Saturday, December 03, 2005

Snap Smack

Once in a while we will see a patient who has been fighting cancer and the pain that goes along with it. They don't come to people like me for that. But maybe they've had a little chest pain and we want to rule them out for an infarct.

If indeed their cardiac enzymes are negative and the echocardiogram and stress test results look okay, I guess you could say that they "outfarcted."

I didn't even walk into the room without dilaudid in hand. Early the first of my two lovely days with these people, we had the doses adjusted upwards. The spouse questioned every pill and injection I gave. I always came in with the meds in their little packages and opened these at bedside, naming and explaining each one.

The spouse always said that I could "just leave them there" and that they would "help" the patient take them, but since I suspected the spouse had the same kind of drug problems that the patient had, I always stayed and assured myself the pills were properly swallowed by the patient. Spousie had their own little stash of various pills and talked sometimes of their own stupifying pain issues and their heroic efforts in dealing with it.

We increased the MS Contin dose from 100mgs twice a day to three times a day. That amount of morphine, alone, would probably adequately sedate a classroom full of hormone-crazed junior highschool students for a day or two.

Let me try to give some idea of how I think morphine is typically dosed, very generally speaking:

If you are having a heart attack, 2 to 4 mgs of morphine (which dilates the cardiac arteries a little, too) usually eases the pain, in conjunction with aspirin and nitroglycerin, which in themselves are not pain medications. If you fall off the roof and get all trauma-like with broken bones and stuff, 10 to 15 mgs of morphine will help you deal with it enough to probably forget about it. I'm just guessing.

Spousie asked me to call the doctor to get that dosage increased every time I went into the room, armed as I was with only 4 mgs of intravenous dilaudid. That dose is likely to translate to maybe about 20 mgs of morphine, I would guess, as dilaudid is about the strongest stuff legally allowed in this country. Maybe Fentanyl is more concentrated. Heroin is not prescribable. I didn't bring it up. They had enough ideas of their own.

Every two hours, on the even hours, within a minute or two of the hour, I knocked on the door with my bundle of Dr. Roberts intravenous elixer. Half a minute late had spousie on the call system yelling at the secretary to get the nurse to their room immediately.

But wait... if you order now, you'll get the Ginsu knives.

Yes, also a complete set of anti-anxietals were prescribed. Klonopin 2 mgs and Xanax 2 mgs each every 8 hours, ("Keith Richards" amounts) with additional doses of Ativan occasionally ordered by the medical doctor, just so I could get spousie to shut up with their constant demands for more drugs for the ailing patient, I guess.

You don't always give medications to treat the patient. Sometimes you give it just to make their family shut up for awhile.

The patient had back and knee pain. Allegedly had a broken foot, too, according to spousie, but they still walked out to the patio to smoke regularly.

The neurosurgeons wanted to immediately excise an abscess (somehow I found time to give the patient intravenous and oral antibiotics, too,) and do a laminectomy, but the patient wanted to wait until they paid their rent. Otherwise they'd be too nervous for the surgery. It was all our fault for making them so nervous, and that made their pain worse, too.

Couldn't we see that?

Since they were from another state, they of course needed to finalize a rental apartment and get a new bank account here, too, so they needed to postpone surgery a few days for all that. Case Management arranged to have a bank clerk come to their room so a a local account could be set up.

The other state's health insurance did not cover their stay with us, naturally. I suspect they had come to our own fair city to avoid legal troubles in the Land of Arnold. They were told that if they continued to refuse the surgery we could arrange to transfer them to a hospital in their home state, a conversation which escalated into yelling and demands for increased pain medications and anti-anxietals, every time.

Spousie even called hospital management a few times, ranting on about how awful we all were for insisting on doing surgery that the patient both needed and wanted, just not today. First they had to have their medication doses increased.

On the one hand we wanted to kick them out for refusing non-elective surgery, but on the other hand, the patient needed it so it wouldn't be nice to do that. The patient and spousie "fired" a series of neurosurgeons, residents, nurses, and managers who tried to persuade them to do something besides sit in the hospital soaking up narcotics like a bog on a foggy day.

I just went in every two hours and delivered the dilaudid and then got the hell out of there, so they loved me. I was their best bud. They said they would write letters about me.

How nice.

Anyways, there are only about two ways you can get to tolerate taking these drugs at these doses: cancer with its often accompanying metastatic pain, and heroin or cocaine addiction.

The patient did not have cancer. Dying cancer patients usually don't need that much morphine, anyways. But then, they don't have this patient's problems.


gail said...

Must be frustrating.

For you, that is.

HypnoKitten said...

I recall reading that dilauded is 10x the strength of morphine, and fentanyl is 100x stronger than morphine. I didn't want to post that unless it was basically true, so I checked it out.


Those people sound like they've got serious issues. I'm glad they thought you were nice to them - don't wait too long for that letter, though.

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