Crying Wolf

A guy came in to the ED last week. He also came in three days ago and again last night. I've only been doing this for about 10 months now, but I'm already starting to recognize some of our regular customers. He uses different chief complaints every time only to mask the real reason for his routine visits: he is homeless and has nothing better to do. Last night's chief complaint was back pain. He says it started four days ago which, oddly enough, was before his last visit three days prior in which back pain was not mentioned.

There was nothing special about the circumstances of his pain: no falls, no recent trauma, and his vitals were stable. I rely on vitals often when someone is complaining of pain. If they are in the room saying this is the worst pain of there life with a heart rate of 68, I'm always a little suspicious about their "pain". As was the case with this guy tonight: severe pain with normal vitals. I gave him a shot of dilaudid IM and was going to reevaluate. Twenty minutes later he was asleep.

I went back in to reevaluate about an hour later and told him I was going to be sending him home soon. He said I had done nothing for his pain. I didn't buy it, but feeling generous I gave him a script for some percocets and told him to follow up with the free clinic in the coming days. He reluctantly agreed.

I got a page from one of my friends who was working the day shift today. The patient came back in with bilateral pulmonary embolisms.

Shit.




Sure I feel bad for sending this guy out with blood clots in his lungs. Could I have done more of a work-up on him? Sure. Should I have? I don't think so. Some people will argue a D-dimer maybe, but I've seen too many false negative even in low risk patients for me to put any credibility in that test (my apologies to Wells and his criteria). Also, you can't Ct scan everyone. Especially those who have spend years abusing the system.

So the guy ended up being put on anti-coagulants and he'll be fine. At least until he comes back tomorrow...