Sucker!

A couple of weeks ago I went to a shelter first thing in the morning. My shifts start at 0630 and we picked up this call at 0640 or so. We arrived to find a 30-something male with intractible vomiting. There was no gastrointestinal bleeding, but he couldn't stop shouting for his friend Ralph. It was hard to even communicate with him about his basic history and his situation. Being that I am trying to be more liberal with Zofran, and being that he looked sincerely pathetic and uncomfortable, I gave him 4 milligrams intramuscularly.

We were closest to a nearby community hospital, but the patient was adamant about going to the city trauma center. He said he had been followed there for a long time. It wasn't significantly farther to go there, so I was okay with that. On the way to the hospital, the retching and vomiting eased and I could chat with the patient and complete an exam.

He sat on the bench as we drove. He was pale and diaphoretic, but appeared feverish with goosebumps and chills. He was tachycardic (HR 130) but normotensive. He was a little tachypneic, as well, but I attributed that to the recent grandiose emesis. He said he hadn't been feeling well when he went to bed the night before, and woke about two hours ago with the nausea and vomiting. He claimed no medical history (at which point a little voice tried unsuccessfully to tell me how it was odd that he was followed at the city trauma center without any medical problems). There was no diarrhea, but he did have some abdominal cramping so maybe he was saving that for later. 

I got out my laptop and started filling in his demographics. I collected his name, birthdate, and such, and asked if he takes medications. "Methadone," he told me.

Methadone. 

"When was the last time you had some?"

"Two days ago," he answered.

"When are your appointments at the clinic?"

"Everyday at seven A.M." he replied.

I looked at my watch. It was about seven o'clock. The whole picture clicked into place. 

We got to the hospital, the patient crossed the threshold into the ED entrance, and loudly proclaimed that he was respectfully refusing further care. He said it as though it was rehearsed; like he had to say this certain thing at a specific time. He turned around, left through the ambulance entrance, and turned right to head to the methadone clinic next door.

And that, ladies and gentlemen, is how I transported a patient to his methadone appointment. Oh, yeah, I gave him Zofran too. You win some and you lose some...