Monday, July 31, 2006

I Dulled Her Pain, and My Judgment - New York Times

That afternoon I walked into the room as if into a one-act play. The patient, a dirty blond in a wheelchair who looked to be in her mid-30’s, observed me coolly from behind sunglasses. Her husband, who had moody eyes under the rounded brim of a well-worn baseball cap, looked exactly like the daytime courier and moonlighting guitarist he was. They watched as I located the rolling stool, opened her chart, reviewed her vital signs and looked up. The encounter could now begin.

She told me she was on an antidepressant (Paxil) as well as Toprol XL for an irregular heart rate. Until recently, she had also been on pain medication, the Duragesic fentanyl patch, which releases a low dose of narcotic over three days. Her relationships with doctors, she explained, had been contentious. A psychiatrist had refused to prescribe Paxil and insisted on switching her to another antidepressant. Another had tapered her pain medication against her wishes. And a third had made inappropriate comments and had begun to stalk her.

I was easily charmed by her theatrical humor, colorful anecdotes (told in a deep Kathleen Turner voice), and seeming sincerity. I was touched by her stories of pain and depression. And she openly flattered me with lines like, “You seem different from the other doctors,” “You’re really listening to me,” and “Wow, you really know your medications.”

A MENTOR had cautioned me that addicts are often creative, ruthless, persistent and even seductive to get what they need. But as a new practitioner, I was like a blossoming teenage girl, startled by my sudden power and vulnerable to experienced advances. I was still pretty green socially as well, having just re-entered the dating world after years of being cocooned by the intense work of graduate school.

She suffered, she reported, from fibromyalgia, which rendered her nonfunctional and nearly bedridden, and she had come to the clinic seeking relief from the pain. Per protocol, I offered Ultram, a new drug that mimics an opiate without inducing addiction.

In nurse practitioner school, they teach that pain is the fifth vital sign, as important to the assessment of a patient’s well being as blood pressure, pulse, temperature and respiratory rate. Although they urge us to treat pain as we might treat bronchitis or bad case of diarrhea, the reality can be more complex.

As a rookie, I looked to the clinic’s head doctor for guidance. He was aggressive in treating pain, an anomaly in clinics that accept Medicaid patients. Most anyone who entered our clinic with persuasive medical records and an MRI report was prescribed a narcotic. Word of this traveled quickly and patients flocked to us like gulls to a beach picnic, some truly in pain and others with the voracious appetite of the addict.


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