Anotha one

“Anotha One”

I still pick up the occasional ER nursing shift to maintain my per-diem status for funzies. Well, fun is probably an overstatement these days, but I genuinely enjoy the people I work with. The emergency department sits in one of the most charming waterfront towns in New Jersey, and after working in several hospitals over the past two decades, I’ve learned that every ER develops its own culture. That culture often reflects the community it serves.

One thing, however, is universal: patients struggling with opioid dependence or seeking opioids can be found in every emergency department.

Early in my career, these encounters frustrated me. Now they mostly make me sad. What kind of life is it when your days revolve around returning to the same emergency department, hoping that this time someone will order morphine, or, as many patients have phrased it over the years, “the one that starts with a D”….

Over the years, I’ve also watched emergency medicine evolve. Providers have become much more thoughtful about opioid prescribing and far more comfortable setting boundaries. Yet consistency matters. If even ONE provider repeatedly reinforces the behavior by prescribing opioids when they are not clinically indicated, patients quickly learn who is most likely to say yes and often return asking for that person by name….

One evening, EMS transported in a young man via stretcher and immediately recognized that I was an unfamiliar face. The EMT as well as several experienced nurses quietly prepared me of what I might be walking into. He was well known to the department. He lived nearby, frequently requested specific providers, was known to name drop a specific hospital leader, and on previous visits had become loud and aggressive enough to require security.

When I introduced myself, he barely opened his eyes. Curled onto his left side, clutching an emesis bag, he described a long and complicated medical history involving persistent abdominal pain and multiple gastrointestinal and vascular evaluations. He explained that specialists had sent him from one office to another without answers. His frustration seemed genuine.

His chart revealed repeated emergency department visits over the preceding weeks. Each visit had included complete work-up with repeat labs and CT scans of the abdomen and pelvis. Again and again, the results were reassuring. No acute surgical process. No obstruction. No perforation. No explanation for the severity of his symptoms.

As I reviewed his imaging history, I couldn’t help but wonder whether anyone had ever talked with him about cumulative radiation exposure. Repeating CT scans can absolutely be necessary, but they are not without consequence. The difficult question for many ER providers isn’t simply whether to order another scan. It is whether we could safely avoid one without overlooking the rare visit when a familiar patient truly has developed a new and significant pathology… you remember the story of the boy who called wolf.

Cases like this remind me just how difficult emergency medicine can be. Deciding not to order another CT scan is often much harder than ordering one. We constantly balance the possibility of missing an evolving, life-threatening condition against the very real harms of repeated imaging, unnecessary radiation exposure, incidental findings, and low-value care.

I was proud of the physician assistant caring for this patient. From the outset, expectations were set respectfully but clearly. Opioids would not be prescribed. His vital signs were stable, labs were reassuring, and he had undergone another CT scan just three days earlier without acute findings. Based on the available clinical evidence, there was no indication to repeat the imaging and again expose this young man of more radiation that will put him at higher and higher risk of developing cancer!

The response was predictable. His volume increased with profanities, threats, and name dropping. Security was called once again not because we had failed to provide care, but because the discharge had become verbally abusive. He was again encouraged to continue following with his specialists and to establish care with pain management, where chronic pain can be evaluated and treated in a setting designed for ongoing management rather than emergency stabilization.

As I reflected on the encounter, one thought lingered: perhaps he returned because of inconsistency. On a previous visit, another provider had prescribed morphine. This visit was different. In healthcare, mixed messages can unintentionally reinforce repeated emergency department utilization, making future encounters even more difficult for everyone involved.

It’s tough. Clinician impressions of “drug-seeking behavior” may lead to bias and may actually represent undertreated pain, opioid withdrawal, or another unmet medical need. Patients DO deserve compassionate, evidence-based assessments…not assumptions..

At the same time, compassion does not mean abandoning clinical judgment. Emergency clinicians should avoid allowing assumptions about drug-seeking behavior to replace thoughtful decision-making. Every patient deserves to have their pain acknowledged and an appropriate evaluation performed.

The challenge is balancing the risk of missing significant pathology when repeated presentations are dismissed with the harms of unnecessary CT imaging and cumulative radiation exposure. Sometimes the hardest decision in emergency medicine isn’t deciding what to do. It’s deciding what not to do…

That decision isn’t always easy. The fear of missing a diagnosis – and the potential liability that follows – can keep providers awake at night. Defensive medicine, or as we call it “CYA” (cover your ass) medicine is real, and ordering “just one more CT” is often the path of least resistance…

But this night, the right decision wasn’t the easy decision.

As he walked out of the emergency department yelling, cursing, and threatening us with yet another name drop, I couldn’t help but think…

Anotha one.