Wednesday, July 31, 2013

Heartless M.F.

"How could you be so Dr. Evil?"

~ Kanye West in "Heartless"


"That medicine that y'all been giving me don't work. It don't do nothing."

Your face was twisted and angry when you told me that. Your body writhing in the bed rhythmically like some kind of cobra being lured by a snake charmer's music. The more I looked the more you danced.

I'd reviewed your chart carefully. I saw that you were young and that, while you did have some chronic medical conditions, none of them warranted some heavy duty pain regimen.

"The tramadol didn't work?" I asked.

"Tramadol? Man, that pill don't do nothing." You shook your head and curled your lips. Then you exhaled hard through flared nostrils. You wanted to emphasize that last statement.

Your chart laid out a story. Twenty-seven ER visits in less than three months. And each visit to the emergency room read like an identical chapter in the most redundant novel of all time. You came in complaining of pain. None of the non-narcotic options given to you at home were working. On a scale of one to ten? Yours was an eleven. Every single time. Yes. Somehow, some way, there was always someone who'd give you either an IV dose or a handful of the pill you wanted.


The vitals signs on all of those visits were equivocal. No racing heart rate or rapid breathing suggestive of someone in a deep, deep struggle with pain. And yes, I know that pain is a subjective thing but still. I was hoping I could have at least one objective finding in favor of your story which unfortunately kept reading like one I'd read many times before.


That's what you said worked best for you. You also said that nearly every other medication caused you some kind of horrible, life-threatening allergic reaction.


Dilaudid? Wow. You meant business. Even by its generic name--hydromorphone--it was still a big gun. And something I didn't feel good about giving you.

And so, I told you just that.

"I don't feel good about giving you that medication. It's habit forming. But more importantly, I just can't see a good reason to use something so strong based upon what I've seen so far."

"This is ridiculous," you told me. "You look at me and see these braids and these gold fronts and just make up your mind about me. And real talk? Tha's some straight up bullshit. Just 'cause I'm a hooligan don't mean I don't have the right to not be in no pain."

The whole team shifted around nervously when you said that. Eyes found squares of linoleum to study and shoelaces to focus upon. And me? I just stared straight at you and wondered why you'd refer to yourself in that way.

You went on. "It's sad how they don't listen to you just from looking at you. 'Specially when you in real, true pain."

They? Who was this "they?" Was I a part of your "they?" Gosh. I hoped not.

I felt my eyes squinting and coached them back to normal. Scanning the room once more, I felt the uncomfortable sensation in the room rising like yeast dough in a bowl. It was thick like that, too. Like you could grab it and knead it if you wanted to.

That's when I got it. That's when I understood how you managed to get "just a few" oxycodone pills "to hold you over." Just like this. Through these sticky accusations and stealthy jabs. The kind that swell into the kind of anxiety that crumbles even the toughest provider into a pile of narcotic prescriptions. You wore people down.

I knew that because you were doing it to me.

I kept my eyes on you and took a deep breath. I wanted to do right by you. At least this is what I wanted to believe. But your words made it fuzzy. I felt myself second-guessing my position and wondering if I had indeed unfairly sized you up. And so I had a little talk with myself right then and there.

Do you want to do right or do you just want to be right? 
Do you want to help him win or do you just want to win? 

I pondered those questions for a few seconds and then made up my mind.

"I'm not going to give you Dilaudid," I said. "But I want to be as fair as possible so I'm going to double check a few more things in your chart and come back. I'm pretty sure, though, that whatever we do it won't involve hydromorphone."


" I mean Dilaudid."

And in response to that you rolled your eyes hard. Then you said a few more of those things that file people down. Subtle suggestions of discrimination or unethical treatment. I decided not to let you do this to me on this day. No. I went back and looked even closer at your record and your data. I re-examined your body and gleaned nothing that made me change my mind.

I returned to let you know that the plan hadn't changed. No more Dilaudid. At least, not from me.

And you were mad. You called me names. A "heartless motherf--ker" even. And that? That almost wore me down enough to give you what you wanted.


I excused myself before I could.

Here is what I want you to know:

I do care about you. I do. And I hope one day you'll understand that I'm not the "they"-- at least I hope I'm not. I do care. It's just that sometimes choosing the hard right instead of the easy wrong just makes it seem like I don't.

Oh yeah--and to me? You're not a hooligan. To me? You're beautiful. Too beautiful to help you destroy.

Happy Wednesday.

Now playing. . . .


  1. I hope more doctors write in his charts what you will write...that will give the next one strength to do the right thing. This post brought up a lot of things for me ...people do just want to wear you down so they can get what they want. I imagine you were just a little scared time maybe call security when you give him / her the decision...he is really no different than a drug addict on the street...reason to be cautious.

    1. Absolutely. I actually never felt like he would hit or harm me, but I have learned to trust my instincts. You're right about that.

  2. You are many things, dear Doctor, but Heartless M.F. is NOT one of them. As a patient with chronic neurological pain, I'm still trying to grasp how anyone without a viable or tangible diagnosis could ever warrant that level of pain medication, repeatedly. But I also understand how my doctors, before an MRI showed my bone spurs and compressed nerves, were willing to give me all kinds of SSRI's, sleeping pills and moderate pain meds to alleviate my symptoms, because they just didn't know what to do, not until I met my neurosurgeon, who promptly sent me to physical therapy, and for some cervical steroid injections, and thankfully, not drugs.

    It always frightens me to come up against angry, unreasonable and pushy people. I'll do almost anything to get out of an uncomfortable situation, because I am a chronic conflict avoider and people pleaser. So I think what you are is one smart, brave and amazing woman. You stood your ground, you listened to your inner reason, and you did the right thing, despite the discomfort in that room.

    After an episode like that one, I would need a day or two to recover. I look strong on the outside, but I'm a quaking flower on the inside. Hope you were able to let that interaction go, and that writing about it helped you release that negative energy. I also hope your team watched and learned.


    1. I was fortunate to have a really insightful team who taught me tons, too. We had a rich discussion about that interaction. When I returned to his room, I was alone. But I did tell them about what happened.

      Good to see you, Mel. :)

  3. I am wondering if you would go back into his room without the large, perhaps intimidatiding teaching entourage and sit with him awhile and tell him you did not give him what he wanted because you care about him. It seems your very important point might be lost on the very one it could help. Jan

    1. Hi Jan. I want to be sure I'm reading this correctly. I'm not sure if it was clear but when I returned (after going to carefully review his chart) I was alone. That's actually the point when he called me a "heartless m.f." I agree that sometimes the "intimidating entourage" can deter us from doing the things we set out to do. Unfortunately, despite this opportunity to speak freely without an audience, that was what happened. I recognize, though, that words like that aren't about me. He was sick and he was just doing what he had to do to feel better.

      Thanks for your comment and for reading here.I appreciate you.


    2. Kimberly -- thank you for your reply. I hope you don't feel any disrespect in my initial question. I went back and re-read your entry and see that you did go back. I did not know that you went alone and think that must make a difference though not in this case. My curiosity still wants to know if you were able to say those last two lines you wrote to your post to him or if his anger and language and feeling like it was hard not to give in to him made that impossible? It is such a sad situation and so, so hard for doctors like you who treat such patients. Do you understand my question? Who has a chance to get through these people after they get out of the hospital? Jan

    3. No disrespect taken at all. As for the last two lines, honesty, I tried to show him more than anything else. Unfortunately he was too sick with his addiction to receive anything deliberate.

      A lot of times we do get through. It often takes time and patience but sometimes we do. So that keeps me trying.

  4. You did well. As the good doctor Hunter Thompson once wrote you can turn your back on a man, but never turn your back on a drug. I know this is true. It runs through my family like a foul black river.

    1. That same river runs through my family as well. Thank you, friend.

  5. I appreciate your thoughtfulness and understand your position here. It's difficult inch navigating the medical world sometimes as a patient with true, verified, hard to control at times pain, I must say thought that as bad as my pain is its almost never an 11. Anyway, my hat is off to docs who know and understand the difference between me and your patient that day. Sometimes we are all lumped into the drug user category and that is just not fair. It's sad that sometimes (even after my drs encouraging me not to) when I'm inpatient I don't ask for adequate medication bc I'm afraid of being judged by the drs and nurses. In our society pain is so often seen as a weakness. If we ask for relief we aren't as strong or courageous as the one who could do without.
    I apologize for rambling. This is just a topic that hits so close to home. Thanks for being such a thoughtful doctor.

  6. This post really resonated with me for so many reasons. One of them being that I have personally witnessed so many loved ones fall down that dark path.

    On the other hand, as a 29 year old suffering from chronic, agonizing lower back pain - I have felt it from the other side as well. I can't tell you how many doctors dismissed me and never took my pain seriously. Many of them didnt believe me and wrote me off because of my age. Even though I never asked for any narcotics (really all I desperately wanted was anything that worked- preferably NO narcotics) I still felt judged by my doctors and dismissed. I've suffered in horrible pain for 4 years, until I finally found a doctor that believed in my pain and finally received a diagnosis for severe sacroilitis and facet joint disease. Just did my first round of SI injections and have noticed improvement, and hoping my course of treatment will make my condition bearable.

    Thank you for being a compassionate enough doctor to spend the time to review his charts and to not automatically judge him. Because some of us are telling the truth and we aren't trying to con anybody- we sincerely want a life where pain can be tolerable and allow us to regain normalcy in our lives again.

    Again I applaud you for taking that extra time for him- a lot of doctors wouldn't. It is unfortunate that those drug seeking patients really ruin it for those of us who have legitimate issues, even when our goal is to find a way to manage without heavy duty medication.

  7. Great job Doc. You know who you are, don't let anybody tell you different.

    He tried to trick you...the devil is a lie! lol



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