminant meningitis, could be a stroke. If you bite through the tubing leading to your PCA in an attempt to siphon off more painkiller, you take me away from those people that need me.

Some days I go to work with a light heart and a happy smile, knowing that I'll have a chance to actually help somebody feel better, maybe even help them heal a bit. Other days I go to work with a sense of duty, reminding myself of the hourly rate I earn. This week has been full of that second sort of day.

There are still compensations, don't get me wrong. I just worry on my day off about the sick, sick people that I might've missed something on, or might've not taken prime care of, because I was busy rooting under a patient's mattress for the ampules of Demerol stashed there.


Bardiac said...

This is an absolutely GREAT post, very evocative and thought-provoking.

I have a question, though: what's a "muncher"? Is it about eating pills or? (Sorry to be clueless here.)

Jo said...

Oh, sorry. That was actually a reference to the original title of the post, "Munchausen by Ineptitude", which I changed. Muncher equals somebody with Munchausen Syndrome or something along those lines, ie, factitious disorders.

Anonymous said...

Munchers are people who have Munchausen's syndrome. They make up symptoms to get attention, sometimes even making themselves (or by proxy, their children) really ill just for the treatment.

Anyway - I hate to tell you that I think our ER admitted a 'seeker' today. Funny how she knew EXACTLY what drugs, in what doses and combinations, would work for her "kidney pain".

And another one duped our ER doc, only to have her relative tell him on the way out that they had been to every ER in the KC area picking up xanax.

Sometimes they slip past the ER. I'm offering my apologies. And my condolences.

Dawn said...

I just want to point out that just because a patient knows exactly what drugs, in what dose and combinations work for their pain does not automatically make them a seeker. My girlfriend has sickle-cell anemia. She absolutely hates narcotics and has found the correct combination to control her pain and minimize the side effects. However, everytime I take to the ER she is treated like she is a seeker. The worst part is that she is resident at the hospital where we go and she is hospitalized less than once a year (amazing for someone with sickle-cell). It can be very difficult particularly in the ER to distinguish between seekers and those with real pain. I wish that the providers would take a minute and read her chart.
P.S. I love the blog!

Anonymous said...

Then there's the nurse friend of mine who threw out her back one day before leaving on a cruise. She waltzed into her own ER, stated "I'm here to get a big jug of vicodin so I don't miss my trip- I'll call the orthopedist and make an appointment if it still hurts after seven days of not being stressed out." She got a small jug of vicodin, a big jug of ibuprofen, and was much better when she got back. I totally admired her- I'm way to chicken that someone would think ill of me to just ask for the drugs!

Anonymous said...

Jo, sounds like you need some time off. Unfortunately, as nurses, we get burned out, stressed out, used and abused by our patients, co-workers, and employers. I guess shit just slids down hill and we are in the valleys. When I stop looking at drug seekers as comedy acts, then I know it's time for a break . Generally, I take the stand that I don't know what they are feeling, don't care what they are feeling at times, and if they want to do the song and dance well enough to get narcs prescribed, then who am I to say when and if they get their drugs? I've been a nurse 20+ yrs, maybe it's apathy, maybe it's burn out, or maybe I'm chemically therapeutic, but I love a well constructed, detailed, story, just for entertainment value.
Take care, R