There are so many nuances to being a doctor. You can know the physiology. The Pathology. The typical presentations, the management, the treatment. You learn about how to elicit the historical details from the patient. And how to match these up to patterns of disease, to form a differential diagnosis. Then you narrow down your differentials, with investigations. Eventually you come to your diagnosis and you treat it. Along the way you probably had a conversation about the weather in Bristol, last night’s football results, and where you had your hair cut. You probably had to ask a nurse or another doctor for some help or advice. Somewhere along this process, which could have taken anywhere from 5 minutes to several days, you might have even got it wrong, and had to change your diagnosis or plan. And all the while, you had to be professional, courteous, charming and just generally a super-human.
 
But, what if the patient isn’t being honest? What if you don’t know their true motives? What if they are angry? Humans aren’t rational normal beings. Being a doctor involves trying to balance all these things at the same time, often with several of these scenarios playing out concurrently on a busy ward or in an emergency department.
 
And I’m still learning. And I still get it wrong. Sometimes, with nasty consequences.

A few weeks ago I was working a night shift in the emergency department. It was 5am. A woman arrived with right iliac fossa pain. I started with my usual opening line. An open question (yes, I was listening in communication tutorials). I like open questions because often the patient gives you most of the information you were going to ask about anyway. So it saves a lot of time. And often they’ll tell you something that you otherwise might have forgotten to ask!
But this lady was a bit unusual. She just reeled off a complete textbook presentation of appendicitis. With a completely straight face. Whilst sitting quite comfortably in a chair. It was like I’d asked Siri to dictate the ‘Presentation’ part of the Wikipedia page on Appendicitis.
Me:     “ So tell me what’s been happening”
Patient: (monotone voice, plain face):

“The pain started in the middle and moved to the side”
“Its worse when I move. The bouncing around in the ambulance made it worse”
“The pain came first, then I started vomiting”
“I’ve had a temperature”
“If I press on it, the pain is worse when I let go”

 
I was a little suspicious. Even a patient who answers an open question really well usually isn’t quite so concise. She was looking nervously across at her partner.  She pressed on her own stomach, and made a yelp of pain as she let go.
 
I took her observations. All normal. I examined her stomach. She was quite dramatic. But abdomen was soft. Apparent rebound tenderness again demonstrated. It was all very suspicious but I couldn’t quite put my finger on why she seemed unusual.
I explained that potentially it could fit with appendicitis, took some bloods, and told her we would do an ultrasound in the morning at about 8am when the ultrasonographer arrived. I prescribed her some basic oral analgesia.
I really didn’t believe her, but being the good doctor I am, I did not judge, and did what I thought was appropriate. I told the registrar who was happy that this lady wasn’t acutely peritonitic and we could wait for the morning scan.
 
An hour later the bloods came back. All normal.
 
Then the trouble started. Every two minutes, the boyfriend comes out asking for pain relief. I gave her some more orals. No good. He was quite twitchy and nervous. He talked a lot. He stood very close to me. He wouldn’t let me see any other patients or get on with my job. Then he began demanding morphine. Aha. Maybe this makes sense now. Is she drug seeking?  He said he was a medical student, and that she needed morphine.
This put me in a difficult situation. Yes, in appendicitis, and in any acute abdominal pain really you should give them morphine.  But, the thing was, I didn’t believe her. And he was demanding 80mg IV STAT. Whoa there. That could sedate a Rhino! I refused to give 80mg of IV morphine stat. And besides, she’d had 20mg of oxycodone, which should kick in soon. I managed to hold him off for a few more minutes, but soon he returned. He was angry. Swearing and shouting in my face. I hate confrontation. I will do anything to avoid confrontation. It’s not in my nature. I never argue with people. I usually just give in or walk away. But not here. I couldn’t. He wouldn’t let me leave.
 
Then the truth. Finally the truth comes out. Its taken two hours but we’ve made it. He tells me ‘she’s a junky’ and she’s run out and she can’t get hold of any opiates. And if I could kindly just give her 80mg of morphine IV (only IV will do) then they will be quietly on their way and leave me in peace. I refused. I tell him that its not my job to give out huge doses of opiates enough to kill someone to patients I’ve just met. He tells me she’s sick. And the treatment required is 80mg of morphine.
All of this is happening at the volume of Gordon Ramsey’s Kitchen in an otherwise quiet part of the department. In the middle of the night. Well, not ‘all’ of this. Half of this. His half. My half is conducted at normal conversation volume. Then, a savior. The triage nurse has noticed this situation and has called security. They escort him away. I am a little flustered. I’m just a poor little doctor trying to do my job please leave me alone! The patient is still in her cubicle. Occasional yelps of pain.
I go to speak with her. She is still going along with the appendicitis story. Oh what to do now?! I can’t leave a patient in apparent pain! But I don’t believe her! And her boyfriend has basically just told me she’s making it up. I speak to the registrar. We decided we will wait until morning handover (now only an hour away) and give her some more oxycodone.
 
Half an hour later the boyfriend returns. He has prescriptions of various opiates from the GP as proof that she is an opiate addict and she can tolerate high doses. He gets angry again. Some shouting. Lots of standing very close to me, his face just centimeters from mine. About 4 nurses and two security guards are all called in as back-up. He is removed again.
 
He returns again. This time with the GP on the phone. Apparently the GP is very angry that we haven’t provided any opiates. I don’t converse with the GP on the phone. I kindly decline that offer. This situation has got very out of control. Is the GP really on the phone? If so, what kind of GP is he?! He offers them a prescription of something, and they leave. Not before some more verbal abuse, and threats of lawyers and malpractice law suits and deportation.
 
I feel relieved. Relieved and uneasy. How did I let it get to that stage? What did I do wrong? Did I do anything wrong? I have a gnawing sense of general unease inside.
 
I discussed it with the consultant after he arrived. He is sympathetic, and gives me some tips on how to better deal with these kinds of patients. I only really made one mistake. I didn’t commit either way. We decided that I should have either:

A)    Disregarded my personal feelings of doubt regarding her story and treated her as I would treat a ‘true’ acute abdomen. Admitted her, given her IV fluids and IV analgesia. Called the surgeon, booked an urgent CT/ USS.

OR

B)    Not treated her at all. Put her in touch with the Pain Management team and treated it solely as a pain management issue

 
Option (B) wasn’t really an option at the time of presentation, because I didn’t ‘diagnose’ that she was drug seeking. So really, option A was my only option. Option B is best reserved for situations when you are totally sure that this is the issue. If there is any doubt that there may be something else pathologically going on, you should always follow path A.
 
So, there we have it. I suppose I let my personal judgments and doubts get in the way of the best management. Not terribly so. At the time I felt that my actions were proportional to her presentation. At least initially. But then my reluctance to give any more pain relief (mainly due to the unusual way in which is was demanded) left me in a no-mans-land between the best management of drug seeking, and the best management of appendicitis, and in the end, in my compromise, I didn’t do a very good job of either.
 
Lesson learnt. Reflection reflected. Portfolio: tick.  

Image from Wikipedia used under CC license