You Win, You Can Have the Morphine

It was the middle of a hectic day during a hectic shift. Mondays are always bad for a myriad of reasons, superseded usually only by those nights with a full moon. Many people decide that they are sick on Friday but don't want to give up their weekend, so they decide that if they're not better by Monday, they'll just pop into the ER. You can guess what kind of a snafu that creates where people aren't seen quickly enough and then they complain that they spent their entire Monday in the ER. Hey, I spend most of my Mondays there too.

Regardless, on one particularly nondescript Monday, some officers brought in a patient from the New York Department of Corrections -- a prisoner. Being that we're Manhattan County public hospital, all medical treatment for people in the prison system in our catchment area comes through our emergency department. This certainly can make for interesting encounters.

The officers brought in someone in the familiar orange jumpsuit yelling and moaning in pain. As a general rule in the ER, one's decible level of yelling is inversely proportional to the amount of time that that person waits to be seen. Thus, with all the commotion this prisoner was causing, I walked quickly to his bedside.

"DOC, YOU GOTTA HELP ME," he pleaded.

"What's the problem? How can I help?" I asked.

"THIS."

The prisoner then pulled his sheet back with his non-cuffed hand, and there on his right upper thigh near his groin was a six-inch gash -- or rather, maceration: muscle fibers were torn and strewn, sticking out of the wound in haphazard fashion. It looked like someone buried an M-80 firecracker in his leg and lit it. The wound edges themselves were jagged and red, angry to the touch. Amazingly, other than a small trickle, the wound was not actively bleeding.

"DOC I NEED SOME MORPHINE, THIS PAIN IS KILLING ME!" he screamed.

"What happened?" I asked him. I expected to hear a sordid tale of prison violence a la Oz, whereby someone fashioned a shank from a spoon and decided to cut this guy when he refused to be his prison bitch.

"I can explain," said an NYPD officer, approaching me from behind.

I turned toward the officer. "Did someone shank this guy?" I asked.

"Not quite."

"What do you mean?"

"He shanked himself. With a pen."

"Huh?" I was confused.

"This guy's an addict. He wanted morphine. He figured the only way he'd get it is if he cut the shit out of himself like that."

"You've got to be kidding," I said in disbelief.

"Nope. Ask him."

So that's what I did. And as it turned out, the officer was correct: after days without his fix, he apparently needed/wanted one so badly that he actually took a regular ballpoint pen, stabbed himself in the thigh with it, and tore through six inches of his skin, bluntly dissecting his thigh muscles to about an inch deep, chewing up the tissue as he systematically went through and through his thigh.

I have a personal rule about drug-seekers in the ER: don't reward them. MANY people come through the emergency room requesting certain drugs: morphine, fentanyl, demerol, percocet, vicodin, all other narcotics, valium, ativan, klonopin, you name it. They say all sorts of things to justify it: my doctor isn't answering his pages, I'm in a lot of pain, I take ativan everyday but I ran out, I'm an alcoholic and I need it so I don't seize, I have a psychiatric condition, I lost my prescription, etc. And when you offer strong non-narcotics, they always -- and I do mean always -- say that they're allergic to them: tylenol, motrin, ibuprofen, naproxen, all NSAIDs, toradol; some go so far as to say they're allergic to every painkiller including all narcotics except for the one they're specifically seeking, say, Demerol. It's fairly easy for anyone to pop into any ER and demand such drugs because chances are that the treating physician doesn't know you, has never met you, and thus doesn't know your true motivation.

And for me, unless they're actively seizing or tremulous from true alcohol or benzodiazepine withdrawal, I don't give in for those very reasons: I don't know them, I don't know their motivations, and I don't want them coming back to the ER because I've rewarded that behavior. This stance is often met with the mantra, "I'm going to call my lawyer!" And I always say, "Give me their number, I'll call them directly myself." This brief exchange is then followed by security escorting them out -- which actually sometimes makes me wonder how long they might wait outside for me to finish a shift.

But as with every rule, there is an exception. And I thought this particular prisoner qualified for serious pain control and light sedation with morpine. "You win," I thought to myself. "If you're fucked up enough to do THIS to yourself, then you can have the morphine and we'll sort the rest out later."

So I gave him a small intravenous dose, it calmed him down, and I was able to more aptly locally numb the wound up and explore it. As it turns out, he did a great deal of muscular damage, but he somehow managed to miss every major and semi-major vessel running in the front thigh compartment. Luckily for him, he also missed -- by less than a centimeter -- his femoral artery, which is actually more superficial and lateral than the femoral vein. Severing that thing could cause you to exsanguinate and die within minutes.

Since the wound was large but not major, we did a deep closure followed by a superficial closure and gave a hefty dose of antibiotics. During this procedure, however, he was very agitated and unfriendly (to say the least), so we restrained him for his own safety by tying both hands and both feet to the gurney. And to protect ourselves, we forced him to wear a faceshield since he decided to try and spit all over us. What an asshole.

So my colleague and I finished the repair and got the surgery consult's blessing to discharge him back to prison. But as I was filling out his discharge paperwork, he then said to me, "Doc, as soon as you untie me, I'm going to do this again."

"What did you say?" I asked.

"You heard me. The second you untie me, I'm going to keep doing this to myself until you give me all the morphine I want."

Next time, hit your damn femoral artery, I thought.

Regardless, that set me up for an interesting dilemma: what do I do now? Give him more morphine? Or untie him and wait for him to come back after he does the same thing when gets back to prison?

I wasn't about to be outfoxed by that loser. I had a strategy in mind.

"Sir," I said, "tell me again what you just said."

He stared at me square in the eye: "Let me say it again clearly for you: as soon as you untie me, I am going to cut myself again, even worse this time."

"Are you saying that you are imminently going to harm yourself?"

"Yes."

"Are you confident that you are a danger to yourself?"

"Yes."

"Are you saying that you could potentially kill yourself?"

"I will try and kill myself if you untie me."

Those were the magic words.

"Give me more morphine!" he demanded.

"I'm sorry, I cannot do that."

"Why the fuck not?" he demanded.

"Because you are acutely suicidal and a danger to yourself. You will have to be restrained and taken to the psychiatric ward for prisoners -- still a prison with bars -- upstairs to be evaluated within seventy-two hours by law. Our entire conversation and your explicit threats are documented and witnessed. Thank you, goodbye."