Ever seen this??

[vamedic4]

To those of you who may work in the ER, have you ever had an attending doc deny treatment to a pain patient who presented with a letter from a neuro/pain specialist?? What happened?

[scrmblr]

I had a pt come in with a letter from her pmd that basically states "this pt is taking so many narcotics that she will require excessive doses of med's to help with her pain-if pt presents in ER please contact me to discuss her care" We called the primary doc and he attempted to help our ER doc decide what to do with her. End result was to refer to pain specialist (AFTER 4mg dilaudid and 25 of phenergine) pt left crying and waving her "letter" saying that she was still in 8/10 pain and needed another shot of dilaudid.

This is a frustrating situation for everyone involved.

[vamedic4, EMT-P]

Thank you for your replies.

Pain contracts from PM specialists here are written so that if the patient truly is in breakthru pain, they can be seen in the ED and cared for by the ED physician. They may contact the pt's physician on call if necessary to discuss treatment.

I agree with scrmblr...this is a frustrating situation. ER docs don't want to be "told" what to do, and would rather do their own thing...patient be damned. The letter is written with directives because the PM doc KNOWS THE PATIENT and knows what works/ what doesn't. Unfortunately for many patients of PM docs, these docs are only open 9-5 M-F, and getting an appointment for a breakthru episode on a timely basis is near impossible. So what do they do? They go to the ER.

It is exceedingly frustrating when a patient who is on chronic narc. therapy presents in BT pain, with a letter, but the ER doc doesn't want to do much of anything about it. Patient presents with entire family at 0300, c/o pain 9/10, nothing helping, nausea/vomiting, b/p 238/133, pulse 154. And the doc doesn't want to follow the letter, instead preferring to give one half the dose of meds recommended on the letter and send them on their way. No calling the patient's physician...nothing.

I just wondered if this were commonplace.

Thank you all again.

vamedic4

[TennNurse]

There is one neurologist in town who gives his migraine patients little business cards with their magic doses of demerol and phenergan hand-written on them, and rare is the day we don't get 7 or 8 of these people. The doses are enormous, 125 of demerol and 50 of phenergan, IV. Our ER docs are not wild about these pts or this doc, and rarely step right up to the plate with that much medication. I've had migraines myself, and know how debilitating they can be. But I've had them at work and given myself a shot of Imitrex and kept going, and it is hard for me to relate to a migraine sufferer who comes to the ER during office hours for unbelievably huge doses of narcotics. I've had cancer pts not request that much medication.

Now a pain management arrangement, where our docs can call and speak with a PM specialist, sounds like a whole nother story. I personally have never had a pt present in this situation. Naturally we do have hundreds of folks limp in c/o chronic pain, and naturally the docs, not knowing these people or being able to verify their history as they rarely have regular docs of any kind, are reluctant to just benevolently grant massive doses of narcotics. A specialist that would be on call for just this sort of thing, so the ER docs could call and get to know the pt's history and needs, would be great. I am inclined to think that if one of our docs talked to a specialist like this, they would most likely be willing to follow that specialist's advice on pain meds.