October 27, 2010, 4:23 pm

It’s Not Good

Have coffee! Time to blog!

Seriously, there is actually coffee in that cup! 32,160 cups!

A Guinness World Record.

Brewed on site at BlogWorld/New Media Expo 10, by the folks at Gourmet Gift Baskets.

I think it represents about 6 months of my yearly consumption.


I’m putting Change of Shift together tonight, so if you have any last minute submissions, I’m “standing by” to take your order!


I am having a crisis.

I’m not sure if it’s an ethical crisis, a moral crisis, or an I’m-just-too-full-of-myself crisis.

But is is getting harder and harder to be an ER nurse.


I can’t detach.

I mean, it’s no skin off my nose if a patient with no discernible pathology calls 911 for the tenth time in four weeks and requests transport from the other end of the county. For narcotics.

It’s no skin off my nose if a patient that has been to five other emergency departments up and down the state in the last 48 hours presents to us. For narcotics.

It’s no skin off my nose if I a patient shows up so medicated they can’t walk straight. For narcotics.

I mean, really.

I should just assess ’em, push ’em, vital ’em and street ’em.



So why does it bother me? I get angry. Angry at the audacity of the abuse of the system in general, angry by the feeling I’m being manipulated, angry at the willingness to order narcotics on demand.

And tired of having to pretend that it’s all good.

It’s not good.

I’m not helping anyone.

I’m certainly not therapeutic in any way.

And I’m not stupid.

I’m aiding and perpetuating addictions.

On a daily basis.


There was a time I could smile and pretend that I didn’t see the holes in the stories or the flat out lies I would catch in the course of a conversation.

Pretend that I believed a patient could not remember the name of that….”oh dear what is it called….Daludad…Dileded…oh yes! Dilaudid! That’s it!”

Pretend that patients weren’t drug seeking, knowing they knew I knew.


Getting patients out of pain is one of the most rewarding aspects of emergency nursing. It’s as close as you can get to instant gratification – you medicate, the patient gets relief.

That isn’t what I’m talking about.

I’m talking obvious, blatant, in-your-face drug seeking that is becoming more obvious, more blatant and more in-your-face every day.

But the narcotics still flow.

And it’s getting harder and harder to be a part of that.


  • Dr Dean

    October 28, 2010 at 2:31 am

    Hey, Kim, glad you are back.

    Sounds like serious burn-out to me! I don’t know how the system can be changed as long as ERs are open to all.

    You have to do the best you can, and focus on the wins!

    Or maybe it’s time for change, for the Change of Shift nurse….
    Hang in there!

  • Kim

    October 28, 2010 at 3:01 am

    I totally agree and after 15 years have decided I don’t have to make everyone happy. The best thing that ever happened in tn is the prescription monitoring database. I can tell when and where they had narcotics filled and I don’t give them any.

  • RehabRN

    October 28, 2010 at 3:26 am


    I have been getting an education in narcs lately due to a project I’m doing.

    It’s amazing how people are in so much pain, and say they’ll try other methods to relieve it, and once the option is in front of them, they refuse it.

    It’s just a lot easier to quit and take a pill rather than be responsible for yourself and seek out other non-pharm options.

    Very ironic…

  • JenRN

    October 28, 2010 at 5:30 am

    I struggle with feeling frustrated and then feeling guilty that I have judged them. Thank you for always saying what a lot of us are feeling.

  • Jacki

    October 28, 2010 at 6:47 am

    I have been experiencing this for the past couple of years and wondering if I need to get out. I look at every patient with a jaded view because we see the same ones over and over and over again. Doctors are the “candy man” due to JACHO and Press-Ganey scores to everyone who asks for them and, they ask and ask and ask – newest is dental pain and “no dentist will take me because I don’t have insurance or the money” – seeing lots of those because the back pain symptoms has worn out. I feel your frustration because I too see this every single day!

  • Sean

    October 28, 2010 at 9:05 am

    Hard not to ‘care’ Kim, even if caring has a negative undertone sometimes.
    You are not alone.

  • Rita Schwab

    October 28, 2010 at 2:34 pm

    Only you can decide whether it’s time for a career change, but Emergency nursing has been your passion for many years.

    Right now you’re focused on those who game the system to feed a habit, and it understandably, makes you angry.

    Is it possible though, to refocus on the satisfaction you gain from helping those who really need you? I for one would love to see an experienced, compassionate nurse like you standing ready to help should I find myself ill or injured. If you decide you must move on, it will be a real loss to the rest of us.


  • Mika

    October 28, 2010 at 4:56 pm

    I resonate with what you are feeling. I am just getting back into a civilian ED but it seems like a lot of people are abusing the system. We are trying to implement a program where the do a MSE, and then send them out the door, but I always wonder what if someone slips away. I just read a book “How Doctor’s Think” by Groopman and it made me think, I have to be a clean slate each time. Honestly, it has me concerned especially since I am in the FNP program, I don’t want to write someone off. Missed reading your blogs..

  • Bif

    October 31, 2010 at 11:36 am

    I agree but I’m getting better at presenting them with the facts about narcotic use for chronic pain. It doesn’t work. In Washington state several ED docs are working to not only make a state wide information system for chronic ED users but give docs, PAs and NPs guidelines. Go to consistentcare.com and see how 4 hospitals in Spokane manage. They are very wiling to help you get a program going.
    Until we can all work together not to treat with narcotics unless there is a reason (cancer, broken bones etc) we just have to be the beacon.
    Good luck.

  • Shauna

    November 1, 2010 at 2:28 pm

    Dear Kim,

    Along with admiring your writing, I have always thought that you are an excellent, empathetic and well-trained ER nurse.

    As a Chronic Pain patient, along with being a nurse, I have seen both sides of the ‘game’, and yes, it has become a true game. But who wants to be the host??

    The key to seeing if a patient is truly interested in obtaining consistent, Dr. followed and managed pain control is their desire to do just that: Find a pain center, a pain doctor, any specialist in treating ongoing pain.

    I am amazed at the amount of people that state they ‘need’ Vicodin for their back pain, yet refuse to do any work on their own to secure a doctor to oversee their pain meds. It is much easier to hit up the local, (then the not-so-local) ER’s once a week or once a month to obtain what they are using strictly to get high.

    I have a very hard time dealing with these types of people, patients or just those I know of….I have dealt with pain and surgeries, procedures, anything there is available to me to help reduce my pain levels. Because of my own experience with pain medications, I can spot a seeker 10 miles away. But what is ethical in the situations that you write of?

    Ethical is reducing the pain a patient states they have. Being a strictly subjective area, pain is only what the patient says they have, right? NO! It is a combined background of either years of suffering from a certain pathology in the spine, for instance, and that patient should be able to easily state what they have done for pain relief in the past, and WHO is treating their pain at the time they show up in the ER. Anyone who is followed closely by a pain doc, does not usually go to an ER at all. The doc and patient have a set plan for what to do if the BTP meds are not working, and only the chronic pain patients know when it is to a point that something needs to be changed. This is to discuss between their pain doc and them, NOT THE ER!!! That is abuse of the staffs time, and taking up a bed/chair/stretcher in the hallway/ that another person with ACUTE pain truly needs.

    There have been times when my pain has been so high, I feel like it is akin to the back labor I had during delivery of my son. I may say I need a Demerol shot, but I don’t take it any further. I will not ever go to the ER b/c my pain is high….I will wait and call my pain doc the next day. It is not an emergency.

    I truly hope that the drug seekers you are seeing do not give you a permanent bad taste in your mouth for ER nursing. Have you talked with the staff about your feelings? Is it possibly time for a meeting on this issue? I’d hate to see you leave your beloved area of nursing Kim.

    You know in your heart, and you know as a nurse, that the seekers are always going to try. I trust you know that not giving them what they want is actually the best thing you could do for them. It may just be that final straw for them to either go a step further and seek a pain management team, seek help for addiction; or at least give up on hitting your ER up, and move on to the next county.

    A sad state though, I agree.
    Good Luck sweetie….

  • Crystal

    November 2, 2010 at 2:46 pm

    here I thought only I was the only one! When I read this posting I felt like I wrote it! It’s really sad how most of these people don’t have insurance or they have state aid and spend their lives bouncing from one hospital to another for drugs. I always say I have two titles, I am an RN and a legal drug dealer! It blows my mind how they set their alarms on their phones to wake them up for the next buzz! Sick is what it is. Dilaudid is one drug I never, ever want. It is worse then heroin and should be outlawed! But until then….we push on! You’re not alone.

  • NPs Save Lives

    November 6, 2010 at 8:42 am

    Kim, I can definitely empathize with you regarding the pain med seeking behaviors. We see it all to often in our office setting. I have actually put up a sign on our front door that “You will not receive narcotics on the first visit” that has actually made people turn around and leave. It’s pretty sad that it comes to that. I have also made it a random habit to call all of the pharmacies in three counties to check if a particular patient is seeing other MDs for controls. I have in turn released a few patients from narcotics. I also research the local sheriff’s dept. online inmate searches before I write. Trafficking in controls will NOT get you anything from me. PERIOD…

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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