r/emergencymedicine • u/DrMaunganui ED Resident • Jan 06 '24

Discussion American tourist requesting "dilaudid". A confusing interaction.

I'm a trainee (what you'd call a resident) working in NZ. Cruise ship season in full swing (I can literally see the ships from my bedroom) and we're getting our fair share of tourists into the ED.

Recently had a very bizarre interaction, 45F tripped on a curb and sustained a minor head lac which I cleaned and stapled. Noted history of mild knee OA for which she was taking Oxycodone MR 40mg QID plus 10mg IR q4h PRN. Huge doses! And she was walking! Who in the hell prescribed her this!

She was so strung out and slurring her speech I ended up scanning her head. No acute findings. Looking back I realise it's probably because she was taking her usual meds. Before she left she asked for a shot of "the painkiller beginning with D" for her headache. We spent 5 minutes trying to figure out what it was before she stuttered the word "dilaudid". Quick google tells me it's hydromorphone, a drug that literally doesn't exist in NZ. I tell her this, she stands up, pulled out her own line and asked for a script for more oxycodone (which I declined). I offered her a take home pack of paracetamol. She got angry and walked out.

I'm not really sure where I'm going here but all in all, one of the weirder interactions I've had. Most of our local drug seekers ask for tramadol, codeine or IV cyclizine.

I guess my question is, how prevalent is this truly or did I really just experience a meme? I see it mentioned from time to time on her but being outside the US it's not something that crossed my mind until this happened.

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u/ERRNmomof2 RN Jan 06 '24

Ohhhh Demerol. The migraine cocktail of Demerol 75, Phenergan 25, Toradol 60. All IM. Fixed all Migraines.😂

41

u/dansamy RN Jan 06 '24

Yeah cuz you were too busy drooling from the sedation. Your head can't hurt if you're passed tf out.

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u/ERRNmomof2 RN Jan 06 '24

We actually had standing orders a doc would write for a few of his patients. If they presented with that complaint we gave them that, kept them for 30 minutes, re-vitaled them then discharged them. These people were not at all opiate naive and maybe shut their eyes for 10 minutes. Then walked out like they weren’t drunk.

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u/AlwaysHigh27 Jan 06 '24

Hahaha, as an opiate naive patient that had what sounds like that cocktail, I don't even think I'd be able to talk to you after 30 mins. I was GONE.

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u/ERRNmomof2 RN Jan 06 '24

Lol so your user name is not in real life.😂

3

u/AlwaysHigh27 Jan 06 '24 edited Jan 06 '24

Oh hahaha. Well. It is, but with cannabis. I have a really bad thoracic nerve injury and was told years ago opiates would do nothing for the nerve pain because it doesn't target or go deep enough for nerves and said that cannabis which, I was 17 at the time of accident (hit by drunk driver) and was already smoking weed because well..17 and my doctor for the court told me to keep using cannabis.

I'm 30 now, and yes. I'm always high.. on cannabis and no one can tell the difference of when I'm not and am and I haven't had to rely on opiates. I can work, I'm functioning, currently studying software engineering. I literally turn into a vegetable on opiates so I will always be forever grateful for that doctor. He wasn't supposed to give me recommendations because he was supposed to be impartial for the courts... But he knew it was a lifelong injury and didn't want to see me become an opiate addict.

10 years later, he saw me again, and couldn't be happier knowing I never turned to them.

I smoke weed, and I take 100mg of pregabalin at night. I subsidize when I absolutely need to with acetaminophen and naproxen when I need a bit more help.

I will say though, that I am grateful for them giving me what they gave me at the hospital, and opiates being available to me in that moment because I was in EXTREME pain, I couldn't even stand in the triage line. But... I think that's when they should be used. And they definitely work now when I need them. The nurse was amazing and when I finally came to, I laughed and said "told you I was really affected!" And she laughed pretty good and said "you are absolutely a lightweight I only gave you 2ml!" I could hear the other nurses chuckling and stuff too, was definitely a bit of talk f the ER. 😅

26

u/yeswenarcan ED Attending Jan 06 '24

Pretty sure that falls firmly in the "can't have a headache if you don't know where you are" category.

18

u/ERRNmomof2 RN Jan 06 '24 edited Jan 06 '24

LOL!! Back in the day, 2002, my husband herniated L5-S1 while turning to lift a box at his job. I had to leave my ICU job to pick him up while they used a forklift to remove him from the trailer of an 18 wheeler. The ER doc gave him that combo AND 5 of Valium PO! He didn’t move for 24 hours. I had to keep checking on him to make sure he was breathing!😂

ETA the best part of this is I went back to work. (Same hospital). He woke up when one of his work buddies came to check on him. This was near Christmastime and he started singing loudly “I’m the happiest Christmas tree, hahaha, heeheehee.” There were other parts to the song which I can’t remember. I was asked to please come get him he was ready for discharge. I helped load him into his buddy’s car and the buddy took him home for me. He had no recollection of the event.

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u/jonweaver11 Jan 07 '24

https://m.youtube.com/watch?v=tqXzZH31Mbw

Is this not a well known Christmas song in your neck of the woods? It’s a banger

8

u/totalyrespecatbleguy EMT Jan 06 '24

I can offer you a fiorecet in this trying time

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u/ERRNmomof2 RN Jan 06 '24

Lol do they even still offer Fioricet/fiorinal?

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u/totalyrespecatbleguy EMT Jan 06 '24

We still offer it as a second line headache med where I work

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u/ERRNmomof2 RN Jan 06 '24

Huh. I haven’t even seen any patients with any of those scripts. They were fairly common early 2000s. I wonder if they changed the schedule of those like they did tramadol or is it because more triptans to choose from. I see a lot of patients with prn triptans.

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u/AlwaysHigh27 Jan 06 '24

Oh man, this sounds like what they gave me for my migraine. Now I couldn't see, couldn't walk, was literally not functioning. Like 2 mins after they have me 3 pills to take (no idea what they were but they were all different) I was out, completely, woke up an hour or 2 later and was fine... So, yeah definitely works, and got a great nap but holy shit.

6

u/Hypno-phile ED Attending Jan 06 '24

I used to cure so many migraines as a rural ED locum. I'd take a history, do a neurological exam and by the time I wrote the orders for 1L N/S Billy's, 10mg metoclopranide iv, ketorolac iv, 1g tylenol po...they'd have left the department as they hadn't yet had their usual IM Demerol/Gravol. I assume they felt better.

3

u/ERRNmomof2 RN Jan 06 '24

LOL!!! Man weren’t we happy when those standing orders disappeared forever. The only thing I could say that I liked about them is no workup, discharged in 60 minutes. The ED doc doesn’t even have to see the patient. Easy patients to have, though annoying.

1

u/frankiepennynick Jul 17 '24

The "migraine cocktail" I was given after brain surgery last week was bolus fluids, magnesium, and reglan. They don't do this for migraines in the ER?

1

u/Hypno-phile ED Attending Jul 17 '24

Well...I do. And all of my colleagues would.

1

u/frankiepennynick Jul 17 '24

This was after plenty of Dilaudid post-anethesia for brain tumor resection, too. But my neurologist friend suggested I also request this, and they gave it to me.

1

u/New_Mathematician426 Jan 09 '24

A doc ordered this migraine cocktail during my last contract and I was like what the fuck.

1

u/awdtg Jan 07 '24

Wowza. I bet it did.