Remya Tharackal Ravindran
The light from my pen torch strikes the steel-blue eyes of the patient lying before me. Her pupils stand wide open and still.
My pager's shrilling pierces the quiet. Fumbling with the buttons, I read the message: "Call 7546 STAT."
It's my first rotation on the floor as a new internal medicine resident. I dial the number, various possible disasters bubbling through my head.
"The patient in 723, Mr. Martini, is complaining of severe abdominal pain," says a nurse's voice. "The day-shift resident ordered one milligram of morphine, but he refused it. I want you to come and evaluate him right away."
"Can you give me two minutes?" I ask. "I'm in the middle of doing a death pronouncement. Is he otherwise stable?"
"His vitals are fine. But don't take long. He's driving me crazy."
Moments later, hurrying to Mr. Martini's room, I grab his chart from the rack. Mr. Martini, fifty-six, was admitted earlier today for abdominal pain. Presumed diagnosis, inflammation of the pancreas. He's suffered from alcohol-induced pancreatic inflammation before. He's also had surgeries on his back and knees. My eyes fix on a line: "CHRONIC ALCOHOL ABUSE AND OPIOID DEPENDENCE."
I note that, for someone supposedly in severe pain, Mr. Martini has a remarkably normal heart rate and blood pressure. The lab results don't suggest an infection. His pancreatic enzymes are only minimally elevated, and his abdominal CAT scan shows no inflammation.
Through the open door of his room, I see a middle-aged man comfortably tucked in bed, eyes glued to the TV screen. Judging by his smile, he finds it amusing.
Is he really in pain? I can't help wondering.
Seeing my white coat, he quickly switches off the TV and turns to me, frowning.
I introduce myself.
"I've been waiting here for an eternity with this excruciating pain in my belly, and no one even cares!" he sputters, throwing off the bed sheet and trying to sit up.
I ask him about his pain--when did it start? How long has it lasted? What is it like? Where does he feel it?
"I have pain all over," he says. His muscular hands, marred with needle tracks, swiftly point to his abdomen and up and down his legs.
"May I examine you?" I ask.
When I inquire about the scars on Mr. Martini's back, he describes in elaborate detail a past back injury and surgery, complicated by an infection that led to other surgeries.
"I'm going to sue the hospital as well as that surgeon," he says. "It's thanks to him that I'm in all this pain..."
He's engrossed in telling his story; as my hands press harder and harder on his abdomen, he doesn't even wince.
"Tell me where it hurts you," I say.
He shoves my hand away and crumples over, moaning as though I'd stabbed him.
I say, "Where--"
"Just give me four milligrams of IV Dilaudid and I'll be fine!" he snaps.
Dilaudid (hydromorphone) is much more potent than morphine. I pause, collecting my thoughts.
"I'm at loss to explain this sudden pain," I say. "It doesn't make any sense, given your physical exam and lab results."
Trying to sound curious, I continue, "I heard you refused morphine earlier. Any particular reason why?"
"Morphine?" Mr. Martini scoffs, his expression telegraphing, Where did you go to medical school?
"Mr. Martini, I understand that you've had some issues with managing your chronic pain with opioids--"
"You think I'm lying?" he says, his voice rising. "Call and ask Dr. Potter. She gave me four milligrams of IV Dilaudid when I was here last time, and oral Dilaudid when I was discharged. It should be in your records. Go check!" he yells, pointing at the door.
Feeling a bit foggy, I walk out to the nurses' station computer.
Someone pats my shoulder. I turn around to see Mr. Martini's nurse. She shoots me a conspiratorial grin.
"You know, he won't accept even oral Dilaudid."
I study his records. Admitted six times over the past year with chronic abdominal pain and back pain...expelled from a pain specialist's practice for breaking the pain-management contract...admitted and discharged only a few days ago for a skin infection. Among the discharge medications: oral Dilaudid 4 mg.
This is hard. What should I do? Is this man really in pain? I've read that patients who suffer from chronic pain may not show it every waking moment. Was he forced to act horribly ill in order to get the care he deserves? Should I give him the benefit of the doubt? If I don't, am I violating my Hippocratic oath?
Hesitantly, I call my senior resident for help.
"Oh my god, is Martini in the hospital again?" he bursts out, half joking, half exasperated. "He's one of our frequent flyers. What is it this time?"
I recite the story.
"Tell him that he's not going to get any IV Dilaudid," he says firmly, then adds, matter-of-factly, "You'd better learn to deal with this man now, because you'll have to put up with him for the rest of your residency."
Mustering my strength, I walk back to Mr. Martini's room.
"Did you see it?" he asks combatively.
"Yes, I did see that you were sent home with oral Dilaudid. How did that work for you?"
"I lost my pills. I...uh...accidentally spilled them into the toilet," he falters, his eyes wandering away.
"Spilled them into the toilet?"
"Look, okay, I'm sorry. It's my fault. I really appreciate all of you wonderful doctors here. And you've been very patient with me. Doctor, please believe me--for some reason, oral Dilaudid does nothing to me while I'm in the hospital. Please give me some IV," he pleads, his eyes welling up.
I'm amazed at this transformation in his demeanor.
"Mr. Martini, I'm sorry," I say. "I hope you understand that my responsibility as a physician is to act in your best interests, which is why I won't medicate you unnecessarily."
"Am I going to die today, doctor?" he asks tremulously. "All my nerves are worn out from pain. Please be honest: Is it time for me to make peace with my maker? Will you let me die here in pain?"
I can't help but marvel at his talent as a tactician.
"Based on my exam and your lab results, you're not in any danger," I say, feeling that my truthful reassurance sounds as phony as his fake concern.
I say goodbye and step out of the room, feeling unsettled; I know this is not the end of the saga.
When all is said and done, I still feel sorry for this man. He wasn't born with chronic alcohol abuse and opioid dependence, and I feel sorry about the circumstances that have led to his present predicament. Yet I also realize that the best help I can offer him at this point is tough love.
I hear nothing more from Mr. Martini that night. A couple of days later, he's discharged.
Months go by. My internship progresses from one rotation to another. Occasionally I remember Mr. Martini's existence when a fellow resident chuckles, "Guess who's back in the hospital?"
Internship transitions into second-year residency. My hospital workload lightens; my on-call nights tend to feature more sleep and fewer pages.
One night the pager does shatter my slumbers. My swollen eyes read a glowing message: "Patient George Martini complaining of abdominal pain. Call back ASAP."
I prop myself up. As I dial the number on my smartphone, I find myself thinking, If only someone were smart enough to invent a Pain-o-Meter--a gadget that could tell me whether real physical pain is present, and if so, how much.
As unlikely it may be, there's always a possibility that, this time, his pain is genuine. Every time I get a call from Mr. Martini, I'll never really know for sure whether it's his physical pain or his addiction that's on the other end of the receiver.
For the moment, I'm having to craft my own Pain-o-Meter--one based upon clinical judgment--and hope that it's accurate enough.
About the author:
Remya Tharackal Ravindran is a third-year internal medicine resident at Overlook Hospital, in Summit, NJ. She grew up in India, where she did her MBBS (the equivalent of an MD degree) at Trivandrum Medical College, Kerala. After graduation, she came to the US with her husband, who is an engineer, and their daughter. This is her second published story; the first, "Ms. Taylor," also appeared in Pulse. "I haven't written much since my high school days. My hobbies (although I hardly have time for them anymore) include astrology, reading scriptures, philosophy, painting and cooking."