Agraphia Medical Tragicomedy


Burnout On Its Way Down

I had a moment today where I caught a piece of my own personal burnout on its way down.

The longer I do this job, the more I really appreciate the nice, normal person that comes to the ER for an honest complaint.  They are unfortunately, shockingly rare, but they command a premium of my attention because I believe that there is potentially real disease.

In this case it was a 22 year old, well dressed, well groomed female who came in with a chief complaint of "toothache."  Normally this is enough to make every ER doctor groan - all these patients want are pain medications because we can't pull the tooth for them.  It's miserable.  We get used for vicodin scripts and mysteriously the "dentist appointment" they have in "4 days" doesn't materialize.  They come back the next friday and repeat the cycle.

This patient, however, was one of the rare cases of someone who has never been seen in the ER before.  No drugs show up on her list.  Well dressed, in college, very polite during the exam.  She had a massive, new dental cavity that was just killing her.  The rest of her teeth were impeccably taken care of.   It was Saturday night, she had called her dentist Friday afternoon, and had an appointment set for Monday.

This same story gets told verbatim thousands of times in ER's across the country; the weekend visit, the soon-but-not-soon-enough dentist, the tylenol-isn't-touching-the-pain... but the context sets the stage. Does the patient look jittery, like they're withdrawing from their habituated opiate dose?  Am I their last bastion for some Vicodins before they can get in touch with their drug dealer in the morning?  Is it a kindly grandmother with threadbare clothes and no physical signs of disease, looking to supplement her medicare by selling Percocets to her grandkids' friends?  All of these happen, more frequently than you want to believe.

In this situation, there is a degree of mistrust towards patients, because all of the above scenarios are not uncommon.  We physicians want to help people.  We start out in this field with trust and honor and caring, but then it takes one patient, with one believable story, one time, to sucker you in. In this case, my patient. My wholesome college toothache came back the next day as a mixed vicodin/xanax/cocaine/alcohol overdose and I realize I got played.  And not just that I got played, but that I gave her that last drug to her overdose cocktail because I was too trusting and its now my fault she is sick.  The worst part is, the nurses who were more jaded than me raised an eyebrow when I said I thought she was "legitimate."  I fought for her against the rest of the ER staff.  I convinced them she needed pain relief.

So I see something like this, and I resolve that the next time, I won't get played.  Even if they look honest, people with a toothache can grit it out until they see their dentist.   They may not have dental insurance, they may not have the money to scrape together for anything more than dinner at Jack 'n The Box, but until they pay the $500 to get their root canal, they can tough it out with Tylenol.

It's a catch-22, really.  In this field you have to learn to spot the liars, call them out, and then act on your intuition.  My hope is to avoid being jaded but to entertain a healthy skepticism.  On the liberal pain relief side you contribute to the opiate overdoses that are plaguing our nation.  On the other you miss actually caring for those that need it.  There is no good answer.

This is how you wear down a person who cares too much, one plausible story at a time.

Comments (16) Trackbacks (0)
  1. But if you don’t go with the ‘most likely’, as in this case, what DO you go with? Who DOES qualify?

  2. It’s not your fault she ODd. It is HER fault.

  3. This one really bothered me. I’d be willing to let a hundred junkies get their fix if it means a single person in pain got the meds they legitimately needed.

  4. It is so NOT your fault. Don’t get jaded, although it’s easy to.

  5. Dentists aren’t open on Fridays, silly.

    In all seriousness, it’s an awful catch-22. Don’t beat yourself up.

  6. $500 for a root canal? Try $1500+, just two weeks ago, for my cracked tooth. The pain is like nothing I’ve ever experienced. I could not function.

    Fortunately, the emergency endo was able to see me on a weekend, because I was on call myself and couldn’t take any narcotics.

  7. Ouch, been there, felt that same punch in the gut.

  8. as someone who cannot afford a dentist and who has lost teeth because of this, please provide pain relief to people who “mysteriously” don’t make their dental appointment.

    there is no resource for someone employed who can’t afford jaw surgery and an extraction of impacted wisdom teeth. if you’ve been sending people to “the dental college” you might want to call there yourself and find put the limitations of their offered treatment- usually they only drill and fill at most, if that.

    the lack of accessible dental care should scare you much more than someone possibly getting illicit vicodin. if you’ve ever had to grit an abscessed tooth until your paycheck came, and then decide between the dentist and rent, your burnout might not affect you on this issue…

    empathy is tough to keep up, but it’s part of your job to do it.

  9. i wanted to add that i don’t go to the ER for my dental pain anymore, people like you taught me it was pointless. i drink to dull the pain now, and lance my own abscess (if one crops up)

    $500 can mean the difference between being housed or homeless to a lot of people.

  10. Have you ever thought about leaving your rural setting for a more urban, perhaps more educated patient population? I grew up around folks like this so I think I could probably hack it, but I could see how the majority of docs (usually kids from upper-middle class families, suburbs, etc) would be completely freaked out by most of the situations you describe on this blog.

  11. I hate this situation. I tend to be on the more liberal side of the pain scale but I am starting to see dental pain as an easier way to weed out seekers. I figure anyone who is going to take a nerve block has enough pain to get at least a short course of narcotics.

    I’ve never seen the same level of relief as when I did a block on a guy with a horrible looking tooth. Very satisfying.

  12. Save the “you don’t know What It’s like doc” for this one….he’s a lost cause. I can almost see him rolling his eyes. He’s already pigeoned holed every person in pain as drug seekers because of the 20% (10% nationwide ) he claims to see.
    This one is already gone.

  13. I would have given her antibiotics and Percocets under the circumstances you described. It was perfectly reasonable to do so. So then, if she lied – as she did – and then OD’s – as she did……Oh Well. Too bad. I would not have lost one iota of sleep over it. Adult persons are responsible for their own actions and we are not their keepers, nor are we their parents. I sincerely hope the young lady lives, recovers from her follies then goes on to lead a productive life. If not and she dies with the next OD, it is no great loss to the gene pool. One thing I am NOT going to do is change my prescribing patterns for people who truly DO need relief from dental pain because of the stupidity and irresponsibility of this bimbo.

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