Sunday, July 24, 2005

Bad Medicine?

Any doctor deals with pain management.

And this case deserves more recognition. Briefly, a doctor gave a patient some pain meds and the kid OD'd. He was charged with murder among other things, and eventually convicted of trafficing drugs. 25 years. Since he's 60, this is essentially life.

Here is a NY Times op/ed piece on the same subject: pain

Pain is a difficult subject. When a patient tells me about pain and there is no obvious source, then what am I to do? This is not a trivial problem. It occurs within every clinic. Some of the patients I know quite well. Others, not at all. Who can I trust? Who is out to scam me? Who is in pain? Who is faking?

All doctors have stories of the fakers. In an ER I treated one man for a sickle crisis, one of the most painful things that can occur, so they say. Hydration offered no relief. Then toradol, no relief. Then the heavy hitters came out. Morphine, fentanyl, more morphine. None offered any relief. That's when I stopped and thought for a second.

"None of this has given you ANY relief. As in even 1%?"


"Let me see you walk."

The patient was so doped up that he could barely walk. That's when I told him we'd try more hydration. To that I was called a "fuck'n piece of shit doctor. I need more morphine." To which I told him that if nothing we are doing is working, then we need to start over.

No go. The guy staggered out of the ER. His old records finally showed up.

He didn't have the sickle gene.

I got scammed.

Every doctor has these stories. Some refuse to give any pain control as a result. I have literally met doctors who will not offer morphine except in half mg doses. Are they wrong?

I wasn't sitting on the jury for this case. But doctors can get hosed. All it takes is one case. From our perspective, that's a huge risk.

After all, I'm not the one in pain.


Blogger marybishop said...

I wish there was a contract one could sign which would alleviate any chance that medical professionals (or pharmaceutical companies) would have any lawsuits against them no matter what happened..then let the old doper kill himself or let the young mother with RA get her Vioxx.

If someone od's on pain meds by haording or doubling up prescriptions or buying the drugs on the street, it isn't the doctor's isn't the drug's fault - it's the person's fault.

11:08 AM  
Blogger Ern said...

Just one of hundreds of ethical issues and legal booby traps docs can fall in, huh? How best to treat and cover one's own ass at the same time?

3:12 PM  
Blogger acumamakiki said...

I can see where an MD would be very wary to hand out meds. Yet as Mary Bishop pointed out, the system fails those that really need medicine and have a hard time getting it.

There will always be scammers that are looking for a way to beat the system and when it comes to junkies, they are the some of the biggest scammers, liars and cheats that I've ever met. (I do speak from experience here, unfortunately.)

In today's world, the ethical ramifications for any health-related industry is huge. Not only is malpractice insurance ridiculously expensive, but there are many, many loopholes where the practitioner isn't covered. Reading the fine print is really vital these days. Tack that on to a sue-happy public and suddenly your scope of practice begins to narrow.

I think it's a sad world, that we have to worry so much about covering our asses when we're trying to help.

3:31 AM  
Blogger echrai said...

I think that doctors have one of the toughest jobs. Not because they have to deal with trauma and drama and human suffering every day, but because they get blamed for so much and have to be so concerned about covering their butts. I'm in law school, but it shames me to see what's happening with our health care systems thanks to litigious freaks and bad lawyers who make doctors, even good ones, care more about covering their every move than about curing. It puts doctors in a dreadful situation, it gives attorneys a bad name, and it shifts the blame from the people really at fault to professionals who are just trying to make a difference.

8:51 AM  
Blogger Doc NOS said...

Echrai: and the other problem is when bad doctors don't get drummed out of business. So we have a system that doesn't really discriminate between good and bad doctors, rewarding some, punishing others, with no regard to their overall abilities. Oh well.

I've actually never met a doctor who didn't want to help people. Weird, isn't it? Most professions are full of people who don't give a shit about anyone/anything. I've met plenty of idiot doctors, lazy doctors, and ignorant doctors. But I've never met one who just wanted to make money without helping people. Obiously they do exist - I've posted on a plastic surgeon in NY who fits this category - but he's not in jail.

10:24 AM  
Blogger laurenbove said...

It's not so hard to discriminate when you are a long time patient (20 yrs) of a Rheumy who knows your whole family has RA and see's your Xrays and your disappearing synovial tissue and your fused elbows and wrists, etc.

That person (she looks around and whistles) should get some fucking pain medication. At least so she can make her family's turkey dinner and wrap presents at Christmas time goddamit!

But no.

She get's told that Tylenol (hack, gag, spit) can be taken up to four times per day! Whoooeee, goodie! Thanks. Maybe she could meditate and do some positive thinking to make the pain go away. Yeah, why didn't she think of that earlier?

She takes her glass of tequila and splashes in another three fingers and says to herself: Fuck it.

8:48 AM  
Blogger Doc NOS said...

LB: ha! Yeah, I have to say that I've recommended conservative therapy to people with perhaps not so much obvious evidence of pain generation. To move up to C, you need to go past A and B. Not that that should make you feel better.

But in a known patient, once you have a good relationship, then I've gotten the Rx pad out for the heavy hitters.

None of this is standardized, and it all depends on the clinical judgement - which is appropriate - but frusterating.

10:09 AM  
Blogger marybishop said...

LB - my mom had RA and was lucky enough to have a doc that would give her pain meds without trepidation.

She'd only take them when absolutely necessary, but it certainly increased the quality of her life to get a break from pain once in a while.

5:13 AM  
Blogger laurenbove said...

GUYS! I was referring to a "friend"! Pas moi! ;)

I do believe in expecting the best out of people until they prove me wrong. Sadly, they have proven me wrong way more often than cementing my initial benefit of the doubt.

However, I don't understand why a doc wouldn't give a gal a break every now and again.

I'm glad you, doc, have been so kind as to offer an occasional vacation from the hard edge of the pain of some of your patients. The underlying ache may never go away but you can't believe what people live with and get used to.

I think you should start a movement w/in the profession. Xmas medication vacation for all pain plagued patients! yeah! You'd get rich and patients will love you.

3:27 PM  
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6:33 PM  

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