People, perspectives and train wrecks.

The patient

This room is suffocating. Like every bit of air in here has already been used up and somehow I was left with the air scraps. But at least I'm in here. I just hope this doctor will understand.

Motrin doesn't work. Naproxen doesn't work. That last stupid doctor I saw in that ER had the nerve to part his lips to say "acetaminophen." Like I'm so dumb that I don't even realize that's the same thing as Tylenol. I looked that dude straight in his eye and let him know. This, Mr. Asinine Doctor, is not a "tylenol" kind of pain.

Or an acetaminophen one.

I need some shit that will work. Let me sleep and not feel sick. And you know? I just wish I could see just one doctor who listened to that and got that and got up off that high horse long enough to just give me some shit that works. No, not your bullshit tramadol or Ultram or "prescription strength ibuprofen" like you like saying. But something real.

Real, yes. And no, not half-assed real either. Like some tylenol -- "but with codeine in it" or naproxen and "a few pills of Flexeril." That isn't what wipes this pain out. Or stops me from feeling sick and miserable and like I'm going to hurt somebody.

So it all becomes this stupid assed dog and pony show where I have to say the right words and pray to the heavens for a doctor that isn't a damn know it all detective. You know. Those ones that get all high and mighty and decide that you are an addict simply on a mission to get high.

What the eff?

I'm in pain. Real true pain. In my neck. My back. My stomach. All over. And now, on top of that, if I don't get what I need, I feel sick. And like I'm gonna go crazy. For real.

My old doctor was cool. At least at first he was. He used to give me what I needed for this pain. He didn't make me feel bad or like some kind of addict or nothing and he gave me what would work. Like the hydromorphone or the oxycodone. That dude didn't hold back on this pain.

He was the one who gave me this medicine in the first place. I told him about my back and my neck and all that and he said, "Here, take this." And it was some oxycodones and that shit knocked that pain back. And when my body started getting used to them, he was okay with giving me a higher dose and then even giving me something stronger. Because that doctor? That doctor cared about me.

Yeah, he was busy and no, he wasn't too touchy feely or anything but, shit, that was cool with me. He wasn't gun-shy with that ink pen when it came to them pain medicines and I appreciated him for that. Matter of fact, that's what he was known for.

Then one day. . .just like the rest. . . .it turned into something else. That main doctor took that vacation or leave or whatever the hell it was and that partner of his was one of those bullshit doctor detectives. Asking me about past history of IV drugs and drinking liquor and all this shit that, to me, don't have nothing to do with this pain or this sick that I feel when I don't get my medicine.

So next thing I know he talking some shit about "weaning" me off the medicine. No more hydromorphone or oxycodone. Just some bullshit he came up with after speaking with some kind of pharmacist. All with a goal "to help me."

Help me? Help me!?

Man, please. The only way you can help me is to do something about this pain. Period. End of story.

So here I am all over again. Seven different emergency departments in six weeks because I really have no choice. No choice but to go there or to do something stupid in the streets to keep myself from feeling sick and in pain.

No choice but to do what I have to do.

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The intern

Shit.

That man is my patient. That man. I already saw him when I walked through the waiting room writhing all around and rocking back and forth. Eyes all wild and body positioned all funny. I swear he moaned louder when he saw me walking by in this white coat. Can't even lie -- I hoped that he didn't belong to me. But Murphy's law. He did. That man.

Shit.

I still have to go back to the wards. And this? It's just too much. I overheard them triaging him and even that was hard. He just wouldn't stop pushing and explaining and moaning -- and that was just his vital signs being taken. Every so often he would let out this yelping sound that sounded like someone stepping on a sleeping dog's tail. I wasn't sure what to make of that, but he did look miserable.

Just not that miserable. Not yelping-out-loud-at-the-top-of-your-lungs miserable.

I looked over his chart and his chief complaint. And the refills he was requesting? Oxycodone? Dilaudid?

Dilaudid? Seriously?

So I introduced myself and listened to what he had to say. And just like in triage, he had a lot to say. A whole lot. And mostly, it wasn't so bad. He actually seemed to be a pretty nice guy for the most part. But it was weird the way he kept going from very, very miserable to very, very mad to very, very syrupy sweet and cooperative.

Something about it made me tired.

I wonder. Would it be the end of the world to just give him what he's asking for?

The attending

Ugggh. 

That poor intern. He looks so exhausted already. And seriously? I don't blame him. These kinds of interactions suck you bone dry. Dry of any traces of the already limited energy you came to clinic with. It sure does.

Especially when you're an intern.

A lot about this is just like what I've seen many times over. Youngish person comes in. Usually not fitting the more common demographic of our patient population. Why this is? I'm not so sure. What it usually suggests is that a wide net of providers has been cast. At least that's what it seems like.  So yeah, the story is usually predictable--some long and convoluted tale about their journey through chronic pain. A journey over rivers and through woods. Some reference usually to college education and a highly successful career that all folded in like origami after the nidus of this pain began. And somehow, some way that journey always seems to end with words like "oxycodone" or "percocet".

Or in this gentleman's case, "hydromorphone or dilaudid."

I know it's bad to think these things. I know. So I'd never say it out loud. But it is what I'm thinking. And I know it's bad.

Yes, it's bad because I know that every patient is different and that every patient has a story that is uniquely their own. But damn there are some truths or at least semi-truths that always seem to relate to this particular scenario. Always.

Truth #1:  I always feel the same way the moment I walk into the room. Tired. Immediately tired. And like I need to pay attention even closer because the words often feel slippery.

Truth #2:  I always end up scolding myself during the encounter. Telling myself to regroup and individualize this one person in front of me. To acknowledge how this one person is feeling and why they might feel this way. Admonishing myself to let go of the countertransference that I surely have -- and to be "the healer" that I promised I would be with that right hand up in front of Hippocrates and whoever else was listening.

Truth #3:  It usually doesn't end well. Even if, at first, it seems okay. Eventually it isn't. And that sucks because it's like a train wreck that you know is about to happen. At least most train wrecks catch you off guard. These kinds don't.

Wouldn't you act funny, too, if you knew the train you were on was about to crash? But I'm the role model so I can't act how I feel. Or even really say it without some sort of extreme filter.

Because really, I'm aggravated that some irresponsible person somewhere gave a patient this much narcotic. Or better yet, even more aggravated that they gave it to him repeatedly and then kicked him out of their practice because he kept coming back for more.

Duh!

Of course he came back for more. You keep putting heavy cream instead of skim milk on the back porch and what do you think is going to happen? Sigh. I know. I can't say that. Or make analogies like that because that's not cool. I know.

But I'm human, too. Remember?

So yeah. Now I'm standing beside my intern and looking at this man with a twisted snarl on his face sitting in front of me. And yes, I do believe that he is in pain-- I do. Pain of one kind or another. That said, I do not believe that his pain warrants the amount of exaggerated behavior I am seeing.

And that's what always leads to truth #1. That.

Damn. I'm exhausted, too.

Part of me wants to say, "Sir? Let's say all of this pain medicine is appropriate or at least some version of it is. Let's just say that. Can I just give you some advice? Don't do that. Don't do that thing where you behave as if a machete is stuck between your shoulder blades and as if your back is spurting out pulsatile arterial blood. Or make that blood-curdling sound like someone grabbed a pair of pliers and pulled four molars out of your jaw without a drop of anesthetic. Because that's how you're acting--hysterical--and this doesn't call for that. Besides. Real, true hysteria is something I've seen before. And it damn sure wasn't in a clinic talking about chronic pain."

That's what I want to say. But I never do.

Real hysteria? Oh, I've seen it. Once when this little pre-school aged boy got his foot caught under a riding lawn mower when I was a resident. He and his parents were really and truly hysterical. And you know? It was warranted. His foot was all mangled up and he was wide awake. Staring at it. The other time was when this kid was jumping on a bed in his cousin's bedroom. It was a high-rise and he leaped off that bed and crashed into a screened window. Problem was, that screen was loose so he fell. Six stories. So yeah, his family was hysterical, too.

And rightfully so.

Okay, and perhaps I did get a wee bit hysterical when I was having that nine pound two ounce baby, but that was before the epidural. Or the dilaudid.

But this? This is a dude walking around with pain of one kind of another, but not one that calls for all of this. Because real, true hysteria has to be short-lived because it is too exhausting to keep up with.

So yeah. These truths (or rather semi-truths) makes it harder to individualize care. Knowing that the train wreck is coming whether I like it or not. Because it is. It always is.

The interaction

"Hi, sir. I'm the senior doctor in the clinic today and your doctor and I have put our heads together about your health problems and the plan of care for today."

"Thank you, doctors. Thank you so mu--AAAAGGGGGHHHHHHH!!!!" The patient started taking deep, exaggerated breaths. Then he added through panting breaths, "Th-th-thank you."

"Mr. Fields? I have spoken to my attending about you. We went over all of the history together and I talked to her about your physical exam. Thank you for bringing in the records from the other hospitals. Do you have anything more recent than four years ago?"

"Arrrrrrrrgggggghhhhhh. . . .do you mind if I lay down on the examining table? I just can't take this pain. It's so---GRRRRRRRRRRR--I'm sorry. It's awful. Now what were you saying doctor?"

"I was saying that the records you gave us are from emergency visits but they appear to be pretty outdated. I want to be sure we aren't missing anything. I know you've had this pain in your neck and back since 2000. Did you have a primary doctor caring for you?"

"Listen, doctors. I had a doctor but eventually he told me I needed to come here to see you guys. He said he couldn't take care of my pain any more. Well, actually, not him. His partner raised some crazy concerns about me like I was some kind of addict. And like I told you, I have a Master's degree. I am not some kind of addict."

The attending interjected. "We want to be honest with you. Our goal is to have the same conversation with you in this room that we just had outside this room. We are concerned about these medicines and no, we aren't calling you an addict. But we do want you to know that we are concerned that there could be some dependency that you've developed on these medications."

"That's some fancy BULLSHIT WAY of just saying the same thing. I'M NOT AN ADDICT. YOU GOT THAT? " His eyes were wild and agitated. The intern backed up and the attending remained between the door and the patient.

"Sir, I never said that."

"The HELL you didn't. I don't know what you expect me to -- AAAAARRRRRGGGGHHHHH!!!!! I'm in PAIN! Don't you see?" The patient dropped his head into his lap and began crying. Hard, loud and exaggerated. Then it tapered off to a whimper. "You have to help me. . . .please."

The attending reached out and touched his hand. "We want to help you. We do. We want to do right by you. We think at some point you may have been given more than you needed. We want to be responsible in caring for you. Even if that means it's a little uncomfortable at first."

"I am happy to cooperate in whatever way you ask, doctor. I just want to not be in pain. I really do."

"First, I want you to know that we do believe that you have pain. I don't want you to feel like we don't believe you." The attending looked like she was willing herself to be patient with him. She was still holding his hand. The intern sat on a nearby chair watching.

"Thank you for helping me. I knew when I saw you that you wouldn't treat me like I was a junkie or something. I went to ivy league schools and have terminal degrees. I'm not the kind of person who would try to just get narcotics just for the sake of getting narcotics. I wish something other than Dilaudid worked for me. But that's what works."

The attending pressed her lips together instead of instantly responding. After an almost uncomfortable pause, she went on. "Words like 'junkie' and 'addict' are hurtful. I wouldn't call you or any of my patients those words."  The patient let out another hysterical yelp in the interim. She pressed her lips together even harder--this time with a deep inhalation.

"I'm sorry, doctor. I'm just so, so much in . . . aaaagghhh. . .pain." This time his voice was a tiny whisper. Almost cartoon-like in it's quality.

"We need to start a process to treating your pain differently. Something that doesn't involve all of these habit forming medications like hyromorphone and oxycodone.  I reviewed your records and also saw that you had a CT scan and an MRI here at our hospital. Fortunately, they were mostly normal with the exception of a little bit of degenerative changes from aging."

"My disks are herniated, though. You knew that right? One doctor wanted to operate. I couldn't afford it. My nerves are pinched from my disks being herniated." He winced again and began audibly gritting his teeth in pain.

"The images they took of you three months ago were much better. That happens sometimes. This doesn't mean you don't have pain, but it also doesn't sound like you need a surgery, so that's good. I noticed from your urine screen that the medicines aren't in your system. This way we don't have to worry as much about your body withdrawing from not having these medicines. It will take your mind some time to readjust, though."

The patient yanked his hand away and stood up. "So you're NOT giving me anything for pain? NOTHING for this pain?"

"We plan to have you go to our cognitive behavioral program for chronic pain. We also want you to see our mental health specialists, too."

"WHAT MEDICINES THOUGH? WHAT ARE YOU GOING TO GIVE ME?" Now he was up and pacing. His hands were shaky and everyone in that room looked nervous. The attending instinctively cracked the door open.

"The plan is to give you a combination of naproxen and also something for nerve-related pain called gabapentin."

"I've TRIED all that and that DOESN'T WORK!!! So you are just going to let me go home in PAIN? Do you even CARE?"

And that attending started trying to explain the best she could. All while coaching herself to stay calm and like something close to a role model. Something close.

The patient turned and looked at the intern. He saw that fear and confusion in his eyes. "Do YOU even care? I could tell that you did. Follow your OWN heart. Don't let what someone else says make you let someone go home in pain. That's the kind of doctor I KNOW you can be." And somehow in all of this he forgot to wince. Or yelp.

"Sir, I'm sorry you are in pain like this. I truly am. We want to help you," the intern offered. And he meant that. His eyes kept darting back over to his attending.

The patient crumbled to the floor and began crying again. On all fours in a way that startled even that attending who had been at this for several years. "Then help me with my pain. Even if you just give me a few to help me make it to another doctor. Please. . . .just. . .please."  And really and truly he curled up into a fetal position right there in the middle of that floor.

The attending gently closed the door again. "Sir? We will help you. But it will be a process. Today we cannot prescribe you any narcotics. It's important that you hear me say that because I want to be clear on that part. We don't think this is in your best interest. We will be ---"

And just like that the patient cut her off. He quickly got to his feet and snatched all of the papers off of the desk. "All of you doctors are FULL OF SHIT." He glared over at that doe-eyed intern. "And that includes YOU, TOO."

The attending opened the door all the way again and the patient marched past her. "I'm going to somewhere that actually HELPS people."

Both doctors stood by watching. Their eyes were on him and speaking words like "sorry that you feel that way" but this time only with eyes and expressions. Not mouths and sounds.

The patient made a ruckus as he walked away from them. Yelling expletives and saying really unflattering things about the doctors. At the end of the hall way he looked back at that attending and that intern and said this:

"I would have liked it better if you had the guts to just call me a JUNKIE or an ADDICT to my face. Cowards."

And with that he disappeared between the double doors. You could tell those words stung that attending like the unexpected snap of a rubber band.

Interestingly, a senior resident walked by and looked toward her with an amused expression. The kind that comes from being desensitized to such interactions. Unfazed by the sight of a train wreck.

The intern was not amused. He just stood there in that corridor looking like he'd witnessed a mugging. And the attending leaned against a wall wishing that truth #3 wasn't true.

Too bad it was.

So again, this was a train wreck. But one that they pretty much saw coming. And just like all train wrecks it didn't end well.

Sigh.

This? This is what complicates medicine and caring and healing so much. The patterns. We all fall into patterns because it's human nature to respond to what we can predict. You avoid Peachtree Road because you know the traffic is heavy. So you take Juniper instead. And you know that because you've seen that over and over again.

See, things in medicine have patterns -- but with these patterns there are people involved. And people are not as simple as patterns. They aren't statues just frozen in time and fixed into one position. They aren't traffic patterns or cell phone signals. They aren't. Not the patients or the providers.

No, they are not.

So the key, I guess, is to fight against becoming a statue. That's what made me write about this today. I need to flesh out these ideas and the perspectives of those involved. I want to fight myself to make certain that I never get so complacent with the sight of a train wreck that I look at it with amusement. Or freeze like I'm made of stone.

So I fight. We fight.

Fight to see the perspectives. Try not to take Juniper because of the train wrecks we see coming on Peachtree.

But most of all? To still be bothered enough to care when they do.


***
Happy Tuesday.