Agraphia Medical Tragicomedy

16Nov/129

Playing With Fire

He looked pretty comfortable on the stretcher - unconcerned, even.

32 years old, already with bilateral toe amputations from massively uncontrolled diabetes.  He had already had bone infections, a condition known as osteomyelitis, and he had been through a few months worth of IV antibiotics through a PICC line.  Somehow he still managed to be completely noncompliant with every and all medical therapy suggested for him.

"Evening, sir, my name is Dr. Zac.  What brought you in tonight?"

"I think I got the bone infection again, and I want my Dilaudid," he said, casually, "I'm allergic to morphine and Vicodin, all I take is Percocet and Dilaudid now.  Also, I would like Phenergan and Benadryl with it."

I paused.  There are few things that bother me more than a patient requesting Dilaudid, Benadryl, and Phenergan in the very first sentence.  That particular cocktail of drugs is well known among ER physicians for being an incredibly potent high, and the immediate request for that triumvirate somehow belies a concern of illness from the patient. Most patients come in worried about what is causing the pain, and want an answer - the pain control comes second.

In this particular case, though, he was really quite sick.  He had a fever, his heart was racing at about 120 beats per minute, and his foot looked infected - and the infection was spreading up his leg.

Turns out he hadn't been bothering to check his blood sugars - routine for him, upon reviewing his chart - and his blood sugar was also around 350, which is great for hungry, thriving bacteria.

I started an IV on him, drew cultures of his blood, started potent IV antibiotics, and immediately called the admitting physician.  I begrudgingly gave him a small dose of Dilaudid - he had put our other pain medications on his "allergy" list, a common gambit among patients who want their physicians locked in to giving them the stronger medications only.

The nurse came to get me 30 minutes later.  "Room 5 says he's leaving.  He's got stuff to do at home."

I was floored, so I went and had a long talk with him.  I'm a firm believer that fear-based talks don't do anything for people and that positive reinforcement is more useful.

Still, I tried both.

"I can't force you to stay, and I know you don't like checking your sugars.  Listen, I'm not the diabetic, I never have been.  I have no idea how difficult it is to check sugars and dose insulin all day, every day.  What I do know is that from what I'm seeing here, you're probably about to lose your leg, just like you lost both toes.  I don't know, maybe the infection will even spread throughout your body this time and kill you."

"I can help you if you stay. I can get your sugars down, I can get antibiotics in you, we can try to figure out a way to make your diabetes control work for you before you become crippled."

"Tonight is one of those turning points in your life.  Stay, and we have a fighting shot at stopping this.  Go, and you'll always regret not staying, right here, right now, when you lose your leg."

Nothing I said stopped him from going.  He said he'd come back in the morning, but he never showed.  It's not often I feel like I've failed someone, but I feel like I failed him.  Then again, if I couldn't convince him to stay despite my best efforts?  Well.

I guess some people just like to play with fire.

Comments (9) Trackbacks (0)
  1. Dude, he had an actual serious illness. That is a magic Dilaudid ticket. You probably weren’t the first ER he hit up that day, and you obviously weren’t the last. He probably got admitted at some point.

    • My thoughts too. He probably hit every ER in town. Are your hospitals connected by database to show patient admissions and flag multiples? If not, maybe they should be. They are in Australia.

      • No they’re not. Maybe a few hospitals are joined in a few states but it’s definitely possible in WA to go to at least 3 close metro hospitals which all use different computer systems.

        That said, I would love one big patient data based shared between every GP and hospital but the logistics of this.. :(

  2. While there would be issues associated with it, I see no huge problem with legalizing all narcotics and letting people like this just buy their cheap injectable hydromorphone on the internet. This would clear quite a few people out of the ED waiting rooms.

    • While I see your point, these are some seriously addictive and truly dangerous medications. Opiate overdoses have been on the rise in part because of physician overprescription, it’s no small problem. Make them widely available at your local gas store next to ibuprofen and tylenol, and we would have a massive problem.

      Decriminalization, on the other hand, I would support. Then again that’s a bit of a different issue.

  3. Sad, but true, and not uncommon I suspect. Thank you for sharing this story.

  4. Am I a horrible person for also thinking that the likelihood of him having great insurance through his job or a private policy is about zero? And that Medicaid or Medicare is stuck paying for this? And no, I’m not saying that every single Medicaid or Medicare patient is negligent in acting of their own best interests with regard to healthcare, but it does seem that quite a few are.

    Meh. Maybe if he could qualify for his narcotics of choice by being required to have his diabetes managed…he’d have more toes.

  5. You may not have made a difference to this guy’s life, but you will to someone else’s one day too. As doctors, I believe we can have such a persuasive role in a patient’s life, but if the patient has already made up their mind on what they want, then it is difficult to make them change their mind I guess. It’s not just the doctor-patient interaction influencing this (although I think that is the one with the most immediate, grassroots level impact), but also a whole bunch of socio-economical reasons. And maybe he’s even heard the ‘I will get you better, please stay’ speech several times over but feels just that deflated enough to think he needs to go home and enjoy his life because he does not believe anything can make him better. Sense of disillusionment on the medical system and maybe his own life does not necessarily mean you failed him. Did you ask him why he didn’t want to stay and what he had to do when he got home, by the way? I would be curious from the patient’s perspective.

    It would be extremely interesting to know what proportion of MediCare and Medicaid users are actively seeking healthier lifestyles, though.

  6. Sounds like you were treating my brother-in-law. He regularly spikes at over 300 mg/dl and is a drug seeking fiend. I doubt he’ll see 40.


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