Like good chocolate or fine wine, they come in many varieties.
There is the Demanding Seeker who knows exactly which drugs will work and refuses any other alternative. The Demanding Seeker wants to report you to the patient complaint representative when you refuse his “2 of Dilaudid and 50 of Benadryl” cocktail of choice. If refused for long enough, the Demander will usually pick up his iPhone, unplug his charger from the hospital outlet, and storm out of the department with a remarkably quick pace for someone with 11 out of 10 low back pain.
The Pathetic Seeker takes a quieter approach. Typically tearful as soon as you walk in the room, she hopes your compassion will play to her advantage. She doesn’t scream her demands, she almost apologetically releases them between gasping sobs. “Only…(deep breath)…Dilaudid…(deep breath)…works…(deep breath)…formypain…(shivering weep).” Unfortunately for the Pathetic Seeker, the compassion of an emergency physician is largely overestimated; we’re trained to be grizzled skeptics with a remarkable tolerance for the pain of others. When discharged, she will require a wheelchair to get to the waiting room, and then walk to her car without too much difficulty.
The Slow Roller unfolds her plan in stages. Initially presenting with what appears to be a completely legitimate problem, she escapes the physicians immediate Seeker Radar. Our interest piqued by what could be an actually disease, we do a careful history and exam and begin investing both mental and physical resources into helping this reasonable patient. We offer pain relief while we’re figuring things out. And then it comes, like the slow creep of darkness at dusk. The nurse says, “She said the Toradol isn’t really helping, maybe we can try some morphine?” Totally reasonable. “Her pain is still 8/10, and she feels like the morphine wearing off.” Sure, that happens; morphine re-dosed. “She wants to know if there is something else that might help.” At this point all the lab and imaging tests are normal, and when you talk to her again she seems to think that she’s had “a pain shot that worked before, I think it starts with a ‘D’…Dilotin? Dinaudil? Dilaudid! That’s the one.’” When refused and discharged, the Slow Roller doesn’t put up much fight. She almost respectful leaves, knowing that after a long battle, she has finally been bested. While less dramatic, she is even more infuriating. The Slow Roller wastes the time and energy of the entire staff for hours on end; I would respect her more if she just came out with it in the beginning.
There are others, to be sure. Each feels that he has discovered a secret and foolproof path to immediate IV opiate administration. But we know. We may get fooled occasionally, but we know.
One of the best parts of my practice now in New Zealand is that I very rarely come across a Seeker, and I almost miss it. But every once in a while it happens, and I fight the urge to say, “We’ve never met, but I remember you.”