When dealing with the boy who cried wolf, it is important to trust your instincts

January 2008

As physicians, we still must take care of those who get “stoned,” one way or another.

Our office policy has always been to take care of the sick patient first, then later ask questions about insurance, payment, custody, follow-up, etc.

As I entered the examination room, Gary, aged 20, was writhing in apparent abdominal pain, swearing at me to stop his pain. He used some choice scurrilous words to describe his abrupt affliction within the last four hours. Thank goodness no nurses in my office were present during the examination room with me. They take great umbrage at anyone who curses in the office.

Not me. I have been through a ruptured lumbar disc three times in my life, worked with construction crews most school summers, and played street basketball with motley crews all my life. I have heard it all. Still I hesitated to supply Gary with pain medication. Why, you may ask.

One must realize that Gary has been a patient of mine since birth. He has had remarkably recalcitrant attention-deficit/hyperactivity disorder, which was real. Yet he never seemed to respond to stimulants because he was selling his pills on the street, sometimes abusing them himself, and had established a crack cocaine habit over the last four years. This wound him up in jail twice and in rehabilitation once so far, in spite of the fact that he was raised by the nicest mother a boy could ever have. His father died while he was in middle school. He also treated his mother happily, swearing at her and belittling her, even while in the office in my presence over the last several years. I finally advised her to take up the notion of tough love, make him find his own home and finally to cut off all his financial support.

Well, needless to say, he was now nearly homeless.

When I asked him where he ate the day before, in order to consider the possibility of food poisoning, he begged off. I did not relent with the questioning and his evasiveness gave way to his exasperation, with cries of “give me some #@@%$$##$ pain medicine.”

Trouble is, Gary did not know what he ate yesterday, because he was so stoned on seven or eight hits of crack throughout the day — a detail he finally divulged.

A ploy?

Four years ago, I had basically cut Gary off from his stimulants and any other abusable prescription drugs, although that never stopped him from coming in and requesting them. He repeatedly complained that he needed his stimulants to help his ADHD and to keep him out of jail. He would often say, “atomoxetine never works, Doctor Block.” Bear in mind that atomoxetine has no abuse potential and has no street value. Or sometimes he complained that he had “really bad headaches,” and insisted on Vicodan, since, he would say, “ibuprofen works like water for pain.”

So you can understand my reluctance to treat this young man’s pain with narcotics. Was this another ploy?

Yet something was nagging at my cerebrum.

Look at the patient

Gary had no recent history of fever, nausea, vomiting, diarrhea or respiratory illness. He had basically been healthy physically all of his life. My examination of him and his abdomen revealed that he really seemed to have some significant left mid-abdominal pain. No guarding, no rebound tenderness. Nothing surgically amenable could possibly be there, I thought. On the other hand, the young man craved his drugs. But his persistent barrage of epithets and apparent writhing told me to look at the patient first.

Much to my office nurse’s chagrin, I asked her to obtain for my patient a dose of meperidine from the family practice group nest door, until I could get him to the hospital for further evaluation. He really had no way of getting there because his license was revoked, his mother was estranged, and his girlfriend was unavailable. I could clearly see it was going to take awhile to get him over to the nearby hospital. I would need to call his mother and beg her to bail him out with transportation. This would be a hard pressed favor, I knew.

He was well groomed, clean shaven, articulate and appeared to me to be in some apparent distress. His complete blood count was normal, he could not urinate and he was afebrile. I had nothing else to rely on, except my gut intuition, that even miscreant or malingering folks get real diseases sometimes.

Thank goodness for mother’s instinct, because his mother came through, much to her disdain, and transported him to the hospital.

Once he was in the hospital, I placed orders for repeat CBC, abdominal X-ray, and computed tomography scan of his abdomen, along with an order for morphine and intravenous fluids.

Somehow, this ruffled the feathers of the nursing staff. First I received a call from the charge nurse who asked “what do you think you are doing. He admits to crack use, and has been using and dealing with drugs for years. Everyone in the community knows that.”

Then I received a telephone call 10 minutes later from the hospital social worker who told me they found a rehabilitation center for him in Lexington.

I calmly reassured both parties that I really needed to evaluate him for his abdominal pain. I thought the pain was significant. I appreciated their concerns about giving a drug addict potent narcotics.

How doctors think

Jerome Groupman, MD, recently published a book titled “How Doctors Think,” in which he states that physicians tend to use shortcuts and heuristic approaches to streamline the daily flow of patient encounters.

Groupman also advises doctors to be careful when using these approaches, and to always consider listening carefully to the patient or parents as we assimilate our deductions as to the diagnosis. He details in his book numerous examples where physicians will jump to conclusions based on prior history, past medical records, or where we tend to judge a book by its cover, before even perusing the pages, by ignoring pertinent findings which contradict our diagnosis. He also emphasizes the importance of occasionally using “gut instinct,” or a gestalt, and to avoid the oversimplification of a patient’s problem, especially when the data presented does not fit the diagnosis we may be pursuing.

In the book, Groupman alleges that the quickest way to a bad outcome is to apply Ockham’s principle to anything other than the simplest of cases. To refresh your memory, Ockham’s razor is the theorem that the simplest, most direct diagnosis will always be the correct diagnosis.

Crying wolf?

Groupman further elaborates that “flesh and blood decision making” often relies on “pattern recognition,” which is often visual, and reflects an “immediacy of perception.” Such was the case here. This patient was a known drug addict, complaining of abdominal pain and seeking narcotics. Was I to be one of the physicians he describes, who often put patients in a narrow category and ignore information that contradicts a fixed notion or presumptive diagnosis?

In this case, possible real abdominal pain. Could Gary be the boy who cried “wolf” too many times, and who has now placed himself in the precarious position of lacking any credibility?

I guess it came down to two things:

1. Did I trust my own physical examination?

The answer is yes. After 28 years, I have very good skills. But I occasionally get fooled, of course.

2. Did I believe in redemption, forgiveness and human frailty?

Often times at my dinner table, my four daughters, as they grew up, would heatedly cast aspersions upon my judgment when they found out I was the physician for their school’s local drug dealer, promiscuous teen, pregnant 14-year-old teenager, etc. “Why can’t you make them stop?” they would ask. My daughters were raised in a quite moralistic background, and were taught to avoid these types of people in their personal lives. Now whether they listened or not, that seemed to be the case for them.

Subsequently, I would have to defend my actions to them. “Somebody has to take care of them, dear. They are people too. They get sick or need help just like any of us, good or bad. That is what I am trained to do as a pediatrician.”

Remember, in our practice, with a sick child, we do not question whether they can pay or not, whether they are going to be ethical or not, whether they are going to take their medicine or not. People make mistakes and nobody is perfect. If I do not help them, who will?

Call me Pollyanna, but these young folks may still have a good future. Redemption is possible. Over the last two decades I have seen many of these folks rise like a phoenix above the ashes of their self destructive behavior.

Truly stoned

Within a few hours of Gary’s hospitalization, I had my answer to his affliction. The wolf was real.

His urinalysis contained scads of erythrocytes. He had a single 5 mm stone lodged midway in his ureter as seen on the CT scan. I continued him on his morphine (of course he said the dose was too low) with forced hydration and diuresis. Within two days his pain had subsided, and he was headed toward the halfway house in nearby Lexington at discharge.

Checking on him two days later by phone, he never showed up. I think he headed for Florida, to get away from his drug-using friends. One can only hope.

For more information:

• Stan L. Block, MD, has a pediatric practice in Bardstown, Ky., and is a member of the Infectious Diseases in Children editorial board.