Having been a nurse for as long as I have, I am definitely not naive. I don’t consider myself cynical, either. I like to think I have reached a fine balance between the two that allows me to treat my patients with compassion and detect (and deflect) the bull that some patients will occasionally throw my way.

Nowhere is this balance of compassion and cynicism more obvious than with caring for patients with chronic pain issues. For this post I will focus on the migraine patient.

I’m no stranger to headaches. Twice in my life I have known what it is like to feel like your head is going to explode. So, the first thing I do after assessing my migraine patient’s color in the triage room is I turn out the light before I get the history, as most of the patients will suffer from photophobia.

I make sure they have a private room with the lights out whenever possible. Sometimes they have to wait a bit longer for the advantage, but I let them know why they are waiting.

For new patients I ask them what has worked in the past. Some don’t know, others can recite specific dosages. I ask because if they know, it saves a lot of time and the need for re-dosing. If a patient states that it usually takes 100mg of Demerol, IM, to take the pain to a tolerable level it seems silly to give it in 25 mg increments. Oh, the doctors can order it that way, but (1) trust me, it will NOT work until the usual dose is reached and (2) the patient stays longer in the ER because of the need to re-evaluated after every administration of the med.

Hopefully the doctor has given them prescriptions for pain at home. I make sure the patient has a ride home. I have bad feelings about putting a female patient under the influence of a narcotic into a taxi, although they will often insist it is their only way home.

And this brings me to the cynical side of my migraine ambivalence.

I’ve been burned.

• I had a patient appearing very ill (headache, vomiting, photophobia) and placed directly into a room. It was discovered that just an hour before, said patient was at our “sister” ER and both departments worked off the same computer system. All it took was one phone call to ascertain that the patient had received enough narcotics to allow him to have floated to our facility. Well, he just floated back home without anything from us!

• Sometimes a nurse will work in more than one facility. One of my patients was identified as having been at another facility already twice that week for the same complaint: migraine. I believe I already told the story in another post that related a nurse traveler who recognized a drug seeker from the east coast while working here in CA.

• There are the patients who take the taxi, drive around the block and then get in their car and drive off. I know this happens because the taxi drivers come back and tell us the patient only went to the corner and then got out of the taxi and walked back up to the parking lot.

• If “New Miracle Drug” comes out on Wednesday and the patient states he is “allergic” to it on Friday, it usually means that somewhere, somehow the patient received the medication and it didn’t work. Saying there is an “allergy” to a medication is one way an illegitimate drug seeker will keep from getting that drug.

This is what ruins it for patients with legitimate pain issues that occasionally need to be addressed by the ER.

If you are a patient with a chronic/recurrent migraine issue:

• Carry with you a letter from your neurologist outlining your treatment plan, discussing what to do in a case of breakthrough pain and gives medication/dosage recommendations. Make sure it is updated often, in other words, don’t bring a letter dated 2000.

• Bring a list of your medications and allergies/reactions with you. The apex of a migraine is no time to be trying to think of your medications. Keep it in your purse/wallet.

• Bring your ride home with you. Don’t take the chance you’ll be medicated and have no way to get home. Don’t drive yourself to the ER when you are in that much pain, it isn’t safe.

• If you are certain that your pain is unmanageable at home with what you have available, it may be worth placing a call to your doctor. Often, they will call ahead to the ER so that we are expecting you. They may even talk with the ER doctor to discuss your case and treatment options.

So you can see when you run into staff who seem suspicious or less than compassion filled, maybe you now have some insight as to why some ER staff tends to be on the “cynical” side when it comes to pain issues.

There is a line in the movie “Ghostbusters” that shows the guys in a TV commercial saying, “We are ready to believe you!”

We are ready to believe you here in the ER, too.

But trust me, we can spot a phony a mile away.