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Challenging Patients in the ED: Part 2

Keri Gardner, MD, MPH, FACEP

Many people come to the Emergency Department because they have pain. Some of them are people that have never been to our ED before and have obvious causes of their pain like a broken hip or an acute appendicitis. Some, however, are familiar faces and have dental pain or abdominal pain that has been present for months.

With the recent admonitions of the CDC and FDA to use fewer narcotics, Emergency Physicians no longer have to feel pushed to give narcotics by Joint Commission standards. (For a fascinating read on how pain became “the fifth vital sign” and the genesis of the opioid epidemic in the United States read Dreamland by Sam Quinones). This article’s purpose is not to give a moral commentary, but rather to give you a risk management compass to guide you through this time of transition.

Oligoanalgesia, not giving enough pain medicine, is still a problem as evidenced by the CMS measure that publicly reports the time it takes patients with long bone fractures to receive a pain medicine. This is a fair measure; patients who break an arm or a leg deserve rapid administration of analgesia. To meet the measure, you do not have to order a narcotic—acetaminophen or ibuprofen administration meets the measure. Depending on how your metrics are abstracted, you should be fine if you note that the patient refuses medication or if the medication is ordered but not given because the patient refused.

Occasionally we see someone who has a chronically painful condition or multiple visits for different painful conditions. For these patients, you have two basic obligations: The first seems obvious, but deserves to be stated: evaluate the patient for an emergency medical condition. More than one physician has found herself embroiled in a malpractice case when a patient who had a chronic pain complaint was incompletely worked up and the diagnosis missed on the nth visit. This is critically important for neurologic complaints ranging from headache to back pain, as neurologic evaluations are frequently superficial. Our experience is that malpractice cases for neurologic cases far surpass every other organ system, and many other risk managers have relayed that their experience is the same.

The second obligation also seems obvious but is often not documented at all: address the patient’s pain. This is the key to avoiding an EMTALA violation and a letter from your hospital peer review committee. Again, you do not have to give narcotics; non-narcotic analgesia, heat/cold therapy, and Lidoderm patches are all good alternatives. If the patient is allergic to everything that is not a narcotic, simply state that the patient record causes you to have concerns for narcotic overuse and topical therapy only was offered. Be sure to detail the patient’s follow up plan to address their pain.

Occasionally there is a disruptive patient who is demanding narcotics. If the patient history reveals that the patient visits the ED twice a year with terrible back pain after running out of his narcotics, I am more sympathetic and will often give an ED dose of narcotics but no prescription. If the patient comes every month 4 days before the next Oxycodone refill, then I am unlikely to give any narcotics, and I have even had security remove such a patient. But before you take that step, you must be certain that there is no underlying medical condition and that you have a firm record of narcotic overuse.

One of the great kindnesses that we can offer patients in the ED is relief from their suffering. Narcotic analgesics are a miracle drug for those who are in severe pain, and I hope that this article will help you find clarity when you weigh the risk and benefits of narcotic therapy for your patients.

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