# I hate being played...



## mtmedic (Sep 28, 2007)

I just wrapped up a call where I gave narcs only to find out the pt was a seeker on arrival to the ED.  The call rang out as a 24 y/o F with abd pain.  UOA she is lying in bed on her right side sobbing c/o R sided abd pain.  She is pwd with a GCS of 15.  She rates the pain at 10/10 and states it was an acute onset shortly before EMS activation.  She admits she has a possible hx of gallbladder disease but has never recieved a definitive dx nor operative care for this.  She is on depo so no last menstrual cycle and no unusual spotting/bleeding.  She has had ovarian cysts in the past but reports this pain is different in location and type.  VS are all within normal limits and the abd is soft with tenderness noted over Mcburney's point on palpation.  She also has a hx of ulcers but denies any recent complications.  We load her up and start an IV and I give her 50 mikes of fentanyl.  Within 2-3 minutes she reports her pain now at 7/10.  Now she had reported her only allergy as Toradol which usually raises a red flag as this is common among seekers but that is all that caught my attention.  She appears uncomfortable and is still in tears.  I reasses her vs and continue with a secondary assessment.  I also place her on the monitor because she is c/o of cx pain with radiation to the L shoulder.  NSR at 80-90 w/o ectopy, elevation, or depression.  She now reports that she has had pancreatitis before as well with no recent complications.  We get to the ED and wheel her into a room with the doc standing there giving me "the look".  I know something is up so I give report to the RN and go talk to the doc.  He states she is a seeker and pulls up her visits.  18 so far this year with most of them for abd pain.  Red flagged as a potential seeker and very good at it.  They tell her no more narcs for now and she beomes more tearfull.  I don't know what the heck was really going on with her but she sure put on a show.  I just hate being played like this but without having run on her before it is hard to tell what she is all about...  It drives me nuts!!! Now all the paperwork to replace the narcs...:wacko:


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## Grady_emt (Sep 28, 2007)

Narcs for non-specific abdominal pain in the field, must be nice... I think we might get fired for that.


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## mtmedic (Sep 28, 2007)

Grady_emt said:


> Narcs for non-specific abdominal pain in the field, must be nice... I think we might get fired for that.




Thats the way it used to be here.  Now the stance is if there is pain treat it.  I hear what you are saying though...


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## Onceamedic (Sep 28, 2007)

I have found that the more tearful the dramatics, the more likely they are drug seekers.  Real pain is usually people trying hard to NOT cry.. with tension in the face, withdrawal from engaging in conversation, etc.   Also, with the exception of kidney stones, real pain tends to be still.  I know these are generalizations.  The other red flag for me is lots of unspecific history...    undiagnosed and unconfirmed stuff that just keeps coming..
I dont blame you tho...    Its really hard to tell and I would rather err on the side of medicating the pain.


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## Guardian (Sep 28, 2007)

mtmedic said:


> I just wrapped up a call where I gave narcs only to find out the pt was a seeker on arrival to the ED.  The call rang out as a 24 y/o F with abd pain.  UOA she is lying in bed on her right side sobbing c/o R sided abd pain.  She is pwd with a GCS of 15.  She rates the pain at 10/10 and states it was an acute onset shortly before EMS activation.  She admits she has a possible hx of gallbladder disease but has never recieved a definitive dx nor operative care for this.  She is on depo so no last menstrual cycle and no unusual spotting/bleeding.  She has had ovarian cysts in the past but reports this pain is different in location and type.  VS are all within normal limits and the abd is soft with tenderness noted over Mcburney's point on palpation.  She also has a hx of ulcers but denies any recent complications.  We load her up and start an IV and I give her 50 mikes of fentanyl.  Within 2-3 minutes she reports her pain now at 7/10.  Now she had reported her only allergy as Toradol which usually raises a red flag as this is common among seekers but that is all that caught my attention.  She appears uncomfortable and is still in tears.  I reasses her vs and continue with a secondary assessment.  I also place her on the monitor because she is c/o of cx pain with radiation to the L shoulder.  NSR at 80-90 w/o ectopy, elevation, or depression.  She now reports that she has had pancreatitis before as well with no recent complications.  We get to the ED and wheel her into a room with the doc standing there giving me "the look".  I know something is up so I give report to the RN and go talk to the doc.  He states she is a seeker and pulls up her visits.  18 so far this year with most of them for abd pain.  Red flagged as a potential seeker and very good at it.  They tell her no more narcs for now and she beomes more tearfull.  I don't know what the heck was really going on with her but she sure put on a show.  I just hate being played like this but without having run on her before it is hard to tell what she is all about...  It drives me nuts!!! Now all the paperwork to replace the narcs...:wacko:




this has happened to me before and it's really no big deal.  Stuff happens.  Next time, tell the pt you're going to give her more pn meds and then hit her with 2 of narcan.  Take that you drug seeker!


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## KEVD18 (Sep 28, 2007)

we cant medicate for undiagnosed abd pain in ma, but thats mainly because we(generally) only carry morphine which can mask the source of the pain for awhile. since you guys carry fent, i guess its kool for you guys.

so she's a med seeker and you loaded her up. no biggie. my opinion, i rather give 10 med seekers a hit than miss one person who's in real pain because im skeptical...


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## Airwaygoddess (Sep 28, 2007)

The sad part about all of this is when it comes to the point in time when this person will be in true acute pain.   Number 1, she will already be labeled as a drug seeker and her care will be delayed and number 2, it is going to take a whopping dose of what ever narcotic that will be ordered to control her pain,  it would put us in a comma and she will still be saying "It still hurts!"  Gee, ain't folks fun!!  How about that full moon the other night, talk about hell on wheels!  Yikes!!


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## Tincanfireman (Sep 28, 2007)

From a non-P bystander point of view, think about how many times she's probably foxed the ED and any local urgent care clinics, too.  With absolutely no disrespect intended, she's probably better at her "job" than you are, and it's nothing to feel bad about.  Now you know her, and there's one less person that she will be able to fool in the future.  In addition, I'd like to second what Goddess said; God help her if she's ever in real pain, cause there won't be a place left in town that will give her more than a Motrin.


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## mtmedic (Sep 29, 2007)

I do pride myself on pt advocacy and I guess thats why it bothers me when people burn you.  I worked in an urgent care/walk in clinic for two years and you wouldn't believe the number of people who doctor shop.  We "fired" many patients from the clinic due to this.  Many of these people present as good average folks and then you start to see the pattern or the excuses begin to develop.  Then it is time to spend and hour or two calling the other clinics and pharmacies in town to nail it all down.  Then comes the confrontation by the doc and a plethora of reactions from screaming and yelling to ok I got caught and everything in between.  Goddess is right though...  These people eventually are only burning themselves.  It doesn't change my perspective on pt care but it does irritate me.  I guess I needed to vent in the middle of the night...:wacko:


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## Ridryder911 (Sep 29, 2007)

It could had been worse. Last night, one of our regulars out foxed one of the new Doc's that even performed a rectal, abd CT, full lab panel, etc.. all for the usual abd pain (her 18'th time in the past 6 months). 

Since I have worked in the local and even surrounding towns ER as well now EMS, I get to see the "seekers" more than my family. You realize, that you know these patients too well when you can remember their allergies and SSN better than your own . Most of them, will change their tune and complaint after my arrival, which totally confuses the first responding squad. I have even had some immediately refuse as soon after I arrive. 

I have been dooped, as well, but as others have described it happens. As well, who to say its not real? 

FYI: Fentyl is 1000 times stronger than Morphine....

R/r 911


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## KEVD18 (Sep 29, 2007)

Ridryder911 said:


> FYI: Fentyl is 1000 times stronger than Morphine....R/r 911



hey rid, sorry to be paranoid but was that aimed my way? my comment was relating to the fact the fent has a much shorter iv half life tham morphine, not its power.


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## Ridryder911 (Sep 29, 2007)

Nawww... just a reminder that many people are on Fentyl already as Duragesic patches and sometimes many are not aware that it is a really potent  medication. 

Just asking... How many ever heard of "stone chest wall"? If you are administering Fentyl? 

R/r 911


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## mtmedic (Sep 29, 2007)

Ridryder911 said:


> Just asking... How many ever heard of "stone chest wall"? If you are administering Fentyl?
> 
> R/r 911



Please elaborate...


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## MMiz (Sep 29, 2007)

One of my most exciting calls in the field was a faker.  Complained of having a stroke and heart attack at the same time.  The medic got him hooked up and started pushing drugs.  He seemed to go out cold in the ER, so the doc started to intubate.  That's when he magically woke up.  

Pulling his medical hx from the system showed several of these types of visits in the past.

I felt taken advantage of and betrayed.  They should have intubated his ***.


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## mtmedic (Sep 29, 2007)

MMiz said:


> They should have intubated his ***.



We coined a term for this in school calling it "intimate intubation!!!"  I to believe this should be carried out in specific situations...:blink:


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## SwissEMT (Sep 29, 2007)

Ridryder911 said:


> Just asking... How many ever heard of "stone chest wall"? If you are administering Fentyl?
> 
> R/r 911


Yep. Just covered it at school a few weeks ago.


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## Greg (Sep 29, 2007)

KEVD18 said:


> we cant medicate for undiagnosed abd pain in ma, but thats mainly because we(generally) only carry morphine which can mask the source of the pain for awhile. since you guys carry fent, i guess its kool for you guys.
> 
> so she's a med seeker and you loaded her up. no biggie. my opinion, i rather give 10 med seekers a hit than miss one person who's in real pain because im skeptical...



How is fentanyl any different than morphine in relation to abdominal pain?


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## Colorado Medic (Oct 6, 2007)

I feel fentanyl is better for abdomianl pain. Due to it's shorter half life of 30 mins. Think about what we are trying to do in the field. That is to take the edge off. Now Morphine last I think 2-7 hrs. So I feel using fentanyl would be better because it will wear off faster so that the Doc and Dx what's going on..


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## RALS504 (Oct 6, 2007)

The other advantage of Fentanyl is that it does not have an associated histamine release like morphine, so you have less hypotensive risks. By the way our state protocols just were updated and Intermediates can now give Fentanyl and as well as Morphine with online med control.


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## medicp94dao (Oct 7, 2007)

Anyone remember The Boy Who Cried Wolf!??? Same thing just different situation. I would have done the same though. Good Job!!!!!


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## MedikErik (Oct 28, 2007)

We had a FF who was like that... when asked about drug allergies, the answer was always "everything but morphine". You think she'd've learned that not being discrete wasn't getting her anywhere by now...

edit: Frequent Flier, not Fire Fighter... just realized I should probably clarify that.


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## Hubbie (Oct 30, 2007)

Where I work we can't give any pain meds for abd pain, and we carry four different narcs for pain! However I can see your view, when I had PID I would have KILLED for just a little bit of pain releif. I finally got it when I got my dx. 

Hang in there, mistakes have a way of happening. And I'm sure you will not make that same mistake.


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## firetender (Oct 30, 2007)

Isn't it kind of incredible how exquisitely twisted and proficient some human beings can be? We get to see more than most: a blessing and a curse!


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## OreoThief (Oct 30, 2007)

I have got to jump in here....  

One of my very first clinicals I had a "seeker", and didn't know it until I got to the back room with the medic who explained it to me. This PT had lots of "undiagnosed" and "not believed" and "dr mistakes" she complained about while crying hysterically. We were actually called to a seizure/possible allergic reaction to her while she was in her car. 

My medic, however, was smart, knew I was a newbie, and so she had let me work her up/comfort her/talk to her, just like any other patient before she got me alone and told me how DUPED I got! :blush:

In hindsight, I should have known something was up when the medic suddenly told the PT to "KNOCK IT OFF!" in the midst of her tearful act. She deserved an award, really. We live, we learn...... we get duped too.


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## Aileana (Nov 1, 2007)

Grady_emt said:


> Narcs for non-specific abdominal pain in the field, must be nice... I think we might get fired for that.



Here, we're only allowed to give narcs for extremity trauma. Abdo pain is a no-no (in our protocol atleast) because the narcs may mask further pain, indicating gross internal bleeds, or other problems. (that's my understanding of the rationale atleast, please correct me if I'm wrong.)


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## MEDIC213 (Nov 1, 2007)

It's rare that we give narcs in the field. Mainly for extremity trauma and burns. I've given a lot more Morphine on inter-facility transfers than on a scene. It's listed in our protocols for AMI, but it's rare that we get one that's legitimate. Mostly just angina that's knocked out with NTG.


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## Aileana (Nov 1, 2007)

Personally, atleast with my knowledge, I prefer fentanyl to morphine. It's a lot stronger, and has fewer side effects. Also, since the time it lasts is shorter, it doesn't restrict treatment the doctor(s) can give, by creating possible contraindications of a drug still being in their system.  
Recently I encountered a patient that seemed to be resistant to fentanyl...how common is this for fentanyl, morphine, and other narcs? And what would you do if you encountered a patient that was discovered to be resistant to a drug after administration?  (Sorry if I'm hijacking the thread )


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## mtmedic (Nov 1, 2007)

I had a police officer with a broken ankle the other night after an altercation during an arrest and rated his pain at a 9/10 and after 100mcg of fentanyl and 5 mg of valium he was still at a 7/10.  The ED gave 5mg more of valium and then 5 mg of ms.  Some people just have a higher tolerance for narcs.  This guy swears he had never had rx narcs at all ever so I thought this would snow him but it never did.  Is it possible to just have decreased receptors???


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## reaper (Nov 1, 2007)

Both my daughter and I are not affected by MS. When she fx her femur, the Dr's had her up to 18mg of MS, with no relief.

Now, give either of us Demerol and we are out like a light!!


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## DisasterMedTech (Nov 2, 2007)

I dont think I would feel too bad about getting played if she managed 18 visits  to the same ED before they called her on it. Obviously you had no way of knowing that you were getting scammed if you hadnt run on this patient before. Sounds like you did a thorough workup...as a Basic the only thing I would have seen was that usually with a true 10/10 on the UPS there would be V/S that are elevated or outside the acceptable parameters. Ah well. You took care of your patient using your best judgment and thats all any of us can do.

As for the poster who suggested blasting her with narcan, even when its joking, I always hate that kind of comment. I never think joking about aggravated battery on a patient is funny. YMMV.


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## jomedic (Nov 25, 2007)

Why does the myth of not administering pain medication to patients with abdominal pain continue. There have been multiple articles written to dispute it. I work in the ER and have never seen a doctor diagnosis a patient based just on their assessment. They are going to do lab work, UA, x ray's, and probably a CT.  We have protocols in my EMS system and in the ER I work in to administer pain meds (including Morphine) prior to the Doc seeing them. Do a google search and you will find all the ammo you need to change things is your system.


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## natrab (Nov 27, 2007)

I noticed the vitals thing too.  Someone in excruciating pain would at least show something in her vitals.  Maybe not.  Mostly when I find someone crying I make sure to question the pain because that's not the typical adult reaction to severe pain.  Guarding, rapid breathing, grunting...more typical in my book.  Not that I'd discount it.  My other concern with a young female who can't give me a solid medical history is if she's actually taking her birth control and if she could be pregnant (especially the way she keeps throwing out major medical conditions that aren't normal for someone that age).  I've had young female pt's with ruptured ovarian cysts grit their teeth, insist on standing up to get on the gurney and refuse pain meds while someone with a twisted ankle will cry and whine until they get their 6mgs of MS which absolutely snows them before they will let me splint (granted it does make them a bit more manageable).  It's always a hard call with when to use narcs.  I can't tell you what I would have done with this pt without being there, but it could have gone either way.  I'm still pretty new at this so my criteria seems to change on every call where pain management comes into play.

Oh, and welcome to the forums jomedic.  I hear what your saying as I just stopped working in a "mother-may-I?" county and began working in one where we get to use our own training and judgment.  To add to what you said, I've also never had a pt who after receiving pain management could no longer tell me where the pain was.


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## FFPARAMEDIC08 (Dec 3, 2007)

I had a 23 y/o F pt who decided to get high and wreck her car into a telephone pole. I gave her a hefty does of narcan.

When she asked for narcs, I informed her that the only drug she'd be getting was ASPIRIN.


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