Monday, 22 May 2017

Instant dislike

There are some patients who come into my trauma bay whom I can instantly tell I will like, both as a person and as a patient.  These people are generally calm, respectful, and cooperative, saying things like "Please" and "Thank you".  Taking care of patients like this, no matter how severely injured they are, is typically easy, bordering on a pleasure.  However, there are others whom, the instant they hit the door, I can tell I won't like one bit.  The patient might be screaming bloody murder for no apparent reason, or hurling invective repeatedly at anyone and everyone, or he may just have a lousy attitude that instantly puts everyone in a bad mood.  But no matter what I think about them as a human being, I still take care of these people exactly the same as anyone else; I don't have to like you to treat you.  But sometimes, rarely (fortunately), I start to dislike someone before I even meet them.

How is that even possible?

Ask Charlene (not her real name™).  She'll fucking tell you.

The day I came across Charlene was a typical busy Friday, in that nearly everyone was drunk, obnoxious, or both.  Right around the time when my stomach started growling for dinner and reminding me that I hadn't eaten anything all day except one vending machine sandwich which contained something that was almost, but not quite, entirely unlike chicken, the head nurse called me to ask how many patients I would accept.

Ugh.  That can't be a good sign.  My Inner Optimist was strangely silent.

Whenever I get that phone call, my mind instantly jumps into mass casualty mode, and I become fearful that my city has finally become the site of a mass attack.  But then my mind starts wandering into regions it probably doesn't belong.  Perhaps a bus from the Haemophiliacs Convention collided with a razor blade delivery van?  Or did the International Space Station land on a church?

Fortunately it was none of those things, but something much more mundane.  My Inner Optimist started singing quietly (and annoyingly) as I discovered it was simply a multi-car accident with numerous victims, none of whom seemed critically injured (according to the medics on the scene).  However, there were lots of them, and all of them needed evaluation.  Unfortunately our department was already relatively full, so we could only accommodate three more patients.

Well, my Inner Optimist said happily, at least it's only three!

About 15 minutes later the first victim arrived.  He was in his 50s and screaming in pain, but despite the din, I did not dislike him - the bone sticking out of his ankle gave him every right to scream as loudly as he wanted.

Ouch.

"Hey Doc, this is Len (not his real name™)", the medic started.  "His car broke down on the side of the road and he was working under the hood trying to fix it.  His son had stopped his car behind his, and some idiot who overdosed on heroin fell asleep at the wheel and plowed into all of them, along with several other cars.  No Ell Oh See {Loss Of Consciousness}.  He's got an open ankle fracture, also complaining of severe pain in the opposite leg and shoulder.  His wife is also on the way.  And so is the OD."

Len's disposition was pleasant despite his pain, but though I didn't know the overdose guy yet, I already didn't like that fucking guy.  At all.  Because fuck that guy.

Len's wife showed up a couple of minutes later looking far less injured, perhaps only a sprained knee and a few abrasions here and there.

As I was working up Len's wife, Charlene arrived.  I heard Charlene before I saw her, which is never a good sign and made me like her even less (if that was even possible).

"Hi Doc, this is Charlene.  She rear-ended a bunch of cars on the side of the road after she fell asleep at the wheel.  She said she used heroin and alcohol just before getting into the car.  She was unresponsive when we got there, so we gave her some Narcan and she immediately woke up and started screaming."  He glanced at her and scowled.  So did I.  Charlene screamed.  A lot.

"OW!  Oh god, I'm hurting everywhere!  I need some pain medicine!  Oh god please help me!"

Of course you're hurting, I thought.  That's what Narcan does - it blocks the effects of opioids.  In addition to waking up narcotic overdose victims, it also makes them very unhappy because they start hurting everywhere.

Other than an abrasion across her chest and abdomen (at least she had the sense to put on her damned seatbelt), she had no obvious injuries.  However, she continued to scream in pain and demand pain medicine.  I asked the nurse to give her a small dose of ketorolac, a non-steroidal (and non-narcotic) anti-inflammatory analgesic, and I made it very clear to everyone listening, including Charlene, that she was not to get any narcotics.

"Ow!  My teeth hurt!"

I did not like Charlene.  No, unless I found some serious injury, Charlene would not be getting any narcotics from me.  At all.  For anything.

A few hours later after her heroin, alcohol, and Narcan all wore off, Charlene was strolling comfortably around the department while her two victims were still on their gurneys in pain.  In addition to his open ankle fracture, Len had a fractured femur on the opposite leg and a broken arm,  He would need multiple surgeries to repair all the damage.  His wife had a broken vertebra in her lumbar spine, but it was a stable fracture so no surgery would be necessary.  I fumed silently as I got Charlene's discharge paperwork together, all the while gritting my teeth and betting she would ask for narcotics.  She did not disappoint.

"Doctor," she started in a all-too-obviously-sweet voice, "would you please give me some oxycodone?  You know, just to tide me over?"   I looked over slowly and silently, and she must have seen the look of fury in my eyes because she quickly added, "I don't usually do heroin, really!  I just ran out of my pain medicine and my friend offered me some heroin, so I did it just this once.  Please?"

Sure, you just did it this once.  While you were drunk.  I did not like Charlene.  "No," I said as steely as possible.  "You may take ibuprofen or aspirin or acetaminophen or naproxen."

She looked disappointed but not the least bit surprised.  However, she wasn't done.  "How about some Xanax?  Please?  Just a few."

No, I thought.  I will absolutely not provide you with drugs that will sedate you and alter your level of consciousness!  You just severely injured multiple people with your car after you overdosed!  What the fuck kind of idiot do you think I am?

"No, you may not," I said as simply as I could.

Again she looked unsurprised.  I was shocked she hadn't claimed an allergy to all the over-the-counter medicines as most addicts do, and I could easily interpret the "Well, it was worth a shot!" look on her face.

Without skipping a beat, she said without a hint of irony, "Well, it was worth a shot!"  Then she smiled.  SHE SMILED.

No, I did not like Charlene.

Twenty minutes later after Charlene had left, the nurse approached me to tell me that after she gave Charlene her discharge paperwork, she overheard her asking three different emergency physicians to write her prescriptions for oxycodone, hydrocodone, Valium, Xanax, and codeine.  The nurse reported that all of them looked at her like she had two heads and denied her repeated requests.

No, I did not like Charlene one bit, but I guaran-goddamn-tee you that I, or one of my colleagues, will see her again.  And probably soon.

30 comments:

  1. Replies
    1. How come? Shouldn't the police be called for this type of stuff?

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    2. sometimes it becomes too complicated to maintain the chain of evidence.

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    3. Drug tests can be done though to prove that the person was on heroin. I don't get why the police wouldn't be involved.

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    4. we HAVE had DUII arrests, here, when a person has caused a crash while under the influence of something other than alcohol. but other drugs become more complex to run field tests and impairment tests on. and if you are charging a person for reckless driving, and throw on a drug charge, then any irregularity in the drug charge can cause the whole thing to go away.

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    5. How complex can it be to get a vial of blood from someone who's already in the ER for an MVA? If the cops pull you over & you refuse a breathalyzer, they drag you to the closest ER for a blood alcohol test. So how do idiots like Caroline get away without being tested?

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    6. remember that anything the paramedics stick into them invalidates the test.

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  2. you have a typo where she asked how many patients you would except. it looks freudian to me.

    we had a rescue at some time in the past where the victim somehow managed to tumble down a steep bank made of large jagged rocks and be in indescribable pain from it without getting a mark on him.

    since it happened before HIPAA, I found out later that not only did he not get the narcotics he needed for the pain, all his clothes were destroyed in the process of determining he didn't have a mark on him.

    I'd have more sympathy if he hadn't dragged us out of bed to look for his pill seeking ass.

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    1. It wasn't a typo, but rather a dictation (and proofreading) error. Thanks for pointing it out.

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    2. I still think it related to wishing you could except charlene from services.

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  3. It pisses me off that it always seems to be the negligent idiot who caused the crash that's in the least amount of pain.

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  4. it bears mentioning that the goal of the paramedic is to administer enough narcan to get the patient breathing, without administering enough to actually wake them up. it makes it a lot easier to take them to the hospital, that way.

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  5. Lool.. I have gotten one "slumper".. Thankfully no one was hurt when he went on the nod.. The sun is coming out, guess what that means- crazy season..

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    1. and your whole population trying to come visit me for the holiday weekend.

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    2. I just received my M.S. in Library & Information Science this past weekend, and it would appear my new career is inadvertently on the front lines of dealing with the opioid epidemic, as part of our public service mission. As I mentioned in my earlier rant, the library I'm a substitute in now has sharps disposal boxes mounted in the public bathrooms, mainly due to the City's plumbers getting fed up with unclogging toilets that were getting plugged up with needles, and worrying about needle sticks in the process; and according to this article (and the earlier one referenced in it, which was how I first learned about this story), librarians in one Philadelphia neighborhood have learned how to administer Narcan and deal with various kinds of ODs until the paramedics get there, because people shoot up in the bathrooms or hang out/do drug deals on the front lawn. (When the hell did Philly get a reputation for having the purest smack around?) Library school just doesn't adequately prepare one for this...

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    3. Aaaaaand the link didn't come through:

      http://www.philly.com/philly/columnists/mike_newall/HEROIN-NEEDLE-PARK-OVERDOSE-LIBRARIANS-NEWALL.html

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    4. Ken I was thinking about coming to visit your side of state because, three days off!!

      I did deal with one heroin crash recently. I must be tired I almost forgot about it- the dumbass nodded off and slammed in to the back of the tow truck my favorite tow truck driver was driving, it totalled her car.. The best part, she admitted to nodding out while texting, double whammy!! My driver was beyond livid.. He was spotting for another driver that had two on, mine was travelling at 55mph and she was merging on to the freeway he had been on for a good 20 miles and hadn't changed lanes, he didn't slow down or change speeds.. She merged, decided to text and when she looked down she nodded and gunned it doing 65ish in to his ass-end, pushed her front end in, spun her out across three lanes of traffic and she came to a rest facing south in a northbound lane..
      Mommy the insurance agent tried to blame us, daddy the realist told us her whole history..

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    5. well, we know who the enabler in that family is.

      I'll be working the weekend doing siding repair for friends. maybe I'll get monday off and maybe I won't. found out last night when I tried to load up the tools that my last deadbeat renter apparently managed to get away with my siding nailer. it may still be buried in the garage, though, because I never get to do anything more than damage control on cleaning and organizing it.

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  6. OK, I know I'm probably a clueless idiot, but could someone please explain to me just what the appeal of heroin and other narcotics is? I've had major (a bowel resection) and minor (appendectomy, metroplasty) surgeries myself, and was on patient-controlled analgesia for the former (the standard "hit-the-button-and-get-a-dose-of-painkiller-up-to-every-6-minutes" routine), along w/percocet at other times, which, while helping with the pain to a degree, were insufficiently entertaining that I'd want to bother to do them again just for sh*ts and giggles. Is heroin or oxy that much more fun than morphine, which only made me sleepy, sweaty, and stupid? I can sympathize somewhat with people who started out needing narcotics for an actual medical issue, found themselves addicted, and ended up turning to street drugs; I also have other friends with genuine pain issues who don't want narcotics per se, and would be more than happy to find something that works that isn't a narcotic, and are fed up with doctors calling them drug-seekers when they aren't--they just want to stop being in pain long enough to do things like, oh, go to work and be a productive person, and they're REALLY pissed at all the damn junkies who make life harder for them.

    Anyway, I still don't get it--maybe I don't have the right kind of escapist/addictive gene (unless chocolate/sugar counts); I've never been a drinker, don't do drugs, etc. I just don't understand why people start doing narcotics when everyone knows by now how bad they are--after all, it's not as if it's a secret that they'll ruin your life and probably kill you in the end--so why? Why start in the first place? The library I work in has sharps dispensers in the bathrooms because the junkies were flushing needles and clogging the toilets, and the plumbers finally demanded that something be done before one of them ended up w/a needle stick, and my podunk hometown in rural northern New England is practically Heroin Central for that region, and why? I just don't get it...

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    1. I suspect that generations from now, it will be determined that there really is a difference in how their thinking works. I am pretty sure that the "business" experiences I have had with people on drugs could be played on a 24 hour loop, and people would watch them and STILL experiment.
      and addicts are frequently driven to spread the addiction by the cost of maintaining the addiction, but also, while they are under the influence, they believe that they are doing okay, or having fun, or getting away from their problems.

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    2. I had a friend that died of a drug overdose (his family chose not to divulge what it was but he was a recovering heroin addict) and before that his roomate in college died of a heroin overdose which was part of the reason he dropped out. I question the choices that led him to try any of it and why hed relapsed after doing so well for so long. He died last september. I remember as the funeral not only was 9/11 it was the day before my birthday too.

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  7. I do have compassion for Charlene actually...it makes one wonder what horrible life she must have had to start using all those drugs. What she did was deplorable and negligent...but probably no one cared about her and now she is super marginalized by society.

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    1. Not everyone that does drugs has a horrible life. You would be surprised at how many "functioning" people are doing hard drugs.

      Most heroin addicts start out getting opiods for legit pain, then the pills run out and the physician won't prescribe more. They're still in pain, and turn to heroin.

      The only thing you can do with an addict is give them an ultimatum. Stop doing drugs, or don't live in your house. There's not really a good middle ground. You can't have those drugs in your house, or you yourself will be arrested.

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    2. I have some compassion, because she probably has a story - but not enough compassion to enable her destructive behavior. or maybe that should be, enough compassion to NOT enable her destructive behavior.

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    3. Addicts are different. If you ever browse through Erowid, you'll find that people sometimes say, "Drug X made me feel normal for the first time in my life," or about being being better able to deal with other people or something like that. It wasn't just that the drug of choice was enjoyable; it made life better.

      I think much of the opioid epidemic is due to despair, and some of the ODs are casual suicides. They don't have any reason to care about their lives so why be careful?

      This has happened before. Take a look at Hogarth's etching "Gin Lane". During the 18th century landlords were kicking cottagers off their land to be replaced by sheep, in most cases; the phenomenon was called the Enclosures. So floods of uprooted peasants streamed into London, where they drank themselves to death with the new drug craze imported from Europe, namely Holland gin.

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  8. Doc B said:

    "Perhaps a bus from the Haemophiliacs Convention collided with a razor blade delivery van? Or did the International Space Station land on a church?"

    And I busted out laughing. I get it!

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  10. Wow, she causes the wreck and walks out, no arrest, no questions, nothing. In my state, that never would have happened.

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