Master Manipulator

One of the biggest challenges I've found with being an attending is learning to deal with drug-seeking patients. I had plenty of those throughout residency, but I was protected because I didn't have a DEA number and therefore couldn't write prescriptions for narcotics. If they needed pain meds, I just said, "Talk to my attending" and left it to the attending to decide whether or not to write for narcs. Now I am the attending, and I have to deal with these narc seekers directly. Sometimes it goes well, other times not.

For the past two weeks I've had to take care of a patient (who, incidentally, used to work as a nurse practitioner before she was injured in the line of duty in Iraq) who was transferred to our hospital for a thoracotomy for a persistent pleural effusion (no CT surg at the other hospital). I'd heard from the EMS reports that the patient was a big-time drug seeker and that the other hospital was glad to be rid of her. That should have been the first indication that the patient would be difficult. She had the VATS and had two chest tubes placed. Most people are simply placed on a PCA Dilaudid until the pain improved, but not her. In addition to the PCA Dilaudid (which she rarely used), she was also getting 1-2 mg Dilaudid IV q3 prn, and then she "begged" the CT surgery team to give her a basal dose on the PCA since she was waking up in pain. There were many times when I tried to wean her off the PCA (at least the bolus), but she'd always cut me off, saying that it was "unethical" for a patient to be in the hospital in so much pain and that she needed to be comfortable so that she can undergo physical therapy and do what she could to get better.

Finally last Monday her chest tubes were pulled, and I can reinitiated plans to wean her off Dilaudid. The plan was to discharge her on Friday. She didn't really make a fuss when I stopped the bolus and then the PCA (she wasn't pressing the button much by then anyhow), but when I tried to stop the q3 Dilaudid, she argued with me, saying that she "needed" the Dilaudid while she was in the hospital. "When you're ready to let me go, I'll be fine with the pills," she said, "but while I'm here, I want to be as comfortable as I can be." Any attempts I had to try to wean her would lead to 30-45 minute conversations/arguments which I don't have time for, so previously I let her have her own way. Then the patient said she didn't want to go home on Friday b/c she didn't feel "safe" being alone especially with the Fortune-1 race in town, and that she was going to go home on Monday instead because "my insurance will cover my stay." That was the last straw. Finally I took a partner's advice and asked a pain specialist to see her. He prescribed her with a Fentanyl patch, discontinued her IV Dilaudid, and cleared her for discharge on Friday. I was told that right after he left her room, she frantically called her nurse asking to speak with me. Fortunately the nurses protected me and told her I was gone for the day, and I did all her discharge paperwork in hopes that one of my partners (who was covering for me since I took Friday off) would be able to discharge her in my absence.

It didn't work. I'd told my partner to write the discharge order and be done with it, but instead she got sucked into another 45 minute debate as my patient listed all the reasons she couldn't go home on Friday, but then agreed to go home on Saturday. See, that was crafty on her part, because Home Health doesn't go to patient's homes on weekends, and the patient needed Home Health. In agreeing to leave the hospital on Saturday, then saying on Saturday that she can't go home until Monday because that's when home health shows up, she essentially bought herself a weekend stay. I was pretty furious when I called her nurse and got this info; I was hoping not to have to deal with her this coming Monday.

But it looks like I will have to deal with her on Monday, but I'll be damned if I let her manipulate me into staying another day longer. It's pathetic to see how a former medical professional like herself became a drug-seeking manipulator, but I'm through with playing her games. She goes Monday, no matter what.