7 Minute Read
Intern Year Day 105:
“Wait, what room is he in?” “Seriously, I’ll just walk by the room and peek in, no harm done!” “He’s probably not even that cute.” A few of my co-interns were joking with me about a patient I was about to admit from the emergency department. We had heard whispers from the nursing staff downstairs that he was very attractive, and everyone wanted to know if it was true. I laughed them away, grabbed my stethoscope, and trotted downstairs.
“Coming in,” I sang as I pulled back the curtain separating his room from the rest of the emergency department. “Hi! My name is Dr. Oye, and I’m from the internal medicine team that will be admitting you to the hospital.” The patient, Mr. K, was in his mid 30s, peanut-butter skinned, and tall (as evidenced by the fact that his feet hung off the bottom of the hospital bed). The sheet that covered his chest and shoulders fell a bit as he sat up in bed, revealing a white fitted tank and muscular arms covered in tattoos.
“Dr. Oh-yay?” he repeated, as an easy, white smile splayed across his face. Oh. So he IS cute.
“Yep!” I replied. For effect, I added my classic line: “Dr. Oye like ‘Oh, yay! It’s my favorite doctor!’”
He laughed. “You must be Nigerian then. And if I’m right, that’s not your full name.”
“You are correct,” I said as I pulled a facesheet from my pocket (a paper with the pictures and full names of every member of the medical team on it) and handed it to him. “My last name is Oyerinde. You can say my full name if you like, but Oye is just fine. What brings you to the hospital today?”
Mr. K proceeded to tell me that he had been having blood-tinged diarrhea and terrible abdominal pain for weeks, but it was getting worse. Over the last 2-3 days it had become unbearable, so he came to the hospital. “My pain is a 9 out of 10 right now. Like… SEVERE. I can’t even walk without doubling over.”
At this, I paused to assess the situation. He was sitting comfortably in bed, having a full conversation with me. Typically, when a patient was having “9/10” pain, they were holding back tears, laying in fetal position, and whispering as though the sound of their own voice would cause the pain to flare.
“No worries Dr. Oye, I know what the problem is and how to fix it. It’s my inflammatory bowel disease issue. All I need is some of that..uhh… that ‘D’ medicine. You know what I’m talkin’ ‘bout?”
“‘D’ medicine?” I repeated, hesitantly.
“Yeah! It’s d-something… It goes through the IV for pain…”
Oh boy. I rolled my eyes internally. This guy just wants narcotics! “Dilaudid?” I asked, with a pursed-lip-hands-on-hip tone to my voice.
“Oh yeahhhhhhhh,” he said. “That’s the one.”
For those who don’t know, “Dilaudid” (or hydromorphone) is an IV narcotic pain medication from a class of medications called opioids. It is a strong medication with significant addictive potential. You may have heard of the “opioid crisis” , a term used to describe the recent surge in opioid addiction and opioid overdose related deaths in the US. According to the National Institute on Drug Abuse, in the US more than 130 people PER DAY die after overdosing on opioids . Physicians, who often prescribe opiates too freely, are at least partially at fault for this crisis, as around 80% of heroin users first misused prescription opioids they received from doctors . With this data in mind, many doctors now avoid giving these medications when possible, watching for signs of narcotic-seeking behavior like a hawk.
I was reminded of a funny conversation I previously had with one of my uncles, an emergency room doctor with a long, Nigerian surname most Americans found difficult to pronounce. “Tewa, in all my years of practice, I have learned one fool-proof way to determine if a patient is drug-seeking. If a patient reaches out to shake my hand when I come in his/her room, and then pronounces my full last-name correctly, I already know for a fact he/she just wants opiates.” I remember laughing and shaking my head, thinking that was ridiculous. “No, it’s true,” my uncle continued. “Patients that are truly in pain don’t have the energy to properly pronounce my name. But med-seekers? They want to make sure I like them so they get what they want!”
Later that morning, my attending browsed the electronic medical record as I presented Mr. K’s case to him. He was immediately suspicious. “OK, first of all, WE WILL SEE if he’s really that cute,” he started with a smirk. OH MY GOSH, OH MY GOSH, HE HEARD US!!!!! How embarrassing! Please, floor, swallow me now. “Secondly, I can’t find ANY record of his so-called ‘inflammatory bowel disease’ anywhere. No notes from any GI doctors, no colonoscopy records, nothing. He might not actually have anything medical going on, but let’s see him as a team and get some blood work to be sure.”
Inflammatory bowel disease (IBD) is an umbrella term that includes multiple disorders of chronic inflammation in the digestive tract. IBD can be very serious and debilitating, causing severe diarrhea, abdominal pain, and fatigue. It also comes with the risk of life-threatening complications. Typically, patients with a diagnosis of this disease are followed closely by GI doctors, have records of blood tests and imaging showing evidence of inflammation in the colon, and take anti-inflammatory medications to prevent flares.
When the team walked in the patient’s room again to examine him with the attending, he winced and sat up slowly, clutching his abdomen as he moved. “Hey Dr. Oyerinde!” he whispered, pronouncing my full last name correctly. I thought of my uncle’s story and held back a chuckle. AHA! Drug seeking!
“First of all, he is NOT that cute,” the attending joked as we walked back upstairs. “You have questionable taste in men.”
“Oh, you don’t think so?” I responded with a nervous laugh.
Mr. K’s picture became more confusing over the next few days of his hospitalization. He told us that we wouldn’t find any records of his IBD because he had not seen a doctor for it in years, and even then it was out of state. We looked him up in the PDMP (Prescription Drug Monitoring Program), an electronic database that tracks each time a patient filled prescriptions for controlled substances. As we expected, he had gone to multiple doctors requesting different prescriptions for opiates over the months. Every morning if you peeked into his room before announcing yourself, he would be on his phone, talking comfortably. He immediately became sullen and winced in pain once he knew someone was in the room, guarding his abdomen to prevent anyone from examining it. His vital signs remained stable (no fever or changes in blood pressure), and his blood work looked completely normal, without any of the changes one would expect in IBD. His abdominal x-ray showed no evidence of any perforation in his colon (a painful and deadly potential complication of IBD). He did have daily bouts of non-bloody diarrhea, which tested negative for some of the common infectious causes we might expect in the hospital. We also sent some stool tests that might be positive in IBD, but those tests would take time to result. As the days passed, he became less and less pleasant, requesting pain medications more and more frequently.
One morning, Mr. K was sleeping when I went into his room to examine him. Instead of waking him up and announcing myself as I typically would, I decided to press on his abdomen while he slept. He immediately woke up, his face scrunched up in severe pain. Hmm, maybe this guy really IS in as much pain as he says, maybe we’re missing something.
We ordered an abdominal CT scan, which showed mild “fat stranding”, evidence of inflammatory changes around his colon. The amount of inflammation of the CT was still much more mild than would be expected by the patient’s level of pain. Our team decided to go ahead and get a colonoscopy, which would allow us to directly visualize the inside of his colon and determine once and for all if the patient truly had IBD. To the surprise of the medical team, the colonoscopy showed swelling, redness, erosions and ulcers throughout a large portion of Mr. K’s colon, consistent with “ulcerative colitis”, a form of IBD. The colonoscopy looked significantly worse than would be expected by the patient’s blood work or CT findings, and it finally made sense why he was in so much pain.
The main thing I learned from this experience was that pain is CONFUSING. It’s subjective. We don’t fully understand it. There are both physical and psychological components to it. It is affected by cultural norms and societal expectations of how we are supposed to respond to certain stimuli.
The truth? There are patients who truly ARE NOT in pain, and just want to get high with IV pain medications. There are patients who truly ARE in pain, and ALSO want to get high with IV pain medications. And of course, there are patients who truly are in pain that refuse pain medications for fear of addiction. It’s just all so confusing, particularly when the standard blood work and imaging studies don’t correlate with a patient’s pain level.
Often times as an intern, you get called naive when you believe a patient is truly in severe pain and it does not correlate with the examination and other investigative findings. I have definitely been fooled by drug-seeking patients multiple times over the last year. Stories like these, however, remind me that being a doctor involves more than just strict science. It involves the use of your intuition, detective skills, and an overlay of empathy and compassion that empowers you to go the extra mile for a patient, even if they might be trying to fool you (or use you to get high.)
Until next time,
 NIH/National Institute on drug abuse, Opioid Overdose Crisis. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis#seven
 Muhuri PK, Gfroerer JC, Davies MC. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBHSQ Data Rev. August 2013.