Thankfully, after reading many different ER blogs about drug seekers, I can definitely state that we don't see that too often on L&D. But, we do see it from time to time. Lucky me, I got to (briefly) take care of a drug seeker the other week.
"Mary"** came in at 23 weeks with a report of low pelvic pain and back pain since the day before. She told me it just was feeling worse today, so she came in to be evaluated. She was accompanied by "James"**, the father of her baby. James was very doting and concerned about Mary's pain, and stayed by her side for most of the visit.
My standard triage assessment for Mary was as follows: doppler fetal heart tones, place toco to assess for contractions. Palpate abdomen for tenderness, rigidity, any specific "hot spots" of pain. Take vital signs, especially looking for tachycardia and fever (signs of infection). Have Mary give a clean catch urine specimen (she wasn't able to urinate yet). Ask about other symptoms -- vaginal bleeding, fluid leaking, urinary tract infection symptoms (pain, burning, frequency), fever, chills, etc. When did it start? What makes it better? What makes it worse? Has she tried anything for comfort?
I glance over her health history/OB history via her prenatals and note that she is a healthy, normal pregnant woman. All OB labs normal. Pregnancy progressing normally for her. Not a whole lot of notes written with her prenatal visits, so one could assume that her course of care so far was normal, right? (This is why it's handy to put notes in the prenatals......can clue others in to what might be going on during future visits.)
Hint #1 of problems ahead: multiple drug allergies in the history to non-narcotic pain medications.
I can barely get through my beginning assessment, when Mary is curled on her side, asking for pain medications. (Hint #2: a nurse cannot just 'give' you pain medications or any other medications, we need a physician's order.)
She's guarding her abdomen, so it's hard to assess via palpation where the pain/tenderness is, but I am already thinking that this is a UTI -- something very common but can be quite painful in pregnant women.
Here is my nursing assessment:
24 yr old G5P2022. BP 100/78, pulse 102, respiratory rate 18, temp 36.5 C. FHR 155, toco: no contractions. Abdomen soft, tender to palpation diffusely, difficult to assess due to patient curling on her side. Skin: pink, warm, dry. Mary currently weighs 125 lb, and is 5 ft 4 inches tall. Blood type O+, rubella immune, RPR/HepB/HepC/HIV all negative. No history of surgeries or medical problems. Allergies: toradol, ibuprofen, naproxen, morphine.
I call her regular physician - as expected, he wants a urine specimen to rule out a UTI.
Hint #3: He also is adamant about how he is NOT coming to see her in person, and she is NOT going to get any pain medications. I didn't even have to mention that she asked for pain medications, he flat out said NO. He told me that she has a long history of drug seeking, even when not pregnant, asking for pain medications.
In I go, and ask her if she can urinate for me yet, since her doctor wants to make sure this isn't a UTI. She asks if it will get her pain medications, and I tell her no - I need to send her urine to the lab to rule out a bladder infection before her doctor will discuss pain management options. She manages to sprint to the bathroom and give a specimen. Cue her boyfriend James going outside to smoke.
Mary is back in bed for no more than 30 seconds, before asking for pain medication again (this is hint #4, the repeated request for pain medication). I look at her point blank and tell her no, she will not get pain medication per her doctor (that I have already explained to her), please bear with me while I label and send her urine to the lab to see if she has an infection. I explain to her about how antibiotics will help the pain if she has a UTI.
As I'm sending her urine to the lab, I run across her doc, who is attending to a woman in labor. I ask him for a drug screen on the urine and he agrees.
I come back to her bedside where I find Mary dressed, contraction monitor off. She's leaving. I encourage her to stay so we can find out if she has a bladder infection, but she insists on leaving.
poof............gone.
Anyone care to guess what the urinalysis showed? How about what the urine drug screen showed?
**Names changed and info changed for privacy.**
28 comments:
(-)for UTI (+) for opiates (my guess would be oxy, but urine screens don't get that specific, right?
I don't even want to know :(
Emma, you are partially correct. And yes, our urine drug testing is specific to the different classes of illegal drugs.
(-) for UTI, (+) for amphetamines, specifically meth. That's our girls drug of choice
(-) for UTI, (+) opiods, marijuana, heroin, and amphetamines... at least... that was what I got on the last pregnant drug seeker I had to evaluate under similar circumstances.
- for UTI, + for opiates and cannabinoids?
Probably had either opiods and or pot or both. It just aggravates the crap out of me that pregnant women will subject their unborn children to illicit substances and then sue the doctor when something is wrong with the baby. P.S. I just have to use that picture! Hope it's not copywrited.. Let me know if it's okay.
i'm curious (not critical):
What are the rules for consent to drug testing? I was not aware that a doctor can use a urine sample for a drug test when it was given for to test for a UTI.
Obviously the result is private but I'm just curious.
-UTI & + for opioids and cannabinoids
Neg for UTI, pos for cannabis and opiates.
Yep, that's a drug seeker!
I was wondering the same thing as Kelley. Where I live, in B.C. - you need to get the consent of the person before you can legally do a drug test.
The only time you don't need consent is for a newborn. That's when we do our testing if the mother doesn't consent after we explain to her the reason.
It has been my experience that most users will tell you exactly what they took if you come right out and ask them and make sure they know it's for the safety of their baby....not to get them to confess for charges.
Just curious!
Interestingly enough, my latest blogpost is about an inmate drug user that I looked after in L&D...
http://callmenurse.blogspot.com/2012/02/if-projectif-only.html
I'm a volunteer in the telemetry unit of a big, urban hospital. I can hear it coming from the drug seekers before they even open their mouths: "No, I don't want Vicodin. Only Dilaudid (sp?)takes away the pain. Why do the doctors always insist on Vicodin when they know it doesn't work?"
*sigh*
I hate that people do this. Because it makes the rare times when my husband's prescribed medicine doesn't work and he is in uncontrollable pain and we do have to go to the ER per our doctor (this has, thankfully, not been an issue in a while), he is treated horribly. When the reality is the last thing he wants is to take any medication! Not knowing what is causing the pain exactly is frustrating, especially when it is long lasting and chronic. And then when you do need help, you get doctor's and nurses who are (understandably so!) jaded and see a 31 year old male presenting with back pain radiating to his thighs and no recent injury and of course they think a drug seeker!
And I've had dilaudid during a gall bladder attack. Even if I were to have another attack that bad (it was worse than childbirth and I'm a precipitous birther so 8-9 hours of pain before I went in was longer than it took to have 3 of my 4 children combined!), I wouldn't let them give me that stuff. Horrible feeling!
In my state, we do not need patient consent to run a urine drug screen. We used to need a signed consent, but it changed several years ago. The same thing with HIV testing - used to have a signed consent, but now no longer needed. So, yes, a doc/midwife can order a urine drug screen on anyone. It's actually good practice to screen someone in possible preterm labor for drug use. Certain drugs can trigger preterm labor/birth, placental abruption. Good to know what you're dealing with.
NP Saves Lives - I found that picture on google.
BTW - the urine was negative for a UTI (she was dehydrated though with her high specific gravity), and the urine drug screen was positive for: opioids, marijuana and PCP. The holy trinity of trippin'.
Let me add this: if you are genuinely in pain, even if you *may* come across as drug seeking, I am going to give you the benefit of the doubt if you truly do have a medical problem related to your pain. If this chick had stayed around, and did have a UTI, I would have most definitely advocated for her to have both antibiotic therapy and something for pain. Not Dilaudid, but perhaps something else specifically to help with the UTI pain.
Everyone gets on at my hospital, practically. No consent is needed, however I wish that they did do consent. I feel like it is going against the patient's back.
The non consent bothers me just because my insurance doesn't cover much. You start ordering a pile of tests I don't know about and I get stuck with a big fatty fat bill. So that's nice. As for this chick, shameful... but my husband ALSO has pain issues, terrifying migraines, to be exact, migraines that land him in the bathroom vomiting for hours on end, regularly, once a week or more. The ONLY thing that has touched this pain is a fat dose of Oxy. That's it. But when we moved to Oregon our PCP saw his "drug history" ( ie, many many mg of oxy prescribed over the years, mixed in with various "lets try out this med" stuff thrown in for good measure) and refuses to RX him any. More than happy to prescribe Butrans patches though ( gee... another opiate.) Like THAT isn't addicting and horrible for your liver.. something he's already got problems with due to his Ichthyosis. Yah. SO this drug seeking woman makes me angry, because of losers like her my husband gets treated like a druggie whenever he's in looking for help.
Sabrina - feel free to ignore if this doesn't apply, but: has your husband's doctor ruled out cluster headaches? Different to migraines but up there with some of the worst pain people can, more common in men, and the fastest treatment is 100% oxygen.
I'm not the least bit surprised by her drug seeking. But a big part of me really wonders...what's going to happen to that baby??
PCP? I must be sheltered; I didn't realize that was still a thing.
wow HIV testing without consent as well? I guess I'm sheltered!
What did you do with this info other than feel smug? Get her into a treatment plan, call CPS, anything productive?
Was this test really necessary ? Almost seems like just another way to increase revenue and bill insurance.
I specifically asked her doc about what we do with the info re: the + drug screen. He was very non-committal about what to do.
What will end up happening, is when she presents to L&D for her birth, she will get another urine drug screen, and her baby will be screened as well. If either are +, then children and youth will be notified.
And yes, we have maternal drug abuse programs for pregnant women. I just wish this doc would have been more pro-active in getting her into a program, or at least offering her some options.
I love that people are asking if this is unnecessary. She's a known seeker, and she's ingesting drugs that affect the growth and development of her unborn baby. Knowing these things ahead of the actual labor/delivery presentation is pretty important to know. I'd love to know ahead of time if I'm going to be catching a 3# meth baby or an 8# term baby with no prenatal drug exposure. Makes a little bit of difference when it comes to resuscitation.
That would be frustrating to deal with. And some hospitals supposedly see this all the time!
It's not a baby! Her body her choice!!!
Where I live (in BC) we need consent to do drug screens both for the mother and the baby if there isn't a specifc medical reason to screen baby.
I work in a pregnancy outreach program as well and we approach all pregnant women through a trauma-informed, harm reduction lens. In my experience, when women are treated with respect and compassion, you can make some headway in supporting and getting them some help.
I'm curious as to whether doing drug/HIV screens only applies to pregnant women, or to ANY patient in this state?
While it may be legal to do it, and I can understand the desire of the health care provider to be prepared...I think it is unethical. Doubly unethical if the woman is then expected to pay for the test that she did not authorize when her insurance refuses to pay.
Not to mention that simple palpatation of the uterus is usually going to tell you if the baby is 3 lbs or 8 lbs...and a very healthy woman can suddenly go into labor with a 3 lb premie and a druggie can go full term. Yes, I know the odds are for the reverse...but I'm just saying that we can't ALWAYS predict, so the Boy Scout motto is applicable here--"Always Be Prepared."
According to this article: http://articles.philly.com/2011-07-28/news/29825065_1_hiv-testing-pretest-counseling-hiv-screening
HIV testing can be done only after the patient has been notified orally or in writing that the testing will be done, and the patient can opt out of the testing. Is there something different for pregnancy? I'm sure that there are some OB's that simply mention in early prenatal care that they will be doing HIV testing, and unless it is opted out at that point, they would consider themselves to have consent for the whole pregnancy. It will be interesting to see if this is ever put to test.
Interestingly, I did consent to the standard STD testing panel in my first pregnancy, and I don't recall being asked to sign a consent for the HIV testing...though I guess I may have, it was nearly 14 years ago.
Post a Comment