19 YO male pops up on the board. CC is "Back Pain/Weakness". Triage note states that patient has worsening LBP over the past two days associated with difficulty walking. Immediately I think "Oh crap" because in the city that I work in, this complaint is pretty much Epidural Abscess until proven otherwise. I've seen more of these than I ever thought I would.
I go in the room and there is this guy laying on the stretcher with his parents sitting in the room. I start asking about what is going on and why he came in, getting most of the answers from the parents. I have to keep redirecting and saying that I'd like the patient himself to answer the questions. He states it is across his lower back, he has been having this back pain for several months but it was worse over the past couple of days. He follows with ortho and had an MRI recently but did not know the results. Denies saddle anesthesia, bowel dysfunction, urinary retention/incontinence. Kicked parents out of the room, questioned about drug use, and he emphatically denied any, except for one time use of anabolic steroids.
Physical exam: has equal symmetric strength b/l LE, 2/4 reflexes, sensation intact. Back exam - tender to palpation mid lower lumbar spine and tender across the paraspinal muscles as well.
Thinking this is most likely muscular strain/inflammation, go back to the computer. Put in my normal back pain cocktail of IM toradol and IM Valium (I believe in the placebo effect of IM vs PO meds) and start looking through his records here. I hit Jackpot.
YESTERDAY, in my system, his MRI from his orthopaedist. Read as L4/L5 and L5/S1 minimal disc protrusion but nothing else. I do a little happy dance. I mean, how often do you get an MRI less than 24 hours old showing that you do not have to worry about cauda equina or SEA? I think to myself wonderful, get him a little more comfortable, likely DC with NSAIDs and muscle relaxants, follow up with ortho and PT.
Father comes over to my workstation (love that everyone can do that). Asks me "Can you give him something for pain? He is in a lot of pain". I tell him "Yes I ordered medicine, I'll have his nurse get it to him right away".
"Well, what pain medicine did you give him?"
I said "A medicine called Toradol for pain and inflammation, and Valium for muscle spasms".
"Oh. Well toradol never worked for me. Only Dilaudid works for me".
...
My heart sank at that moment.
Now I'll say this after the fact, but I will openly admit that when I saw the parents, I thought drug abusers. Yes I'm a bad person, I prejudge people whom I don't know, I had no compelling evidence of it, they're people too, we're all God's children blah blah blah. I still thought what I thought.
I tell the father that toradol works for a lot of patients, and in particular for his son would target the likely cause of the exacerbation of the pain which is inflammation. So I would like to give him the medicines and then see how he does. He grumbles and goes back into the room, for what I would imagine would be him telling his son that he's going to get a medicine that will never work.
Magically the patient's pain improves. He is able to sit up on the bed and says his back feels looser. IT isn't that busy in the ED on Thanksgiving so I have a prolonged discussion with all of them about the MRI results, about back pain, about how the worst thing he can do is sit in bed, that he needs antiinflammatories, movement, and follow up with ortho and PT. Mom tells me that the patient still has pain and she can't bear to see him with pain. I explain to them that we will not be getting him 100% pain free in the Emergency department, but our job is to make sure there is nothing life threatening, to improve his symptoms so they are tolerable, and to have him follow up with the right people. I tell the nurse that we need to get him up and walk him around the ED and if he can walk, he can go.
Back at my station, prepping discharge instructions, the nurse comes to me and says that Mom says that he is in too much pain and cannot walk. My attending sitting next to me, an older gentleman, very laid back, nonconfrontational, who has been practicing > 25 years, said "Just (admit to) OBS him and be done with it".
I was annoyed. I said "OBS him for what? He hasn't even tried to walk yet. He hasn't failed anything. Lets get him up and walking".
Patient ambulates out of the room, not in marathon shape, but able to get around unassisted. Discharge is clicked.
Mom comes up to me. "He can't go home. He can't walk!". I reply with "What do you mean? I just saw him walking. He looks much better than when he came in." "Yeah his pain is fine now but what happens at home tomorrow when he has to go up stairs?". "That is why he will be getting the oral version of the medications he got today, and first thing tomorrow I want you to call the orthopaedic doctors". She leaves.
Nurse comes back again from her discharge attempt. Informs me the mother states once again the patient cannot walk. When the nurse tried to explain to her that narcotic medications are not the answer and an admission wouldn't actually fix any of the problems causing her son's pain, she replies with "I know all about narcotics. I've been clean for two years"
I go in the room. Get the patient out of bed. Walk the patient around the very large ED Pod. He is walking, unassisted, next to me. But, right in the background, is mom yelling "DONT WALK IF YOURE IN PAIN!!"
The patient, and his parents, ended up leaving the ED, with parting words of "Don't worry baby. If you're still in pain, we'll just go somewhere else."
It was like drug seeking by proxy. The kid never asked for narcotics, or anything else beyond what I told him. But here were the parents, setting him up for failure before he even got his first treatment. Telling him the non -narcotics were not going to work and that for his herniated discs he needed to stay in bed and use dilaudid. It's like watching a car crash in slow motion. We all know what direction this kid is headed in because we see it each and every day. A road involving surgeries and pain medications, disability and ER visits. All predetermined for someone who isn't even old enough to legally drink his pain away.
This is how it all begins
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How it all begins...
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